Boulder City Hospital Last Updated: 07/07/2024 "De-Identified Minimum Reimbursement *Items and services that do not easily translate to an individual line are not included. " "De-Identified Maximum Reimbursement *Items and services that do not easily translate to an individual line are not included. " Aetna - Medicare Aetna Anthem Blue Cross Blue Shield - Indemnity; Traditional; PAR/PPO Anthem Blue Cross Blue Shield - HMO; Pathway PPO/HMO Networks; Pathway X HMO/PPO Networks Anthem Medicaid Cigna Managed Care Coalition-Health Services Humana - Medicare Advantage (Choicecare) Humana - Commerical MultiPlan One Health Saint Mary's Health Plans Sierra Healthcare Options HPN Medicaid Sierra/HPN Southpoint (Gaughan South) Teachers Trust TriWest United Healthcare UHN-Universal Health Network PPO Select Health Medicare Blue Cross Blue Shield Medicare Alignment Medicare Silversummit Medicare Optum Medicare Self-Pay Charge Code Department Billing Description CPT Code HCPCS Code Rev Code Gross Charge Inpatient Outpatient Professional Inpatient Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment (excluding MRI and CT). Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient: Emergency paid at 70% of billed charge with a max of $2313. Observation paid at 70% of charge with a max of $1850 Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient: Emergency paid at 55% of billed charge with a max of $3300. Observation paid at 55% of charge with a max of $3300. PT/OT/ST is $200 per visit total. Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Excluding MRI and CT " Outpatient: Paid at 70% of charge, not to exceed $3710 for Emergency, Therapy, Radiology, Lab and Misc outpatinet services. Observation paid at 70% of charge not to exceed $1300. Same day surgery paid at 65% of charges not to exceed $4770. " Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. " Outpatient: Paid at 70% of charge, not to exceed $1400, excluding same day surgery. " Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. " Outpatient: Paid at 60% of charge, not to exceed $2250, excluding same day surgery. " Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. " Outpatient: Emergency 68% of charge not to exceed $3581. Observation $100 per/hr not to exceed $2387. General Radiology 65% of charge not to exceed $2387, excluding Emergency " Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Excluding MRI and CT " Outpatient: 70% of charge not to exceed $5913.18 for Emergency, Observation, Therapy, Radiology, Lab and Misc Outpatient Services. Same Day Surgery 65% of charge not to exceed $7602.66 " Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient: paid at a per day rate. All other hospital services are included in payment. Outpatient Professional Inpatient Outpatient Professional 4000684 Blood Bank Crossmatch 86922 390 $347.00 $- $17.97 $- $- $277.60 $- N/A $90.22 N/A N/A $21.34 N/A N/A $208.20 N/A N/A $173.50 N/A N/A $17.97 N/A N/A $235.96 N/A N/A $170.03 N/A N/A $135.33 N/A N/A $242.90 N/A N/A $277.60 N/A N/A $190.85 N/A N/A $242.90 N/A N/A $116.25 N/A N/A $17.97 N/A N/A $208.20 N/A N/A $121.45 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $208.20 N/A N/A $242.90 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A $347.00 $347.00 N/A 4000684 Blood Bank Crossmatch 86922 390 $347.00 $- $17.97 $- $- $277.60 $- N/A $90.22 N/A N/A $21.34 N/A N/A $208.20 N/A N/A $173.50 N/A N/A $17.97 N/A N/A $235.96 N/A N/A $170.03 N/A N/A $135.33 N/A N/A $242.90 N/A N/A $277.60 N/A N/A $190.85 N/A N/A $242.90 N/A N/A $116.25 N/A N/A $17.97 N/A N/A $208.20 N/A N/A $121.45 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $208.20 N/A N/A $242.90 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A $347.00 $347.00 N/A 4010109 Blood Bank ABO/Rh Retype 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4020080 Blood Bank Antibody Screen Tube 2 86886 302 $311.00 $- $3.32 $- $- $248.80 $- N/A $80.86 N/A N/A $5.54 N/A N/A $186.60 N/A N/A $155.50 N/A N/A $3.32 N/A N/A $211.48 N/A N/A $152.39 N/A N/A $121.29 N/A N/A $217.70 N/A N/A $248.80 N/A N/A $171.05 N/A N/A $217.70 N/A N/A $104.19 N/A N/A $3.32 N/A N/A $186.60 N/A N/A $108.85 N/A N/A $202.15 N/A N/A $93.30 N/A N/A $186.60 N/A N/A $217.70 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A $311.00 $311.00 N/A 4020293 Blood Bank Bill Antigen Type Product 86902 300 $277.00 $- $2.46 $- $- $221.60 $- N/A $72.02 N/A N/A $4.09 N/A N/A $166.20 N/A N/A $138.50 N/A N/A $2.46 N/A N/A $188.36 N/A N/A $135.73 N/A N/A $108.03 N/A N/A $193.90 N/A N/A $221.60 N/A N/A $152.35 N/A N/A $193.90 N/A N/A $92.80 N/A N/A $2.46 N/A N/A $166.20 N/A N/A $96.95 N/A N/A $180.05 N/A N/A $83.10 N/A N/A $166.20 N/A N/A $193.90 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A $277.00 $277.00 N/A 4024272 Blood Bank Irradiated Units P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Leukoreduced Units P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4026903 Blood Bank CMV Neg 86902 300 $189.00 $- $2.46 $- $- $151.20 $- N/A $49.14 N/A N/A $4.09 N/A N/A $113.40 N/A N/A $94.50 N/A N/A $2.46 N/A N/A $128.52 N/A N/A $92.61 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A $2.46 N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 4026903 Blood Bank CMV/Irradiated 86902 300 $189.00 $- $2.46 $- $- $151.20 $- N/A $49.14 N/A N/A $4.09 N/A N/A $113.40 N/A N/A $94.50 N/A N/A $2.46 N/A N/A $128.52 N/A N/A $92.61 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A $2.46 N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 4029001 Blood Bank ABO 3 86900 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029001 Blood Bank ABO/Rh 86900 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029010 Blood Bank ABO 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029010 Blood Bank ABO Retype 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029010 Blood Bank Rh 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029010 Blood Bank Rh Retype 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4029010 Blood Bank Rh3 86901 300 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4021900 Blood Bank Product Aph Plt ACDA LR P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR 1 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR 2 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR 3 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR Irr P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR Irr 1 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR Irr 2 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product Aph Plt ACDA LR Irr 3 P9019 P9019 390 "$1,255.00 " $- $269.63 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $269.63 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4021900 Blood Bank Product E5032 Aph Plt ACDA LR BM 2 P9016 P9016 390 "$1,255.00 " $- $326.30 $- $- "$1,004.00 " $- N/A $326.30 N/A N/A $468.58 N/A N/A $753.00 N/A N/A $627.50 N/A N/A N/A N/A N/A $853.40 N/A N/A $614.95 N/A N/A $489.45 N/A N/A $878.50 N/A N/A "$1,004.00 " N/A N/A $690.25 N/A N/A $878.50 N/A N/A $420.43 N/A N/A N/A N/A N/A $753.00 N/A N/A $439.25 N/A N/A $815.75 N/A N/A $376.50 N/A N/A $753.00 N/A N/A $878.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A N/A $376.50 N/A "$1,255.00 " "$1,255.00 " N/A 4023886 Blood Bank Product Aph FFP CP2D Thawed P9017 P9017 383 $578.00 $- $115.49 $- $- $462.40 $- N/A $150.28 N/A N/A $115.49 N/A N/A $346.80 N/A N/A $289.00 N/A N/A N/A N/A N/A $393.04 N/A N/A $283.22 N/A N/A $225.42 N/A N/A $404.60 N/A N/A $462.40 N/A N/A $317.90 N/A N/A $404.60 N/A N/A $193.63 N/A N/A N/A N/A N/A $346.80 N/A N/A $202.30 N/A N/A $375.70 N/A N/A $173.40 N/A N/A $346.80 N/A N/A $404.60 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A $578.00 $578.00 N/A 4023886 Blood Bank Product Thawed Plasma CP2D <24h P9017 P9017 383 $578.00 $- $115.49 $- $- $462.40 $- N/A $150.28 N/A N/A $115.49 N/A N/A $346.80 N/A N/A $289.00 N/A N/A N/A N/A N/A $393.04 N/A N/A $283.22 N/A N/A $225.42 N/A N/A $404.60 N/A N/A $462.40 N/A N/A $317.90 N/A N/A $404.60 N/A N/A $193.63 N/A N/A N/A N/A N/A $346.80 N/A N/A $202.30 N/A N/A $375.70 N/A N/A $173.40 N/A N/A $346.80 N/A N/A $404.60 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A N/A $173.40 N/A $578.00 $578.00 N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR Irr P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR Irr 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS3 LR Irr 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS1 LR 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS1 LR 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS1 LR Irr1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC ACDA AS1 LR Irr 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR Irr 2 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR Irr P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product Aph RBC CP2D AS3 LR Irr 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product P9019 P9019 390 "$1,425.00 " $- $269.63 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $269.63 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product E5031 Aph Plt ACDA LR BM 1 P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product RBC CPD AS1 500 LR P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product RBC CP2D AS3 500 LR P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product RBC CP2D AS3 500 LR Irr P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4024272 Blood Bank Product RBC CPD AS1 500 LR Irr P9016 P9016 390 "$1,425.00 " $- $370.50 $- $- "$1,140.00 " $- N/A $370.50 N/A N/A $468.58 N/A N/A $855.00 N/A N/A $712.50 N/A N/A N/A N/A N/A $969.00 N/A N/A $698.25 N/A N/A $555.75 N/A N/A $997.50 N/A N/A "$1,140.00 " N/A N/A $783.75 N/A N/A $997.50 N/A N/A $477.38 N/A N/A N/A N/A N/A $855.00 N/A N/A $498.75 N/A N/A $926.25 N/A N/A $427.50 N/A N/A $855.00 N/A N/A $997.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A N/A $427.50 N/A "$1,425.00 " "$1,425.00 " N/A 4180008 Cardiac/Cardiac Rehab Charges 93005 EKG TRACING ONLY CHARGE 93005 730 $723.00 $- $6.96 $- $- $578.40 $- N/A $187.98 N/A N/A $273.29 N/A N/A $433.80 N/A N/A $361.50 N/A N/A $6.96 N/A N/A $491.64 N/A N/A $426.57 N/A N/A $281.97 N/A N/A $506.10 N/A N/A $578.40 N/A N/A $397.65 N/A N/A $506.10 N/A N/A $242.21 N/A N/A $6.96 N/A N/A $433.80 N/A N/A $253.05 N/A N/A $469.95 N/A N/A $216.90 N/A N/A $433.80 N/A N/A $506.10 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A $723.00 $723.00 N/A 4180008 Cardiac/Cardiac Rehab Charges 93005 EKG TRACING ONLY CHARGE 93005 730 $723.00 $- $6.96 $- $- $578.40 $- N/A $187.98 N/A N/A $273.29 N/A N/A $433.80 N/A N/A $361.50 N/A N/A $6.96 N/A N/A $491.64 N/A N/A $426.57 N/A N/A $281.97 N/A N/A $506.10 N/A N/A $578.40 N/A N/A $397.65 N/A N/A $506.10 N/A N/A $242.21 N/A N/A $6.96 N/A N/A $433.80 N/A N/A $253.05 N/A N/A $469.95 N/A N/A $216.90 N/A N/A $433.80 N/A N/A $506.10 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A $723.00 $723.00 N/A 4183077 Cardiac/Cardiac Rehab Charges 93307 ECHOCARDIOGRAM 2D M CHARGE 93307 483 "$2,196.00 " $- $110.37 $- $- "$1,756.80 " $- N/A $570.96 N/A N/A $830.09 N/A N/A "$1,317.60 " N/A N/A "$1,098.00 " N/A N/A $110.37 N/A N/A "$1,493.28 " N/A N/A "$1,295.64 " N/A N/A $856.44 N/A N/A "$1,537.20 " N/A N/A "$1,756.80 " N/A N/A "$1,207.80 " N/A N/A "$1,537.20 " N/A N/A $735.66 N/A N/A $110.37 N/A N/A "$1,317.60 " N/A N/A $768.60 N/A N/A "$1,427.40 " N/A N/A $658.80 N/A N/A "$1,317.60 " N/A N/A "$1,537.20 " N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A "$2,196.00 " "$2,196.00 " N/A 4183077 Cardiac/Cardiac Rehab Charges 93307 ECHOCARDIOGRAM 2D M CHARGE 93307 483 "$2,196.00 " $- $110.37 $- $- "$1,756.80 " $- N/A $570.96 N/A N/A $830.09 N/A N/A "$1,317.60 " N/A N/A "$1,098.00 " N/A N/A $110.37 N/A N/A "$1,493.28 " N/A N/A "$1,295.64 " N/A N/A $856.44 N/A N/A "$1,537.20 " N/A N/A "$1,756.80 " N/A N/A "$1,207.80 " N/A N/A "$1,537.20 " N/A N/A $735.66 N/A N/A $110.37 N/A N/A "$1,317.60 " N/A N/A $768.60 N/A N/A "$1,427.40 " N/A N/A $658.80 N/A N/A "$1,317.60 " N/A N/A "$1,537.20 " N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A N/A $658.80 N/A "$2,196.00 " "$2,196.00 " N/A 4183200 Cardiac/Cardiac Rehab Charges 93320 DOPPLER CARDIAC CHARGE 93320 483 $899.00 $- $45.65 $- $- $719.20 $- N/A $233.74 N/A N/A $339.82 N/A N/A $539.40 N/A N/A $449.50 N/A N/A $45.65 N/A N/A $611.32 N/A N/A $530.41 N/A N/A $350.61 N/A N/A $629.30 N/A N/A $719.20 N/A N/A $494.45 N/A N/A $629.30 N/A N/A $301.17 N/A N/A $45.65 N/A N/A $539.40 N/A N/A $314.65 N/A N/A $584.35 N/A N/A $269.70 N/A N/A $539.40 N/A N/A $629.30 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A $899.00 $899.00 N/A 4183200 Cardiac/Cardiac Rehab Charges 93320 DOPPLER CARDIAC CHARGE 93320 483 $899.00 $- $45.65 $- $- $719.20 $- N/A $233.74 N/A N/A $339.82 N/A N/A $539.40 N/A N/A $449.50 N/A N/A $45.65 N/A N/A $611.32 N/A N/A $530.41 N/A N/A $350.61 N/A N/A $629.30 N/A N/A $719.20 N/A N/A $494.45 N/A N/A $629.30 N/A N/A $301.17 N/A N/A $45.65 N/A N/A $539.40 N/A N/A $314.65 N/A N/A $584.35 N/A N/A $269.70 N/A N/A $539.40 N/A N/A $629.30 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A $899.00 $899.00 N/A 4183259 Cardiac/Cardiac Rehab Charges 93325 DOPPLER COLOR FLOW CHARGE 93325 483 "$1,178.00 " $- $21.97 $- $- $942.40 $- N/A $306.28 N/A N/A $445.28 N/A N/A $706.80 N/A N/A $589.00 N/A N/A $21.97 N/A N/A $801.04 N/A N/A $695.02 N/A N/A $459.42 N/A N/A $824.60 N/A N/A $942.40 N/A N/A $647.90 N/A N/A $824.60 N/A N/A $394.63 N/A N/A $21.97 N/A N/A $706.80 N/A N/A $412.30 N/A N/A $765.70 N/A N/A $353.40 N/A N/A $706.80 N/A N/A $824.60 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A "$1,178.00 " "$1,178.00 " N/A 4183259 Cardiac/Cardiac Rehab Charges 93325 DOPPLER COLOR FLOW CHARGE 93325 483 "$1,178.00 " $- $21.97 $- $- $942.40 $- N/A $306.28 N/A N/A $445.28 N/A N/A $706.80 N/A N/A $589.00 N/A N/A $21.97 N/A N/A $801.04 N/A N/A $695.02 N/A N/A $459.42 N/A N/A $824.60 N/A N/A $942.40 N/A N/A $647.90 N/A N/A $824.60 N/A N/A $394.63 N/A N/A $21.97 N/A N/A $706.80 N/A N/A $412.30 N/A N/A $765.70 N/A N/A $353.40 N/A N/A $706.80 N/A N/A $824.60 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A N/A $353.40 N/A "$1,178.00 " "$1,178.00 " N/A 4183306 Cardiac/Cardiac Rehab Charges 93306 TT ECHO COMPLETE CHARGE 93306 483 "$4,554.00 " $- $191.33 $- $- "$3,643.20 " $- N/A "$1,184.04 " N/A N/A "$1,721.41 " N/A N/A "$2,732.40 " N/A N/A "$2,277.00 " N/A N/A $191.33 N/A N/A "$3,096.72 " N/A N/A "$2,686.86 " N/A N/A "$1,776.06 " N/A N/A "$3,187.80 " N/A N/A "$3,643.20 " N/A N/A "$2,504.70 " N/A N/A "$3,187.80 " N/A N/A "$1,525.59 " N/A N/A $191.33 N/A N/A "$2,732.40 " N/A N/A "$1,593.90 " N/A N/A "$2,960.10 " N/A N/A "$1,366.20 " N/A N/A "$2,732.40 " N/A N/A "$3,187.80 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A "$4,554.00 " "$4,554.00 " N/A 4183306 Cardiac/Cardiac Rehab Charges 93306 TT ECHO COMPLETE CHARGE 93306 483 "$4,554.00 " $- $191.33 $- $- "$3,643.20 " $- N/A "$1,184.04 " N/A N/A "$1,721.41 " N/A N/A "$2,732.40 " N/A N/A "$2,277.00 " N/A N/A $191.33 N/A N/A "$3,096.72 " N/A N/A "$2,686.86 " N/A N/A "$1,776.06 " N/A N/A "$3,187.80 " N/A N/A "$3,643.20 " N/A N/A "$2,504.70 " N/A N/A "$3,187.80 " N/A N/A "$1,525.59 " N/A N/A $191.33 N/A N/A "$2,732.40 " N/A N/A "$1,593.90 " N/A N/A "$2,960.10 " N/A N/A "$1,366.20 " N/A N/A "$2,732.40 " N/A N/A "$3,187.80 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A "$4,554.00 " "$4,554.00 " N/A 3230047 Critical Care "96360 - Hydration, first hour" 96360 260 "$1,098.00 " $- $47.80 $- $- $878.40 $- N/A $285.48 N/A N/A $415.04 N/A N/A $658.80 N/A N/A $549.00 N/A N/A $47.80 N/A N/A $746.64 N/A N/A $647.82 N/A N/A $428.22 N/A N/A $768.60 N/A N/A $878.40 N/A N/A $603.90 N/A N/A $768.60 N/A N/A $367.83 N/A N/A $47.80 N/A N/A $658.80 N/A N/A $384.30 N/A N/A $746.64 N/A N/A $329.40 N/A N/A $658.80 N/A N/A $768.60 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A "$1,098.00 " "$1,098.00 " N/A 3230049 Critical Care "96361 - Hydration, each additional hour" 96361 260 $403.00 $- $12.56 $- $- $322.40 $- N/A $104.78 N/A N/A $152.33 N/A N/A $241.80 N/A N/A $201.50 N/A N/A $12.56 N/A N/A $274.04 N/A N/A $237.77 N/A N/A $157.17 N/A N/A $282.10 N/A N/A $322.40 N/A N/A $221.65 N/A N/A $282.10 N/A N/A $135.01 N/A N/A $12.56 N/A N/A $241.80 N/A N/A $141.05 N/A N/A $274.04 N/A N/A $120.90 N/A N/A $241.80 N/A N/A $282.10 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A $403.00 $403.00 N/A 3230051 Critical Care "96367 - IV tx, sequential infusion" 96367 260 $428.00 $- $25.09 $- $- $342.40 $- N/A $111.28 N/A N/A $161.78 N/A N/A $256.80 N/A N/A $214.00 N/A N/A $25.09 N/A N/A $291.04 N/A N/A $252.52 N/A N/A $166.92 N/A N/A $299.60 N/A N/A $342.40 N/A N/A $235.40 N/A N/A $299.60 N/A N/A $143.38 N/A N/A $25.09 N/A N/A $256.80 N/A N/A $149.80 N/A N/A $291.04 N/A N/A $128.40 N/A N/A $256.80 N/A N/A $299.60 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A $428.00 $428.00 N/A 3230052 Critical Care "96368 - IV tx, concurrent infusion" 96368 260 $253.00 $- $16.97 $- $- $202.40 $- N/A $65.78 N/A N/A $95.63 N/A N/A $151.80 N/A N/A $126.50 N/A N/A $16.97 N/A N/A $172.04 N/A N/A $149.27 N/A N/A $98.67 N/A N/A $177.10 N/A N/A $202.40 N/A N/A $139.15 N/A N/A $177.10 N/A N/A $84.76 N/A N/A $16.97 N/A N/A $151.80 N/A N/A $88.55 N/A N/A $172.04 N/A N/A $75.90 N/A N/A $151.80 N/A N/A $177.10 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A $253.00 $253.00 N/A 3230053 Critical Care "96374 - IV Injection, single/initial" 96374 260 $289.00 $- $47.18 $- $- $231.20 $- N/A $75.14 N/A N/A $109.24 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $47.18 N/A N/A $196.52 N/A N/A $170.51 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $47.18 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $196.52 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3230054 Critical Care "96375 - IV Injection, add new drug" 96375 260 $289.00 $- $18.59 $- $- $231.20 $- N/A $75.14 N/A N/A $109.24 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $18.59 N/A N/A $196.52 N/A N/A $170.51 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $18.59 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $196.52 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3230056 Critical Care "96376 - IV Injection, add same drug" 96376 260 $108.00 $- $12.00 $- $- $86.40 $- N/A $28.08 N/A N/A $40.82 N/A N/A $64.80 N/A N/A $54.00 N/A N/A $12.00 N/A N/A $73.44 N/A N/A $63.72 N/A N/A $42.12 N/A N/A $75.60 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $75.60 N/A N/A $36.18 N/A N/A $12.00 N/A N/A $64.80 N/A N/A $37.80 N/A N/A $73.44 N/A N/A $32.40 N/A N/A $64.80 N/A N/A $75.60 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A $108.00 $108.00 N/A 3230058 Critical Care 99201 ER TRIAGE EM 99201 450 $278.00 $- $22.94 $- $- $222.40 $- N/A $72.28 N/A N/A Included in ER case rate N/A N/A $166.80 N/A N/A $139.00 N/A N/A $22.94 N/A N/A $189.04 N/A N/A $164.02 N/A N/A $108.42 N/A N/A $194.60 N/A N/A $222.40 N/A N/A $152.90 N/A N/A $194.60 N/A N/A $93.13 N/A N/A $22.94 N/A N/A $166.80 N/A N/A $97.30 N/A N/A $189.04 N/A N/A $83.40 N/A N/A $166.80 N/A N/A $194.60 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A $278.00 $278.00 N/A 3230094 Critical Care "96365 - IV tx, first hour" 96365 260 $823.00 $- $57.70 $- $- $658.40 $- N/A $213.98 N/A N/A $311.09 N/A N/A $493.80 N/A N/A $411.50 N/A N/A $57.70 N/A N/A $559.64 N/A N/A $485.57 N/A N/A $320.97 N/A N/A $576.10 N/A N/A $658.40 N/A N/A $452.65 N/A N/A $576.10 N/A N/A $275.71 N/A N/A $57.70 N/A N/A $493.80 N/A N/A $288.05 N/A N/A $559.64 N/A N/A $246.90 N/A N/A $493.80 N/A N/A $576.10 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A $823.00 $823.00 N/A 3230620 Critical Care 99291 - Critical Care 99291 450 "$5,279.00 " $- $193.64 $- $- "$4,223.20 " $- N/A "$1,372.54 " N/A N/A Included in ER case rate N/A N/A "$3,167.40 " N/A N/A "$2,639.50 " N/A N/A $193.64 N/A N/A "$3,589.72 " N/A N/A "$3,114.61 " N/A N/A "$2,058.81 " N/A N/A "$3,695.30 " N/A N/A "$4,223.20 " N/A N/A "$2,903.45 " N/A N/A "$3,695.30 " N/A N/A "$1,768.47 " N/A N/A $193.64 N/A N/A "$3,167.40 " N/A N/A "$1,847.65 " N/A N/A "$3,589.72 " N/A N/A "$1,583.70 " N/A N/A "$3,167.40 " N/A N/A "$3,695.30 " N/A N/A "$1,583.70 " N/A N/A "$1,583.70 " N/A N/A "$1,583.70 " N/A N/A "$1,583.70 " N/A N/A "$1,583.70 " N/A N/A "$1,583.70 " N/A "$5,279.00 " "$5,279.00 " N/A 3230783 Critical Care 96372 - Subq/IM Injection 96372 260 $250.00 $- $20.89 $- $- $200.00 $- N/A $65.00 N/A N/A $94.50 N/A N/A $150.00 N/A N/A $125.00 N/A N/A $20.89 N/A N/A $170.00 N/A N/A $147.50 N/A N/A $97.50 N/A N/A $175.00 N/A N/A $200.00 N/A N/A $137.50 N/A N/A $175.00 N/A N/A $83.75 N/A N/A $20.89 N/A N/A $150.00 N/A N/A $87.50 N/A N/A $170.00 N/A N/A $75.00 N/A N/A $150.00 N/A N/A $175.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A $250.00 $250.00 N/A 3232920 Critical Care "Critical care, evaluation and management of the critically i" 99292 450 "$1,811.00 " $- $96.98 $- $- "$1,448.80 " $- N/A $470.86 N/A N/A Included in ER case rate N/A N/A "$1,086.60 " N/A N/A $905.50 N/A N/A $96.98 N/A N/A "$1,231.48 " N/A N/A "$1,068.49 " N/A N/A $706.29 N/A N/A "$1,267.70 " N/A N/A "$1,448.80 " N/A N/A $996.05 N/A N/A "$1,267.70 " N/A N/A $606.69 N/A N/A $96.98 N/A N/A "$1,086.60 " N/A N/A $633.85 N/A N/A "$1,231.48 " N/A N/A $543.30 N/A N/A "$1,086.60 " N/A N/A "$1,267.70 " N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A "$1,811.00 " "$1,811.00 " N/A 3236366 Critical Care "96366 - IV tx, each additional hour" 96366 260 $316.00 $- $15.44 $- $- $252.80 $- N/A $82.16 N/A N/A $119.45 N/A N/A $189.60 N/A N/A $158.00 N/A N/A $15.44 N/A N/A $214.88 N/A N/A $186.44 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $15.44 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $214.88 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 3239281 Critical Care 99281 - Level 1 99281 450 $389.00 $- $18.18 $- $- $311.20 $- N/A $101.14 N/A N/A $1500.00 per visit total N/A N/A $233.40 N/A N/A $194.50 N/A N/A $18.18 N/A N/A $264.52 N/A N/A $229.51 N/A N/A $151.71 N/A N/A $272.30 N/A N/A $311.20 N/A N/A $213.95 N/A N/A $272.30 N/A N/A $130.32 N/A N/A $18.18 N/A N/A $233.40 N/A N/A $136.15 N/A N/A $264.52 N/A N/A $116.70 N/A N/A $233.40 N/A N/A $272.30 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A $389.00 $389.00 N/A 3239282 Critical Care 99282 - Level 2 99282 450 $672.00 $- $35.76 $- $- $537.60 $- N/A $174.72 N/A N/A $1500.00 per visit total N/A N/A $403.20 N/A N/A $336.00 N/A N/A $35.76 N/A N/A $456.96 N/A N/A $396.48 N/A N/A $262.08 N/A N/A $470.40 N/A N/A $537.60 N/A N/A $369.60 N/A N/A $470.40 N/A N/A $225.12 N/A N/A $35.76 N/A N/A $403.20 N/A N/A $235.20 N/A N/A $456.96 N/A N/A $201.60 N/A N/A $403.20 N/A N/A $470.40 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A $672.00 $672.00 N/A 3239283 Critical Care 99283 - Level 3 99283 450 "$1,505.00 " $- $53.28 $- $- "$1,204.00 " $- N/A $391.30 N/A N/A $1500.00 per visit total N/A N/A $903.00 N/A N/A $752.50 N/A N/A $53.28 N/A N/A "$1,023.40 " N/A N/A $887.95 N/A N/A $586.95 N/A N/A "$1,053.50 " N/A N/A "$1,204.00 " N/A N/A $827.75 N/A N/A "$1,053.50 " N/A N/A $504.18 N/A N/A $53.28 N/A N/A $903.00 N/A N/A $526.75 N/A N/A "$1,023.40 " N/A N/A $451.50 N/A N/A $903.00 N/A N/A "$1,053.50 " N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A "$1,505.00 " "$1,505.00 " N/A 3239284 Critical Care 99284 - Level 4 99284 450 "$2,534.00 " $- $101.66 $- $- "$2,027.20 " $- N/A $658.84 N/A N/A $1500.00 per visit total N/A N/A "$1,520.40 " N/A N/A "$1,267.00 " N/A N/A $101.66 N/A N/A "$1,723.12 " N/A N/A "$1,495.06 " N/A N/A $988.26 N/A N/A "$1,773.80 " N/A N/A "$2,027.20 " N/A N/A "$1,393.70 " N/A N/A "$1,773.80 " N/A N/A $848.89 N/A N/A $101.66 N/A N/A "$1,520.40 " N/A N/A $886.90 N/A N/A "$1,723.12 " N/A N/A $760.20 N/A N/A "$1,520.40 " N/A N/A "$1,773.80 " N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A "$2,534.00 " "$2,534.00 " N/A 3239285 Critical Care 99285 - Level 5 99285 450 "$3,402.00 " $- $149.31 $- $- "$2,721.60 " $- N/A $884.52 N/A N/A $1500.00 per visit total N/A N/A "$2,041.20 " N/A N/A "$1,701.00 " N/A N/A $149.31 N/A N/A "$2,313.36 " N/A N/A "$2,007.18 " N/A N/A "$1,326.78 " N/A N/A "$2,381.40 " N/A N/A "$2,721.60 " N/A N/A "$1,871.10 " N/A N/A "$2,381.40 " N/A N/A "$1,139.67 " N/A N/A $149.31 N/A N/A "$2,041.20 " N/A N/A "$1,190.70 " N/A N/A "$2,313.36 " N/A N/A "$1,020.60 " N/A N/A "$2,041.20 " N/A N/A "$2,381.40 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A "$3,402.00 " "$3,402.00 " N/A 3450100 Dialysis Charges 36831 OPEN THROMBECTOMYAV FISTU CHARGE 36831 940 "$10,503.00 " $- $414.80 $- $- "$8,402.40 " $- N/A "$2,730.78 " N/A N/A "$3,970.13 " N/A N/A "$6,301.80 " N/A N/A "$5,251.50 " N/A N/A $414.80 N/A N/A "$7,142.04 " N/A N/A "$6,196.77 " N/A N/A "$4,096.17 " N/A N/A "$7,352.10 " N/A N/A "$8,402.40 " N/A N/A "$5,776.65 " N/A N/A "$7,352.10 " N/A N/A "$3,518.51 " N/A N/A $414.80 N/A N/A "$6,301.80 " N/A N/A "$3,676.05 " N/A N/A "$6,826.95 " N/A N/A "$3,150.90 " N/A N/A "$6,301.80 " N/A N/A "$7,352.10 " N/A N/A "$3,150.90 " N/A N/A "$3,150.90 " N/A N/A "$3,150.90 " N/A N/A "$3,150.90 " N/A N/A "$3,150.90 " N/A N/A "$3,150.90 " N/A "$10,503.00 " "$10,503.00 " N/A 3450115 Dialysis Charges 36832 AV FISTULA REVISION OPEN CHARGE 36832 940 "$11,905.00 " $- $528.89 $- $- "$9,524.00 " $- N/A "$3,095.30 " N/A N/A "$4,500.09 " N/A N/A "$7,143.00 " N/A N/A "$5,952.50 " N/A N/A $528.89 N/A N/A "$8,095.40 " N/A N/A "$7,023.95 " N/A N/A "$4,642.95 " N/A N/A "$8,333.50 " N/A N/A "$9,524.00 " N/A N/A "$6,547.75 " N/A N/A "$8,333.50 " N/A N/A "$3,988.18 " N/A N/A $528.89 N/A N/A "$7,143.00 " N/A N/A "$4,166.75 " N/A N/A "$7,738.25 " N/A N/A "$3,571.50 " N/A N/A "$7,143.00 " N/A N/A "$8,333.50 " N/A N/A "$3,571.50 " N/A N/A "$3,571.50 " N/A N/A "$3,571.50 " N/A N/A "$3,571.50 " N/A N/A "$3,571.50 " N/A N/A "$3,571.50 " N/A "$11,905.00 " "$11,905.00 " N/A 3450120 Dialysis Charges 36833 AV FISTULA REVISION CHARGE 36833 940 "$13,563.00 " $- $599.61 $- $- "$10,850.40 " $- N/A "$3,526.38 " N/A N/A "$5,126.81 " N/A N/A "$8,137.80 " N/A N/A "$6,781.50 " N/A N/A $599.61 N/A N/A "$9,222.84 " N/A N/A "$8,002.17 " N/A N/A "$5,289.57 " N/A N/A "$9,494.10 " N/A N/A "$10,850.40 " N/A N/A "$7,459.65 " N/A N/A "$9,494.10 " N/A N/A "$4,543.61 " N/A N/A $599.61 N/A N/A "$8,137.80 " N/A N/A "$4,747.05 " N/A N/A "$8,815.95 " N/A N/A "$4,068.90 " N/A N/A "$8,137.80 " N/A N/A "$9,494.10 " N/A N/A "$4,068.90 " N/A N/A "$4,068.90 " N/A N/A "$4,068.90 " N/A N/A "$4,068.90 " N/A N/A "$4,068.90 " N/A N/A "$4,068.90 " N/A "$13,563.00 " "$13,563.00 " N/A 3450125 Dialysis Charges 36147 ACCESS AV DIAL GRAFT FOR CHARGE 940 "$1,127.00 " $- $293.02 $- $- $901.60 $- N/A $293.02 N/A N/A $426.01 N/A N/A $676.20 N/A N/A $563.50 N/A N/A N/A N/A N/A $766.36 N/A N/A $664.93 N/A N/A $439.53 N/A N/A $788.90 N/A N/A $901.60 N/A N/A $619.85 N/A N/A $788.90 N/A N/A $377.55 N/A N/A N/A N/A N/A $676.20 N/A N/A $394.45 N/A N/A $732.55 N/A N/A $338.10 N/A N/A $676.20 N/A N/A $788.90 N/A N/A $338.10 N/A N/A $338.10 N/A N/A $338.10 N/A N/A $338.10 N/A N/A $338.10 N/A N/A $338.10 N/A "$1,127.00 " "$1,127.00 " N/A 3450130 Dialysis Charges 36148 ACCESS AV DIAL GRFT PRO CHARGE 940 "$3,256.00 " $- $846.56 $- $- "$2,604.80 " $- N/A $846.56 N/A N/A "$1,230.77 " N/A N/A "$1,953.60 " N/A N/A "$1,628.00 " N/A N/A N/A N/A N/A "$2,214.08 " N/A N/A "$1,921.04 " N/A N/A "$1,269.84 " N/A N/A "$2,279.20 " N/A N/A "$2,604.80 " N/A N/A "$1,790.80 " N/A N/A "$2,279.20 " N/A N/A "$1,090.76 " N/A N/A N/A N/A N/A "$1,953.60 " N/A N/A "$1,139.60 " N/A N/A "$2,116.40 " N/A N/A $976.80 N/A N/A "$1,953.60 " N/A N/A "$2,279.20 " N/A N/A $976.80 N/A N/A $976.80 N/A N/A $976.80 N/A N/A $976.80 N/A N/A $976.80 N/A N/A $976.80 N/A "$3,256.00 " "$3,256.00 " N/A 3450135 Dialysis Charges 90945 DIALYSIS ONE EVAL CHARGE 90945 800 "$2,431.00 " $- $632.06 $- $- "$1,944.80 " $- N/A $632.06 N/A N/A $918.92 N/A N/A "$1,458.60 " N/A N/A "$1,215.50 " N/A N/A N/A N/A N/A "$1,653.08 " N/A N/A "$1,434.29 " N/A N/A $948.09 N/A N/A "$1,701.70 " N/A N/A "$1,944.80 " N/A N/A "$1,337.05 " N/A N/A "$1,701.70 " N/A N/A $814.39 N/A N/A N/A N/A N/A "$1,458.60 " N/A N/A $850.85 N/A N/A "$1,580.15 " N/A N/A $729.30 N/A N/A "$1,458.60 " N/A N/A "$1,701.70 " N/A N/A $729.30 N/A N/A $729.30 N/A N/A $729.30 N/A N/A $729.30 N/A N/A $729.30 N/A N/A $729.30 N/A "$2,431.00 " "$2,431.00 " N/A 3450140 Dialysis Charges 49418 INSERT TUNNELED IP CATH P CHARGE 49418 940 "$6,170.00 " $- "$1,604.20 " $- $- "$4,936.00 " $- N/A "$1,604.20 " N/A N/A "$2,332.26 " N/A N/A "$3,702.00 " N/A N/A "$3,085.00 " N/A N/A N/A N/A N/A "$4,195.60 " N/A N/A "$3,640.30 " N/A N/A "$2,406.30 " N/A N/A "$4,319.00 " N/A N/A "$4,936.00 " N/A N/A "$3,393.50 " N/A N/A "$4,319.00 " N/A N/A "$2,066.95 " N/A N/A N/A N/A N/A "$3,702.00 " N/A N/A "$2,159.50 " N/A N/A "$4,010.50 " N/A N/A "$1,851.00 " N/A N/A "$3,702.00 " N/A N/A "$4,319.00 " N/A N/A "$1,851.00 " N/A N/A "$1,851.00 " N/A N/A "$1,851.00 " N/A N/A "$1,851.00 " N/A N/A "$1,851.00 " N/A N/A "$1,851.00 " N/A "$6,170.00 " "$6,170.00 " N/A 3450145 Dialysis Charges 49419 INSERT TUN IP CATH W/PORT CHARGE 49419 940 "$13,882.00 " $- $395.04 $- $- "$11,105.60 " $- N/A "$3,609.32 " N/A N/A "$5,247.40 " N/A N/A "$8,329.20 " N/A N/A "$6,941.00 " N/A N/A $395.04 N/A N/A "$9,439.76 " N/A N/A "$8,190.38 " N/A N/A "$5,413.98 " N/A N/A "$9,717.40 " N/A N/A "$11,105.60 " N/A N/A "$7,635.10 " N/A N/A "$9,717.40 " N/A N/A "$4,650.47 " N/A N/A $395.04 N/A N/A "$8,329.20 " N/A N/A "$4,858.70 " N/A N/A "$9,023.30 " N/A N/A "$4,164.60 " N/A N/A "$8,329.20 " N/A N/A "$9,717.40 " N/A N/A "$4,164.60 " N/A N/A "$4,164.60 " N/A N/A "$4,164.60 " N/A N/A "$4,164.60 " N/A N/A "$4,164.60 " N/A N/A "$4,164.60 " N/A "$13,882.00 " "$13,882.00 " N/A 3450150 Dialysis Charges 49421 INSERT TUN IP CATH FOR DI CHARGE 49421 940 "$12,704.00 " $- $204.11 $- $- "$10,163.20 " $- N/A "$3,303.04 " N/A N/A "$4,802.11 " N/A N/A "$7,622.40 " N/A N/A "$6,352.00 " N/A N/A $204.11 N/A N/A "$8,638.72 " N/A N/A "$7,495.36 " N/A N/A "$4,954.56 " N/A N/A "$8,892.80 " N/A N/A "$10,163.20 " N/A N/A "$6,987.20 " N/A N/A "$8,892.80 " N/A N/A "$4,255.84 " N/A N/A $204.11 N/A N/A "$7,622.40 " N/A N/A "$4,446.40 " N/A N/A "$8,257.60 " N/A N/A "$3,811.20 " N/A N/A "$7,622.40 " N/A N/A "$8,892.80 " N/A N/A "$3,811.20 " N/A N/A "$3,811.20 " N/A N/A "$3,811.20 " N/A N/A "$3,811.20 " N/A N/A "$3,811.20 " N/A N/A "$3,811.20 " N/A "$12,704.00 " "$12,704.00 " N/A 3450155 Dialysis Charges 49422 REMOVE TUNNELED IP CATH CHARGE 49422 940 "$5,392.00 " $- $338.87 $- $- "$4,313.60 " $- N/A "$1,401.92 " N/A N/A "$2,038.18 " N/A N/A "$3,235.20 " N/A N/A "$2,696.00 " N/A N/A $338.87 N/A N/A "$3,666.56 " N/A N/A "$3,181.28 " N/A N/A "$2,102.88 " N/A N/A "$3,774.40 " N/A N/A "$4,313.60 " N/A N/A "$2,965.60 " N/A N/A "$3,774.40 " N/A N/A "$1,806.32 " N/A N/A $338.87 N/A N/A "$3,235.20 " N/A N/A "$1,887.20 " N/A N/A "$3,504.80 " N/A N/A "$1,617.60 " N/A N/A "$3,235.20 " N/A N/A "$3,774.40 " N/A N/A "$1,617.60 " N/A N/A "$1,617.60 " N/A N/A "$1,617.60 " N/A N/A "$1,617.60 " N/A N/A "$1,617.60 " N/A N/A "$1,617.60 " N/A "$5,392.00 " "$5,392.00 " N/A 3450160 Dialysis Charges 90935 HEMODIALYSIS ONE EVAL CHARGE 90935 800 "$1,888.00 " $- $490.88 $- $- "$1,510.40 " $- N/A $490.88 N/A N/A $713.66 N/A N/A "$1,132.80 " N/A N/A $944.00 N/A N/A N/A N/A N/A "$1,283.84 " N/A N/A "$1,113.92 " N/A N/A $736.32 N/A N/A "$1,321.60 " N/A N/A "$1,510.40 " N/A N/A "$1,038.40 " N/A N/A "$1,321.60 " N/A N/A $632.48 N/A N/A N/A N/A N/A "$1,132.80 " N/A N/A $660.80 N/A N/A "$1,227.20 " N/A N/A $566.40 N/A N/A "$1,132.80 " N/A N/A "$1,321.60 " N/A N/A $566.40 N/A N/A $566.40 N/A N/A $566.40 N/A N/A $566.40 N/A N/A $566.40 N/A N/A $566.40 N/A "$1,888.00 " "$1,888.00 " N/A 3450165 Dialysis Charges 36818 AV FUSE UPPER ARM CEPHALI CHARGE 36818 940 "$13,247.00 " $- "$3,444.22 " $- $- "$10,597.60 " $- N/A "$3,444.22 " N/A N/A "$5,007.37 " N/A N/A "$7,948.20 " N/A N/A "$6,623.50 " N/A N/A N/A N/A N/A "$9,007.96 " N/A N/A "$7,815.73 " N/A N/A "$5,166.33 " N/A N/A "$9,272.90 " N/A N/A "$10,597.60 " N/A N/A "$7,285.85 " N/A N/A "$9,272.90 " N/A N/A "$4,437.75 " N/A N/A N/A N/A N/A "$7,948.20 " N/A N/A "$4,636.45 " N/A N/A "$8,610.55 " N/A N/A "$3,974.10 " N/A N/A "$7,948.20 " N/A N/A "$9,272.90 " N/A N/A "$3,974.10 " N/A N/A "$3,974.10 " N/A N/A "$3,974.10 " N/A N/A "$3,974.10 " N/A N/A "$3,974.10 " N/A N/A "$3,974.10 " N/A "$13,247.00 " "$13,247.00 " N/A 3450170 Dialysis Charges 36819 AV FUSE UPPER ARM BASILIC CHARGE 36819 940 "$15,024.00 " $- $672.41 $- $- "$12,019.20 " $- N/A "$3,906.24 " N/A N/A "$5,679.07 " N/A N/A "$9,014.40 " N/A N/A "$7,512.00 " N/A N/A $672.41 N/A N/A "$10,216.32 " N/A N/A "$8,864.16 " N/A N/A "$5,859.36 " N/A N/A "$10,516.80 " N/A N/A "$12,019.20 " N/A N/A "$8,263.20 " N/A N/A "$10,516.80 " N/A N/A "$5,033.04 " N/A N/A $672.41 N/A N/A "$9,014.40 " N/A N/A "$5,258.40 " N/A N/A "$9,765.60 " N/A N/A "$4,507.20 " N/A N/A "$9,014.40 " N/A N/A "$10,516.80 " N/A N/A "$4,507.20 " N/A N/A "$4,507.20 " N/A N/A "$4,507.20 " N/A N/A "$4,507.20 " N/A N/A "$4,507.20 " N/A N/A "$4,507.20 " N/A "$15,024.00 " "$15,024.00 " N/A 3450175 Dialysis Charges 36820 AV FUSION/FOREARM VEIN CHARGE 36820 940 "$13,292.00 " $- $735.13 $- $- "$10,633.60 " $- N/A "$3,455.92 " N/A N/A "$5,024.38 " N/A N/A "$7,975.20 " N/A N/A "$6,646.00 " N/A N/A $735.13 N/A N/A "$9,038.56 " N/A N/A "$7,842.28 " N/A N/A "$5,183.88 " N/A N/A "$9,304.40 " N/A N/A "$10,633.60 " N/A N/A "$7,310.60 " N/A N/A "$9,304.40 " N/A N/A "$4,452.82 " N/A N/A $735.13 N/A N/A "$7,975.20 " N/A N/A "$4,652.20 " N/A N/A "$8,639.80 " N/A N/A "$3,987.60 " N/A N/A "$7,975.20 " N/A N/A "$9,304.40 " N/A N/A "$3,987.60 " N/A N/A "$3,987.60 " N/A N/A "$3,987.60 " N/A N/A "$3,987.60 " N/A N/A "$3,987.60 " N/A N/A "$3,987.60 " N/A "$13,292.00 " "$13,292.00 " N/A 3450180 Dialysis Charges 36821 AV FUSION DIRECT ANY SITE CHARGE 36821 940 "$11,986.00 " $- $633.32 $- $- "$9,588.80 " $- N/A "$3,116.36 " N/A N/A "$4,530.71 " N/A N/A "$7,191.60 " N/A N/A "$5,993.00 " N/A N/A $633.32 N/A N/A "$8,150.48 " N/A N/A "$7,071.74 " N/A N/A "$4,674.54 " N/A N/A "$8,390.20 " N/A N/A "$9,588.80 " N/A N/A "$6,592.30 " N/A N/A "$8,390.20 " N/A N/A "$4,015.31 " N/A N/A $633.32 N/A N/A "$7,191.60 " N/A N/A "$4,195.10 " N/A N/A "$7,790.90 " N/A N/A "$3,595.80 " N/A N/A "$7,191.60 " N/A N/A "$8,390.20 " N/A N/A "$3,595.80 " N/A N/A "$3,595.80 " N/A N/A "$3,595.80 " N/A N/A "$3,595.80 " N/A N/A "$3,595.80 " N/A N/A "$3,595.80 " N/A "$11,986.00 " "$11,986.00 " N/A 3450185 Dialysis Charges 36810 INSERTION OF CANNULA EXT CHARGE 36810 940 "$4,655.00 " $- $196.38 $- $- "$3,724.00 " $- N/A "$1,210.30 " N/A N/A "$1,759.59 " N/A N/A "$2,793.00 " N/A N/A "$2,327.50 " N/A N/A $196.38 N/A N/A "$3,165.40 " N/A N/A "$2,746.45 " N/A N/A "$1,815.45 " N/A N/A "$3,258.50 " N/A N/A "$3,724.00 " N/A N/A "$2,560.25 " N/A N/A "$3,258.50 " N/A N/A "$1,559.43 " N/A N/A $196.38 N/A N/A "$2,793.00 " N/A N/A "$1,629.25 " N/A N/A "$3,025.75 " N/A N/A "$1,396.50 " N/A N/A "$2,793.00 " N/A N/A "$3,258.50 " N/A N/A "$1,396.50 " N/A N/A "$1,396.50 " N/A N/A "$1,396.50 " N/A N/A "$1,396.50 " N/A N/A "$1,396.50 " N/A N/A "$1,396.50 " N/A "$4,655.00 " "$4,655.00 " N/A 3450190 Dialysis Charges 36815 INSERT OF CANNULA FOR HEM CHARGE 36815 940 "$3,468.00 " $- $132.77 $- $- "$2,774.40 " $- N/A $901.68 N/A N/A "$1,310.90 " N/A N/A "$2,080.80 " N/A N/A "$1,734.00 " N/A N/A $132.77 N/A N/A "$2,358.24 " N/A N/A "$2,046.12 " N/A N/A "$1,352.52 " N/A N/A "$2,427.60 " N/A N/A "$2,774.40 " N/A N/A "$1,907.40 " N/A N/A "$2,427.60 " N/A N/A "$1,161.78 " N/A N/A $132.77 N/A N/A "$2,080.80 " N/A N/A "$1,213.80 " N/A N/A "$2,254.20 " N/A N/A "$1,040.40 " N/A N/A "$2,080.80 " N/A N/A "$2,427.60 " N/A N/A "$1,040.40 " N/A N/A "$1,040.40 " N/A N/A "$1,040.40 " N/A N/A "$1,040.40 " N/A N/A "$1,040.40 " N/A N/A "$1,040.40 " N/A "$3,468.00 " "$3,468.00 " N/A 3450195 Dialysis Charges 93990 DOPPLER FLOW TESTING CHARGE 93990 920 "$1,628.00 " $- $164.87 $- $- "$1,302.40 " $- N/A $423.28 N/A N/A $615.38 N/A N/A $976.80 N/A N/A $814.00 N/A N/A $164.87 N/A N/A "$1,107.04 " N/A N/A $960.52 N/A N/A $634.92 N/A N/A "$1,139.60 " N/A N/A "$1,302.40 " N/A N/A $895.40 N/A N/A "$1,139.60 " N/A N/A $545.38 N/A N/A $164.87 N/A N/A $976.80 N/A N/A $569.80 N/A N/A "$1,058.20 " N/A N/A $488.40 N/A N/A $976.80 N/A N/A "$1,139.60 " N/A N/A $488.40 N/A N/A $488.40 N/A N/A $488.40 N/A N/A $488.40 N/A N/A $488.40 N/A N/A $488.40 N/A "$1,628.00 " "$1,628.00 " N/A 1500274 Emer Charges SKIN STAPLE REMOVER Charge 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A Included in ER case rate N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A $46.02 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $53.04 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 3025175 Emer Charges INSERT TEMP BLADDER CATH INDWELLING CHARGE 51702 361 $437.00 $- $26.77 $- $- $349.60 $- N/A $113.62 N/A N/A Included in ER case rate N/A N/A $262.20 N/A N/A $218.50 N/A N/A $26.77 N/A N/A $297.16 N/A N/A $257.83 N/A N/A $170.43 N/A N/A $305.90 N/A N/A $349.60 N/A N/A $240.35 N/A N/A $305.90 N/A N/A $146.40 N/A N/A $26.77 N/A N/A $262.20 N/A N/A $152.95 N/A N/A $297.16 N/A N/A $131.10 N/A N/A $262.20 N/A N/A $305.90 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A $437.00 $437.00 N/A 3230000 Emer Charges 28400 ED TRTMT CLOSED CALCANEAL FX W/O MANIP CHARGE 28400 450 "$1,006.00 " $- $204.28 $- $- $804.80 $- N/A $261.56 N/A N/A Included in ER case rate N/A N/A $603.60 N/A N/A $503.00 N/A N/A $204.28 N/A N/A $684.08 N/A N/A $593.54 N/A N/A $392.34 N/A N/A $704.20 N/A N/A $804.80 N/A N/A $553.30 N/A N/A $704.20 N/A N/A $337.01 N/A N/A $204.28 N/A N/A $603.60 N/A N/A $352.10 N/A N/A $684.08 N/A N/A $301.80 N/A N/A $603.60 N/A N/A $704.20 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A "$1,006.00 " "$1,006.00 " N/A 3230001 Emer Charges CLSD TX POST HIP ARTHRO W 27265 490 "$1,492.00 " $- $356.69 $- $- "$1,193.60 " $- N/A $387.92 N/A N/A Included in ER case rate N/A N/A $895.20 N/A N/A $746.00 N/A N/A $356.69 N/A N/A "$1,014.56 " N/A N/A $880.28 N/A N/A $581.88 N/A N/A "$1,044.40 " N/A N/A "$1,193.60 " N/A N/A $820.60 N/A N/A "$1,044.40 " N/A N/A $499.82 N/A N/A $356.69 N/A N/A $895.20 N/A N/A $522.20 N/A N/A "$1,014.56 " N/A N/A $447.60 N/A N/A $895.20 N/A N/A "$1,044.40 " N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A "$1,492.00 " "$1,492.00 " N/A 3230003 Emer Charges 27250 CLO TX HIP DISLOC TRAUMAT 27250 450 "$1,573.00 " $- $162.94 $- $- "$1,258.40 " $- N/A $408.98 N/A N/A Included in ER case rate N/A N/A $943.80 N/A N/A $786.50 N/A N/A $162.94 N/A N/A "$1,069.64 " N/A N/A $928.07 N/A N/A $613.47 N/A N/A "$1,101.10 " N/A N/A "$1,258.40 " N/A N/A $865.15 N/A N/A "$1,101.10 " N/A N/A $526.96 N/A N/A $162.94 N/A N/A $943.80 N/A N/A $550.55 N/A N/A "$1,069.64 " N/A N/A $471.90 N/A N/A $943.80 N/A N/A "$1,101.10 " N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A "$1,573.00 " "$1,573.00 " N/A 3230004 Emer Charges CLOSED TX HIP DISLOC ANST 27252 490 "$6,821.00 " $- $678.04 $- $- "$5,456.80 " $- N/A "$1,773.46 " N/A N/A Included in ER case rate N/A N/A "$4,092.60 " N/A N/A "$3,410.50 " N/A N/A $678.04 N/A N/A "$4,638.28 " N/A N/A "$4,024.39 " N/A N/A "$2,660.19 " N/A N/A "$4,774.70 " N/A N/A "$5,456.80 " N/A N/A "$3,751.55 " N/A N/A "$4,774.70 " N/A N/A "$2,285.04 " N/A N/A $678.04 N/A N/A "$4,092.60 " N/A N/A "$2,387.35 " N/A N/A "$4,638.28 " N/A N/A "$2,046.30 " N/A N/A "$4,092.60 " N/A N/A "$4,774.70 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A "$6,821.00 " "$6,821.00 " N/A 3230005 Emer Charges "10061 ED I D ABSCESS, COMPL CHARGE" 10061 450 $643.00 $- $158.55 $- $- $514.40 $- N/A $167.18 N/A N/A Included in ER case rate N/A N/A $385.80 N/A N/A $321.50 N/A N/A $158.55 N/A N/A $437.24 N/A N/A $379.37 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $158.55 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $437.24 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 3230007 Emer Charges 11000 DEBRIDE INFECTED SKIN 11000 450 "$1,619.00 " $- $25.32 $- $- "$1,295.20 " $- N/A $420.94 N/A N/A Included in ER case rate N/A N/A $971.40 N/A N/A $809.50 N/A N/A $25.32 N/A N/A "$1,100.92 " N/A N/A $955.21 N/A N/A $631.41 N/A N/A "$1,133.30 " N/A N/A "$1,295.20 " N/A N/A $890.45 N/A N/A "$1,133.30 " N/A N/A $542.37 N/A N/A $25.32 N/A N/A $971.40 N/A N/A $566.65 N/A N/A "$1,100.92 " N/A N/A $485.70 N/A N/A $971.40 N/A N/A "$1,133.30 " N/A N/A $485.70 N/A N/A $485.70 N/A N/A $485.70 N/A N/A $485.70 N/A N/A $485.70 N/A N/A $485.70 N/A "$1,619.00 " "$1,619.00 " N/A 3230009 Emer Charges 16000 ED INITIAL TREATMENT BURN 1ST DEG CHARGE 16000 450 $410.00 $- $40.92 $- $- $328.00 $- N/A $106.60 N/A N/A Included in ER case rate N/A N/A $246.00 N/A N/A $205.00 N/A N/A $40.92 N/A N/A $278.80 N/A N/A $241.90 N/A N/A $159.90 N/A N/A $287.00 N/A N/A $328.00 N/A N/A $225.50 N/A N/A $287.00 N/A N/A $137.35 N/A N/A $40.92 N/A N/A $246.00 N/A N/A $143.50 N/A N/A $278.80 N/A N/A $123.00 N/A N/A $246.00 N/A N/A $287.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A $410.00 $410.00 N/A 3230011 Emer Charges REDUCTION GREAT TOE 28660 490 $694.00 $- $79.75 $- $- $555.20 $- N/A $180.44 N/A N/A Included in ER case rate N/A N/A $416.40 N/A N/A $347.00 N/A N/A $79.75 N/A N/A $471.92 N/A N/A $409.46 N/A N/A $270.66 N/A N/A $485.80 N/A N/A $555.20 N/A N/A $381.70 N/A N/A $485.80 N/A N/A $232.49 N/A N/A $79.75 N/A N/A $416.40 N/A N/A $242.90 N/A N/A $471.92 N/A N/A $208.20 N/A N/A $416.40 N/A N/A $485.80 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A $694.00 $694.00 N/A 3230014 Emer Charges 12001 SIMP REPR <2.5CM ED Charge 12001 450 $560.00 $- $40.08 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $40.08 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $40.08 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230015 Emer Charges 12031 ED INTERMEDIATE CLOSURE WOUNDS <2.5CM CHARGE 12031 450 $587.00 $- $135.99 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $135.99 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $135.99 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230016 Emer Charges 12032 I LAC 2.6 cm TO 7.5 12032 450 "$1,323.00 " $- $172.62 $- $- "$1,058.40 " $- N/A $343.98 N/A N/A Included in ER case rate N/A N/A $793.80 N/A N/A $661.50 N/A N/A $172.62 N/A N/A $899.64 N/A N/A $780.57 N/A N/A $515.97 N/A N/A $926.10 N/A N/A "$1,058.40 " N/A N/A $727.65 N/A N/A $926.10 N/A N/A $443.21 N/A N/A $172.62 N/A N/A $793.80 N/A N/A $463.05 N/A N/A $899.64 N/A N/A $396.90 N/A N/A $793.80 N/A N/A $926.10 N/A N/A $396.90 N/A N/A $396.90 N/A N/A $396.90 N/A N/A $396.90 N/A N/A $396.90 N/A N/A $396.90 N/A "$1,323.00 " "$1,323.00 " N/A 3230017 Emer Charges 12034 ED INTERMEDIATE CLOSURE WOUNDS 7.6 TO 12.5CM CHARGE 12034 450 $560.00 $- $145.60 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $183.90 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $183.90 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230018 Emer Charges 12041 ED LAYERED CLOSURE OF WOUNDS <2.5CM CHARGE 12041 450 $560.00 $- $139.01 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $139.01 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $139.01 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230019 Emer Charges 12042 ED LAYERED CLOSURE OF WOUNDS 2.6 TO 7.5CM CHARGE 12042 450 $809.00 $- $177.34 $- $- $647.20 $- N/A $210.34 N/A N/A Included in ER case rate N/A N/A $485.40 N/A N/A $404.50 N/A N/A $177.34 N/A N/A $550.12 N/A N/A $477.31 N/A N/A $315.51 N/A N/A $566.30 N/A N/A $647.20 N/A N/A $444.95 N/A N/A $566.30 N/A N/A $271.02 N/A N/A $177.34 N/A N/A $485.40 N/A N/A $283.15 N/A N/A $550.12 N/A N/A $242.70 N/A N/A $485.40 N/A N/A $566.30 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A $809.00 $809.00 N/A 3230022 Emer Charges 12002 ED REPAIR SMPL WOUNDS SP-NK-TR-EXT 2.6 TO 7.5CM CHARGE 12002 450 $560.00 $- $52.78 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $52.78 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $52.78 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230023 Emer Charges 12044 ED LAYERED CLOSURE OF WOUNDS 7.6 TO 12.5CM CHARGE 12044 450 $587.00 $- $152.62 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $191.89 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $191.89 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230024 Emer Charges 12051 ED LAYERED CLOSURE OF WOUNDS OF FACE <2.5CM CHARGE 12051 450 "$1,460.00 " $- $152.44 $- $- "$1,168.00 " $- N/A $379.60 N/A N/A Included in ER case rate N/A N/A $876.00 N/A N/A $730.00 N/A N/A $152.44 N/A N/A $992.80 N/A N/A $861.40 N/A N/A $569.40 N/A N/A "$1,022.00 " N/A N/A "$1,168.00 " N/A N/A $803.00 N/A N/A "$1,022.00 " N/A N/A $489.10 N/A N/A $152.44 N/A N/A $876.00 N/A N/A $511.00 N/A N/A $992.80 N/A N/A $438.00 N/A N/A $876.00 N/A N/A "$1,022.00 " N/A N/A $438.00 N/A N/A $438.00 N/A N/A $438.00 N/A N/A $438.00 N/A N/A $438.00 N/A N/A $438.00 N/A "$1,460.00 " "$1,460.00 " N/A 3230025 Emer Charges 12052 ED LAYERED CLOSURE OF WOUNDS OF FACE 2.6 TO 5.0CM CHARGE 12052 450 $560.00 $- $145.60 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $180.42 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $180.42 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230026 Emer Charges 12053 ED LAYERED CLOSURE OF WOUNDS OF FACE 5.1 TO 7.5CM CHARGE 12053 450 $560.00 $- $145.60 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $193.80 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $193.80 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230027 Emer Charges 13132 ED COMPLEX REPAIR WOUNDS FACE/NECK/HANDS/FEET 2.6 TO 7.5CM CHARGE 13132 450 "$2,828.00 " $- $279.73 $- $- "$2,262.40 " $- N/A $735.28 N/A N/A Included in ER case rate N/A N/A "$1,696.80 " N/A N/A "$1,414.00 " N/A N/A $279.73 N/A N/A "$1,923.04 " N/A N/A "$1,668.52 " N/A N/A "$1,102.92 " N/A N/A "$1,979.60 " N/A N/A "$2,262.40 " N/A N/A "$1,555.40 " N/A N/A "$1,979.60 " N/A N/A $947.38 N/A N/A $279.73 N/A N/A "$1,696.80 " N/A N/A $989.80 N/A N/A "$1,923.04 " N/A N/A $848.40 N/A N/A "$1,696.80 " N/A N/A "$1,979.60 " N/A N/A $848.40 N/A N/A $848.40 N/A N/A $848.40 N/A N/A $848.40 N/A N/A $848.40 N/A N/A $848.40 N/A "$2,828.00 " "$2,828.00 " N/A 3230028 Emer Charges 16020 BURN SMALL 1-2 DEGREE ED CHARGE 16020 450 $867.00 $- $48.56 $- $- $693.60 $- N/A $225.42 N/A N/A Included in ER case rate N/A N/A $520.20 N/A N/A $433.50 N/A N/A $48.56 N/A N/A $589.56 N/A N/A $511.53 N/A N/A $338.13 N/A N/A $606.90 N/A N/A $693.60 N/A N/A $476.85 N/A N/A $606.90 N/A N/A $290.45 N/A N/A $48.56 N/A N/A $520.20 N/A N/A $303.45 N/A N/A $589.56 N/A N/A $260.10 N/A N/A $520.20 N/A N/A $606.90 N/A N/A $260.10 N/A N/A $260.10 N/A N/A $260.10 N/A N/A $260.10 N/A N/A $260.10 N/A N/A $260.10 N/A $867.00 $867.00 N/A 3230029 Emer Charges 16025 BURN MEDIUM 1-2 DEGREE ED CHARGE 16025 450 $868.00 $- $100.23 $- $- $694.40 $- N/A $225.68 N/A N/A Included in ER case rate N/A N/A $520.80 N/A N/A $434.00 N/A N/A $100.23 N/A N/A $590.24 N/A N/A $512.12 N/A N/A $338.52 N/A N/A $607.60 N/A N/A $694.40 N/A N/A $477.40 N/A N/A $607.60 N/A N/A $290.78 N/A N/A $100.23 N/A N/A $520.80 N/A N/A $303.80 N/A N/A $590.24 N/A N/A $260.40 N/A N/A $520.80 N/A N/A $607.60 N/A N/A $260.40 N/A N/A $260.40 N/A N/A $260.40 N/A N/A $260.40 N/A N/A $260.40 N/A N/A $260.40 N/A $868.00 $868.00 N/A 3230031 Emer Charges 16030 BURN LARGE ED CHARGE 16030 450 $660.00 $- $121.21 $- $- $528.00 $- N/A $171.60 N/A N/A Included in ER case rate N/A N/A $396.00 N/A N/A $330.00 N/A N/A $121.21 N/A N/A $448.80 N/A N/A $389.40 N/A N/A $257.40 N/A N/A $462.00 N/A N/A $528.00 N/A N/A $363.00 N/A N/A $462.00 N/A N/A $221.10 N/A N/A $121.21 N/A N/A $396.00 N/A N/A $231.00 N/A N/A $448.80 N/A N/A $198.00 N/A N/A $396.00 N/A N/A $462.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A $660.00 $660.00 N/A 3230032 Emer Charges 25565 CLD RED ULNA/RAD W/MANIP 25565 450 "$2,418.00 " $- $418.61 $- $- "$1,934.40 " $- N/A $628.68 N/A N/A Included in ER case rate N/A N/A "$1,450.80 " N/A N/A "$1,209.00 " N/A N/A $418.61 N/A N/A "$1,644.24 " N/A N/A "$1,426.62 " N/A N/A $943.02 N/A N/A "$1,692.60 " N/A N/A "$1,934.40 " N/A N/A "$1,329.90 " N/A N/A "$1,692.60 " N/A N/A $810.03 N/A N/A $418.61 N/A N/A "$1,450.80 " N/A N/A $846.30 N/A N/A "$1,644.24 " N/A N/A $725.40 N/A N/A "$1,450.80 " N/A N/A "$1,692.60 " N/A N/A $725.40 N/A N/A $725.40 N/A N/A $725.40 N/A N/A $725.40 N/A N/A $725.40 N/A N/A $725.40 N/A "$2,418.00 " "$2,418.00 " N/A 3230033 Emer Charges 29280 STRAPPING HAND/FINGER 29280 450 $497.00 $- $31.84 $- $- $397.60 $- N/A $129.22 N/A N/A Included in ER case rate N/A N/A $298.20 N/A N/A $248.50 N/A N/A $31.84 N/A N/A $337.96 N/A N/A $293.23 N/A N/A $193.83 N/A N/A $347.90 N/A N/A $397.60 N/A N/A $273.35 N/A N/A $347.90 N/A N/A $166.50 N/A N/A $31.84 N/A N/A $298.20 N/A N/A $173.95 N/A N/A $337.96 N/A N/A $149.10 N/A N/A $298.20 N/A N/A $347.90 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A $497.00 $497.00 N/A 3230034 Emer Charges 36000 ED INTRO OF NEEDLE OR INTRACATHETER VEIN CHARGE 36000 450 $352.00 $- $8.71 $- $- $281.60 $- N/A $91.52 N/A N/A Included in ER case rate N/A N/A $211.20 N/A N/A $176.00 N/A N/A $8.71 N/A N/A $239.36 N/A N/A $207.68 N/A N/A $137.28 N/A N/A $246.40 N/A N/A $281.60 N/A N/A $193.60 N/A N/A $246.40 N/A N/A $117.92 N/A N/A $8.71 N/A N/A $211.20 N/A N/A $123.20 N/A N/A $239.36 N/A N/A $105.60 N/A N/A $211.20 N/A N/A $246.40 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A $352.00 $352.00 N/A 3230035 Emer Charges 43752 NG TUBE PLACEMENT 43752 450 $507.00 $- $36.53 $- $- $405.60 $- N/A $131.82 N/A N/A Included in ER case rate N/A N/A $304.20 N/A N/A $253.50 N/A N/A $36.53 N/A N/A $344.76 N/A N/A $299.13 N/A N/A $197.73 N/A N/A $354.90 N/A N/A $405.60 N/A N/A $278.85 N/A N/A $354.90 N/A N/A $169.85 N/A N/A $36.53 N/A N/A $304.20 N/A N/A $177.45 N/A N/A $344.76 N/A N/A $152.10 N/A N/A $304.20 N/A N/A $354.90 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A $507.00 $507.00 N/A 3230036 Emer Charges 45915 REM FECAL IMPACT/FB ED Charge 45915 450 "$5,563.00 " $- $202.43 $- $- "$4,450.40 " $- N/A "$1,446.38 " N/A N/A Included in ER case rate N/A N/A "$3,337.80 " N/A N/A "$2,781.50 " N/A N/A $202.43 N/A N/A "$3,782.84 " N/A N/A "$3,282.17 " N/A N/A "$2,169.57 " N/A N/A "$3,894.10 " N/A N/A "$4,450.40 " N/A N/A "$3,059.65 " N/A N/A "$3,894.10 " N/A N/A "$1,863.61 " N/A N/A $202.43 N/A N/A "$3,337.80 " N/A N/A "$1,947.05 " N/A N/A "$3,782.84 " N/A N/A "$1,668.90 " N/A N/A "$3,337.80 " N/A N/A "$3,894.10 " N/A N/A "$1,668.90 " N/A N/A "$1,668.90 " N/A N/A "$1,668.90 " N/A N/A "$1,668.90 " N/A N/A "$1,668.90 " N/A N/A "$1,668.90 " N/A "$5,563.00 " "$5,563.00 " N/A 3230037 Emer Charges "46600 Anoscopy, Diag W/W/O Spec" 46600 450 $295.00 $- $36.64 $- $- $236.00 $- N/A $76.70 N/A N/A Included in ER case rate N/A N/A $177.00 N/A N/A $147.50 N/A N/A $36.64 N/A N/A $200.60 N/A N/A $174.05 N/A N/A $115.05 N/A N/A $206.50 N/A N/A $236.00 N/A N/A $162.25 N/A N/A $206.50 N/A N/A $98.83 N/A N/A $36.64 N/A N/A $177.00 N/A N/A $103.25 N/A N/A $200.60 N/A N/A $88.50 N/A N/A $177.00 N/A N/A $206.50 N/A N/A $88.50 N/A N/A $88.50 N/A N/A $88.50 N/A N/A $88.50 N/A N/A $88.50 N/A N/A $88.50 N/A $295.00 $295.00 N/A 3230039 Emer Charges 58301 ED REMOVAL OF INTRAUTERINE DEVICE (IUD) CHARGE 58301 450 $722.00 $- $61.57 $- $- $577.60 $- N/A $187.72 N/A N/A Included in ER case rate N/A N/A $433.20 N/A N/A $361.00 N/A N/A $61.57 N/A N/A $490.96 N/A N/A $425.98 N/A N/A $281.58 N/A N/A $505.40 N/A N/A $577.60 N/A N/A $397.10 N/A N/A $505.40 N/A N/A $241.87 N/A N/A $61.57 N/A N/A $433.20 N/A N/A $252.70 N/A N/A $490.96 N/A N/A $216.60 N/A N/A $433.20 N/A N/A $505.40 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A $722.00 $722.00 N/A 3230041 Emer Charges 59409 DELIVERY 59409 450 "$7,138.00 " $- $748.56 $- $- "$5,710.40 " $- N/A "$1,855.88 " N/A N/A Included in ER case rate N/A N/A "$4,282.80 " N/A N/A "$3,569.00 " N/A N/A $748.56 N/A N/A "$4,853.84 " N/A N/A "$4,211.42 " N/A N/A "$2,783.82 " N/A N/A "$4,996.60 " N/A N/A "$5,710.40 " N/A N/A "$3,925.90 " N/A N/A "$4,996.60 " N/A N/A "$2,391.23 " N/A N/A $748.56 N/A N/A "$4,282.80 " N/A N/A "$2,498.30 " N/A N/A "$4,853.84 " N/A N/A "$2,141.40 " N/A N/A "$4,282.80 " N/A N/A "$4,996.60 " N/A N/A "$2,141.40 " N/A N/A "$2,141.40 " N/A N/A "$2,141.40 " N/A N/A "$2,141.40 " N/A N/A "$2,141.40 " N/A N/A "$2,141.40 " N/A "$7,138.00 " "$7,138.00 " N/A 3230042 Emer Charges ENEMA ADMIN 74283 320 $555.00 $- $144.30 $- $- $444.00 $- N/A $144.30 N/A N/A Included in ER case rate N/A N/A $333.00 N/A N/A $277.50 N/A N/A $202.48 N/A N/A $377.40 N/A N/A $327.45 N/A N/A $216.45 N/A N/A $388.50 N/A N/A $444.00 N/A N/A $305.25 N/A N/A $388.50 N/A N/A $185.93 N/A N/A $202.48 N/A N/A $333.00 N/A N/A $194.25 N/A N/A $377.40 N/A N/A $166.50 N/A N/A $333.00 N/A N/A $388.50 N/A N/A $166.50 N/A N/A $166.50 N/A N/A $166.50 N/A N/A $166.50 N/A N/A $166.50 N/A N/A $166.50 N/A $555.00 $555.00 N/A 3230043 Emer Charges 43753 GASTRIC INTUB AND ASP/LAVAGE ED CHARGE 43753 450 $603.00 $- $18.50 $- $- $482.40 $- N/A $156.78 N/A N/A Included in ER case rate N/A N/A $361.80 N/A N/A $301.50 N/A N/A $18.50 N/A N/A $410.04 N/A N/A $355.77 N/A N/A $235.17 N/A N/A $422.10 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $422.10 N/A N/A $202.01 N/A N/A $18.50 N/A N/A $361.80 N/A N/A $211.05 N/A N/A $410.04 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $422.10 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 3230045 Emer Charges 29240 ED STRAPPING SHOULDER CHARGE 29240 450 $497.00 $- $38.56 $- $- $397.60 $- N/A $129.22 N/A N/A Included in ER case rate N/A N/A $298.20 N/A N/A $248.50 N/A N/A $38.56 N/A N/A $337.96 N/A N/A $293.23 N/A N/A $193.83 N/A N/A $347.90 N/A N/A $397.60 N/A N/A $273.35 N/A N/A $347.90 N/A N/A $166.50 N/A N/A $38.56 N/A N/A $298.20 N/A N/A $173.95 N/A N/A $337.96 N/A N/A $149.10 N/A N/A $298.20 N/A N/A $347.90 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A $497.00 $497.00 N/A 3230046 Emer Charges INHALATION TREATMENT 94640 460 $176.00 $- $15.42 $- $- $140.80 $- N/A $45.76 N/A N/A Included in ER case rate N/A N/A $105.60 N/A N/A $88.00 N/A N/A $15.42 N/A N/A $119.68 N/A N/A $103.84 N/A N/A $68.64 N/A N/A $123.20 N/A N/A $140.80 N/A N/A $96.80 N/A N/A $123.20 N/A N/A $58.96 N/A N/A $15.42 N/A N/A $105.60 N/A N/A $61.60 N/A N/A $119.68 N/A N/A $52.80 N/A N/A $105.60 N/A N/A $123.20 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A $176.00 $176.00 N/A 3230047 Emer Charges IV HYDRATION INFUSIUON 31 96360 260 "$1,098.00 " $- $47.80 $- $- $878.40 $- N/A $285.48 N/A N/A Included in ER case rate N/A N/A $658.80 N/A N/A $549.00 N/A N/A $47.80 N/A N/A $746.64 N/A N/A $647.82 N/A N/A $428.22 N/A N/A $768.60 N/A N/A $878.40 N/A N/A $603.90 N/A N/A $768.60 N/A N/A $367.83 N/A N/A $47.80 N/A N/A $658.80 N/A N/A $384.30 N/A N/A $746.64 N/A N/A $329.40 N/A N/A $658.80 N/A N/A $768.60 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A "$1,098.00 " "$1,098.00 " N/A 3230048 Emer Charges 12004 SIMP RPR 7.6-12.5CM ED Charge 12004 450 $560.00 $- $65.80 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $65.80 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $65.80 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230049 Emer Charges IV HYDRATION INFUSIUON EA 96361 260 $403.00 $- $12.56 $- $- $322.40 $- N/A $104.78 N/A N/A Included in ER case rate N/A N/A $241.80 N/A N/A $201.50 N/A N/A $12.56 N/A N/A $274.04 N/A N/A $237.77 N/A N/A $157.17 N/A N/A $282.10 N/A N/A $322.40 N/A N/A $221.65 N/A N/A $282.10 N/A N/A $135.01 N/A N/A $12.56 N/A N/A $241.80 N/A N/A $141.05 N/A N/A $274.04 N/A N/A $120.90 N/A N/A $241.80 N/A N/A $282.10 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A $403.00 $403.00 N/A 3230051 Emer Charges ADDL IV DRUG INFUSION 0-5 96367 260 $428.00 $- $25.09 $- $- $342.40 $- N/A $111.28 N/A N/A Included in ER case rate N/A N/A $256.80 N/A N/A $214.00 N/A N/A $25.09 N/A N/A $291.04 N/A N/A $252.52 N/A N/A $166.92 N/A N/A $299.60 N/A N/A $342.40 N/A N/A $235.40 N/A N/A $299.60 N/A N/A $143.38 N/A N/A $25.09 N/A N/A $256.80 N/A N/A $149.80 N/A N/A $291.04 N/A N/A $128.40 N/A N/A $256.80 N/A N/A $299.60 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A N/A $128.40 N/A $428.00 $428.00 N/A 3230052 Emer Charges ADDL IV DRUG INFUSION CON 96368 260 $253.00 $- $16.97 $- $- $202.40 $- N/A $65.78 N/A N/A Included in ER case rate N/A N/A $151.80 N/A N/A $126.50 N/A N/A $16.97 N/A N/A $172.04 N/A N/A $149.27 N/A N/A $98.67 N/A N/A $177.10 N/A N/A $202.40 N/A N/A $139.15 N/A N/A $177.10 N/A N/A $84.76 N/A N/A $16.97 N/A N/A $151.80 N/A N/A $88.55 N/A N/A $172.04 N/A N/A $75.90 N/A N/A $151.80 N/A N/A $177.10 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A $253.00 $253.00 N/A 3230053 Emer Charges IV PUSH SGL/INITIAL USE D 96374 260 $289.00 $- $47.18 $- $- $231.20 $- N/A $75.14 N/A N/A Included in ER case rate N/A N/A $173.40 N/A N/A $144.50 N/A N/A $47.18 N/A N/A $196.52 N/A N/A $170.51 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $47.18 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $196.52 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3230054 Emer Charges "EA. ADDL SEQ IV PUSH, DIF" 96375 260 $289.00 $- $18.59 $- $- $231.20 $- N/A $75.14 N/A N/A Included in ER case rate N/A N/A $173.40 N/A N/A $144.50 N/A N/A $18.59 N/A N/A $196.52 N/A N/A $170.51 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $18.59 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $196.52 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3230055 Emer Charges 12005 ED REPAIR SMPL WOUNDS SP-NK-TR-EXT 12.6 TO 20.0CM CHARGE 12005 450 $560.00 $- $89.05 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $89.05 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $89.05 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230056 Emer Charges "EA ADDL SEQ IV PUSH, SAME" 96376 260 $108.00 $- $12.00 $- $- $86.40 $- N/A $28.08 N/A N/A Included in ER case rate N/A N/A $64.80 N/A N/A $54.00 N/A N/A $12.00 N/A N/A $73.44 N/A N/A $63.72 N/A N/A $42.12 N/A N/A $75.60 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $75.60 N/A N/A $36.18 N/A N/A $12.00 N/A N/A $64.80 N/A N/A $37.80 N/A N/A $73.44 N/A N/A $32.40 N/A N/A $64.80 N/A N/A $75.60 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A $108.00 $108.00 N/A 3230057 Emer Charges 99144 CONSCIOUS SED MOD OVER 5 ED Charge 450 $736.00 $- $191.36 $- $- $588.80 $- N/A $191.36 N/A N/A Included in ER case rate N/A N/A $441.60 N/A N/A $368.00 N/A N/A N/A N/A N/A $500.48 N/A N/A $434.24 N/A N/A $287.04 N/A N/A $515.20 N/A N/A $588.80 N/A N/A $404.80 N/A N/A $515.20 N/A N/A $246.56 N/A N/A N/A N/A N/A $441.60 N/A N/A $257.60 N/A N/A $500.48 N/A N/A $220.80 N/A N/A $441.60 N/A N/A $515.20 N/A N/A $220.80 N/A N/A $220.80 N/A N/A $220.80 N/A N/A $220.80 N/A N/A $220.80 N/A N/A $220.80 N/A $736.00 $736.00 N/A 3230058 Emer Charges 99201 EMERGENCY ROOM OBSER ED Charge 99201 450 $278.00 $- $22.94 $- $- $222.40 $- N/A $72.28 N/A N/A Included in ER case rate N/A N/A $166.80 N/A N/A $139.00 N/A N/A $22.94 N/A N/A $189.04 N/A N/A $164.02 N/A N/A $108.42 N/A N/A $194.60 N/A N/A $222.40 N/A N/A $152.90 N/A N/A $194.60 N/A N/A $93.13 N/A N/A $22.94 N/A N/A $166.80 N/A N/A $97.30 N/A N/A $189.04 N/A N/A $83.40 N/A N/A $166.80 N/A N/A $194.60 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A $278.00 $278.00 N/A 3230058 Emer Charges 99201 ER TRIAGE EM 99201 450 $278.00 $- $22.94 $- $- $222.40 $- N/A $72.28 N/A N/A Included in ER case rate N/A N/A $166.80 N/A N/A $139.00 N/A N/A $22.94 N/A N/A $189.04 N/A N/A $164.02 N/A N/A $108.42 N/A N/A $194.60 N/A N/A $222.40 N/A N/A $152.90 N/A N/A $194.60 N/A N/A $93.13 N/A N/A $22.94 N/A N/A $166.80 N/A N/A $97.30 N/A N/A $189.04 N/A N/A $83.40 N/A N/A $166.80 N/A N/A $194.60 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A N/A $83.40 N/A $278.00 $278.00 N/A 3230059 Emer Charges 12006 ED REPAIR SMPL WOUNDS SP-NK-TR-EXT 20.1 TO 30.0CM CHARGE 12006 450 $560.00 $- $107.97 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $107.97 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $107.97 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230062 Emer Charges 12007 ED REPAIR SMPL WOUNDS SP-NK-TR-EXT OVER 30.0CM CHARGE 12007 450 $587.00 $- $134.14 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $134.14 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $134.14 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230063 Emer Charges 12015 ED REPAIR SMPL WOUNDS FACE-MM 7.6 TO 12.5CM CHARGE 12015 450 $560.00 $- $88.39 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $88.39 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $88.39 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230064 Emer Charges 12016 LAC SIMPLE 12.6-20.0 FACE/EARS ED CHARGE 12016 450 $560.00 $- $120.05 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $120.05 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $120.05 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230065 Emer Charges 12017 ED REPAIR SMPL WOUNDS FACE-MM 20.1 TO 30.0CM CHARGE 12017 450 $587.00 $- $137.29 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $137.29 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $137.29 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230066 Emer Charges 12018 S LAC OVER 30.1 cm 12018 450 $587.00 $- $152.62 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $155.25 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $155.25 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230067 Emer Charges 12035 ED INTERMEDIATE CLOSURE WOUNDS 12.6 TO 20.0CM CHARGE 12035 450 $560.00 $- $145.60 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $216.19 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $216.19 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230068 Emer Charges 12054 ED LAYERED CLOSURE OF WOUNDS OF FACE 7.6 TO 12.5CM CHARGE 12054 450 $560.00 $- $145.60 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $203.95 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $203.95 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230069 Emer Charges 13122 ED REPAIR COMPLEX WOUND EA ADD'L 5 CM CHARGE 13122 450 $587.00 $- $76.70 $- $- $469.60 $- N/A $152.62 N/A N/A Included in ER case rate N/A N/A $352.20 N/A N/A $293.50 N/A N/A $76.70 N/A N/A $399.16 N/A N/A $346.33 N/A N/A $228.93 N/A N/A $410.90 N/A N/A $469.60 N/A N/A $322.85 N/A N/A $410.90 N/A N/A $196.65 N/A N/A $76.70 N/A N/A $352.20 N/A N/A $205.45 N/A N/A $399.16 N/A N/A $176.10 N/A N/A $352.20 N/A N/A $410.90 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A N/A $176.10 N/A $587.00 $587.00 N/A 3230071 Emer Charges 12021 ED WOUND DEHISCENCE/PACKING CHARGE 12021 450 "$1,389.00 " $- $125.92 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $125.92 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $125.92 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230072 Emer Charges 12037 ED INTERMEDIATE CLOSURE WOUNDS OVER 30.0CM CHARGE 12037 450 "$1,389.00 " $- $293.18 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $293.18 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $293.18 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230073 Emer Charges 12036 ED INTERMEDIATE CLOSURE WOUNDS 20.1 TO 30.0CM CHARGE 12036 450 "$1,389.00 " $- $250.72 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $250.72 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $250.72 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230074 Emer Charges 12045 ED LAYERED CLOSURE OF WOUNDS 12.6 TO 20.0CM CHARGE 12045 450 "$1,389.00 " $- $241.02 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $241.02 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $241.02 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230075 Emer Charges 12046 I LAC 20.1 cm TO 30.0 12046 450 "$1,389.00 " $- $273.68 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $273.68 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $273.68 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230076 Emer Charges 12047 I LAC OVER 30.0 cm 12047 450 "$1,389.00 " $- $304.77 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $304.77 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $304.77 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230077 Emer Charges 12055 I LAC 12.6 cm TO 20.0 12055 450 "$1,688.00 " $- $270.95 $- $- "$1,350.40 " $- N/A $438.88 N/A N/A Included in ER case rate N/A N/A "$1,012.80 " N/A N/A $844.00 N/A N/A $270.95 N/A N/A "$1,147.84 " N/A N/A $995.92 N/A N/A $658.32 N/A N/A "$1,181.60 " N/A N/A "$1,350.40 " N/A N/A $928.40 N/A N/A "$1,181.60 " N/A N/A $565.48 N/A N/A $270.95 N/A N/A "$1,012.80 " N/A N/A $590.80 N/A N/A "$1,147.84 " N/A N/A $506.40 N/A N/A "$1,012.80 " N/A N/A "$1,181.60 " N/A N/A $506.40 N/A N/A $506.40 N/A N/A $506.40 N/A N/A $506.40 N/A N/A $506.40 N/A N/A $506.40 N/A "$1,688.00 " "$1,688.00 " N/A 3230078 Emer Charges 12056 I LAC 20.1 cm TO 30.0 12056 450 "$1,389.00 " $- $336.68 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $336.68 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $336.68 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230079 Emer Charges 12057 INTERM OVER 30.0 CM ED Charge 12057 450 "$1,389.00 " $- $338.56 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $338.56 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $338.56 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230081 Emer Charges 13120 ED COMPLEX REPAIR WOUNDS SCLP/ARMS/LEGS 1.1 TO 2.5CM CHARGE 13120 450 "$1,872.00 " $- $210.33 $- $- "$1,497.60 " $- N/A $486.72 N/A N/A Included in ER case rate N/A N/A "$1,123.20 " N/A N/A $936.00 N/A N/A $210.33 N/A N/A "$1,272.96 " N/A N/A "$1,104.48 " N/A N/A $730.08 N/A N/A "$1,310.40 " N/A N/A "$1,497.60 " N/A N/A "$1,029.60 " N/A N/A "$1,310.40 " N/A N/A $627.12 N/A N/A $210.33 N/A N/A "$1,123.20 " N/A N/A $655.20 N/A N/A "$1,272.96 " N/A N/A $561.60 N/A N/A "$1,123.20 " N/A N/A "$1,310.40 " N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A "$1,872.00 " "$1,872.00 " N/A 3230082 Emer Charges 13121 ED COMPLEX REPAIR WOUNDS SCLP/ARMS/LEGS 2.6 TO 7.5CM CHARGE 13121 450 "$1,872.00 " $- $237.68 $- $- "$1,497.60 " $- N/A $486.72 N/A N/A Included in ER case rate N/A N/A "$1,123.20 " N/A N/A $936.00 N/A N/A $237.68 N/A N/A "$1,272.96 " N/A N/A "$1,104.48 " N/A N/A $730.08 N/A N/A "$1,310.40 " N/A N/A "$1,497.60 " N/A N/A "$1,029.60 " N/A N/A "$1,310.40 " N/A N/A $627.12 N/A N/A $237.68 N/A N/A "$1,123.20 " N/A N/A $655.20 N/A N/A "$1,272.96 " N/A N/A $561.60 N/A N/A "$1,123.20 " N/A N/A "$1,310.40 " N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A N/A $561.60 N/A "$1,872.00 " "$1,872.00 " N/A 3230083 Emer Charges 13131 ED COMPLEX REPAIR WOUNDS FACE/NECK/HANDS/FEET 1.1 TO 2.5CM CHARGE 13131 450 "$1,389.00 " $- $223.06 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $223.06 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $223.06 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230084 Emer Charges "13133 ED REPAIR COMPLEX FOREHEAD/CHEEK/MOUTH/NECK,AXILLAE,GENITALIA,HANDS AND/OR" 13133 450 "$1,389.00 " $- $117.16 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $117.16 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $117.16 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230085 Emer Charges "13153 ED REPAIR, COMPLEX, EYELIDS, NOSE, EARS AND/OR LIPS; EACH ADDITIONAL 5 CM" 13153 450 "$1,389.00 " $- $126.81 $- $- "$1,111.20 " $- N/A $361.14 N/A N/A Included in ER case rate N/A N/A $833.40 N/A N/A $694.50 N/A N/A $126.81 N/A N/A $944.52 N/A N/A $819.51 N/A N/A $541.71 N/A N/A $972.30 N/A N/A "$1,111.20 " N/A N/A $763.95 N/A N/A $972.30 N/A N/A $465.32 N/A N/A $126.81 N/A N/A $833.40 N/A N/A $486.15 N/A N/A $944.52 N/A N/A $416.70 N/A N/A $833.40 N/A N/A $972.30 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A N/A $416.70 N/A "$1,389.00 " "$1,389.00 " N/A 3230086 Emer Charges 12020 CLOSURE OF SPLIT WOUND ED CHARGE 12020 450 "$2,747.00 " $- $169.88 $- $- "$2,197.60 " $- N/A $714.22 N/A N/A Included in ER case rate N/A N/A "$1,648.20 " N/A N/A "$1,373.50 " N/A N/A $169.88 N/A N/A "$1,867.96 " N/A N/A "$1,620.73 " N/A N/A "$1,071.33 " N/A N/A "$1,922.90 " N/A N/A "$2,197.60 " N/A N/A "$1,510.85 " N/A N/A "$1,922.90 " N/A N/A $920.25 N/A N/A $169.88 N/A N/A "$1,648.20 " N/A N/A $961.45 N/A N/A "$1,867.96 " N/A N/A $824.10 N/A N/A "$1,648.20 " N/A N/A "$1,922.90 " N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A "$2,747.00 " "$2,747.00 " N/A 3230087 Emer Charges 13100 ED CMPLX REPAIR 1.1-2.5 CM CHARGE 13100 450 "$2,747.00 " $- $183.16 $- $- "$2,197.60 " $- N/A $714.22 N/A N/A Included in ER case rate N/A N/A "$1,648.20 " N/A N/A "$1,373.50 " N/A N/A $183.16 N/A N/A "$1,867.96 " N/A N/A "$1,620.73 " N/A N/A "$1,071.33 " N/A N/A "$1,922.90 " N/A N/A "$2,197.60 " N/A N/A "$1,510.85 " N/A N/A "$1,922.90 " N/A N/A $920.25 N/A N/A $183.16 N/A N/A "$1,648.20 " N/A N/A $961.45 N/A N/A "$1,867.96 " N/A N/A $824.10 N/A N/A "$1,648.20 " N/A N/A "$1,922.90 " N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A "$2,747.00 " "$2,747.00 " N/A 3230088 Emer Charges "13101 ED REPAIR, COMPLEX, TRUNK; 2.6 CM TO 7.5 CM CHARGE" 13101 450 "$2,747.00 " $- $225.62 $- $- "$2,197.60 " $- N/A $714.22 N/A N/A Included in ER case rate N/A N/A "$1,648.20 " N/A N/A "$1,373.50 " N/A N/A $225.62 N/A N/A "$1,867.96 " N/A N/A "$1,620.73 " N/A N/A "$1,071.33 " N/A N/A "$1,922.90 " N/A N/A "$2,197.60 " N/A N/A "$1,510.85 " N/A N/A "$1,922.90 " N/A N/A $920.25 N/A N/A $225.62 N/A N/A "$1,648.20 " N/A N/A $961.45 N/A N/A "$1,867.96 " N/A N/A $824.10 N/A N/A "$1,648.20 " N/A N/A "$1,922.90 " N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A N/A $824.10 N/A "$2,747.00 " "$2,747.00 " N/A 3230089 Emer Charges 13102 ED CMPLX REPAIR EA ADD 5 CM CHARGE 13102 450 "$2,037.00 " $- $66.74 $- $- "$1,629.60 " $- N/A $529.62 N/A N/A Included in ER case rate N/A N/A "$1,222.20 " N/A N/A "$1,018.50 " N/A N/A $66.74 N/A N/A "$1,385.16 " N/A N/A "$1,201.83 " N/A N/A $794.43 N/A N/A "$1,425.90 " N/A N/A "$1,629.60 " N/A N/A "$1,120.35 " N/A N/A "$1,425.90 " N/A N/A $682.40 N/A N/A $66.74 N/A N/A "$1,222.20 " N/A N/A $712.95 N/A N/A "$1,385.16 " N/A N/A $611.10 N/A N/A "$1,222.20 " N/A N/A "$1,425.90 " N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A "$2,037.00 " "$2,037.00 " N/A 3230090 Emer Charges 13150 ED COMPLEX REPAIR WOUNDS EYELID/NOSE/EAR/LIP <1.0CM CHARGE 13150 450 "$2,037.00 " $- $529.62 $- $- "$1,629.60 " $- N/A $529.62 N/A N/A Included in ER case rate N/A N/A "$1,222.20 " N/A N/A "$1,018.50 " N/A N/A N/A N/A N/A "$1,385.16 " N/A N/A "$1,201.83 " N/A N/A $794.43 N/A N/A "$1,425.90 " N/A N/A "$1,629.60 " N/A N/A "$1,120.35 " N/A N/A "$1,425.90 " N/A N/A $682.40 N/A N/A N/A N/A N/A "$1,222.20 " N/A N/A $712.95 N/A N/A "$1,385.16 " N/A N/A $611.10 N/A N/A "$1,222.20 " N/A N/A "$1,425.90 " N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A "$2,037.00 " "$2,037.00 " N/A 3230091 Emer Charges 13151 ED COMPLEX REPAIR WOUNDS EYELID/NOSE/EAR/LIP 1.1 TO 2.5CM CHARGE 13151 450 "$2,037.00 " $- $255.74 $- $- "$1,629.60 " $- N/A $529.62 N/A N/A Included in ER case rate N/A N/A "$1,222.20 " N/A N/A "$1,018.50 " N/A N/A $255.74 N/A N/A "$1,385.16 " N/A N/A "$1,201.83 " N/A N/A $794.43 N/A N/A "$1,425.90 " N/A N/A "$1,629.60 " N/A N/A "$1,120.35 " N/A N/A "$1,425.90 " N/A N/A $682.40 N/A N/A $255.74 N/A N/A "$1,222.20 " N/A N/A $712.95 N/A N/A "$1,385.16 " N/A N/A $611.10 N/A N/A "$1,222.20 " N/A N/A "$1,425.90 " N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A "$2,037.00 " "$2,037.00 " N/A 3230092 Emer Charges 13152 ED COMPLEX REPAIR WOUNDS EYELID/NOSE/EAR/LIP 2.6 TO 7.5CM CHARGE 13152 450 "$2,037.00 " $- $309.97 $- $- "$1,629.60 " $- N/A $529.62 N/A N/A Included in ER case rate N/A N/A "$1,222.20 " N/A N/A "$1,018.50 " N/A N/A $309.97 N/A N/A "$1,385.16 " N/A N/A "$1,201.83 " N/A N/A $794.43 N/A N/A "$1,425.90 " N/A N/A "$1,629.60 " N/A N/A "$1,120.35 " N/A N/A "$1,425.90 " N/A N/A $682.40 N/A N/A $309.97 N/A N/A "$1,222.20 " N/A N/A $712.95 N/A N/A "$1,385.16 " N/A N/A $611.10 N/A N/A "$1,222.20 " N/A N/A "$1,425.90 " N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A N/A $611.10 N/A "$2,037.00 " "$2,037.00 " N/A 3230093 Emer Charges 92960 CARDIOVERSION 92960 450 "$2,370.00 " $- $100.90 $- $- "$1,896.00 " $- N/A $616.20 N/A N/A Included in ER case rate N/A N/A "$1,422.00 " N/A N/A "$1,185.00 " N/A N/A $100.90 N/A N/A "$1,611.60 " N/A N/A "$1,398.30 " N/A N/A $924.30 N/A N/A "$1,659.00 " N/A N/A "$1,896.00 " N/A N/A "$1,303.50 " N/A N/A "$1,659.00 " N/A N/A $793.95 N/A N/A $100.90 N/A N/A "$1,422.00 " N/A N/A $829.50 N/A N/A "$1,611.60 " N/A N/A $711.00 N/A N/A "$1,422.00 " N/A N/A "$1,659.00 " N/A N/A $711.00 N/A N/A $711.00 N/A N/A $711.00 N/A N/A $711.00 N/A N/A $711.00 N/A N/A $711.00 N/A "$2,370.00 " "$2,370.00 " N/A 3230094 Emer Charges INITIAL IVPB UNDER 60 MIN 96365 260 $823.00 $- $57.70 $- $- $658.40 $- N/A $213.98 N/A N/A Included in ER case rate N/A N/A $493.80 N/A N/A $411.50 N/A N/A $57.70 N/A N/A $559.64 N/A N/A $485.57 N/A N/A $320.97 N/A N/A $576.10 N/A N/A $658.40 N/A N/A $452.65 N/A N/A $576.10 N/A N/A $275.71 N/A N/A $57.70 N/A N/A $493.80 N/A N/A $288.05 N/A N/A $559.64 N/A N/A $246.90 N/A N/A $493.80 N/A N/A $576.10 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A $823.00 $823.00 N/A 3230095 Emer Charges 36569 PICC LINE AGE 5 YRS OR OLDER ED CHARGE 36569 450 "$4,391.00 " $- $82.34 $- $- "$3,512.80 " $- N/A "$1,141.66 " N/A N/A Included in ER case rate N/A N/A "$2,634.60 " N/A N/A "$2,195.50 " N/A N/A $82.34 N/A N/A "$2,985.88 " N/A N/A "$2,590.69 " N/A N/A "$1,712.49 " N/A N/A "$3,073.70 " N/A N/A "$3,512.80 " N/A N/A "$2,415.05 " N/A N/A "$3,073.70 " N/A N/A "$1,470.99 " N/A N/A $82.34 N/A N/A "$2,634.60 " N/A N/A "$1,536.85 " N/A N/A "$2,985.88 " N/A N/A "$1,317.30 " N/A N/A "$2,634.60 " N/A N/A "$3,073.70 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A "$4,391.00 " "$4,391.00 " N/A 3230098 Emer Charges 27788 CLO TX DIST FIBFX W MAN 27788 450 "$1,058.00 " $- $275.08 $- $- $846.40 $- N/A $275.08 N/A N/A Included in ER case rate N/A N/A $634.80 N/A N/A $529.00 N/A N/A $343.13 N/A N/A $719.44 N/A N/A $624.22 N/A N/A $412.62 N/A N/A $740.60 N/A N/A $846.40 N/A N/A $581.90 N/A N/A $740.60 N/A N/A $354.43 N/A N/A $343.13 N/A N/A $634.80 N/A N/A $370.30 N/A N/A $719.44 N/A N/A $317.40 N/A N/A $634.80 N/A N/A $740.60 N/A N/A $317.40 N/A N/A $317.40 N/A N/A $317.40 N/A N/A $317.40 N/A N/A $317.40 N/A N/A $317.40 N/A "$1,058.00 " "$1,058.00 " N/A 3230102 Emer Charges 24650 - CD TX RADIALHEAD/NK FX WO 24650 450 $778.00 $- $202.28 $- $- $622.40 $- N/A $202.28 N/A N/A Included in ER case rate N/A N/A $466.80 N/A N/A $389.00 N/A N/A $213.95 N/A N/A $529.04 N/A N/A $459.02 N/A N/A $303.42 N/A N/A $544.60 N/A N/A $622.40 N/A N/A $427.90 N/A N/A $544.60 N/A N/A $260.63 N/A N/A $213.95 N/A N/A $466.80 N/A N/A $272.30 N/A N/A $529.04 N/A N/A $233.40 N/A N/A $466.80 N/A N/A $544.60 N/A N/A $233.40 N/A N/A $233.40 N/A N/A $233.40 N/A N/A $233.40 N/A N/A $233.40 N/A N/A $233.40 N/A $778.00 $778.00 N/A 3230104 Emer Charges 27520 CLSD TX PATELA FX W/O MNP 27520 450 $809.00 $- $210.34 $- $- $647.20 $- N/A $210.34 N/A N/A Included in ER case rate N/A N/A $485.40 N/A N/A $404.50 N/A N/A $263.20 N/A N/A $550.12 N/A N/A $477.31 N/A N/A $315.51 N/A N/A $566.30 N/A N/A $647.20 N/A N/A $444.95 N/A N/A $566.30 N/A N/A $271.02 N/A N/A $263.20 N/A N/A $485.40 N/A N/A $283.15 N/A N/A $550.12 N/A N/A $242.70 N/A N/A $485.40 N/A N/A $566.30 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A N/A $242.70 N/A $809.00 $809.00 N/A 3230109 Emer Charges 32554 THORACENTESIS W/O IMAGING 32554 450 "$2,018.00 " $- $80.41 $- $- "$1,614.40 " $- N/A $524.68 N/A N/A Included in ER case rate N/A N/A "$1,210.80 " N/A N/A "$1,009.00 " N/A N/A $80.41 N/A N/A "$1,372.24 " N/A N/A "$1,190.62 " N/A N/A $787.02 N/A N/A "$1,412.60 " N/A N/A "$1,614.40 " N/A N/A "$1,109.90 " N/A N/A "$1,412.60 " N/A N/A $676.03 N/A N/A $80.41 N/A N/A "$1,210.80 " N/A N/A $706.30 N/A N/A "$1,372.24 " N/A N/A $605.40 N/A N/A "$1,210.80 " N/A N/A "$1,412.60 " N/A N/A $605.40 N/A N/A $605.40 N/A N/A $605.40 N/A N/A $605.40 N/A N/A $605.40 N/A N/A $605.40 N/A "$2,018.00 " "$2,018.00 " N/A 3230110 Emer Charges 27818 CLD TX TRIMAL W/MANI 27818 450 "$1,705.00 " $- $388.73 $- $- "$1,364.00 " $- N/A $443.30 N/A N/A Included in ER case rate N/A N/A "$1,023.00 " N/A N/A $852.50 N/A N/A $388.73 N/A N/A "$1,159.40 " N/A N/A "$1,005.95 " N/A N/A $664.95 N/A N/A "$1,193.50 " N/A N/A "$1,364.00 " N/A N/A $937.75 N/A N/A "$1,193.50 " N/A N/A $571.18 N/A N/A $388.73 N/A N/A "$1,023.00 " N/A N/A $596.75 N/A N/A "$1,159.40 " N/A N/A $511.50 N/A N/A "$1,023.00 " N/A N/A "$1,193.50 " N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A "$1,705.00 " "$1,705.00 " N/A 3230112 Emer Charges 11760 ED REPAIR OF NAIL BED CHARGE 11760 450 $591.00 $- $119.23 $- $- $472.80 $- N/A $153.66 N/A N/A Included in ER case rate N/A N/A $354.60 N/A N/A $295.50 N/A N/A $119.23 N/A N/A $401.88 N/A N/A $348.69 N/A N/A $230.49 N/A N/A $413.70 N/A N/A $472.80 N/A N/A $325.05 N/A N/A $413.70 N/A N/A $197.99 N/A N/A $119.23 N/A N/A $354.60 N/A N/A $206.85 N/A N/A $401.88 N/A N/A $177.30 N/A N/A $354.60 N/A N/A $413.70 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A $591.00 $591.00 N/A 3230113 Emer Charges 12011 ED REPAIR SMPL WOUNDS FACE-MM <2.5CM CHARGE 12011 450 $560.00 $- $50.01 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $50.01 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $50.01 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230115 Emer Charges 51701 BLADDER CATH FOR URINE SPEC 51701 450 $333.00 $- $24.52 $- $- $266.40 $- N/A $86.58 N/A N/A Included in ER case rate N/A N/A $199.80 N/A N/A $166.50 N/A N/A $24.52 N/A N/A $226.44 N/A N/A $196.47 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $24.52 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $226.44 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 3230116 Emer Charges 25605 CLO TRMT DISTAL FX W MANI 25605 450 "$2,575.00 " $- $459.35 $- $- "$2,060.00 " $- N/A $669.50 N/A N/A Included in ER case rate N/A N/A "$1,545.00 " N/A N/A "$1,287.50 " N/A N/A $459.35 N/A N/A "$1,751.00 " N/A N/A "$1,519.25 " N/A N/A "$1,004.25 " N/A N/A "$1,802.50 " N/A N/A "$2,060.00 " N/A N/A "$1,416.25 " N/A N/A "$1,802.50 " N/A N/A $862.63 N/A N/A $459.35 N/A N/A "$1,545.00 " N/A N/A $901.25 N/A N/A "$1,751.00 " N/A N/A $772.50 N/A N/A "$1,545.00 " N/A N/A "$1,802.50 " N/A N/A $772.50 N/A N/A $772.50 N/A N/A $772.50 N/A N/A $772.50 N/A N/A $772.50 N/A N/A $772.50 N/A "$2,575.00 " "$2,575.00 " N/A 3230117 Emer Charges 32422 CHEST TUBE INSERTION ED Charge 32422 450 "$2,511.00 " $- $652.86 $- $- "$2,008.80 " $- N/A $652.86 N/A N/A Included in ER case rate N/A N/A "$1,506.60 " N/A N/A "$1,255.50 " N/A N/A N/A N/A N/A "$1,707.48 " N/A N/A "$1,481.49 " N/A N/A $979.29 N/A N/A "$1,757.70 " N/A N/A "$2,008.80 " N/A N/A "$1,381.05 " N/A N/A "$1,757.70 " N/A N/A $841.19 N/A N/A N/A N/A N/A "$1,506.60 " N/A N/A $878.85 N/A N/A "$1,707.48 " N/A N/A $753.30 N/A N/A "$1,506.60 " N/A N/A "$1,757.70 " N/A N/A $753.30 N/A N/A $753.30 N/A N/A $753.30 N/A N/A $753.30 N/A N/A $753.30 N/A N/A $753.30 N/A "$2,511.00 " "$2,511.00 " N/A 3230125 Emer Charges 25650 CD FX TX ULNAR STYLOID Charge 25650 450 $889.00 $- $231.14 $- $- $711.20 $- N/A $231.14 N/A N/A Included in ER case rate N/A N/A $533.40 N/A N/A $444.50 N/A N/A $268.35 N/A N/A $604.52 N/A N/A $524.51 N/A N/A $346.71 N/A N/A $622.30 N/A N/A $711.20 N/A N/A $488.95 N/A N/A $622.30 N/A N/A $297.82 N/A N/A $268.35 N/A N/A $533.40 N/A N/A $311.15 N/A N/A $604.52 N/A N/A $266.70 N/A N/A $533.40 N/A N/A $622.30 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A $889.00 $889.00 N/A 3230135 Emer Charges 27530 CLO TX TIBFX PROX W/O MAN 27530 450 $909.00 $- $236.34 $- $- $727.20 $- N/A $236.34 N/A N/A Included in ER case rate N/A N/A $545.40 N/A N/A $454.50 N/A N/A $249.99 N/A N/A $618.12 N/A N/A $536.31 N/A N/A $354.51 N/A N/A $636.30 N/A N/A $727.20 N/A N/A $499.95 N/A N/A $636.30 N/A N/A $304.52 N/A N/A $249.99 N/A N/A $545.40 N/A N/A $318.15 N/A N/A $618.12 N/A N/A $272.70 N/A N/A $545.40 N/A N/A $636.30 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A $909.00 $909.00 N/A 3230139 Emer Charges 12013 ED REPAIR SMPL WOUNDS FACE-MM 2.6 TO 5.0CM CHARGE 12013 450 $560.00 $- $55.86 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $55.86 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $55.86 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230147 Emer Charges 12014 ED REPAIR SMPL WOUNDS FACE-MM 5.1 TO 7.5CM CHARGE 12014 450 $560.00 $- $71.05 $- $- $448.00 $- N/A $145.60 N/A N/A Included in ER case rate N/A N/A $336.00 N/A N/A $280.00 N/A N/A $71.05 N/A N/A $380.80 N/A N/A $330.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $71.05 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $380.80 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 3230162 Emer Charges LAC.FACENCK 12.6-20 12016 490 $969.00 $- $120.05 $- $- $775.20 $- N/A $251.94 N/A N/A Included in ER case rate N/A N/A $581.40 N/A N/A $484.50 N/A N/A $120.05 N/A N/A $658.92 N/A N/A $571.71 N/A N/A $377.91 N/A N/A $678.30 N/A N/A $775.20 N/A N/A $532.95 N/A N/A $678.30 N/A N/A $324.62 N/A N/A $120.05 N/A N/A $581.40 N/A N/A $339.15 N/A N/A $658.92 N/A N/A $290.70 N/A N/A $581.40 N/A N/A $678.30 N/A N/A $290.70 N/A N/A $290.70 N/A N/A $290.70 N/A N/A $290.70 N/A N/A $290.70 N/A N/A $290.70 N/A $969.00 $969.00 N/A 3230175 Emer Charges "41252 ED REPAIR OF LACERATION OF TONGUE, FLOOR OF MOUTH, OVER 2.6 CM OR COMPLEX" 41252 450 "$1,849.00 " $- $192.10 $- $- "$1,479.20 " $- N/A $480.74 N/A N/A Included in ER case rate N/A N/A "$1,109.40 " N/A N/A $924.50 N/A N/A $192.10 N/A N/A "$1,257.32 " N/A N/A "$1,090.91 " N/A N/A $721.11 N/A N/A "$1,294.30 " N/A N/A "$1,479.20 " N/A N/A "$1,016.95 " N/A N/A "$1,294.30 " N/A N/A $619.42 N/A N/A $192.10 N/A N/A "$1,109.40 " N/A N/A $647.15 N/A N/A "$1,257.32 " N/A N/A $554.70 N/A N/A "$1,109.40 " N/A N/A "$1,294.30 " N/A N/A $554.70 N/A N/A $554.70 N/A N/A $554.70 N/A N/A $554.70 N/A N/A $554.70 N/A N/A $554.70 N/A "$1,849.00 " "$1,849.00 " N/A 3230288 Emer Charges 25630 CO TX CARPAL W/O MANIP 25630 450 "$2,424.00 " $- $249.44 $- $- "$1,939.20 " $- N/A $630.24 N/A N/A Included in ER case rate N/A N/A "$1,454.40 " N/A N/A "$1,212.00 " N/A N/A $249.44 N/A N/A "$1,648.32 " N/A N/A "$1,430.16 " N/A N/A $945.36 N/A N/A "$1,696.80 " N/A N/A "$1,939.20 " N/A N/A "$1,333.20 " N/A N/A "$1,696.80 " N/A N/A $812.04 N/A N/A $249.44 N/A N/A "$1,454.40 " N/A N/A $848.40 N/A N/A "$1,648.32 " N/A N/A $727.20 N/A N/A "$1,454.40 " N/A N/A "$1,696.80 " N/A N/A $727.20 N/A N/A $727.20 N/A N/A $727.20 N/A N/A $727.20 N/A N/A $727.20 N/A N/A $727.20 N/A "$2,424.00 " "$2,424.00 " N/A 3230310 Emer Charges 24600 ELBOW DISLOCATION 24600 450 $728.00 $- $189.28 $- $- $582.40 $- N/A $189.28 N/A N/A Included in ER case rate N/A N/A $436.80 N/A N/A $364.00 N/A N/A $297.75 N/A N/A $495.04 N/A N/A $429.52 N/A N/A $283.92 N/A N/A $509.60 N/A N/A $582.40 N/A N/A $400.40 N/A N/A $509.60 N/A N/A $243.88 N/A N/A $297.75 N/A N/A $436.80 N/A N/A $254.80 N/A N/A $495.04 N/A N/A $218.40 N/A N/A $436.80 N/A N/A $509.60 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A $728.00 $728.00 N/A 3230320 Emer Charges 27780 ED TRTMT CLOSED PROX FIBULA FX W/O MANIP CHARGE 27780 450 "$2,336.00 " $- $249.09 $- $- "$1,868.80 " $- N/A $607.36 N/A N/A Included in ER case rate N/A N/A "$1,401.60 " N/A N/A "$1,168.00 " N/A N/A $249.09 N/A N/A "$1,588.48 " N/A N/A "$1,378.24 " N/A N/A $911.04 N/A N/A "$1,635.20 " N/A N/A "$1,868.80 " N/A N/A "$1,284.80 " N/A N/A "$1,635.20 " N/A N/A $782.56 N/A N/A $249.09 N/A N/A "$1,401.60 " N/A N/A $817.60 N/A N/A "$1,588.48 " N/A N/A $700.80 N/A N/A "$1,401.60 " N/A N/A "$1,635.20 " N/A N/A $700.80 N/A N/A $700.80 N/A N/A $700.80 N/A N/A $700.80 N/A N/A $700.80 N/A N/A $700.80 N/A "$2,336.00 " "$2,336.00 " N/A 3230325 Emer Charges 25500 CLO TRMT RADIAL SHFT W/O 25500 450 "$1,727.00 " $- $222.47 $- $- "$1,381.60 " $- N/A $449.02 N/A N/A Included in ER case rate N/A N/A "$1,036.20 " N/A N/A $863.50 N/A N/A $222.47 N/A N/A "$1,174.36 " N/A N/A "$1,018.93 " N/A N/A $673.53 N/A N/A "$1,208.90 " N/A N/A "$1,381.60 " N/A N/A $949.85 N/A N/A "$1,208.90 " N/A N/A $578.55 N/A N/A $222.47 N/A N/A "$1,036.20 " N/A N/A $604.45 N/A N/A "$1,174.36 " N/A N/A $518.10 N/A N/A "$1,036.20 " N/A N/A "$1,208.90 " N/A N/A $518.10 N/A N/A $518.10 N/A N/A $518.10 N/A N/A $518.10 N/A N/A $518.10 N/A N/A $518.10 N/A "$1,727.00 " "$1,727.00 " N/A 3230380 Emer Charges "21800 ED CLOSED TREATMENT OF RIB FRACTURE, UNCOMPLICATED, EACH CHARGE" 450 $782.00 $- $203.32 $- $- $625.60 $- N/A $203.32 N/A N/A Included in ER case rate N/A N/A $469.20 N/A N/A $391.00 N/A N/A N/A N/A N/A $531.76 N/A N/A $461.38 N/A N/A $304.98 N/A N/A $547.40 N/A N/A $625.60 N/A N/A $430.10 N/A N/A $547.40 N/A N/A $261.97 N/A N/A N/A N/A N/A $469.20 N/A N/A $273.70 N/A N/A $531.76 N/A N/A $234.60 N/A N/A $469.20 N/A N/A $547.40 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A $782.00 $782.00 N/A 3230381 Emer Charges 27808 CLD TX BIMALL FX W/O MANI 27808 450 $782.00 $- $203.32 $- $- $625.60 $- N/A $203.32 N/A N/A Included in ER case rate N/A N/A $469.20 N/A N/A $391.00 N/A N/A $268.95 N/A N/A $531.76 N/A N/A $461.38 N/A N/A $304.98 N/A N/A $547.40 N/A N/A $625.60 N/A N/A $430.10 N/A N/A $547.40 N/A N/A $261.97 N/A N/A $268.95 N/A N/A $469.20 N/A N/A $273.70 N/A N/A $531.76 N/A N/A $234.60 N/A N/A $469.20 N/A N/A $547.40 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A N/A $234.60 N/A $782.00 $782.00 N/A 3230382 Emer Charges 26011 DRNG FINGER ABSCESS COMPL 26011 450 $737.00 $- $164.46 $- $- $589.60 $- N/A $191.62 N/A N/A Included in ER case rate N/A N/A $442.20 N/A N/A $368.50 N/A N/A $164.46 N/A N/A $501.16 N/A N/A $434.83 N/A N/A $287.43 N/A N/A $515.90 N/A N/A $589.60 N/A N/A $405.35 N/A N/A $515.90 N/A N/A $246.90 N/A N/A $164.46 N/A N/A $442.20 N/A N/A $257.95 N/A N/A $501.16 N/A N/A $221.10 N/A N/A $442.20 N/A N/A $515.90 N/A N/A $221.10 N/A N/A $221.10 N/A N/A $221.10 N/A N/A $221.10 N/A N/A $221.10 N/A N/A $221.10 N/A $737.00 $737.00 N/A 3230405 Emer Charges 11010 ED DEBRIDE RMV FB W/FX SKIN CHARGE 11010 450 $983.00 $- $247.85 $- $- $786.40 $- N/A $255.58 N/A N/A Included in ER case rate N/A N/A $589.80 N/A N/A $491.50 N/A N/A $247.85 N/A N/A $668.44 N/A N/A $579.97 N/A N/A $383.37 N/A N/A $688.10 N/A N/A $786.40 N/A N/A $540.65 N/A N/A $688.10 N/A N/A $329.31 N/A N/A $247.85 N/A N/A $589.80 N/A N/A $344.05 N/A N/A $668.44 N/A N/A $294.90 N/A N/A $589.80 N/A N/A $688.10 N/A N/A $294.90 N/A N/A $294.90 N/A N/A $294.90 N/A N/A $294.90 N/A N/A $294.90 N/A N/A $294.90 N/A $983.00 $983.00 N/A 3230410 Emer Charges 11042 DEBRIDE SUBQ TISSUE 1ST 20SQCM ED CHARGE 11042 450 "$1,036.00 " $- $54.82 $- $- $828.80 $- N/A $269.36 N/A N/A Included in ER case rate N/A N/A $621.60 N/A N/A $518.00 N/A N/A $54.82 N/A N/A $704.48 N/A N/A $611.24 N/A N/A $404.04 N/A N/A $725.20 N/A N/A $828.80 N/A N/A $569.80 N/A N/A $725.20 N/A N/A $347.06 N/A N/A $54.82 N/A N/A $621.60 N/A N/A $362.60 N/A N/A $704.48 N/A N/A $310.80 N/A N/A $621.60 N/A N/A $725.20 N/A N/A $310.80 N/A N/A $310.80 N/A N/A $310.80 N/A N/A $310.80 N/A N/A $310.80 N/A N/A $310.80 N/A "$1,036.00 " "$1,036.00 " N/A 3230411 Emer Charges 20605 ARTHROCENTESIS ASP/INJ INT JNT ED CHARGE 20605 450 "$2,582.00 " $- $33.22 $- $- "$2,065.60 " $- N/A $671.32 N/A N/A Included in ER case rate N/A N/A "$1,549.20 " N/A N/A "$1,291.00 " N/A N/A $33.22 N/A N/A "$1,755.76 " N/A N/A "$1,523.38 " N/A N/A "$1,006.98 " N/A N/A "$1,807.40 " N/A N/A "$2,065.60 " N/A N/A "$1,420.10 " N/A N/A "$1,807.40 " N/A N/A $864.97 N/A N/A $33.22 N/A N/A "$1,549.20 " N/A N/A $903.70 N/A N/A "$1,755.76 " N/A N/A $774.60 N/A N/A "$1,549.20 " N/A N/A "$1,807.40 " N/A N/A $774.60 N/A N/A $774.60 N/A N/A $774.60 N/A N/A $774.60 N/A N/A $774.60 N/A N/A $774.60 N/A "$2,582.00 " "$2,582.00 " N/A 3230412 Emer Charges 10160 ED PUNCTURE ASPIRATION (ABSCESS/HEMTOMA/CYS) CHARGE 10160 450 $788.00 $- $85.16 $- $- $630.40 $- N/A $204.88 N/A N/A Included in ER case rate N/A N/A $472.80 N/A N/A $394.00 N/A N/A $85.16 N/A N/A $535.84 N/A N/A $464.92 N/A N/A $307.32 N/A N/A $551.60 N/A N/A $630.40 N/A N/A $433.40 N/A N/A $551.60 N/A N/A $263.98 N/A N/A $85.16 N/A N/A $472.80 N/A N/A $275.80 N/A N/A $535.84 N/A N/A $236.40 N/A N/A $472.80 N/A N/A $551.60 N/A N/A $236.40 N/A N/A $236.40 N/A N/A $236.40 N/A N/A $236.40 N/A N/A $236.40 N/A N/A $236.40 N/A $788.00 $788.00 N/A 3230430 Emer Charges 43760 CHANGE GASTROSTOMY TUBE 43760 450 "$1,299.00 " $- $337.74 $- $- "$1,039.20 " $- N/A $337.74 N/A N/A Included in ER case rate N/A N/A $779.40 N/A N/A $649.50 N/A N/A N/A N/A N/A $883.32 N/A N/A $766.41 N/A N/A $506.61 N/A N/A $909.30 N/A N/A "$1,039.20 " N/A N/A $714.45 N/A N/A $909.30 N/A N/A $435.17 N/A N/A N/A N/A N/A $779.40 N/A N/A $454.65 N/A N/A $883.32 N/A N/A $389.70 N/A N/A $779.40 N/A N/A $909.30 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A "$1,299.00 " "$1,299.00 " N/A 3230440 Emer Charges 36556 INSERT CENTRAL VENOUS CATH 5 YRS 36556 450 "$3,731.00 " $- $108.61 $- $- "$2,984.80 " $- N/A $970.06 N/A N/A Included in ER case rate N/A N/A "$2,238.60 " N/A N/A "$1,865.50 " N/A N/A $108.61 N/A N/A "$2,537.08 " N/A N/A "$2,201.29 " N/A N/A "$1,455.09 " N/A N/A "$2,611.70 " N/A N/A "$2,984.80 " N/A N/A "$2,052.05 " N/A N/A "$2,611.70 " N/A N/A "$1,249.89 " N/A N/A $108.61 N/A N/A "$2,238.60 " N/A N/A "$1,305.85 " N/A N/A "$2,537.08 " N/A N/A "$1,119.30 " N/A N/A "$2,238.60 " N/A N/A "$2,611.70 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A "$3,731.00 " "$3,731.00 " N/A 3230450 Emer Charges 99145 MOD SED SVC SAME MD EA 15 MIN ED CHARGE 450 $189.00 $- $49.14 $- $- $151.20 $- N/A $49.14 N/A N/A Included in ER case rate N/A N/A $113.40 N/A N/A $94.50 N/A N/A N/A N/A N/A $128.52 N/A N/A $111.51 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A N/A N/A N/A $113.40 N/A N/A $66.15 N/A N/A $128.52 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 3230451 Emer Charges 99143 CONSCIOUS SED UNDER 5YRS ED Charge 450 $563.00 $- $146.38 $- $- $450.40 $- N/A $146.38 N/A N/A Included in ER case rate N/A N/A $337.80 N/A N/A $281.50 N/A N/A N/A N/A N/A $382.84 N/A N/A $332.17 N/A N/A $219.57 N/A N/A $394.10 N/A N/A $450.40 N/A N/A $309.65 N/A N/A $394.10 N/A N/A $188.61 N/A N/A N/A N/A N/A $337.80 N/A N/A $197.05 N/A N/A $382.84 N/A N/A $168.90 N/A N/A $337.80 N/A N/A $394.10 N/A N/A $168.90 N/A N/A $168.90 N/A N/A $168.90 N/A N/A $168.90 N/A N/A $168.90 N/A N/A $168.90 N/A $563.00 $563.00 N/A 3230475 Emer Charges 54220 IRRIG COPORA CAVERNSA PRIAPISM ED CHARGE 54220 450 $885.00 $- $118.26 $- $- $708.00 $- N/A $230.10 N/A N/A Included in ER case rate N/A N/A $531.00 N/A N/A $442.50 N/A N/A $118.26 N/A N/A $601.80 N/A N/A $522.15 N/A N/A $345.15 N/A N/A $619.50 N/A N/A $708.00 N/A N/A $486.75 N/A N/A $619.50 N/A N/A $296.48 N/A N/A $118.26 N/A N/A $531.00 N/A N/A $309.75 N/A N/A $601.80 N/A N/A $265.50 N/A N/A $531.00 N/A N/A $619.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A $885.00 $885.00 N/A 3230492 Emer Charges 17250 CHEM CAUTERIZATION/GRAN TISSUE ED CHARGE 17250 450 $672.00 $- $33.19 $- $- $537.60 $- N/A $174.72 N/A N/A Included in ER case rate N/A N/A $403.20 N/A N/A $336.00 N/A N/A $33.19 N/A N/A $456.96 N/A N/A $396.48 N/A N/A $262.08 N/A N/A $470.40 N/A N/A $537.60 N/A N/A $369.60 N/A N/A $470.40 N/A N/A $225.12 N/A N/A $33.19 N/A N/A $403.20 N/A N/A $235.20 N/A N/A $456.96 N/A N/A $201.60 N/A N/A $403.20 N/A N/A $470.40 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A $672.00 $672.00 N/A 3230495 Emer Charges 23675 CLSD TRMT SHLDR DISLOC W/MANIP ED CHARGE 23675 450 "$1,296.00 " $- $336.96 $- $- "$1,036.80 " $- N/A $336.96 N/A N/A Included in ER case rate N/A N/A $777.60 N/A N/A $648.00 N/A N/A $445.57 N/A N/A $881.28 N/A N/A $764.64 N/A N/A $505.44 N/A N/A $907.20 N/A N/A "$1,036.80 " N/A N/A $712.80 N/A N/A $907.20 N/A N/A $434.16 N/A N/A $445.57 N/A N/A $777.60 N/A N/A $453.60 N/A N/A $881.28 N/A N/A $388.80 N/A N/A $777.60 N/A N/A $907.20 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A "$1,296.00 " "$1,296.00 " N/A 3230500 Emer Charges 23540 ED CLSD TRT AC DISLOCATION CHARGE 23540 450 $602.00 $- $156.52 $- $- $481.60 $- N/A $156.52 N/A N/A Included in ER case rate N/A N/A $361.20 N/A N/A $301.00 N/A N/A $202.68 N/A N/A $409.36 N/A N/A $355.18 N/A N/A $234.78 N/A N/A $421.40 N/A N/A $481.60 N/A N/A $331.10 N/A N/A $421.40 N/A N/A $201.67 N/A N/A $202.68 N/A N/A $361.20 N/A N/A $210.70 N/A N/A $409.36 N/A N/A $180.60 N/A N/A $361.20 N/A N/A $421.40 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A $602.00 $602.00 N/A 3230505 Emer Charges 23500 CLO TX CLAV FX WO MANIP 23500 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $198.11 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $198.11 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230506 Emer Charges 26755 CLOTX DIST PH FX FING MAN 26755 450 $925.00 $- $240.50 $- $- $740.00 $- N/A $240.50 N/A N/A Included in ER case rate N/A N/A $555.00 N/A N/A $462.50 N/A N/A $243.71 N/A N/A $629.00 N/A N/A $545.75 N/A N/A $360.75 N/A N/A $647.50 N/A N/A $740.00 N/A N/A $508.75 N/A N/A $647.50 N/A N/A $309.88 N/A N/A $243.71 N/A N/A $555.00 N/A N/A $323.75 N/A N/A $629.00 N/A N/A $277.50 N/A N/A $555.00 N/A N/A $647.50 N/A N/A $277.50 N/A N/A $277.50 N/A N/A $277.50 N/A N/A $277.50 N/A N/A $277.50 N/A N/A $277.50 N/A $925.00 $925.00 N/A 3230507 Emer Charges 25600 CLO TX DIST RADIAL FX W/O 25600 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $276.33 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $276.33 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230508 Emer Charges 24500 ED CLOSED TRTMT OF HUMERAL SHAFT FX W/O MANIP CHARGE 24500 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $289.53 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $289.53 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230509 Emer Charges 23650 CLO TX SHLDR DISLC W/MANI 23650 450 "$1,030.00 " $- $256.04 $- $- $824.00 $- N/A $267.80 N/A N/A Included in ER case rate N/A N/A $618.00 N/A N/A $515.00 N/A N/A $256.04 N/A N/A $700.40 N/A N/A $607.70 N/A N/A $401.70 N/A N/A $721.00 N/A N/A $824.00 N/A N/A $566.50 N/A N/A $721.00 N/A N/A $345.05 N/A N/A $256.04 N/A N/A $618.00 N/A N/A $360.50 N/A N/A $700.40 N/A N/A $309.00 N/A N/A $618.00 N/A N/A $721.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A "$1,030.00 " "$1,030.00 " N/A 3230510 Emer Charges 26600 CLD TX MTCPL FX W/O MANIP 26600 450 $816.00 $- $212.16 $- $- $652.80 $- N/A $212.16 N/A N/A Included in ER case rate N/A N/A $489.60 N/A N/A $408.00 N/A N/A $246.82 N/A N/A $554.88 N/A N/A $481.44 N/A N/A $318.24 N/A N/A $571.20 N/A N/A $652.80 N/A N/A $448.80 N/A N/A $571.20 N/A N/A $273.36 N/A N/A $246.82 N/A N/A $489.60 N/A N/A $285.60 N/A N/A $554.88 N/A N/A $244.80 N/A N/A $489.60 N/A N/A $571.20 N/A N/A $244.80 N/A N/A $244.80 N/A N/A $244.80 N/A N/A $244.80 N/A N/A $244.80 N/A N/A $244.80 N/A $816.00 $816.00 N/A 3230512 Emer Charges 28470 ED TRTMT CLOSED METATARSAL FX W/O MANIP CHARGE 28470 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $184.87 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $184.87 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230515 Emer Charges 26750 CLO TX DIST PHAL FX FINGE 26750 450 $709.00 $- $164.78 $- $- $567.20 $- N/A $184.34 N/A N/A Included in ER case rate N/A N/A $425.40 N/A N/A $354.50 N/A N/A $164.78 N/A N/A $482.12 N/A N/A $418.31 N/A N/A $276.51 N/A N/A $496.30 N/A N/A $567.20 N/A N/A $389.95 N/A N/A $496.30 N/A N/A $237.52 N/A N/A $164.78 N/A N/A $425.40 N/A N/A $248.15 N/A N/A $482.12 N/A N/A $212.70 N/A N/A $425.40 N/A N/A $496.30 N/A N/A $212.70 N/A N/A $212.70 N/A N/A $212.70 N/A N/A $212.70 N/A N/A $212.70 N/A N/A $212.70 N/A $709.00 $709.00 N/A 3230516 Emer Charges 27508 CLSD TX FEMRAL FX W/O MNP 27508 450 $757.00 $- $196.82 $- $- $605.60 $- N/A $196.82 N/A N/A Included in ER case rate N/A N/A $454.20 N/A N/A $378.50 N/A N/A $441.85 N/A N/A $514.76 N/A N/A $446.63 N/A N/A $295.23 N/A N/A $529.90 N/A N/A $605.60 N/A N/A $416.35 N/A N/A $529.90 N/A N/A $253.60 N/A N/A $441.85 N/A N/A $454.20 N/A N/A $264.95 N/A N/A $514.76 N/A N/A $227.10 N/A N/A $454.20 N/A N/A $529.90 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A $757.00 $757.00 N/A 3230520 Emer Charges 21315 CLSD TMT NASL BONE FX W/O STAB ED CHARGE 21310 450 $496.00 $- $24.79 $- $- $396.80 $- N/A $128.96 N/A N/A Included in ER case rate N/A N/A $297.60 N/A N/A $248.00 N/A N/A $24.79 N/A N/A $337.28 N/A N/A $292.64 N/A N/A $193.44 N/A N/A $347.20 N/A N/A $396.80 N/A N/A $272.80 N/A N/A $347.20 N/A N/A $166.16 N/A N/A $24.79 N/A N/A $297.60 N/A N/A $173.60 N/A N/A $337.28 N/A N/A $148.80 N/A N/A $297.60 N/A N/A $347.20 N/A N/A $148.80 N/A N/A $148.80 N/A N/A $148.80 N/A N/A $148.80 N/A N/A $148.80 N/A N/A $148.80 N/A $496.00 $496.00 N/A 3230525 Emer Charges 27265 CLD TX POST HIP ARTHRO DIS W/O ED CHARGE 27265 450 $923.00 $- $239.98 $- $- $738.40 $- N/A $239.98 N/A N/A Included in ER case rate N/A N/A $553.80 N/A N/A $461.50 N/A N/A $356.69 N/A N/A $627.64 N/A N/A $544.57 N/A N/A $359.97 N/A N/A $646.10 N/A N/A $738.40 N/A N/A $507.65 N/A N/A $646.10 N/A N/A $309.21 N/A N/A $356.69 N/A N/A $553.80 N/A N/A $323.05 N/A N/A $627.64 N/A N/A $276.90 N/A N/A $553.80 N/A N/A $646.10 N/A N/A $276.90 N/A N/A $276.90 N/A N/A $276.90 N/A N/A $276.90 N/A N/A $276.90 N/A N/A $276.90 N/A $923.00 $923.00 N/A 3230530 Emer Charges 26720 CLO TX FINGER FX PROX/MID 26720 450 $802.00 $- $164.52 $- $- $641.60 $- N/A $208.52 N/A N/A Included in ER case rate N/A N/A $481.20 N/A N/A $401.00 N/A N/A $164.52 N/A N/A $545.36 N/A N/A $473.18 N/A N/A $312.78 N/A N/A $561.40 N/A N/A $641.60 N/A N/A $441.10 N/A N/A $561.40 N/A N/A $268.67 N/A N/A $164.52 N/A N/A $481.20 N/A N/A $280.70 N/A N/A $545.36 N/A N/A $240.60 N/A N/A $481.20 N/A N/A $561.40 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A $802.00 $802.00 N/A 3230531 Emer Charges 23600 CLSD TX PROX HUMER FX W/O 23600 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $274.45 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $274.45 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230534 Emer Charges 24565 CLOSED TX HUMERAL EPICONDYLAR FX W/MANIP 24565 450 "$1,341.00 " $- $348.66 $- $- "$1,072.80 " $- N/A $348.66 N/A N/A Included in ER case rate N/A N/A $804.60 N/A N/A $670.50 N/A N/A $434.76 N/A N/A $911.88 N/A N/A $791.19 N/A N/A $522.99 N/A N/A $938.70 N/A N/A "$1,072.80 " N/A N/A $737.55 N/A N/A $938.70 N/A N/A $449.24 N/A N/A $434.76 N/A N/A $804.60 N/A N/A $469.35 N/A N/A $911.88 N/A N/A $402.30 N/A N/A $804.60 N/A N/A $938.70 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A "$1,341.00 " "$1,341.00 " N/A 3230537 Emer Charges 24560 ED CLOSED TRTMT OF HUMERAL EPICONDYLAR FX W/O MANIP CHARGE 24560 450 "$1,142.00 " $- $256.88 $- $- $913.60 $- N/A $296.92 N/A N/A Included in ER case rate N/A N/A $685.20 N/A N/A $571.00 N/A N/A $256.88 N/A N/A $776.56 N/A N/A $673.78 N/A N/A $445.38 N/A N/A $799.40 N/A N/A $913.60 N/A N/A $628.10 N/A N/A $799.40 N/A N/A $382.57 N/A N/A $256.88 N/A N/A $685.20 N/A N/A $399.70 N/A N/A $776.56 N/A N/A $342.60 N/A N/A $685.20 N/A N/A $799.40 N/A N/A $342.60 N/A N/A $342.60 N/A N/A $342.60 N/A N/A $342.60 N/A N/A $342.60 N/A N/A $342.60 N/A "$1,142.00 " "$1,142.00 " N/A 3230540 Emer Charges 25560 CLSD TX RAD/ULNA W/O MANI 25560 450 $655.00 $- $170.30 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $224.14 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $224.14 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3230543 Emer Charges 23620 CLSD TX GREATER HUMERAL TUBEROSITY FX W/O MANIP 23620 450 "$1,630.00 " $- $228.38 $- $- "$1,304.00 " $- N/A $423.80 N/A N/A Included in ER case rate N/A N/A $978.00 N/A N/A $815.00 N/A N/A $228.38 N/A N/A "$1,108.40 " N/A N/A $961.70 N/A N/A $635.70 N/A N/A "$1,141.00 " N/A N/A "$1,304.00 " N/A N/A $896.50 N/A N/A "$1,141.00 " N/A N/A $546.05 N/A N/A $228.38 N/A N/A $978.00 N/A N/A $570.50 N/A N/A "$1,108.40 " N/A N/A $489.00 N/A N/A $978.00 N/A N/A "$1,141.00 " N/A N/A $489.00 N/A N/A $489.00 N/A N/A $489.00 N/A N/A $489.00 N/A N/A $489.00 N/A N/A $489.00 N/A "$1,630.00 " "$1,630.00 " N/A 3230545 Emer Charges 28435 ED Closed treatment of talus fracture with manipulation 28435 450 $929.00 $- $241.54 $- $- $743.20 $- N/A $241.54 N/A N/A Included in ER case rate N/A N/A $557.40 N/A N/A $464.50 N/A N/A $261.27 N/A N/A $631.72 N/A N/A $548.11 N/A N/A $362.31 N/A N/A $650.30 N/A N/A $743.20 N/A N/A $510.95 N/A N/A $650.30 N/A N/A $311.22 N/A N/A $261.27 N/A N/A $557.40 N/A N/A $325.15 N/A N/A $631.72 N/A N/A $278.70 N/A N/A $557.40 N/A N/A $650.30 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A $929.00 $929.00 N/A 3230549 Emer Charges 27786 CLO TX DIST FIBFX W/O MAN 27786 450 $878.00 $- $228.28 $- $- $702.40 $- N/A $228.28 N/A N/A Included in ER case rate N/A N/A $526.80 N/A N/A $439.00 N/A N/A $255.83 N/A N/A $597.04 N/A N/A $518.02 N/A N/A $342.42 N/A N/A $614.60 N/A N/A $702.40 N/A N/A $482.90 N/A N/A $614.60 N/A N/A $294.13 N/A N/A $255.83 N/A N/A $526.80 N/A N/A $307.30 N/A N/A $597.04 N/A N/A $263.40 N/A N/A $526.80 N/A N/A $614.60 N/A N/A $263.40 N/A N/A $263.40 N/A N/A $263.40 N/A N/A $263.40 N/A N/A $263.40 N/A N/A $263.40 N/A $878.00 $878.00 N/A 3230553 Emer Charges 27760 TREATMENT OF ANKLE FRACTURE 27760 450 $763.00 $- $198.38 $- $- $610.40 $- N/A $198.38 N/A N/A Included in ER case rate N/A N/A $457.80 N/A N/A $381.50 N/A N/A $272.84 N/A N/A $518.84 N/A N/A $450.17 N/A N/A $297.57 N/A N/A $534.10 N/A N/A $610.40 N/A N/A $419.65 N/A N/A $534.10 N/A N/A $255.61 N/A N/A $272.84 N/A N/A $457.80 N/A N/A $267.05 N/A N/A $518.84 N/A N/A $228.90 N/A N/A $457.80 N/A N/A $534.10 N/A N/A $228.90 N/A N/A $228.90 N/A N/A $228.90 N/A N/A $228.90 N/A N/A $228.90 N/A N/A $228.90 N/A $763.00 $763.00 N/A 3230558 Emer Charges 27252 ED TRTMT HIP DISLOCATION REQ ANES CHARGE 27252 450 "$6,821.00 " $- $678.04 $- $- "$5,456.80 " $- N/A "$1,773.46 " N/A N/A Included in ER case rate N/A N/A "$4,092.60 " N/A N/A "$3,410.50 " N/A N/A $678.04 N/A N/A "$4,638.28 " N/A N/A "$4,024.39 " N/A N/A "$2,660.19 " N/A N/A "$4,774.70 " N/A N/A "$5,456.80 " N/A N/A "$3,751.55 " N/A N/A "$4,774.70 " N/A N/A "$2,285.04 " N/A N/A $678.04 N/A N/A "$4,092.60 " N/A N/A "$2,387.35 " N/A N/A "$4,638.28 " N/A N/A "$2,046.30 " N/A N/A "$4,092.60 " N/A N/A "$4,774.70 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A N/A "$2,046.30 " N/A "$6,821.00 " "$6,821.00 " N/A 3230560 Emer Charges IMMUNIZATION ADMIN ER 90471 771 $171.00 $- $20.89 $- $- $136.80 $- N/A $44.46 N/A N/A Included in ER case rate N/A N/A $102.60 N/A N/A $85.50 N/A N/A $20.89 N/A N/A $116.28 N/A N/A $100.89 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $20.89 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $116.28 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 3230565 Emer Charges IMMUN ADMIN THROUGH 18 YRS 90460 771 $188.00 $- $20.89 $- $- $150.40 $- N/A $48.88 N/A N/A Included in ER case rate N/A N/A $112.80 N/A N/A $94.00 N/A N/A $20.89 N/A N/A $127.84 N/A N/A $110.92 N/A N/A $73.32 N/A N/A $131.60 N/A N/A $150.40 N/A N/A $103.40 N/A N/A $131.60 N/A N/A $62.98 N/A N/A $20.89 N/A N/A $112.80 N/A N/A $65.80 N/A N/A $127.84 N/A N/A $56.40 N/A N/A $112.80 N/A N/A $131.60 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A $188.00 $188.00 N/A 3230570 Emer Charges 24655 CLSD TRTMT RADIAL HEAD W/MANIP ED CHARGE 24655 450 "$3,113.00 " $- $355.67 $- $- "$2,490.40 " $- N/A $809.38 N/A N/A Included in ER case rate N/A N/A "$1,867.80 " N/A N/A "$1,556.50 " N/A N/A $355.67 N/A N/A "$2,116.84 " N/A N/A "$1,836.67 " N/A N/A "$1,214.07 " N/A N/A "$2,179.10 " N/A N/A "$2,490.40 " N/A N/A "$1,712.15 " N/A N/A "$2,179.10 " N/A N/A "$1,042.86 " N/A N/A $355.67 N/A N/A "$1,867.80 " N/A N/A "$1,089.55 " N/A N/A "$2,116.84 " N/A N/A $933.90 N/A N/A "$1,867.80 " N/A N/A "$2,179.10 " N/A N/A $933.90 N/A N/A $933.90 N/A N/A $933.90 N/A N/A $933.90 N/A N/A $933.90 N/A N/A $933.90 N/A "$3,113.00 " "$3,113.00 " N/A 3230575 Emer Charges 26725 CLO TX FING FX W/MANIP 26725 450 $929.00 $- $241.54 $- $- $743.20 $- N/A $241.54 N/A N/A Included in ER case rate N/A N/A $557.40 N/A N/A $464.50 N/A N/A $270.56 N/A N/A $631.72 N/A N/A $548.11 N/A N/A $362.31 N/A N/A $650.30 N/A N/A $743.20 N/A N/A $510.95 N/A N/A $650.30 N/A N/A $311.22 N/A N/A $270.56 N/A N/A $557.40 N/A N/A $325.15 N/A N/A $631.72 N/A N/A $278.70 N/A N/A $557.40 N/A N/A $650.30 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A N/A $278.70 N/A $929.00 $929.00 N/A 3230580 Emer Charges 24530 TREAT HUMERUS FX W/O MANI 24530 450 $936.00 $- $243.36 $- $- $748.80 $- N/A $243.36 N/A N/A Included in ER case rate N/A N/A $561.60 N/A N/A $468.00 N/A N/A $305.79 N/A N/A $636.48 N/A N/A $552.24 N/A N/A $365.04 N/A N/A $655.20 N/A N/A $748.80 N/A N/A $514.80 N/A N/A $655.20 N/A N/A $313.56 N/A N/A $305.79 N/A N/A $561.60 N/A N/A $327.60 N/A N/A $636.48 N/A N/A $280.80 N/A N/A $561.60 N/A N/A $655.20 N/A N/A $280.80 N/A N/A $280.80 N/A N/A $280.80 N/A N/A $280.80 N/A N/A $280.80 N/A N/A $280.80 N/A $936.00 $936.00 N/A 3230585 Emer Charges 24670 Clsd Tx Ulnar Fx W/O Mani 24670 450 $854.00 $- $222.04 $- $- $683.20 $- N/A $222.04 N/A N/A Included in ER case rate N/A N/A $512.40 N/A N/A $427.00 N/A N/A $233.91 N/A N/A $580.72 N/A N/A $503.86 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $233.91 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $580.72 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 3230590 Emer Charges 25622 CLO TX WRIST W/O MANIP 25622 450 "$1,953.00 " $- $246.90 $- $- "$1,562.40 " $- N/A $507.78 N/A N/A Included in ER case rate N/A N/A "$1,171.80 " N/A N/A $976.50 N/A N/A $246.90 N/A N/A "$1,328.04 " N/A N/A "$1,152.27 " N/A N/A $761.67 N/A N/A "$1,367.10 " N/A N/A "$1,562.40 " N/A N/A "$1,074.15 " N/A N/A "$1,367.10 " N/A N/A $654.26 N/A N/A $246.90 N/A N/A "$1,171.80 " N/A N/A $683.55 N/A N/A "$1,328.04 " N/A N/A $585.90 N/A N/A "$1,171.80 " N/A N/A "$1,367.10 " N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A "$1,953.00 " "$1,953.00 " N/A 3230595 Emer Charges 21450 RED DISL MANDIB WO MANIP ED Charge 21450 450 "$3,334.00 " $- $445.09 $- $- "$2,667.20 " $- N/A $866.84 N/A N/A Included in ER case rate N/A N/A "$2,000.40 " N/A N/A "$1,667.00 " N/A N/A $445.09 N/A N/A "$2,267.12 " N/A N/A "$1,967.06 " N/A N/A "$1,300.26 " N/A N/A "$2,333.80 " N/A N/A "$2,667.20 " N/A N/A "$1,833.70 " N/A N/A "$2,333.80 " N/A N/A "$1,116.89 " N/A N/A $445.09 N/A N/A "$2,000.40 " N/A N/A "$1,166.90 " N/A N/A "$2,267.12 " N/A N/A "$1,000.20 " N/A N/A "$2,000.40 " N/A N/A "$2,333.80 " N/A N/A "$1,000.20 " N/A N/A "$1,000.20 " N/A N/A "$1,000.20 " N/A N/A "$1,000.20 " N/A N/A "$1,000.20 " N/A N/A "$1,000.20 " N/A "$3,334.00 " "$3,334.00 " N/A 3230596 Emer Charges 27750 - CLOTX TIBIAL SHAFT FX W/O 27750 450 "$1,953.00 " $- $283.85 $- $- "$1,562.40 " $- N/A $507.78 N/A N/A Included in ER case rate N/A N/A "$1,171.80 " N/A N/A $976.50 N/A N/A $283.85 N/A N/A "$1,328.04 " N/A N/A "$1,152.27 " N/A N/A $761.67 N/A N/A "$1,367.10 " N/A N/A "$1,562.40 " N/A N/A "$1,074.15 " N/A N/A "$1,367.10 " N/A N/A $654.26 N/A N/A $283.85 N/A N/A "$1,171.80 " N/A N/A $683.55 N/A N/A "$1,328.04 " N/A N/A $585.90 N/A N/A "$1,171.80 " N/A N/A "$1,367.10 " N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A "$1,953.00 " "$1,953.00 " N/A 3230597 Emer Charges 28490 CLOTX FX BIGTOE PHAX/PHAL 28490 450 "$1,953.00 " $- $111.83 $- $- "$1,562.40 " $- N/A $507.78 N/A N/A Included in ER case rate N/A N/A "$1,171.80 " N/A N/A $976.50 N/A N/A $111.83 N/A N/A "$1,328.04 " N/A N/A "$1,152.27 " N/A N/A $761.67 N/A N/A "$1,367.10 " N/A N/A "$1,562.40 " N/A N/A "$1,074.15 " N/A N/A "$1,367.10 " N/A N/A $654.26 N/A N/A $111.83 N/A N/A "$1,171.80 " N/A N/A $683.55 N/A N/A "$1,328.04 " N/A N/A $585.90 N/A N/A "$1,171.80 " N/A N/A "$1,367.10 " N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A N/A $585.90 N/A "$1,953.00 " "$1,953.00 " N/A 3230605 Emer Charges 46050 ID PERIANAL ABSCESS ED CHARGE 46050 450 "$3,004.00 " $- $87.87 $- $- "$2,403.20 " $- N/A $781.04 N/A N/A Included in ER case rate N/A N/A "$1,802.40 " N/A N/A "$1,502.00 " N/A N/A $87.87 N/A N/A "$2,042.72 " N/A N/A "$1,772.36 " N/A N/A "$1,171.56 " N/A N/A "$2,102.80 " N/A N/A "$2,403.20 " N/A N/A "$1,652.20 " N/A N/A "$2,102.80 " N/A N/A "$1,006.34 " N/A N/A $87.87 N/A N/A "$1,802.40 " N/A N/A "$1,051.40 " N/A N/A "$2,042.72 " N/A N/A $901.20 N/A N/A "$1,802.40 " N/A N/A "$2,102.80 " N/A N/A $901.20 N/A N/A $901.20 N/A N/A $901.20 N/A N/A $901.20 N/A N/A $901.20 N/A N/A $901.20 N/A "$3,004.00 " "$3,004.00 " N/A 3230606 Emer Charges 10060 ED ID ABSCESS SIMPLE/SINGLE CHARGE 10060 450 $777.00 $- $85.15 $- $- $621.60 $- N/A $202.02 N/A N/A Included in ER case rate N/A N/A $466.20 N/A N/A $388.50 N/A N/A $85.15 N/A N/A $528.36 N/A N/A $458.43 N/A N/A $303.03 N/A N/A $543.90 N/A N/A $621.60 N/A N/A $427.35 N/A N/A $543.90 N/A N/A $260.30 N/A N/A $85.15 N/A N/A $466.20 N/A N/A $271.95 N/A N/A $528.36 N/A N/A $233.10 N/A N/A $466.20 N/A N/A $543.90 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A $777.00 $777.00 N/A 3230610 Emer Charges "42000 DRAINAGE ABSCESS PALATE, UVULA ED CHARGE" 42000 450 $699.00 $- $94.06 $- $- $559.20 $- N/A $181.74 N/A N/A Included in ER case rate N/A N/A $419.40 N/A N/A $349.50 N/A N/A $94.06 N/A N/A $475.32 N/A N/A $412.41 N/A N/A $272.61 N/A N/A $489.30 N/A N/A $559.20 N/A N/A $384.45 N/A N/A $489.30 N/A N/A $234.17 N/A N/A $94.06 N/A N/A $419.40 N/A N/A $244.65 N/A N/A $475.32 N/A N/A $209.70 N/A N/A $419.40 N/A N/A $489.30 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A $699.00 $699.00 N/A 3230615 Emer Charges 54700 DRAINAGE OF SCROTUM 54700 450 "$5,420.00 " $- $188.34 $- $- "$4,336.00 " $- N/A "$1,409.20 " N/A N/A Included in ER case rate N/A N/A "$3,252.00 " N/A N/A "$2,710.00 " N/A N/A $188.34 N/A N/A "$3,685.60 " N/A N/A "$3,197.80 " N/A N/A "$2,113.80 " N/A N/A "$3,794.00 " N/A N/A "$4,336.00 " N/A N/A "$2,981.00 " N/A N/A "$3,794.00 " N/A N/A "$1,815.70 " N/A N/A $188.34 N/A N/A "$3,252.00 " N/A N/A "$1,897.00 " N/A N/A "$3,685.60 " N/A N/A "$1,626.00 " N/A N/A "$3,252.00 " N/A N/A "$3,794.00 " N/A N/A "$1,626.00 " N/A N/A "$1,626.00 " N/A N/A "$1,626.00 " N/A N/A "$1,626.00 " N/A N/A "$1,626.00 " N/A N/A "$1,626.00 " N/A "$5,420.00 " "$5,420.00 " N/A 3230625 Emer Charges 26605 ED TRTMT CLOSED METACARPAL FX SINGLE W/ MANIP CHARGE 26605 450 "$1,053.00 " $- $260.63 $- $- $842.40 $- N/A $273.78 N/A N/A Included in ER case rate N/A N/A $631.80 N/A N/A $526.50 N/A N/A $260.63 N/A N/A $716.04 N/A N/A $621.27 N/A N/A $410.67 N/A N/A $737.10 N/A N/A $842.40 N/A N/A $579.15 N/A N/A $737.10 N/A N/A $352.76 N/A N/A $260.63 N/A N/A $631.80 N/A N/A $368.55 N/A N/A $716.04 N/A N/A $315.90 N/A N/A $631.80 N/A N/A $737.10 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A "$1,053.00 " "$1,053.00 " N/A 3230782 Emer Charges OUTPT IM INJECTION T 96372 260 $216.00 $- $20.89 $- $- $172.80 $- N/A $56.16 N/A N/A Included in ER case rate N/A N/A $129.60 N/A N/A $108.00 N/A N/A $20.89 N/A N/A $146.88 N/A N/A $127.44 N/A N/A $84.24 N/A N/A $151.20 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $151.20 N/A N/A $72.36 N/A N/A $20.89 N/A N/A $129.60 N/A N/A $75.60 N/A N/A $146.88 N/A N/A $64.80 N/A N/A $129.60 N/A N/A $151.20 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A $216.00 $216.00 N/A 3230783 Emer Charges 96372 ED SQ / INTRAMUSCULAR INJ 96372 260 $250.00 $- $20.89 $- $- $200.00 $- N/A $65.00 N/A N/A Included in ER case rate N/A N/A $150.00 N/A N/A $125.00 N/A N/A $20.89 N/A N/A $170.00 N/A N/A $147.50 N/A N/A $97.50 N/A N/A $175.00 N/A N/A $200.00 N/A N/A $137.50 N/A N/A $175.00 N/A N/A $83.75 N/A N/A $20.89 N/A N/A $150.00 N/A N/A $87.50 N/A N/A $170.00 N/A N/A $75.00 N/A N/A $150.00 N/A N/A $175.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A $250.00 $250.00 N/A 3230803 Emer Charges 49082 ABD PARACEN (DX/THER)W/O IMAGE ED CHARGE 49082 450 "$2,442.00 " $- $65.93 $- $- "$1,953.60 " $- N/A $634.92 N/A N/A Included in ER case rate N/A N/A "$1,465.20 " N/A N/A "$1,221.00 " N/A N/A $65.93 N/A N/A "$1,660.56 " N/A N/A "$1,440.78 " N/A N/A $952.38 N/A N/A "$1,709.40 " N/A N/A "$1,953.60 " N/A N/A "$1,343.10 " N/A N/A "$1,709.40 " N/A N/A $818.07 N/A N/A $65.93 N/A N/A "$1,465.20 " N/A N/A $854.70 N/A N/A "$1,660.56 " N/A N/A $732.60 N/A N/A "$1,465.20 " N/A N/A "$1,709.40 " N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A "$2,442.00 " "$2,442.00 " N/A 3230902 Emer Charges RN CAPILLARY LAB DRAW 36416 300 $42.00 $- $2.51 $- $- $33.60 $- N/A $10.92 N/A N/A Included in ER case rate N/A N/A $25.20 N/A N/A $21.00 N/A N/A $2.51 N/A N/A $28.56 N/A N/A $24.78 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $2.51 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $28.56 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 3230903 Emer Charges RN LAB VIA VENOUS DEVICE 36591 300 $276.00 $- $20.81 $- $- $220.80 $- N/A $71.76 N/A N/A Included in ER case rate N/A N/A $165.60 N/A N/A $138.00 N/A N/A $20.81 N/A N/A $187.68 N/A N/A $162.84 N/A N/A $107.64 N/A N/A $193.20 N/A N/A $220.80 N/A N/A $151.80 N/A N/A $193.20 N/A N/A $92.46 N/A N/A $20.81 N/A N/A $165.60 N/A N/A $96.60 N/A N/A $187.68 N/A N/A $82.80 N/A N/A $165.60 N/A N/A $193.20 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A $276.00 $276.00 N/A 3230904 Emer Charges RN LAB VIA PICC 36592 300 $276.00 $- $23.36 $- $- $220.80 $- N/A $71.76 N/A N/A Included in ER case rate N/A N/A $165.60 N/A N/A $138.00 N/A N/A $23.36 N/A N/A $187.68 N/A N/A $162.84 N/A N/A $107.64 N/A N/A $193.20 N/A N/A $220.80 N/A N/A $151.80 N/A N/A $193.20 N/A N/A $92.46 N/A N/A $23.36 N/A N/A $165.60 N/A N/A $96.60 N/A N/A $187.68 N/A N/A $82.80 N/A N/A $165.60 N/A N/A $193.20 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A N/A $82.80 N/A $276.00 $276.00 N/A 3230940 Emer Charges 28450 ED TREATMENT OF TARSAL BONE FRACTURE (EXCEPT TALUS AND CALCANEUS); WITHOUT 28450 450 "$1,514.00 " $- $172.67 $- $- "$1,211.20 " $- N/A $393.64 N/A N/A Included in ER case rate N/A N/A $908.40 N/A N/A $757.00 N/A N/A $172.67 N/A N/A "$1,029.52 " N/A N/A $893.26 N/A N/A $590.46 N/A N/A "$1,059.80 " N/A N/A "$1,211.20 " N/A N/A $832.70 N/A N/A "$1,059.80 " N/A N/A $507.19 N/A N/A $172.67 N/A N/A $908.40 N/A N/A $529.90 N/A N/A "$1,029.52 " N/A N/A $454.20 N/A N/A $908.40 N/A N/A "$1,059.80 " N/A N/A $454.20 N/A N/A $454.20 N/A N/A $454.20 N/A N/A $454.20 N/A N/A $454.20 N/A N/A $454.20 N/A "$1,514.00 " "$1,514.00 " N/A 3231054 Emer Charges 29105 ED APPLICATION LONG ARM SPLINT CHARGE 29105 450 $588.00 $- $53.14 $- $- $470.40 $- N/A $152.88 N/A N/A Included in ER case rate N/A N/A $352.80 N/A N/A $294.00 N/A N/A $53.14 N/A N/A $399.84 N/A N/A $346.92 N/A N/A $229.32 N/A N/A $411.60 N/A N/A $470.40 N/A N/A $323.40 N/A N/A $411.60 N/A N/A $196.98 N/A N/A $53.14 N/A N/A $352.80 N/A N/A $205.80 N/A N/A $399.84 N/A N/A $176.40 N/A N/A $352.80 N/A N/A $411.60 N/A N/A $176.40 N/A N/A $176.40 N/A N/A $176.40 N/A N/A $176.40 N/A N/A $176.40 N/A N/A $176.40 N/A $588.00 $588.00 N/A 3231109 Emer Charges ID HEMATOMA ED 27301 490 "$6,975.00 " $- $441.48 $- $- "$5,580.00 " $- N/A "$1,813.50 " N/A N/A Included in ER case rate N/A N/A "$4,185.00 " N/A N/A "$3,487.50 " N/A N/A $441.48 N/A N/A "$4,743.00 " N/A N/A "$4,115.25 " N/A N/A "$2,720.25 " N/A N/A "$4,882.50 " N/A N/A "$5,580.00 " N/A N/A "$3,836.25 " N/A N/A "$4,882.50 " N/A N/A "$2,336.63 " N/A N/A $441.48 N/A N/A "$4,185.00 " N/A N/A "$2,441.25 " N/A N/A "$4,743.00 " N/A N/A "$2,092.50 " N/A N/A "$4,185.00 " N/A N/A "$4,882.50 " N/A N/A "$2,092.50 " N/A N/A "$2,092.50 " N/A N/A "$2,092.50 " N/A N/A "$2,092.50 " N/A N/A "$2,092.50 " N/A N/A "$2,092.50 " N/A "$6,975.00 " "$6,975.00 " N/A 3231120 Emer Charges "26010 DRAIN FINGER ABSCESS, SIMPLE ED CHARGE" 26010 450 "$1,850.00 " $- $123.14 $- $- "$1,480.00 " $- N/A $481.00 N/A N/A Included in ER case rate N/A N/A "$1,110.00 " N/A N/A $925.00 N/A N/A $123.14 N/A N/A "$1,258.00 " N/A N/A "$1,091.50 " N/A N/A $721.50 N/A N/A "$1,295.00 " N/A N/A "$1,480.00 " N/A N/A "$1,017.50 " N/A N/A "$1,295.00 " N/A N/A $619.75 N/A N/A $123.14 N/A N/A "$1,110.00 " N/A N/A $647.50 N/A N/A "$1,258.00 " N/A N/A $555.00 N/A N/A "$1,110.00 " N/A N/A "$1,295.00 " N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A "$1,850.00 " "$1,850.00 " N/A 3231129 Emer Charges 27810 CDTX BIMALANKLE FX W/MANI 27810 450 "$6,270.00 " $- $380.02 $- $- "$5,016.00 " $- N/A "$1,630.20 " N/A N/A Included in ER case rate N/A N/A "$3,762.00 " N/A N/A "$3,135.00 " N/A N/A $380.02 N/A N/A "$4,263.60 " N/A N/A "$3,699.30 " N/A N/A "$2,445.30 " N/A N/A "$4,389.00 " N/A N/A "$5,016.00 " N/A N/A "$3,448.50 " N/A N/A "$4,389.00 " N/A N/A "$2,100.45 " N/A N/A $380.02 N/A N/A "$3,762.00 " N/A N/A "$2,194.50 " N/A N/A "$4,263.60 " N/A N/A "$1,881.00 " N/A N/A "$3,762.00 " N/A N/A "$4,389.00 " N/A N/A "$1,881.00 " N/A N/A "$1,881.00 " N/A N/A "$1,881.00 " N/A N/A "$1,881.00 " N/A N/A "$1,881.00 " N/A N/A "$1,881.00 " N/A "$6,270.00 " "$6,270.00 " N/A 3231204 Emer Charges "10120 ED FOREIGN BODY REMOVAL, SMPL CHARGE" 10120 450 "$1,143.00 " $- $91.93 $- $- $914.40 $- N/A $297.18 N/A N/A Included in ER case rate N/A N/A $685.80 N/A N/A $571.50 N/A N/A $91.93 N/A N/A $777.24 N/A N/A $674.37 N/A N/A $445.77 N/A N/A $800.10 N/A N/A $914.40 N/A N/A $628.65 N/A N/A $800.10 N/A N/A $382.91 N/A N/A $91.93 N/A N/A $685.80 N/A N/A $400.05 N/A N/A $777.24 N/A N/A $342.90 N/A N/A $685.80 N/A N/A $800.10 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A "$1,143.00 " "$1,143.00 " N/A 3231252 Emer Charges 29125 ED APPLICATION SHORT ARM SPLINT CHARGE 29125 450 $497.00 $- $35.44 $- $- $397.60 $- N/A $129.22 N/A N/A Included in ER case rate N/A N/A $298.20 N/A N/A $248.50 N/A N/A $35.44 N/A N/A $337.96 N/A N/A $293.23 N/A N/A $193.83 N/A N/A $347.90 N/A N/A $397.60 N/A N/A $273.35 N/A N/A $347.90 N/A N/A $166.50 N/A N/A $35.44 N/A N/A $298.20 N/A N/A $173.95 N/A N/A $337.96 N/A N/A $149.10 N/A N/A $298.20 N/A N/A $347.90 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A $497.00 $497.00 N/A 3231302 Emer Charges 29130 ED APPLICATION FINGER SPLINT CHARGE 29130 450 $531.00 $- $25.52 $- $- $424.80 $- N/A $138.06 N/A N/A Included in ER case rate N/A N/A $318.60 N/A N/A $265.50 N/A N/A $25.52 N/A N/A $361.08 N/A N/A $313.29 N/A N/A $207.09 N/A N/A $371.70 N/A N/A $424.80 N/A N/A $292.05 N/A N/A $371.70 N/A N/A $177.89 N/A N/A $25.52 N/A N/A $318.60 N/A N/A $185.85 N/A N/A $361.08 N/A N/A $159.30 N/A N/A $318.60 N/A N/A $371.70 N/A N/A $159.30 N/A N/A $159.30 N/A N/A $159.30 N/A N/A $159.30 N/A N/A $159.30 N/A N/A $159.30 N/A $531.00 $531.00 N/A 3231510 Emer Charges 23570 CLSD TX SCAPULAR FX W/O M 23570 450 "$2,244.00 " $- $212.30 $- $- "$1,795.20 " $- N/A $583.44 N/A N/A Included in ER case rate N/A N/A "$1,346.40 " N/A N/A "$1,122.00 " N/A N/A $212.30 N/A N/A "$1,525.92 " N/A N/A "$1,323.96 " N/A N/A $875.16 N/A N/A "$1,570.80 " N/A N/A "$1,795.20 " N/A N/A "$1,234.20 " N/A N/A "$1,570.80 " N/A N/A $751.74 N/A N/A $212.30 N/A N/A "$1,346.40 " N/A N/A $785.40 N/A N/A "$1,525.92 " N/A N/A $673.20 N/A N/A "$1,346.40 " N/A N/A "$1,570.80 " N/A N/A $673.20 N/A N/A $673.20 N/A N/A $673.20 N/A N/A $673.20 N/A N/A $673.20 N/A N/A $673.20 N/A "$2,244.00 " "$2,244.00 " N/A 3231750 Emer Charges 33210 INSERT TEMP TRANS PACEMAKER ED CHARGE 33210 450 "$25,521.00 " $- $160.34 $- $- "$20,416.80 " $- N/A "$6,635.46 " N/A N/A Included in ER case rate N/A N/A "$15,312.60 " N/A N/A "$12,760.50 " N/A N/A $160.34 N/A N/A "$17,354.28 " N/A N/A "$15,057.39 " N/A N/A "$9,953.19 " N/A N/A "$17,864.70 " N/A N/A "$20,416.80 " N/A N/A "$14,036.55 " N/A N/A "$17,864.70 " N/A N/A "$8,549.54 " N/A N/A $160.34 N/A N/A "$15,312.60 " N/A N/A "$8,932.35 " N/A N/A "$17,354.28 " N/A N/A "$7,656.30 " N/A N/A "$15,312.60 " N/A N/A "$17,864.70 " N/A N/A "$7,656.30 " N/A N/A "$7,656.30 " N/A N/A "$7,656.30 " N/A N/A "$7,656.30 " N/A N/A "$7,656.30 " N/A N/A "$7,656.30 " N/A "$25,521.00 " "$25,521.00 " N/A 3232004 Emer Charges 69200 ED FB REMOVE EXTERNAL AUDITORY CANAL W/O ANES CHARGE 69200 450 $281.00 $- $52.30 $- $- $224.80 $- N/A $73.06 N/A N/A Included in ER case rate N/A N/A $168.60 N/A N/A $140.50 N/A N/A $52.30 N/A N/A $191.08 N/A N/A $165.79 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $52.30 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $191.08 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 3232057 Emer Charges 65205 ED FB REMOVE SUPERFICIAL CONJUNCTIVAL CHARGE 65205 450 $408.00 $- $40.89 $- $- $326.40 $- N/A $106.08 N/A N/A Included in ER case rate N/A N/A $244.80 N/A N/A $204.00 N/A N/A $40.89 N/A N/A $277.44 N/A N/A $240.72 N/A N/A $159.12 N/A N/A $285.60 N/A N/A $326.40 N/A N/A $224.40 N/A N/A $285.60 N/A N/A $136.68 N/A N/A $40.89 N/A N/A $244.80 N/A N/A $142.80 N/A N/A $277.44 N/A N/A $122.40 N/A N/A $244.80 N/A N/A $285.60 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A $408.00 $408.00 N/A 3232103 Emer Charges 69210 CERUMEN REMOVAL 69210 450 $281.00 $- $29.49 $- $- $224.80 $- N/A $73.06 N/A N/A Included in ER case rate N/A N/A $168.60 N/A N/A $140.50 N/A N/A $29.49 N/A N/A $191.08 N/A N/A $165.79 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $29.49 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $191.08 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 3232107 Emer Charges 65222 CORNEAL FB REMOV W/ SL/LP ED CHARGE 65222 450 $433.00 $- $48.70 $- $- $346.40 $- N/A $112.58 N/A N/A Included in ER case rate N/A N/A $259.80 N/A N/A $216.50 N/A N/A $48.70 N/A N/A $294.44 N/A N/A $255.47 N/A N/A $168.87 N/A N/A $303.10 N/A N/A $346.40 N/A N/A $238.15 N/A N/A $303.10 N/A N/A $145.06 N/A N/A $48.70 N/A N/A $259.80 N/A N/A $151.55 N/A N/A $294.44 N/A N/A $129.90 N/A N/A $259.80 N/A N/A $303.10 N/A N/A $129.90 N/A N/A $129.90 N/A N/A $129.90 N/A N/A $129.90 N/A N/A $129.90 N/A N/A $129.90 N/A $433.00 $433.00 N/A 3232108 Emer Charges 28190 ED REMOVE FOREIGN BODY SUB CHARGE 28190 450 "$1,413.00 " $- $119.79 $- $- "$1,130.40 " $- N/A $367.38 N/A N/A Included in ER case rate N/A N/A $847.80 N/A N/A $706.50 N/A N/A $119.79 N/A N/A $960.84 N/A N/A $833.67 N/A N/A $551.07 N/A N/A $989.10 N/A N/A "$1,130.40 " N/A N/A $777.15 N/A N/A $989.10 N/A N/A $473.36 N/A N/A $119.79 N/A N/A $847.80 N/A N/A $494.55 N/A N/A $960.84 N/A N/A $423.90 N/A N/A $847.80 N/A N/A $989.10 N/A N/A $423.90 N/A N/A $423.90 N/A N/A $423.90 N/A N/A $423.90 N/A N/A $423.90 N/A N/A $423.90 N/A "$1,413.00 " "$1,413.00 " N/A 3232110 Emer Charges 30300 ED REMOVE FOREIGN BODY INTRANASAL CHARGE 30300 450 $427.00 $- $111.02 $- $- $341.60 $- N/A $111.02 N/A N/A Included in ER case rate N/A N/A $256.20 N/A N/A $213.50 N/A N/A $113.85 N/A N/A $290.36 N/A N/A $251.93 N/A N/A $166.53 N/A N/A $298.90 N/A N/A $341.60 N/A N/A $234.85 N/A N/A $298.90 N/A N/A $143.05 N/A N/A $113.85 N/A N/A $256.20 N/A N/A $149.45 N/A N/A $290.36 N/A N/A $128.10 N/A N/A $256.20 N/A N/A $298.90 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A $427.00 $427.00 N/A 3232129 Emer Charges 11011 DEBRIDE SKIN/MUS FX O/DIS 11011 450 "$2,237.00 " $- $268.69 $- $- "$1,789.60 " $- N/A $581.62 N/A N/A Included in ER case rate N/A N/A "$1,342.20 " N/A N/A "$1,118.50 " N/A N/A $268.69 N/A N/A "$1,521.16 " N/A N/A "$1,319.83 " N/A N/A $872.43 N/A N/A "$1,565.90 " N/A N/A "$1,789.60 " N/A N/A "$1,230.35 " N/A N/A "$1,565.90 " N/A N/A $749.40 N/A N/A $268.69 N/A N/A "$1,342.20 " N/A N/A $782.95 N/A N/A "$1,521.16 " N/A N/A $671.10 N/A N/A "$1,342.20 " N/A N/A "$1,565.90 " N/A N/A $671.10 N/A N/A $671.10 N/A N/A $671.10 N/A N/A $671.10 N/A N/A $671.10 N/A N/A $671.10 N/A "$2,237.00 " "$2,237.00 " N/A 3232150 Emer Charges 42809 ED REMOVAL FOREIGN BODY PHARYNX CHARGE 42809 450 $654.00 $- $120.47 $- $- $523.20 $- N/A $170.04 N/A N/A Included in ER case rate N/A N/A $392.40 N/A N/A $327.00 N/A N/A $120.47 N/A N/A $444.72 N/A N/A $385.86 N/A N/A $255.06 N/A N/A $457.80 N/A N/A $523.20 N/A N/A $359.70 N/A N/A $457.80 N/A N/A $219.09 N/A N/A $120.47 N/A N/A $392.40 N/A N/A $228.90 N/A N/A $444.72 N/A N/A $196.20 N/A N/A $392.40 N/A N/A $457.80 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A $654.00 $654.00 N/A 3232207 Emer Charges 65220 CORNEAL FB REMOV W/O SLIT LAMP ED CHARGE 65220 450 $408.00 $- $38.35 $- $- $326.40 $- N/A $106.08 N/A N/A Included in ER case rate N/A N/A $244.80 N/A N/A $204.00 N/A N/A $38.35 N/A N/A $277.44 N/A N/A $240.72 N/A N/A $159.12 N/A N/A $285.60 N/A N/A $326.40 N/A N/A $224.40 N/A N/A $285.60 N/A N/A $136.68 N/A N/A $38.35 N/A N/A $244.80 N/A N/A $142.80 N/A N/A $277.44 N/A N/A $122.40 N/A N/A $244.80 N/A N/A $285.60 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A $408.00 $408.00 N/A 3232702 Emer Charges 62270 ED SPINAL PUNCTURE LUMBAR CHARGE 62270 450 "$1,706.00 " $- $70.68 $- $- "$1,364.80 " $- N/A $443.56 N/A N/A Included in ER case rate N/A N/A "$1,023.60 " N/A N/A $853.00 N/A N/A $70.68 N/A N/A "$1,160.08 " N/A N/A "$1,006.54 " N/A N/A $665.34 N/A N/A "$1,194.20 " N/A N/A "$1,364.80 " N/A N/A $938.30 N/A N/A "$1,194.20 " N/A N/A $571.51 N/A N/A $70.68 N/A N/A "$1,023.60 " N/A N/A $597.10 N/A N/A "$1,160.08 " N/A N/A $511.80 N/A N/A "$1,023.60 " N/A N/A "$1,194.20 " N/A N/A $511.80 N/A N/A $511.80 N/A N/A $511.80 N/A N/A $511.80 N/A N/A $511.80 N/A N/A $511.80 N/A "$1,706.00 " "$1,706.00 " N/A 3232945 Emer Charges 20552 INJ SINGLE/MULT TRIGGER PTS ED CHARGE 20552 450 "$1,199.00 " $- $33.88 $- $- $959.20 $- N/A $311.74 N/A N/A Included in ER case rate N/A N/A $719.40 N/A N/A $599.50 N/A N/A $33.88 N/A N/A $815.32 N/A N/A $707.41 N/A N/A $467.61 N/A N/A $839.30 N/A N/A $959.20 N/A N/A $659.45 N/A N/A $839.30 N/A N/A $401.67 N/A N/A $33.88 N/A N/A $719.40 N/A N/A $419.65 N/A N/A $815.32 N/A N/A $359.70 N/A N/A $719.40 N/A N/A $839.30 N/A N/A $359.70 N/A N/A $359.70 N/A N/A $359.70 N/A N/A $359.70 N/A N/A $359.70 N/A N/A $359.70 N/A "$1,199.00 " "$1,199.00 " N/A 3232950 Emer Charges 64450 INJ NERVE BLOCK OTHER PERIPHERAL NERVE 64450 450 $662.00 $- $40.75 $- $- $529.60 $- N/A $172.12 N/A N/A Included in ER case rate N/A N/A $397.20 N/A N/A $331.00 N/A N/A $40.75 N/A N/A $450.16 N/A N/A $390.58 N/A N/A $258.18 N/A N/A $463.40 N/A N/A $529.60 N/A N/A $364.10 N/A N/A $463.40 N/A N/A $221.77 N/A N/A $40.75 N/A N/A $397.20 N/A N/A $231.70 N/A N/A $450.16 N/A N/A $198.60 N/A N/A $397.20 N/A N/A $463.40 N/A N/A $198.60 N/A N/A $198.60 N/A N/A $198.60 N/A N/A $198.60 N/A N/A $198.60 N/A N/A $198.60 N/A $662.00 $662.00 N/A 3232955 Emer Charges "64400 ED INJECTION, ANESTHETIC AGENT; TRIGEMINAL NERVE, ANT DIVISION OR BRANCH C" 64400 450 "$1,181.00 " $- $61.76 $- $- $944.80 $- N/A $307.06 N/A N/A Included in ER case rate N/A N/A $708.60 N/A N/A $590.50 N/A N/A $61.76 N/A N/A $803.08 N/A N/A $696.79 N/A N/A $460.59 N/A N/A $826.70 N/A N/A $944.80 N/A N/A $649.55 N/A N/A $826.70 N/A N/A $395.64 N/A N/A $61.76 N/A N/A $708.60 N/A N/A $413.35 N/A N/A $803.08 N/A N/A $354.30 N/A N/A $708.60 N/A N/A $826.70 N/A N/A $354.30 N/A N/A $354.30 N/A N/A $354.30 N/A N/A $354.30 N/A N/A $354.30 N/A N/A $354.30 N/A "$1,181.00 " "$1,181.00 " N/A 3232965 Emer Charges "64402 INJ ANEST TRIG. NERVE, FACIAL ED CHARGE" 64402 450 "$1,596.00 " $- $414.96 $- $- "$1,276.80 " $- N/A $414.96 N/A N/A Included in ER case rate N/A N/A $957.60 N/A N/A $798.00 N/A N/A N/A N/A N/A "$1,085.28 " N/A N/A $941.64 N/A N/A $622.44 N/A N/A "$1,117.20 " N/A N/A "$1,276.80 " N/A N/A $877.80 N/A N/A "$1,117.20 " N/A N/A $534.66 N/A N/A N/A N/A N/A $957.60 N/A N/A $558.60 N/A N/A "$1,085.28 " N/A N/A $478.80 N/A N/A $957.60 N/A N/A "$1,117.20 " N/A N/A $478.80 N/A N/A $478.80 N/A N/A $478.80 N/A N/A $478.80 N/A N/A $478.80 N/A N/A $478.80 N/A "$1,596.00 " "$1,596.00 " N/A 3233010 Emer Charges "31525 LARYNGOSCOPY DIR DIAG, NOT NB ED CHARGE" 31525 450 "$3,779.00 " $- $144.26 $- $- "$3,023.20 " $- N/A $982.54 N/A N/A Included in ER case rate N/A N/A "$2,267.40 " N/A N/A "$1,889.50 " N/A N/A $144.26 N/A N/A "$2,569.72 " N/A N/A "$2,229.61 " N/A N/A "$1,473.81 " N/A N/A "$2,645.30 " N/A N/A "$3,023.20 " N/A N/A "$2,078.45 " N/A N/A "$2,645.30 " N/A N/A "$1,265.97 " N/A N/A $144.26 N/A N/A "$2,267.40 " N/A N/A "$1,322.65 " N/A N/A "$2,569.72 " N/A N/A "$1,133.70 " N/A N/A "$2,267.40 " N/A N/A "$2,645.30 " N/A N/A "$1,133.70 " N/A N/A "$1,133.70 " N/A N/A "$1,133.70 " N/A N/A "$1,133.70 " N/A N/A "$1,133.70 " N/A N/A "$1,133.70 " N/A "$3,779.00 " "$3,779.00 " N/A 3233030 Emer Charges 29540 STRAPPING ANKLE 29540 450 $334.00 $- $23.07 $- $- $267.20 $- N/A $86.84 N/A N/A Included in ER case rate N/A N/A $200.40 N/A N/A $167.00 N/A N/A $23.07 N/A N/A $227.12 N/A N/A $197.06 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $23.07 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $227.12 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 3233031 Emer Charges 29530 STRAPPING KNEE 29530 450 $492.00 $- $32.73 $- $- $393.60 $- N/A $127.92 N/A N/A Included in ER case rate N/A N/A $295.20 N/A N/A $246.00 N/A N/A $32.73 N/A N/A $334.56 N/A N/A $290.28 N/A N/A $191.88 N/A N/A $344.40 N/A N/A $393.60 N/A N/A $270.60 N/A N/A $344.40 N/A N/A $164.82 N/A N/A $32.73 N/A N/A $295.20 N/A N/A $172.20 N/A N/A $334.56 N/A N/A $147.60 N/A N/A $295.20 N/A N/A $344.40 N/A N/A $147.60 N/A N/A $147.60 N/A N/A $147.60 N/A N/A $147.60 N/A N/A $147.60 N/A N/A $147.60 N/A $492.00 $492.00 N/A 3233035 Emer Charges 29550 STRAPPING TOES ED CHARGE 29550 450 $439.00 $- $17.20 $- $- $351.20 $- N/A $114.14 N/A N/A Included in ER case rate N/A N/A $263.40 N/A N/A $219.50 N/A N/A $17.20 N/A N/A $298.52 N/A N/A $259.01 N/A N/A $171.21 N/A N/A $307.30 N/A N/A $351.20 N/A N/A $241.45 N/A N/A $307.30 N/A N/A $147.07 N/A N/A $17.20 N/A N/A $263.40 N/A N/A $153.65 N/A N/A $298.52 N/A N/A $131.70 N/A N/A $263.40 N/A N/A $307.30 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A $439.00 $439.00 N/A 3233349 Emer Charges 46320 ENUC/EXC EXT THROMBOTIC HEMORR ED CHARGE 46320 450 "$5,476.00 " $- $99.77 $- $- "$4,380.80 " $- N/A "$1,423.76 " N/A N/A Included in ER case rate N/A N/A "$3,285.60 " N/A N/A "$2,738.00 " N/A N/A $99.77 N/A N/A "$3,723.68 " N/A N/A "$3,230.84 " N/A N/A "$2,135.64 " N/A N/A "$3,833.20 " N/A N/A "$4,380.80 " N/A N/A "$3,011.80 " N/A N/A "$3,833.20 " N/A N/A "$1,834.46 " N/A N/A $99.77 N/A N/A "$3,285.60 " N/A N/A "$1,916.60 " N/A N/A "$3,723.68 " N/A N/A "$1,642.80 " N/A N/A "$3,285.60 " N/A N/A "$3,833.20 " N/A N/A "$1,642.80 " N/A N/A "$1,642.80 " N/A N/A "$1,642.80 " N/A N/A "$1,642.80 " N/A N/A "$1,642.80 " N/A N/A "$1,642.80 " N/A "$5,476.00 " "$5,476.00 " N/A 3233402 Emer Charges 20610 ARTHROCENTESIS MAJOR JOINT ED CHARGE 20610 450 "$1,116.00 " $- $41.09 $- $- $892.80 $- N/A $290.16 N/A N/A Included in ER case rate N/A N/A $669.60 N/A N/A $558.00 N/A N/A $41.09 N/A N/A $758.88 N/A N/A $658.44 N/A N/A $435.24 N/A N/A $781.20 N/A N/A $892.80 N/A N/A $613.80 N/A N/A $781.20 N/A N/A $373.86 N/A N/A $41.09 N/A N/A $669.60 N/A N/A $390.60 N/A N/A $758.88 N/A N/A $334.80 N/A N/A $669.60 N/A N/A $781.20 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A "$1,116.00 " "$1,116.00 " N/A 3233410 Emer Charges 20600 ARTHROCENTESIS ASP/INJ JOINT ED CHARGE 20600 450 "$1,314.00 " $- $31.65 $- $- "$1,051.20 " $- N/A $341.64 N/A N/A Included in ER case rate N/A N/A $788.40 N/A N/A $657.00 N/A N/A $31.65 N/A N/A $893.52 N/A N/A $775.26 N/A N/A $512.46 N/A N/A $919.80 N/A N/A "$1,051.20 " N/A N/A $722.70 N/A N/A $919.80 N/A N/A $440.19 N/A N/A $31.65 N/A N/A $788.40 N/A N/A $459.90 N/A N/A $893.52 N/A N/A $394.20 N/A N/A $788.40 N/A N/A $919.80 N/A N/A $394.20 N/A N/A $394.20 N/A N/A $394.20 N/A N/A $394.20 N/A N/A $394.20 N/A N/A $394.20 N/A "$1,314.00 " "$1,314.00 " N/A 3233428 Emer Charges 24640 CLO TX ELBOW- CHILD 24640 450 $694.00 $- $84.31 $- $- $555.20 $- N/A $180.44 N/A N/A Included in ER case rate N/A N/A $416.40 N/A N/A $347.00 N/A N/A $84.31 N/A N/A $471.92 N/A N/A $409.46 N/A N/A $270.66 N/A N/A $485.80 N/A N/A $555.20 N/A N/A $381.70 N/A N/A $485.80 N/A N/A $232.49 N/A N/A $84.31 N/A N/A $416.40 N/A N/A $242.90 N/A N/A $471.92 N/A N/A $208.20 N/A N/A $416.40 N/A N/A $485.80 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A N/A $208.20 N/A $694.00 $694.00 N/A 3233540 Emer Charges 32551 CHEST TUBE INSERT 32551 450 "$6,048.00 " $- $159.75 $- $- "$4,838.40 " $- N/A "$1,572.48 " N/A N/A Included in ER case rate N/A N/A "$3,628.80 " N/A N/A "$3,024.00 " N/A N/A $159.75 N/A N/A "$4,112.64 " N/A N/A "$3,568.32 " N/A N/A "$2,358.72 " N/A N/A "$4,233.60 " N/A N/A "$4,838.40 " N/A N/A "$3,326.40 " N/A N/A "$4,233.60 " N/A N/A "$2,026.08 " N/A N/A $159.75 N/A N/A "$3,628.80 " N/A N/A "$2,116.80 " N/A N/A "$4,112.64 " N/A N/A "$1,814.40 " N/A N/A "$3,628.80 " N/A N/A "$4,233.60 " N/A N/A "$1,814.40 " N/A N/A "$1,814.40 " N/A N/A "$1,814.40 " N/A N/A "$1,814.40 " N/A N/A "$1,814.40 " N/A N/A "$1,814.40 " N/A "$6,048.00 " "$6,048.00 " N/A 3233550 Emer Charges 99355 ED PROLONGED SERV OFFICE/OUT PT CHARGE 99355 450 $350.00 $- $78.81 $- $- $280.00 $- N/A $91.00 N/A N/A Included in ER case rate N/A N/A $210.00 N/A N/A $175.00 N/A N/A $78.81 N/A N/A $238.00 N/A N/A $206.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A $78.81 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $238.00 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 3234051 Emer Charges ID PERINEAL ABCESS 56405 490 "$1,146.00 " $- $98.04 $- $- $916.80 $- N/A $297.96 N/A N/A Included in ER case rate N/A N/A $687.60 N/A N/A $573.00 N/A N/A $98.04 N/A N/A $779.28 N/A N/A $676.14 N/A N/A $446.94 N/A N/A $802.20 N/A N/A $916.80 N/A N/A $630.30 N/A N/A $802.20 N/A N/A $383.91 N/A N/A $98.04 N/A N/A $687.60 N/A N/A $401.10 N/A N/A $779.28 N/A N/A $343.80 N/A N/A $687.60 N/A N/A $802.20 N/A N/A $343.80 N/A N/A $343.80 N/A N/A $343.80 N/A N/A $343.80 N/A N/A $343.80 N/A N/A $343.80 N/A "$1,146.00 " "$1,146.00 " N/A 3234108 Emer Charges 36410 CENTRAL LINE COLL 36410 450 $120.00 $- $8.71 $- $- $96.00 $- N/A $31.20 N/A N/A Included in ER case rate N/A N/A $72.00 N/A N/A $60.00 N/A N/A $8.71 N/A N/A $81.60 N/A N/A $70.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $8.71 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $81.60 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 3234203 Emer Charges 56420 DRAINAGE OF GLAND ABSCESS 56420 450 $722.00 $- $82.41 $- $- $577.60 $- N/A $187.72 N/A N/A Included in ER case rate N/A N/A $433.20 N/A N/A $361.00 N/A N/A $82.41 N/A N/A $490.96 N/A N/A $425.98 N/A N/A $281.58 N/A N/A $505.40 N/A N/A $577.60 N/A N/A $397.10 N/A N/A $505.40 N/A N/A $241.87 N/A N/A $82.41 N/A N/A $433.20 N/A N/A $252.70 N/A N/A $490.96 N/A N/A $216.60 N/A N/A $433.20 N/A N/A $505.40 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A N/A $216.60 N/A $722.00 $722.00 N/A 3234207 Emer Charges 46083 INCIS OF EXT THROMBOSED HEMORR ED CHARGE 46083 450 "$1,109.00 " $- $95.19 $- $- $887.20 $- N/A $288.34 N/A N/A Included in ER case rate N/A N/A $665.40 N/A N/A $554.50 N/A N/A $95.19 N/A N/A $754.12 N/A N/A $654.31 N/A N/A $432.51 N/A N/A $776.30 N/A N/A $887.20 N/A N/A $609.95 N/A N/A $776.30 N/A N/A $371.52 N/A N/A $95.19 N/A N/A $665.40 N/A N/A $388.15 N/A N/A $754.12 N/A N/A $332.70 N/A N/A $665.40 N/A N/A $776.30 N/A N/A $332.70 N/A N/A $332.70 N/A N/A $332.70 N/A N/A $332.70 N/A N/A $332.70 N/A N/A $332.70 N/A "$1,109.00 " "$1,109.00 " N/A 3234210 Emer Charges 46040 ED ID RECTAL ABSCESS CHARGE 46040 450 "$6,839.00 " $- $368.16 $- $- "$5,471.20 " $- N/A "$1,778.14 " N/A N/A Included in ER case rate N/A N/A "$4,103.40 " N/A N/A "$3,419.50 " N/A N/A $368.16 N/A N/A "$4,650.52 " N/A N/A "$4,035.01 " N/A N/A "$2,667.21 " N/A N/A "$4,787.30 " N/A N/A "$5,471.20 " N/A N/A "$3,761.45 " N/A N/A "$4,787.30 " N/A N/A "$2,291.07 " N/A N/A $368.16 N/A N/A "$4,103.40 " N/A N/A "$2,393.65 " N/A N/A "$4,650.52 " N/A N/A "$2,051.70 " N/A N/A "$4,103.40 " N/A N/A "$4,787.30 " N/A N/A "$2,051.70 " N/A N/A "$2,051.70 " N/A N/A "$2,051.70 " N/A N/A "$2,051.70 " N/A N/A "$2,051.70 " N/A N/A "$2,051.70 " N/A "$6,839.00 " "$6,839.00 " N/A 3234809 Emer Charges 21480 TEMPORAMANDIBULAR DISLOCATION ED CHARGE 21480 450 $507.00 $- $28.58 $- $- $405.60 $- N/A $131.82 N/A N/A Included in ER case rate N/A N/A $304.20 N/A N/A $253.50 N/A N/A $28.58 N/A N/A $344.76 N/A N/A $299.13 N/A N/A $197.73 N/A N/A $354.90 N/A N/A $405.60 N/A N/A $278.85 N/A N/A $354.90 N/A N/A $169.85 N/A N/A $28.58 N/A N/A $304.20 N/A N/A $177.45 N/A N/A $344.76 N/A N/A $152.10 N/A N/A $304.20 N/A N/A $354.90 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A N/A $152.10 N/A $507.00 $507.00 N/A 3235002 Emer Charges 31500 ED INTUBATION EMERGENCY PROCEDURE CHARGE 31500 450 "$1,499.00 " $- $98.34 $- $- "$1,199.20 " $- N/A $389.74 N/A N/A Included in ER case rate N/A N/A $899.40 N/A N/A $749.50 N/A N/A $98.34 N/A N/A "$1,019.32 " N/A N/A $884.41 N/A N/A $584.61 N/A N/A "$1,049.30 " N/A N/A "$1,199.20 " N/A N/A $824.45 N/A N/A "$1,049.30 " N/A N/A $502.17 N/A N/A $98.34 N/A N/A $899.40 N/A N/A $524.65 N/A N/A "$1,019.32 " N/A N/A $449.70 N/A N/A $899.40 N/A N/A "$1,049.30 " N/A N/A $449.70 N/A N/A $449.70 N/A N/A $449.70 N/A N/A $449.70 N/A N/A $449.70 N/A N/A $449.70 N/A "$1,499.00 " "$1,499.00 " N/A 3235051 Emer Charges "31505 LARYNGOSCOPY, INDIRECT, DIAG ED CHARGE" 31505 450 $518.00 $- $44.19 $- $- $414.40 $- N/A $134.68 N/A N/A Included in ER case rate N/A N/A $310.80 N/A N/A $259.00 N/A N/A $44.19 N/A N/A $352.24 N/A N/A $305.62 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $44.19 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $352.24 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 3235055 Emer Charges "29505 APPLICATION, LONG LEG SPLINT ED CHARGE" 29505 450 $575.00 $- $44.77 $- $- $460.00 $- N/A $149.50 N/A N/A Included in ER case rate N/A N/A $345.00 N/A N/A $287.50 N/A N/A $44.77 N/A N/A $391.00 N/A N/A $339.25 N/A N/A $224.25 N/A N/A $402.50 N/A N/A $460.00 N/A N/A $316.25 N/A N/A $402.50 N/A N/A $192.63 N/A N/A $44.77 N/A N/A $345.00 N/A N/A $201.25 N/A N/A $391.00 N/A N/A $172.50 N/A N/A $345.00 N/A N/A $402.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A $575.00 $575.00 N/A 3235154 Emer Charges 29515 ED APPLICATION SHORT LEG SPLINT CHARGE 29515 450 $553.00 $- $44.69 $- $- $442.40 $- N/A $143.78 N/A N/A Included in ER case rate N/A N/A $331.80 N/A N/A $276.50 N/A N/A $44.69 N/A N/A $376.04 N/A N/A $326.27 N/A N/A $215.67 N/A N/A $387.10 N/A N/A $442.40 N/A N/A $304.15 N/A N/A $387.10 N/A N/A $185.26 N/A N/A $44.69 N/A N/A $331.80 N/A N/A $193.55 N/A N/A $376.04 N/A N/A $165.90 N/A N/A $331.80 N/A N/A $387.10 N/A N/A $165.90 N/A N/A $165.90 N/A N/A $165.90 N/A N/A $165.90 N/A N/A $165.90 N/A N/A $165.90 N/A $553.00 $553.00 N/A 3235170 Emer Charges 51700 Bladder Irrigation 51700 450 "$1,153.00 " $- $39.30 $- $- $922.40 $- N/A $299.78 N/A N/A Included in ER case rate N/A N/A $691.80 N/A N/A $576.50 N/A N/A $39.30 N/A N/A $784.04 N/A N/A $680.27 N/A N/A $449.67 N/A N/A $807.10 N/A N/A $922.40 N/A N/A $634.15 N/A N/A $807.10 N/A N/A $386.26 N/A N/A $39.30 N/A N/A $691.80 N/A N/A $403.55 N/A N/A $784.04 N/A N/A $345.90 N/A N/A $691.80 N/A N/A $807.10 N/A N/A $345.90 N/A N/A $345.90 N/A N/A $345.90 N/A N/A $345.90 N/A N/A $345.90 N/A N/A $345.90 N/A "$1,153.00 " "$1,153.00 " N/A 3235172 Emer Charges 51702 CATH INSERT FOLEY ED Charge 51702 450 $479.00 $- $26.77 $- $- $383.20 $- N/A $124.54 N/A N/A Included in ER case rate N/A N/A $287.40 N/A N/A $239.50 N/A N/A $26.77 N/A N/A $325.72 N/A N/A $282.61 N/A N/A $186.81 N/A N/A $335.30 N/A N/A $383.20 N/A N/A $263.45 N/A N/A $335.30 N/A N/A $160.47 N/A N/A $26.77 N/A N/A $287.40 N/A N/A $167.65 N/A N/A $325.72 N/A N/A $143.70 N/A N/A $287.40 N/A N/A $335.30 N/A N/A $143.70 N/A N/A $143.70 N/A N/A $143.70 N/A N/A $143.70 N/A N/A $143.70 N/A N/A $143.70 N/A $479.00 $479.00 N/A 3235203 Emer Charges 11012 DEB REMOV F MAT SKIN/TISS/BONE ED CHARGE 11012 450 "$1,307.00 " $- $339.82 $- $- "$1,045.60 " $- N/A $339.82 N/A N/A Included in ER case rate N/A N/A $784.20 N/A N/A $653.50 N/A N/A $379.52 N/A N/A $888.76 N/A N/A $771.13 N/A N/A $509.73 N/A N/A $914.90 N/A N/A "$1,045.60 " N/A N/A $718.85 N/A N/A $914.90 N/A N/A $437.85 N/A N/A $379.52 N/A N/A $784.20 N/A N/A $457.45 N/A N/A $888.76 N/A N/A $392.10 N/A N/A $784.20 N/A N/A $914.90 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A "$1,307.00 " "$1,307.00 " N/A 3235503 Emer Charges 27550 CLO TX KNEE DISLOC WO ANE 27550 450 $872.00 $- $226.72 $- $- $697.60 $- N/A $226.72 N/A N/A Included in ER case rate N/A N/A $523.20 N/A N/A $436.00 N/A N/A $419.35 N/A N/A $592.96 N/A N/A $514.48 N/A N/A $340.08 N/A N/A $610.40 N/A N/A $697.60 N/A N/A $479.60 N/A N/A $610.40 N/A N/A $292.12 N/A N/A $419.35 N/A N/A $523.20 N/A N/A $305.20 N/A N/A $592.96 N/A N/A $261.60 N/A N/A $523.20 N/A N/A $610.40 N/A N/A $261.60 N/A N/A $261.60 N/A N/A $261.60 N/A N/A $261.60 N/A N/A $261.60 N/A N/A $261.60 N/A $872.00 $872.00 N/A 3236025 Emer Charges 19000 ED BREAST ASPIRATION PUNCTURE CHARGE 19000 450 "$1,798.00 " $- $39.09 $- $- "$1,438.40 " $- N/A $467.48 N/A N/A Included in ER case rate N/A N/A "$1,078.80 " N/A N/A $899.00 N/A N/A $39.09 N/A N/A "$1,222.64 " N/A N/A "$1,060.82 " N/A N/A $701.22 N/A N/A "$1,258.60 " N/A N/A "$1,438.40 " N/A N/A $988.90 N/A N/A "$1,258.60 " N/A N/A $602.33 N/A N/A $39.09 N/A N/A "$1,078.80 " N/A N/A $629.30 N/A N/A "$1,222.64 " N/A N/A $539.40 N/A N/A "$1,078.80 " N/A N/A "$1,258.60 " N/A N/A $539.40 N/A N/A $539.40 N/A N/A $539.40 N/A N/A $539.40 N/A N/A $539.40 N/A N/A $539.40 N/A "$1,798.00 " "$1,798.00 " N/A 3236034 Emer Charges TRACHEOTOMY 31603 450 "$2,829.00 " $- $201.46 $- $- "$2,263.20 " $- N/A $735.54 N/A N/A Included in ER case rate N/A N/A "$1,697.40 " N/A N/A "$1,414.50 " N/A N/A $201.46 N/A N/A "$1,923.72 " N/A N/A "$1,669.11 " N/A N/A "$1,103.31 " N/A N/A "$1,980.30 " N/A N/A "$2,263.20 " N/A N/A "$1,555.95 " N/A N/A "$1,980.30 " N/A N/A $947.72 N/A N/A $201.46 N/A N/A "$1,697.40 " N/A N/A $990.15 N/A N/A "$1,923.72 " N/A N/A $848.70 N/A N/A "$1,697.40 " N/A N/A "$1,980.30 " N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A "$2,829.00 " "$2,829.00 " N/A 3236365 Emer Charges OUT PATIENT IV THERAPY 1S 96365 260 $764.00 $- $57.70 $- $- $611.20 $- N/A $198.64 N/A N/A Included in ER case rate N/A N/A $458.40 N/A N/A $382.00 N/A N/A $57.70 N/A N/A $519.52 N/A N/A $450.76 N/A N/A $297.96 N/A N/A $534.80 N/A N/A $611.20 N/A N/A $420.20 N/A N/A $534.80 N/A N/A $255.94 N/A N/A $57.70 N/A N/A $458.40 N/A N/A $267.40 N/A N/A $519.52 N/A N/A $229.20 N/A N/A $458.40 N/A N/A $534.80 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A $764.00 $764.00 N/A 3236366 Emer Charges ADDL DRUG INFUSION 96366 260 $316.00 $- $15.44 $- $- $252.80 $- N/A $82.16 N/A N/A Included in ER case rate N/A N/A $189.60 N/A N/A $158.00 N/A N/A $15.44 N/A N/A $214.88 N/A N/A $186.44 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $15.44 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $214.88 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 3236405 Emer Charges 24605 Clsd Elbw Dslctn w/Anes 24605 450 "$6,032.00 " $- $417.98 $- $- "$4,825.60 " $- N/A "$1,568.32 " N/A N/A Included in ER case rate N/A N/A "$3,619.20 " N/A N/A "$3,016.00 " N/A N/A $417.98 N/A N/A "$4,101.76 " N/A N/A "$3,558.88 " N/A N/A "$2,352.48 " N/A N/A "$4,222.40 " N/A N/A "$4,825.60 " N/A N/A "$3,317.60 " N/A N/A "$4,222.40 " N/A N/A "$2,020.72 " N/A N/A $417.98 N/A N/A "$3,619.20 " N/A N/A "$2,111.20 " N/A N/A "$4,101.76 " N/A N/A "$1,809.60 " N/A N/A "$3,619.20 " N/A N/A "$4,222.40 " N/A N/A "$1,809.60 " N/A N/A "$1,809.60 " N/A N/A "$1,809.60 " N/A N/A "$1,809.60 " N/A N/A "$1,809.60 " N/A N/A "$1,809.60 " N/A "$6,032.00 " "$6,032.00 " N/A 3236406 Emer Charges 26770 CLSD REDUCTN DSLCTED FING 26770 450 $651.00 $- $169.26 $- $- $520.80 $- N/A $169.26 N/A N/A Included in ER case rate N/A N/A $390.60 N/A N/A $325.50 N/A N/A $227.80 N/A N/A $442.68 N/A N/A $384.09 N/A N/A $253.89 N/A N/A $455.70 N/A N/A $520.80 N/A N/A $358.05 N/A N/A $455.70 N/A N/A $218.09 N/A N/A $227.80 N/A N/A $390.60 N/A N/A $227.85 N/A N/A $442.68 N/A N/A $195.30 N/A N/A $390.60 N/A N/A $455.70 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A $651.00 $651.00 N/A 3236410 Emer Charges 40830 REPAIR MOUTH LACERATION 40830 450 "$1,143.00 " $- $152.57 $- $- $914.40 $- N/A $297.18 N/A N/A Included in ER case rate N/A N/A $685.80 N/A N/A $571.50 N/A N/A $152.57 N/A N/A $777.24 N/A N/A $674.37 N/A N/A $445.77 N/A N/A $800.10 N/A N/A $914.40 N/A N/A $628.65 N/A N/A $800.10 N/A N/A $382.91 N/A N/A $152.57 N/A N/A $685.80 N/A N/A $400.05 N/A N/A $777.24 N/A N/A $342.90 N/A N/A $685.80 N/A N/A $800.10 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A N/A $342.90 N/A "$1,143.00 " "$1,143.00 " N/A 3236415 Emer Charges 41250 ED REPAIR OF LACERATION 2.5 CM OR LESS; FLOOR OF MOUTH AND/OR ANTERIOR TWO 41250 450 $591.00 $- $141.18 $- $- $472.80 $- N/A $153.66 N/A N/A Included in ER case rate N/A N/A $354.60 N/A N/A $295.50 N/A N/A $141.18 N/A N/A $401.88 N/A N/A $348.69 N/A N/A $230.49 N/A N/A $413.70 N/A N/A $472.80 N/A N/A $325.05 N/A N/A $413.70 N/A N/A $197.99 N/A N/A $141.18 N/A N/A $354.60 N/A N/A $206.85 N/A N/A $401.88 N/A N/A $177.30 N/A N/A $354.60 N/A N/A $413.70 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A $591.00 $591.00 N/A 3236420 Emer Charges 29260 STRAPPING ELBOW OR WRIST 29260 450 $489.00 $- $32.75 $- $- $391.20 $- N/A $127.14 N/A N/A Included in ER case rate N/A N/A $293.40 N/A N/A $244.50 N/A N/A $32.75 N/A N/A $332.52 N/A N/A $288.51 N/A N/A $190.71 N/A N/A $342.30 N/A N/A $391.20 N/A N/A $268.95 N/A N/A $342.30 N/A N/A $163.82 N/A N/A $32.75 N/A N/A $293.40 N/A N/A $171.15 N/A N/A $332.52 N/A N/A $146.70 N/A N/A $293.40 N/A N/A $342.30 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A $489.00 $489.00 N/A 3236430 Emer Charges TRANSFUSION BLOOD PR 36430 391 "$1,418.00 " $- $30.40 $- $- "$1,134.40 " $- N/A $368.68 N/A N/A Included in ER case rate N/A N/A $850.80 N/A N/A $709.00 N/A N/A $30.40 N/A N/A $964.24 N/A N/A $836.62 N/A N/A $553.02 N/A N/A $992.60 N/A N/A "$1,134.40 " N/A N/A $779.90 N/A N/A $992.60 N/A N/A $475.03 N/A N/A $30.40 N/A N/A $850.80 N/A N/A $496.30 N/A N/A $964.24 N/A N/A $425.40 N/A N/A $850.80 N/A N/A $992.60 N/A N/A $425.40 N/A N/A $425.40 N/A N/A $425.40 N/A N/A $425.40 N/A N/A $425.40 N/A N/A $425.40 N/A "$1,418.00 " "$1,418.00 " N/A 3236707 Emer Charges REDUCTION FINGER 26670 490 $728.00 $- $189.28 $- $- $582.40 $- N/A $189.28 N/A N/A Included in ER case rate N/A N/A $436.80 N/A N/A $364.00 N/A N/A $273.87 N/A N/A $495.04 N/A N/A $429.52 N/A N/A $283.92 N/A N/A $509.60 N/A N/A $582.40 N/A N/A $400.40 N/A N/A $509.60 N/A N/A $243.88 N/A N/A $273.87 N/A N/A $436.80 N/A N/A $254.80 N/A N/A $495.04 N/A N/A $218.40 N/A N/A $436.80 N/A N/A $509.60 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A N/A $218.40 N/A $728.00 $728.00 N/A 3236750 Emer Charges DISLOCATION WRIST 25675 490 $699.00 $- $181.74 $- $- $559.20 $- N/A $181.74 N/A N/A Included in ER case rate N/A N/A $419.40 N/A N/A $349.50 N/A N/A $354.60 N/A N/A $475.32 N/A N/A $412.41 N/A N/A $272.61 N/A N/A $489.30 N/A N/A $559.20 N/A N/A $384.45 N/A N/A $489.30 N/A N/A $234.17 N/A N/A $354.60 N/A N/A $419.40 N/A N/A $244.65 N/A N/A $475.32 N/A N/A $209.70 N/A N/A $419.40 N/A N/A $489.30 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A N/A $209.70 N/A $699.00 $699.00 N/A 3237265 Emer Charges POST ARTHROPLASTY HI 27265 490 $893.00 $- $232.18 $- $- $714.40 $- N/A $232.18 N/A N/A Included in ER case rate N/A N/A $535.80 N/A N/A $446.50 N/A N/A $356.69 N/A N/A $607.24 N/A N/A $526.87 N/A N/A $348.27 N/A N/A $625.10 N/A N/A $714.40 N/A N/A $491.15 N/A N/A $625.10 N/A N/A $299.16 N/A N/A $356.69 N/A N/A $535.80 N/A N/A $312.55 N/A N/A $607.24 N/A N/A $267.90 N/A N/A $535.80 N/A N/A $625.10 N/A N/A $267.90 N/A N/A $267.90 N/A N/A $267.90 N/A N/A $267.90 N/A N/A $267.90 N/A N/A $267.90 N/A $893.00 $893.00 N/A 3237309 Emer Charges 11730 AVULSION OF NAIL PLATE ED CHARGE 11730 450 $894.00 $- $45.01 $- $- $715.20 $- N/A $232.44 N/A N/A Included in ER case rate N/A N/A $536.40 N/A N/A $447.00 N/A N/A $45.01 N/A N/A $607.92 N/A N/A $527.46 N/A N/A $348.66 N/A N/A $625.80 N/A N/A $715.20 N/A N/A $491.70 N/A N/A $625.80 N/A N/A $299.49 N/A N/A $45.01 N/A N/A $536.40 N/A N/A $312.90 N/A N/A $607.92 N/A N/A $268.20 N/A N/A $536.40 N/A N/A $625.80 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A $894.00 $894.00 N/A 3237408 Emer Charges 11740 ED EVACUATION OF SUBUNGUAL HEMATOMA CHARGE 11740 450 $403.00 $- $29.18 $- $- $322.40 $- N/A $104.78 N/A N/A Included in ER case rate N/A N/A $241.80 N/A N/A $201.50 N/A N/A $29.18 N/A N/A $274.04 N/A N/A $237.77 N/A N/A $157.17 N/A N/A $282.10 N/A N/A $322.40 N/A N/A $221.65 N/A N/A $282.10 N/A N/A $135.01 N/A N/A $29.18 N/A N/A $241.80 N/A N/A $141.05 N/A N/A $274.04 N/A N/A $120.90 N/A N/A $241.80 N/A N/A $282.10 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A $403.00 $403.00 N/A 3237410 Emer Charges 10140 ED DRAINAGE OF HEMATOMA CHARGE 10140 450 "$5,966.00 " $- $105.14 $- $- "$4,772.80 " $- N/A "$1,551.16 " N/A N/A Included in ER case rate N/A N/A "$3,579.60 " N/A N/A "$2,983.00 " N/A N/A $105.14 N/A N/A "$4,056.88 " N/A N/A "$3,519.94 " N/A N/A "$2,326.74 " N/A N/A "$4,176.20 " N/A N/A "$4,772.80 " N/A N/A "$3,281.30 " N/A N/A "$4,176.20 " N/A N/A "$1,998.61 " N/A N/A $105.14 N/A N/A "$3,579.60 " N/A N/A "$2,088.10 " N/A N/A "$4,056.88 " N/A N/A "$1,789.80 " N/A N/A "$3,579.60 " N/A N/A "$4,176.20 " N/A N/A "$1,789.80 " N/A N/A "$1,789.80 " N/A N/A "$1,789.80 " N/A N/A "$1,789.80 " N/A N/A "$1,789.80 " N/A N/A "$1,789.80 " N/A "$5,966.00 " "$5,966.00 " N/A 3237507 Emer Charges 11750 ED EXC NAIL/MATRIX CHARGE 11750 450 "$1,850.00 " $- $154.19 $- $- "$1,480.00 " $- N/A $481.00 N/A N/A Included in ER case rate N/A N/A "$1,110.00 " N/A N/A $925.00 N/A N/A $154.19 N/A N/A "$1,258.00 " N/A N/A "$1,091.50 " N/A N/A $721.50 N/A N/A "$1,295.00 " N/A N/A "$1,480.00 " N/A N/A "$1,017.50 " N/A N/A "$1,295.00 " N/A N/A $619.75 N/A N/A $154.19 N/A N/A "$1,110.00 " N/A N/A $647.50 N/A N/A "$1,258.00 " N/A N/A $555.00 N/A N/A "$1,110.00 " N/A N/A "$1,295.00 " N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A N/A $555.00 N/A "$1,850.00 " "$1,850.00 " N/A 3237510 Emer Charges 11765 ED WEDGE EXCISION SKIN OF NAIL FOLD CHARGE 11765 450 "$1,581.00 " $- $82.87 $- $- "$1,264.80 " $- N/A $411.06 N/A N/A Included in ER case rate N/A N/A $948.60 N/A N/A $790.50 N/A N/A $82.87 N/A N/A "$1,075.08 " N/A N/A $932.79 N/A N/A $616.59 N/A N/A "$1,106.70 " N/A N/A "$1,264.80 " N/A N/A $869.55 N/A N/A "$1,106.70 " N/A N/A $529.64 N/A N/A $82.87 N/A N/A $948.60 N/A N/A $553.35 N/A N/A "$1,075.08 " N/A N/A $474.30 N/A N/A $948.60 N/A N/A "$1,106.70 " N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A "$1,581.00 " "$1,581.00 " N/A 3238001 Emer Charges 10080 ED ID PILONIDAL CYST SIMPLE CHARGE 10080 450 $811.00 $- $91.98 $- $- $648.80 $- N/A $210.86 N/A N/A Included in ER case rate N/A N/A $486.60 N/A N/A $405.50 N/A N/A $91.98 N/A N/A $551.48 N/A N/A $478.49 N/A N/A $316.29 N/A N/A $567.70 N/A N/A $648.80 N/A N/A $446.05 N/A N/A $567.70 N/A N/A $271.69 N/A N/A $91.98 N/A N/A $486.60 N/A N/A $283.85 N/A N/A $551.48 N/A N/A $243.30 N/A N/A $486.60 N/A N/A $567.70 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A $811.00 $811.00 N/A 3238408 Emer Charges 27840 CLO TX ANK DISLOC WO ANEX 27840 450 $965.00 $- $250.90 $- $- $772.00 $- N/A $250.90 N/A N/A Included in ER case rate N/A N/A $579.00 N/A N/A $482.50 N/A N/A $330.75 N/A N/A $656.20 N/A N/A $569.35 N/A N/A $376.35 N/A N/A $675.50 N/A N/A $772.00 N/A N/A $530.75 N/A N/A $675.50 N/A N/A $323.28 N/A N/A $330.75 N/A N/A $579.00 N/A N/A $337.75 N/A N/A $656.20 N/A N/A $289.50 N/A N/A $579.00 N/A N/A $675.50 N/A N/A $289.50 N/A N/A $289.50 N/A N/A $289.50 N/A N/A $289.50 N/A N/A $289.50 N/A N/A $289.50 N/A $965.00 $965.00 N/A 3238510 Emer Charges 28510 CLO TX FX PHALANX 28510 450 $655.00 $- $107.32 $- $- $524.00 $- N/A $170.30 N/A N/A Included in ER case rate N/A N/A $393.00 N/A N/A $327.50 N/A N/A $107.32 N/A N/A $445.40 N/A N/A $386.45 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $107.32 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $445.40 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 3239013 Emer Charges 30901 CNTRL NSAL HMRR-ANT-SIMP 30901 450 $476.00 $- $50.56 $- $- $380.80 $- N/A $123.76 N/A N/A Included in ER case rate N/A N/A $285.60 N/A N/A $238.00 N/A N/A $50.56 N/A N/A $323.68 N/A N/A $280.84 N/A N/A $185.64 N/A N/A $333.20 N/A N/A $380.80 N/A N/A $261.80 N/A N/A $333.20 N/A N/A $159.46 N/A N/A $50.56 N/A N/A $285.60 N/A N/A $166.60 N/A N/A $323.68 N/A N/A $142.80 N/A N/A $285.60 N/A N/A $333.20 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A $476.00 $476.00 N/A 3239039 Emer Charges 30903 CNTRL NSAL HMRR COMPLEX 30903 450 $476.00 $- $71.05 $- $- $380.80 $- N/A $123.76 N/A N/A Included in ER case rate N/A N/A $285.60 N/A N/A $238.00 N/A N/A $71.05 N/A N/A $323.68 N/A N/A $280.84 N/A N/A $185.64 N/A N/A $333.20 N/A N/A $380.80 N/A N/A $261.80 N/A N/A $333.20 N/A N/A $159.46 N/A N/A $71.05 N/A N/A $285.60 N/A N/A $166.60 N/A N/A $323.68 N/A N/A $142.80 N/A N/A $285.60 N/A N/A $333.20 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A $476.00 $476.00 N/A 3239054 Emer Charges 30905 CNTRL NSAL HMRR-POSTER 30905 450 $476.00 $- $90.28 $- $- $380.80 $- N/A $123.76 N/A N/A Included in ER case rate N/A N/A $285.60 N/A N/A $238.00 N/A N/A $90.28 N/A N/A $323.68 N/A N/A $280.84 N/A N/A $185.64 N/A N/A $333.20 N/A N/A $380.80 N/A N/A $261.80 N/A N/A $333.20 N/A N/A $159.46 N/A N/A $90.28 N/A N/A $285.60 N/A N/A $166.60 N/A N/A $323.68 N/A N/A $142.80 N/A N/A $285.60 N/A N/A $333.20 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A N/A $142.80 N/A $476.00 $476.00 N/A 3239505 Emer Charges 92950 CARDIOPULM RESUSCITA ED Charge 92950 450 "$1,781.00 " $- $154.02 $- $- "$1,424.80 " $- N/A $463.06 N/A N/A Included in ER case rate N/A N/A "$1,068.60 " N/A N/A $890.50 N/A N/A $154.02 N/A N/A "$1,211.08 " N/A N/A "$1,050.79 " N/A N/A $694.59 N/A N/A "$1,246.70 " N/A N/A "$1,424.80 " N/A N/A $979.55 N/A N/A "$1,246.70 " N/A N/A $596.64 N/A N/A $154.02 N/A N/A "$1,068.60 " N/A N/A $623.35 N/A N/A "$1,211.08 " N/A N/A $534.30 N/A N/A "$1,068.60 " N/A N/A "$1,246.70 " N/A N/A $534.30 N/A N/A $534.30 N/A N/A $534.30 N/A N/A $534.30 N/A N/A $534.30 N/A N/A $534.30 N/A "$1,781.00 " "$1,781.00 " N/A 3239536 Emer Charges 92953 ED EXT PACEMAKER NON INVASIVE CHARGE 92953 450 "$1,150.00 " $- $9.03 $- $- $920.00 $- N/A $299.00 N/A N/A Included in ER case rate N/A N/A $690.00 N/A N/A $575.00 N/A N/A $9.03 N/A N/A $782.00 N/A N/A $678.50 N/A N/A $448.50 N/A N/A $805.00 N/A N/A $920.00 N/A N/A $632.50 N/A N/A $805.00 N/A N/A $385.25 N/A N/A $9.03 N/A N/A $690.00 N/A N/A $402.50 N/A N/A $782.00 N/A N/A $345.00 N/A N/A $690.00 N/A N/A $805.00 N/A N/A $345.00 N/A N/A $345.00 N/A N/A $345.00 N/A N/A $345.00 N/A N/A $345.00 N/A N/A $345.00 N/A "$1,150.00 " "$1,150.00 " N/A 3416115 Emer Charges 11732 ED AVULSION OF NAIL PLATE PARTIAL/COMPLETE EACH ADD CHARGE 11732 450 $312.00 $- $17.87 $- $- $249.60 $- N/A $81.12 N/A N/A Included in ER case rate N/A N/A $187.20 N/A N/A $156.00 N/A N/A $17.87 N/A N/A $212.16 N/A N/A $184.08 N/A N/A $121.68 N/A N/A $218.40 N/A N/A $249.60 N/A N/A $171.60 N/A N/A $218.40 N/A N/A $104.52 N/A N/A $17.87 N/A N/A $187.20 N/A N/A $109.20 N/A N/A $212.16 N/A N/A $93.60 N/A N/A $187.20 N/A N/A $218.40 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A $312.00 $312.00 N/A 24453382 Emer Charges INJ SINGLE TENDON SHEATH/LIGAMENT 20550 450 "$2,952.00 " $- $36.95 $- $- "$2,361.60 " $- N/A $767.52 N/A N/A Included in ER case rate N/A N/A "$1,771.20 " N/A N/A "$1,476.00 " N/A N/A $36.95 N/A N/A "$2,007.36 " N/A N/A "$1,741.68 " N/A N/A "$1,151.28 " N/A N/A "$2,066.40 " N/A N/A "$2,361.60 " N/A N/A "$1,623.60 " N/A N/A "$2,066.40 " N/A N/A $988.92 N/A N/A $36.95 N/A N/A "$1,771.20 " N/A N/A "$1,033.20 " N/A N/A "$2,007.36 " N/A N/A $885.60 N/A N/A "$1,771.20 " N/A N/A "$2,066.40 " N/A N/A $885.60 N/A N/A $885.60 N/A N/A $885.60 N/A N/A $885.60 N/A N/A $885.60 N/A N/A $885.60 N/A "$2,952.00 " "$2,952.00 " N/A 24453387 Emer Charges EXC BENIGN LESION W/MARGINS EXCEPT SKIN TAG-SCALP-NECK-HAND 11421 450 "$2,337.00 " $- $98.33 $- $- "$1,869.60 " $- N/A $607.62 N/A N/A Included in ER case rate N/A N/A "$1,402.20 " N/A N/A "$1,168.50 " N/A N/A $98.33 N/A N/A "$1,589.16 " N/A N/A "$1,378.83 " N/A N/A $911.43 N/A N/A "$1,635.90 " N/A N/A "$1,869.60 " N/A N/A "$1,285.35 " N/A N/A "$1,635.90 " N/A N/A $782.90 N/A N/A $98.33 N/A N/A "$1,402.20 " N/A N/A $817.95 N/A N/A "$1,589.16 " N/A N/A $701.10 N/A N/A "$1,402.20 " N/A N/A "$1,635.90 " N/A N/A $701.10 N/A N/A $701.10 N/A N/A $701.10 N/A N/A $701.10 N/A N/A $701.10 N/A N/A $701.10 N/A "$2,337.00 " "$2,337.00 " N/A 45011401 Emer Charges Excision Benign Lesion Including Margins 0.6-1.0 CM Trunk Ar 11401 450 "$1,483.00 " $- $91.89 $- $- "$1,186.40 " $- N/A $385.58 N/A N/A Included in ER case rate N/A N/A $889.80 N/A N/A $741.50 N/A N/A $91.89 N/A N/A "$1,008.44 " N/A N/A $874.97 N/A N/A $578.37 N/A N/A "$1,038.10 " N/A N/A "$1,186.40 " N/A N/A $815.65 N/A N/A "$1,038.10 " N/A N/A $496.81 N/A N/A $91.89 N/A N/A $889.80 N/A N/A $519.05 N/A N/A "$1,008.44 " N/A N/A $444.90 N/A N/A $889.80 N/A N/A "$1,038.10 " N/A N/A $444.90 N/A N/A $444.90 N/A N/A $444.90 N/A N/A $444.90 N/A N/A $444.90 N/A N/A $444.90 N/A "$1,483.00 " "$1,483.00 " N/A 45019020 Emer Charges "19020 INCISION OF BREAST LESION, DEEP" 19020 450 "$3,431.00 " $- $270.53 $- $- "$2,744.80 " $- N/A $892.06 N/A N/A Included in ER case rate N/A N/A "$2,058.60 " N/A N/A "$1,715.50 " N/A N/A $270.53 N/A N/A "$2,333.08 " N/A N/A "$2,024.29 " N/A N/A "$1,338.09 " N/A N/A "$2,401.70 " N/A N/A "$2,744.80 " N/A N/A "$1,887.05 " N/A N/A "$2,401.70 " N/A N/A "$1,149.39 " N/A N/A $270.53 N/A N/A "$2,058.60 " N/A N/A "$1,200.85 " N/A N/A "$2,333.08 " N/A N/A "$1,029.30 " N/A N/A "$2,058.60 " N/A N/A "$2,401.70 " N/A N/A "$1,029.30 " N/A N/A "$1,029.30 " N/A N/A "$1,029.30 " N/A N/A "$1,029.30 " N/A N/A "$1,029.30 " N/A N/A "$1,029.30 " N/A "$3,431.00 " "$3,431.00 " N/A 45023665 Emer Charges CLSD TX SHOULDER DISLOCATION FX HUMERAL TUBEROSITY W/MANIP 23665 450 "$1,296.00 " $- $336.96 $- $- "$1,036.80 " $- N/A $336.96 N/A N/A Included in ER case rate N/A N/A $777.60 N/A N/A $648.00 N/A N/A $353.08 N/A N/A $881.28 N/A N/A $764.64 N/A N/A $505.44 N/A N/A $907.20 N/A N/A "$1,036.80 " N/A N/A $712.80 N/A N/A $907.20 N/A N/A $434.16 N/A N/A $353.08 N/A N/A $777.60 N/A N/A $453.60 N/A N/A $881.28 N/A N/A $388.80 N/A N/A $777.60 N/A N/A $907.20 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A N/A $388.80 N/A "$1,296.00 " "$1,296.00 " N/A 45025505 Emer Charges 25505 CLOSED TX OF RADIAL SHAFT FX W/MANIP CHARGE 25505 450 "$2,933.00 " $- $409.25 $- $- "$2,346.40 " $- N/A $762.58 N/A N/A Included in ER case rate N/A N/A "$1,759.80 " N/A N/A "$1,466.50 " N/A N/A $409.25 N/A N/A "$1,994.44 " N/A N/A "$1,730.47 " N/A N/A "$1,143.87 " N/A N/A "$2,053.10 " N/A N/A "$2,346.40 " N/A N/A "$1,613.15 " N/A N/A "$2,053.10 " N/A N/A $982.56 N/A N/A $409.25 N/A N/A "$1,759.80 " N/A N/A "$1,026.55 " N/A N/A "$1,994.44 " N/A N/A $879.90 N/A N/A "$1,759.80 " N/A N/A "$2,053.10 " N/A N/A $879.90 N/A N/A $879.90 N/A N/A $879.90 N/A N/A $879.90 N/A N/A $879.90 N/A N/A $879.90 N/A "$2,933.00 " "$2,933.00 " N/A 45025530 Emer Charges CLOSED TX ULNAR SHAFT FX W/O MANIPULATION 25530 450 $550.00 $- $143.00 $- $- $440.00 $- N/A $143.00 N/A N/A Included in ER case rate N/A N/A $330.00 N/A N/A $275.00 N/A N/A $210.86 N/A N/A $374.00 N/A N/A $324.50 N/A N/A $214.50 N/A N/A $385.00 N/A N/A $440.00 N/A N/A $302.50 N/A N/A $385.00 N/A N/A $184.25 N/A N/A $210.86 N/A N/A $330.00 N/A N/A $192.50 N/A N/A $374.00 N/A N/A $165.00 N/A N/A $330.00 N/A N/A $385.00 N/A N/A $165.00 N/A N/A $165.00 N/A N/A $165.00 N/A N/A $165.00 N/A N/A $165.00 N/A N/A $165.00 N/A $550.00 $550.00 N/A 45026700 Emer Charges CLSD TX METACARPOPHALANGEAL DISLOC W/MANIP AND W/O ANEST 26700 450 $651.00 $- $169.26 $- $- $520.80 $- N/A $169.26 N/A N/A Included in ER case rate N/A N/A $390.60 N/A N/A $325.50 N/A N/A $271.60 N/A N/A $442.68 N/A N/A $384.09 N/A N/A $253.89 N/A N/A $455.70 N/A N/A $520.80 N/A N/A $358.05 N/A N/A $455.70 N/A N/A $218.09 N/A N/A $271.60 N/A N/A $390.60 N/A N/A $227.85 N/A N/A $442.68 N/A N/A $195.30 N/A N/A $390.60 N/A N/A $455.70 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A $651.00 $651.00 N/A 45026951 Emer Charges AMPUTATION FINGER OR THUMB 26951 450 "$5,572.00 " $- $574.38 $- $- "$4,457.60 " $- N/A "$1,448.72 " N/A N/A Included in ER case rate N/A N/A "$3,343.20 " N/A N/A "$2,786.00 " N/A N/A $574.38 N/A N/A "$3,788.96 " N/A N/A "$3,287.48 " N/A N/A "$2,173.08 " N/A N/A "$3,900.40 " N/A N/A "$4,457.60 " N/A N/A "$3,064.60 " N/A N/A "$3,900.40 " N/A N/A "$1,866.62 " N/A N/A $574.38 N/A N/A "$3,343.20 " N/A N/A "$1,950.20 " N/A N/A "$3,788.96 " N/A N/A "$1,671.60 " N/A N/A "$3,343.20 " N/A N/A "$3,900.40 " N/A N/A "$1,671.60 " N/A N/A "$1,671.60 " N/A N/A "$1,671.60 " N/A N/A "$1,671.60 " N/A N/A "$1,671.60 " N/A N/A "$1,671.60 " N/A "$5,572.00 " "$5,572.00 " N/A 45027501 Emer Charges TX THIGH FRACTURE 27501 450 $777.00 $- $202.02 $- $- $621.60 $- N/A $202.02 N/A N/A Included in ER case rate N/A N/A $466.20 N/A N/A $388.50 N/A N/A $444.73 N/A N/A $528.36 N/A N/A $458.43 N/A N/A $303.03 N/A N/A $543.90 N/A N/A $621.60 N/A N/A $427.35 N/A N/A $543.90 N/A N/A $260.30 N/A N/A $444.73 N/A N/A $466.20 N/A N/A $271.95 N/A N/A $528.36 N/A N/A $233.10 N/A N/A $466.20 N/A N/A $543.90 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A N/A $233.10 N/A $777.00 $777.00 N/A 45027560 Emer Charges 27560 CLSD TX PATELLAR DISLOCATION W/O ANESTHESIA 27560 450 "$2,252.00 " $- $297.73 $- $- "$1,801.60 " $- N/A $585.52 N/A N/A Included in ER case rate N/A N/A "$1,351.20 " N/A N/A "$1,126.00 " N/A N/A $297.73 N/A N/A "$1,531.36 " N/A N/A "$1,328.68 " N/A N/A $878.28 N/A N/A "$1,576.40 " N/A N/A "$1,801.60 " N/A N/A "$1,238.60 " N/A N/A "$1,576.40 " N/A N/A $754.42 N/A N/A $297.73 N/A N/A "$1,351.20 " N/A N/A $788.20 N/A N/A "$1,531.36 " N/A N/A $675.60 N/A N/A "$1,351.20 " N/A N/A "$1,576.40 " N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A "$2,252.00 " "$2,252.00 " N/A 45027562 Emer Charges CL TX PATELLAR DISLOC; W ANEST Charge 27562 450 $990.00 $- $257.40 $- $- $792.00 $- N/A $257.40 N/A N/A Included in ER case rate N/A N/A $594.00 N/A N/A $495.00 N/A N/A $430.67 N/A N/A $673.20 N/A N/A $584.10 N/A N/A $386.10 N/A N/A $693.00 N/A N/A $792.00 N/A N/A $544.50 N/A N/A $693.00 N/A N/A $331.65 N/A N/A $430.67 N/A N/A $594.00 N/A N/A $346.50 N/A N/A $673.20 N/A N/A $297.00 N/A N/A $594.00 N/A N/A $693.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A $990.00 $990.00 N/A 45027634 Emer Charges EXC TUMOR SOFT TISSUE LEG/ANKLE > 5CM 27634 450 "$4,880.00 " $- #N/A $- $- #N/A $- N/A "$1,268.80 " N/A N/A Included in ER case rate N/A N/A "$2,928.00 " N/A N/A "$2,440.00 " N/A N/A N/A N/A N/A "$3,318.40 " N/A N/A "$2,879.20 " N/A N/A "$1,903.20 " N/A N/A "$3,416.00 " N/A N/A "$3,904.00 " N/A N/A "$2,684.00 " N/A N/A "$3,416.00 " N/A N/A "$1,634.80 " N/A N/A #N/A N/A N/A "$2,928.00 " N/A N/A "$1,708.00 " N/A N/A "$3,318.40 " N/A N/A "$1,464.00 " N/A N/A "$2,928.00 " N/A N/A "$3,416.00 " N/A N/A "$1,464.00 " N/A N/A "$1,464.00 " N/A N/A "$1,464.00 " N/A N/A "$1,464.00 " N/A N/A "$1,464.00 " N/A N/A "$1,464.00 " N/A "$4,880.00 " "$4,880.00 " N/A 45027762 Emer Charges CLOSED TX MEDIAL MALLEOLUS ANKLE FX WITH MANIPULATION 27762 450 $885.00 $- $230.10 $- $- $708.00 $- N/A $230.10 N/A N/A Included in ER case rate N/A N/A $531.00 N/A N/A $442.50 N/A N/A N/A N/A N/A $601.80 N/A N/A $522.15 N/A N/A $345.15 N/A N/A $619.50 N/A N/A $708.00 N/A N/A $486.75 N/A N/A $619.50 N/A N/A $296.48 N/A N/A $390.00 N/A N/A $531.00 N/A N/A $309.75 N/A N/A $601.80 N/A N/A $265.50 N/A N/A $531.00 N/A N/A $619.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A N/A $265.50 N/A $885.00 $885.00 N/A 45027816 Emer Charges CLSD TX TRIMALLEOLAR ANKLE FX W/O MANIPULATION 27816 450 $687.00 $- $178.62 $- $- $549.60 $- N/A $178.62 N/A N/A Included in ER case rate N/A N/A $412.20 N/A N/A $343.50 N/A N/A $255.42 N/A N/A $467.16 N/A N/A $405.33 N/A N/A $267.93 N/A N/A $480.90 N/A N/A $549.60 N/A N/A $377.85 N/A N/A $480.90 N/A N/A $230.15 N/A N/A $255.42 N/A N/A $412.20 N/A N/A $240.45 N/A N/A $467.16 N/A N/A $206.10 N/A N/A $412.20 N/A N/A $480.90 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A $687.00 $687.00 N/A 45027842 Emer Charges CLOSED TREATMENT OF ANKLE DISLOCATION REQUIRING ANESTHESIA C 27842 450 "$2,309.00 " $- $441.44 $- $- "$1,847.20 " $- N/A $600.34 N/A N/A Included in ER case rate N/A N/A "$1,385.40 " N/A N/A "$1,154.50 " N/A N/A $441.44 N/A N/A "$1,570.12 " N/A N/A "$1,362.31 " N/A N/A $900.51 N/A N/A "$1,616.30 " N/A N/A "$1,847.20 " N/A N/A "$1,269.95 " N/A N/A "$1,616.30 " N/A N/A $773.52 N/A N/A $441.44 N/A N/A "$1,385.40 " N/A N/A $808.15 N/A N/A "$1,570.12 " N/A N/A $692.70 N/A N/A "$1,385.40 " N/A N/A "$1,616.30 " N/A N/A $692.70 N/A N/A $692.70 N/A N/A $692.70 N/A N/A $692.70 N/A N/A $692.70 N/A N/A $692.70 N/A "$2,309.00 " "$2,309.00 " N/A 45028430 Emer Charges 28430 CLOSED TX OF TALUS FX W/O MANIPULATION 28430 450 "$2,252.00 " $- $187.45 $- $- "$1,801.60 " $- N/A $585.52 N/A N/A Included in ER case rate N/A N/A "$1,351.20 " N/A N/A "$1,126.00 " N/A N/A $187.45 N/A N/A "$1,531.36 " N/A N/A "$1,328.68 " N/A N/A $878.28 N/A N/A "$1,576.40 " N/A N/A "$1,801.60 " N/A N/A "$1,238.60 " N/A N/A "$1,576.40 " N/A N/A $754.42 N/A N/A $187.45 N/A N/A "$1,351.20 " N/A N/A $788.20 N/A N/A "$1,531.36 " N/A N/A $675.60 N/A N/A "$1,351.20 " N/A N/A "$1,576.40 " N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A N/A $675.60 N/A "$2,252.00 " "$2,252.00 " N/A 45028475 Emer Charges CLOSED TX METATARSAL FX WITH MANIPULATION EACH 28475 450 $909.00 $- $202.83 $- $- $727.20 $- N/A $236.34 N/A N/A Included in ER case rate N/A N/A $545.40 N/A N/A $454.50 N/A N/A $202.83 N/A N/A $618.12 N/A N/A $536.31 N/A N/A $354.51 N/A N/A $636.30 N/A N/A $727.20 N/A N/A $499.95 N/A N/A $636.30 N/A N/A $304.52 N/A N/A $202.83 N/A N/A $545.40 N/A N/A $318.15 N/A N/A $618.12 N/A N/A $272.70 N/A N/A $545.40 N/A N/A $636.30 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A $909.00 $909.00 N/A 45028495 Emer Charges CLSD TX FX GREAT TOE W/MANIP 28495 450 $740.00 $- $133.44 $- $- $592.00 $- N/A $192.40 N/A N/A Included in ER case rate N/A N/A $444.00 N/A N/A $370.00 N/A N/A $133.44 N/A N/A $503.20 N/A N/A $436.60 N/A N/A $288.60 N/A N/A $518.00 N/A N/A $592.00 N/A N/A $407.00 N/A N/A $518.00 N/A N/A $247.90 N/A N/A $133.44 N/A N/A $444.00 N/A N/A $259.00 N/A N/A $503.20 N/A N/A $222.00 N/A N/A $444.00 N/A N/A $518.00 N/A N/A $222.00 N/A N/A $222.00 N/A N/A $222.00 N/A N/A $222.00 N/A N/A $222.00 N/A N/A $222.00 N/A $740.00 $740.00 N/A 45028515 Emer Charges 28515 CLSD TX FX TOE W/MANIP 28515 450 "$2,844.00 " $- $126.89 $- $- "$2,275.20 " $- N/A $739.44 N/A N/A Included in ER case rate N/A N/A "$1,706.40 " N/A N/A "$1,422.00 " N/A N/A $126.89 N/A N/A "$1,933.92 " N/A N/A "$1,677.96 " N/A N/A "$1,109.16 " N/A N/A "$1,990.80 " N/A N/A "$2,275.20 " N/A N/A "$1,564.20 " N/A N/A "$1,990.80 " N/A N/A $952.74 N/A N/A $126.89 N/A N/A "$1,706.40 " N/A N/A $995.40 N/A N/A "$1,933.92 " N/A N/A $853.20 N/A N/A "$1,706.40 " N/A N/A "$1,990.80 " N/A N/A $853.20 N/A N/A $853.20 N/A N/A $853.20 N/A N/A $853.20 N/A N/A $853.20 N/A N/A $853.20 N/A "$2,844.00 " "$2,844.00 " N/A 45031502 Emer Charges TRACHEOTOMY TUBE CHANGE 31502 450 $702.00 $- $31.34 $- $- $561.60 $- N/A $182.52 N/A N/A Included in ER case rate N/A N/A $421.20 N/A N/A $351.00 N/A N/A $31.34 N/A N/A $477.36 N/A N/A $414.18 N/A N/A $273.78 N/A N/A $491.40 N/A N/A $561.60 N/A N/A $386.10 N/A N/A $491.40 N/A N/A $235.17 N/A N/A $31.34 N/A N/A $421.20 N/A N/A $245.70 N/A N/A $477.36 N/A N/A $210.60 N/A N/A $421.20 N/A N/A $491.40 N/A N/A $210.60 N/A N/A $210.60 N/A N/A $210.60 N/A N/A $210.60 N/A N/A $210.60 N/A N/A $210.60 N/A $702.00 $702.00 N/A 45031511 Emer Charges REMOVE FOREIGN BODY LARYNX 31511 450 $609.00 $- $116.84 $- $- $487.20 $- N/A $158.34 N/A N/A Included in ER case rate N/A N/A $365.40 N/A N/A $304.50 N/A N/A $116.84 N/A N/A $414.12 N/A N/A $359.31 N/A N/A $237.51 N/A N/A $426.30 N/A N/A $487.20 N/A N/A $334.95 N/A N/A $426.30 N/A N/A $204.02 N/A N/A $116.84 N/A N/A $365.40 N/A N/A $213.15 N/A N/A $414.12 N/A N/A $182.70 N/A N/A $365.40 N/A N/A $426.30 N/A N/A $182.70 N/A N/A $182.70 N/A N/A $182.70 N/A N/A $182.70 N/A N/A $182.70 N/A N/A $182.70 N/A $609.00 $609.00 N/A 45036571 Emer Charges 36571 INSERT PIC CENTRAL ACCESS DEVICE W/SUBCUTE PORT OVER 5 36571 450 "$4,391.00 " $- $291.43 $- $- "$3,512.80 " $- N/A "$1,141.66 " N/A N/A Included in ER case rate N/A N/A "$2,634.60 " N/A N/A "$2,195.50 " N/A N/A $291.43 N/A N/A "$2,985.88 " N/A N/A "$2,590.69 " N/A N/A "$1,712.49 " N/A N/A "$3,073.70 " N/A N/A "$3,512.80 " N/A N/A "$2,415.05 " N/A N/A "$3,073.70 " N/A N/A "$1,470.99 " N/A N/A $291.43 N/A N/A "$2,634.60 " N/A N/A "$1,536.85 " N/A N/A "$2,985.88 " N/A N/A "$1,317.30 " N/A N/A "$2,634.60 " N/A N/A "$3,073.70 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A N/A "$1,317.30 " N/A "$4,391.00 " "$4,391.00 " N/A 45036680 Emer Charges 36680 PLACEMENT OF NEEDLE FOR INTRAOSSEOUS INFUSION 36680 450 $798.00 $- $53.69 $- $- $638.40 $- N/A $207.48 N/A N/A Included in ER case rate N/A N/A $478.80 N/A N/A $399.00 N/A N/A $53.69 N/A N/A $542.64 N/A N/A $470.82 N/A N/A $311.22 N/A N/A $558.60 N/A N/A $638.40 N/A N/A $438.90 N/A N/A $558.60 N/A N/A $267.33 N/A N/A $53.69 N/A N/A $478.80 N/A N/A $279.30 N/A N/A $542.64 N/A N/A $239.40 N/A N/A $478.80 N/A N/A $558.60 N/A N/A $239.40 N/A N/A $239.40 N/A N/A $239.40 N/A N/A $239.40 N/A N/A $239.40 N/A N/A $239.40 N/A $798.00 $798.00 N/A 45041800 Emer Charges DRAINAGE OF GUM LESION 41800 450 $603.00 $- $135.10 $- $- $482.40 $- N/A $156.78 N/A N/A Included in ER case rate N/A N/A $361.80 N/A N/A $301.50 N/A N/A $135.10 N/A N/A $410.04 N/A N/A $355.77 N/A N/A $235.17 N/A N/A $422.10 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $422.10 N/A N/A $202.01 N/A N/A $135.10 N/A N/A $361.80 N/A N/A $211.05 N/A N/A $410.04 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $422.10 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 45043762 Emer Charges PERCUTANEOUS REMOVAL AND REPLACEMENT GTUBE 43762 450 "$2,660.00 " $- $32.90 $- $- "$2,128.00 " $- N/A $691.60 N/A N/A Included in ER case rate N/A N/A "$1,596.00 " N/A N/A "$1,330.00 " N/A N/A $32.90 N/A N/A "$1,808.80 " N/A N/A "$1,569.40 " N/A N/A "$1,037.40 " N/A N/A "$1,862.00 " N/A N/A "$2,128.00 " N/A N/A "$1,463.00 " N/A N/A "$1,862.00 " N/A N/A $891.10 N/A N/A $32.90 N/A N/A "$1,596.00 " N/A N/A $931.00 N/A N/A "$1,808.80 " N/A N/A $798.00 N/A N/A "$1,596.00 " N/A N/A "$1,862.00 " N/A N/A $798.00 N/A N/A $798.00 N/A N/A $798.00 N/A N/A $798.00 N/A N/A $798.00 N/A N/A $798.00 N/A "$2,660.00 " "$2,660.00 " N/A 45049083 Emer Charges ABD PARACENTESIS W/IMAGING ED CHARGE 49083 450 "$2,442.00 " $- $97.40 $- $- "$1,953.60 " $- N/A $634.92 N/A N/A Included in ER case rate N/A N/A "$1,465.20 " N/A N/A "$1,221.00 " N/A N/A $97.40 N/A N/A "$1,660.56 " N/A N/A "$1,440.78 " N/A N/A $952.38 N/A N/A "$1,709.40 " N/A N/A "$1,953.60 " N/A N/A "$1,343.10 " N/A N/A "$1,709.40 " N/A N/A $818.07 N/A N/A $97.40 N/A N/A "$1,465.20 " N/A N/A $854.70 N/A N/A "$1,660.56 " N/A N/A $732.60 N/A N/A "$1,465.20 " N/A N/A "$1,709.40 " N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A "$2,442.00 " "$2,442.00 " N/A 45051705 Emer Charges CHANGE OF BLADDER TUBE 51705 450 $502.00 $- $45.99 $- $- $401.60 $- N/A $130.52 N/A N/A Included in ER case rate N/A N/A $301.20 N/A N/A $251.00 N/A N/A $45.99 N/A N/A $341.36 N/A N/A $296.18 N/A N/A $195.78 N/A N/A $351.40 N/A N/A $401.60 N/A N/A $276.10 N/A N/A $351.40 N/A N/A $168.17 N/A N/A $45.99 N/A N/A $301.20 N/A N/A $175.70 N/A N/A $341.36 N/A N/A $150.60 N/A N/A $301.20 N/A N/A $351.40 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A $502.00 $502.00 N/A 45067700 Emer Charges BLEPHAROTOMY DRAINAGE ABSCESS EYELID 67700 450 $953.00 $- $106.77 $- $- $762.40 $- N/A $247.78 N/A N/A Included in ER case rate N/A N/A $571.80 N/A N/A $476.50 N/A N/A $106.77 N/A N/A $648.04 N/A N/A $562.27 N/A N/A $371.67 N/A N/A $667.10 N/A N/A $762.40 N/A N/A $524.15 N/A N/A $667.10 N/A N/A $319.26 N/A N/A $106.77 N/A N/A $571.80 N/A N/A $333.55 N/A N/A $648.04 N/A N/A $285.90 N/A N/A $571.80 N/A N/A $667.10 N/A N/A $285.90 N/A N/A $285.90 N/A N/A $285.90 N/A N/A $285.90 N/A N/A $285.90 N/A N/A $285.90 N/A $953.00 $953.00 N/A 45069000 Emer Charges 69000 DRAIN EXTERNAL EAR LESION 69000 450 $608.00 $- $107.87 $- $- $486.40 $- N/A $158.08 N/A N/A Included in ER case rate N/A N/A $364.80 N/A N/A $304.00 N/A N/A $107.87 N/A N/A $413.44 N/A N/A $358.72 N/A N/A $237.12 N/A N/A $425.60 N/A N/A $486.40 N/A N/A $334.40 N/A N/A $425.60 N/A N/A $203.68 N/A N/A $107.87 N/A N/A $364.80 N/A N/A $212.80 N/A N/A $413.44 N/A N/A $182.40 N/A N/A $364.80 N/A N/A $425.60 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A $608.00 $608.00 N/A 45069020 Emer Charges DRAIN EXTERNAL EAR CANAL ABSCESS 69020 450 $608.00 $- $128.57 $- $- $486.40 $- N/A $158.08 N/A N/A Included in ER case rate N/A N/A $364.80 N/A N/A $304.00 N/A N/A $128.57 N/A N/A $413.44 N/A N/A $358.72 N/A N/A $237.12 N/A N/A $425.60 N/A N/A $486.40 N/A N/A $334.40 N/A N/A $425.60 N/A N/A $203.68 N/A N/A $128.57 N/A N/A $364.80 N/A N/A $212.80 N/A N/A $413.44 N/A N/A $182.40 N/A N/A $364.80 N/A N/A $425.60 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A $608.00 $608.00 N/A 45069209 Emer Charges UNILATERAL REMOVAL OF IMPACTED EAR WAX BY LAVAGE 69209 450 $281.00 $- $11.45 $- $- $224.80 $- N/A $73.06 N/A N/A Included in ER case rate N/A N/A $168.60 N/A N/A $140.50 N/A N/A $11.45 N/A N/A $191.08 N/A N/A $165.79 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $11.45 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $191.08 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 45090472 Emer Charges IMMUNIZATION ADMIN EACH ADD VACCINE 90472 771 $193.00 $- $10.35 $- $- $154.40 $- N/A $50.18 N/A N/A Included in ER case rate N/A N/A $115.80 N/A N/A $96.50 N/A N/A $10.35 N/A N/A $131.24 N/A N/A $113.87 N/A N/A $75.27 N/A N/A $135.10 N/A N/A $154.40 N/A N/A $106.15 N/A N/A $135.10 N/A N/A $64.66 N/A N/A $10.35 N/A N/A $115.80 N/A N/A $67.55 N/A N/A $131.24 N/A N/A $57.90 N/A N/A $115.80 N/A N/A $135.10 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A $193.00 $193.00 N/A 99201 Evaluation and Management Office/New Patient-Focused (10) 99201 521 $168.00 $- $22.94 $- $- $134.40 $- N/A $43.68 N/A N/A $63.50 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $22.94 N/A N/A $114.24 N/A N/A $99.12 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $22.94 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 99202 Evaluation and Management Office/New Patient-Expanded (20) 99202 521 $189.00 $- $43.68 $- $- $151.20 $- N/A $49.14 N/A N/A $71.44 N/A N/A $113.40 N/A N/A $94.50 N/A N/A $43.68 N/A N/A $128.52 N/A N/A $111.51 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A $43.68 N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 99203 Evaluation and Management Office/New Patient-Detailed (30) 99203 521 $241.94 $- $62.90 $- $- $193.55 $- N/A $62.90 N/A N/A $91.45 N/A N/A $145.16 N/A N/A $120.97 N/A N/A $66.63 N/A N/A $164.52 N/A N/A $142.74 N/A N/A $94.36 N/A N/A $169.36 N/A N/A $193.55 N/A N/A $133.07 N/A N/A $169.36 N/A N/A $81.05 N/A N/A $66.63 N/A N/A $145.16 N/A N/A $84.68 N/A N/A $157.26 N/A N/A $72.58 N/A N/A $145.16 N/A N/A $169.36 N/A N/A $72.58 N/A N/A $72.58 N/A N/A $72.58 N/A N/A $72.58 N/A N/A $72.58 N/A N/A $72.58 N/A $241.94 $241.94 N/A 99204 Evaluation and Management Office/New Patient-Comprehensive (45) 99204 521 $369.29 $- $96.02 $- $- $295.43 $- N/A $96.02 N/A N/A $139.59 N/A N/A $221.57 N/A N/A $184.65 N/A N/A $114.04 N/A N/A $251.12 N/A N/A $217.88 N/A N/A $144.02 N/A N/A $258.50 N/A N/A $295.43 N/A N/A $203.11 N/A N/A $258.50 N/A N/A $123.71 N/A N/A $114.04 N/A N/A $221.57 N/A N/A $129.25 N/A N/A $240.04 N/A N/A $110.79 N/A N/A $221.57 N/A N/A $258.50 N/A N/A $110.79 N/A N/A $110.79 N/A N/A $110.79 N/A N/A $110.79 N/A N/A $110.79 N/A N/A $110.79 N/A $369.29 $369.29 N/A 99205 Evaluation and Management Office/New Patient-Comprehensive/High Complexity (60) 99205 521 $382.02 $- $99.33 $- $- $305.62 $- N/A $99.33 N/A N/A $144.40 N/A N/A $229.21 N/A N/A $191.01 N/A N/A $147.10 N/A N/A $259.77 N/A N/A $225.39 N/A N/A $148.99 N/A N/A $267.41 N/A N/A $305.62 N/A N/A $210.11 N/A N/A $267.41 N/A N/A $127.98 N/A N/A $147.10 N/A N/A $229.21 N/A N/A $133.71 N/A N/A $248.31 N/A N/A $114.61 N/A N/A $229.21 N/A N/A $267.41 N/A N/A $114.61 N/A N/A $114.61 N/A N/A $114.61 N/A N/A $114.61 N/A N/A $114.61 N/A N/A $114.61 N/A $382.02 $382.02 N/A 99212 Evaluation and Management Office/Established Patient-Focused (10) 99212 521 $121.55 $- $21.98 $- $- $97.24 $- N/A $31.60 N/A N/A $45.95 N/A N/A $72.93 N/A N/A $60.78 N/A N/A $21.98 N/A N/A $82.65 N/A N/A $71.71 N/A N/A $47.40 N/A N/A $85.09 N/A N/A $97.24 N/A N/A $66.85 N/A N/A $85.09 N/A N/A $40.72 N/A N/A $21.98 N/A N/A $72.93 N/A N/A $42.54 N/A N/A $79.01 N/A N/A $36.47 N/A N/A $72.93 N/A N/A $85.09 N/A N/A $36.47 N/A N/A $36.47 N/A N/A $36.47 N/A N/A $36.47 N/A N/A $36.47 N/A N/A $36.47 N/A $121.55 $121.55 N/A 99213 Evaluation and Management Office/Established Patient-Expanded (15) 99213 521 $181.74 $- $44.57 $- $- $145.39 $- N/A $47.25 N/A N/A $68.70 N/A N/A $109.04 N/A N/A $90.87 N/A N/A $44.57 N/A N/A $123.58 N/A N/A $107.23 N/A N/A $70.88 N/A N/A $127.22 N/A N/A $145.39 N/A N/A $99.96 N/A N/A $127.22 N/A N/A $60.88 N/A N/A $44.57 N/A N/A $109.04 N/A N/A $63.61 N/A N/A $118.13 N/A N/A $54.52 N/A N/A $109.04 N/A N/A $127.22 N/A N/A $54.52 N/A N/A $54.52 N/A N/A $54.52 N/A N/A $54.52 N/A N/A $54.52 N/A N/A $54.52 N/A $181.74 $181.74 N/A 99214 Evaluation and Management Office/Established Patient-Detailed (25) 99214 521 $252.37 $- $65.62 $- $- $201.90 $- N/A $65.62 N/A N/A $95.40 N/A N/A $151.42 N/A N/A $126.19 N/A N/A $68.37 N/A N/A $171.61 N/A N/A $148.90 N/A N/A $98.42 N/A N/A $176.66 N/A N/A $201.90 N/A N/A $138.80 N/A N/A $176.66 N/A N/A $84.54 N/A N/A $68.37 N/A N/A $151.42 N/A N/A $88.33 N/A N/A $164.04 N/A N/A $75.71 N/A N/A $151.42 N/A N/A $176.66 N/A N/A $75.71 N/A N/A $75.71 N/A N/A $75.71 N/A N/A $75.71 N/A N/A $75.71 N/A N/A $75.71 N/A $252.37 $252.37 N/A 99215 Evaluation and Management Office/Established Patient-Comprehensive/High Complexity (45 99215 521 $286.55 $- $74.50 $- $- $229.24 $- N/A $74.50 N/A N/A $108.32 N/A N/A $171.93 N/A N/A $143.28 N/A N/A $96.20 N/A N/A $194.85 N/A N/A $169.06 N/A N/A $111.75 N/A N/A $200.59 N/A N/A $229.24 N/A N/A $157.60 N/A N/A $200.59 N/A N/A $95.99 N/A N/A $96.20 N/A N/A $171.93 N/A N/A $100.29 N/A N/A $186.26 N/A N/A $85.97 N/A N/A $171.93 N/A N/A $200.59 N/A N/A $85.97 N/A N/A $85.97 N/A N/A $85.97 N/A N/A $85.97 N/A N/A $85.97 N/A N/A $85.97 N/A $286.55 $286.55 N/A 9.60992E+11 Evaluation and Management INITIAL HOSP CARE - 99221 99221 960 $103.05 $- $- $56.56 $- $- $174.03 N/A N/A $56.56 N/A N/A $82.23 N/A N/A $130.52 N/A N/A $108.77 N/A N/A $88.25 N/A N/A $147.93 N/A N/A $134.87 N/A N/A $85.93 N/A N/A $152.28 N/A N/A $174.03 N/A N/A $119.65 N/A N/A $152.28 N/A N/A $72.88 N/A N/A $88.25 N/A N/A $130.52 N/A N/A $76.14 N/A N/A $141.40 N/A N/A $65.26 N/A N/A $130.52 N/A N/A $152.28 N/A N/A $65.26 N/A N/A $65.26 N/A N/A $65.26 N/A N/A $65.26 N/A N/A $65.26 N/A N/A $65.26 N/A N/A $103.05 9.60992E+11 Evaluation and Management INITIAL HOSP CARE LEVEL 2 - 99222 99222 960 $139.20 $- $- $75.58 $- $- $232.56 N/A N/A $75.58 N/A N/A $109.88 N/A N/A $174.42 N/A N/A $145.35 N/A N/A $119.80 N/A N/A $197.68 N/A N/A $180.23 N/A N/A $114.83 N/A N/A $203.49 N/A N/A $232.56 N/A N/A $159.89 N/A N/A $203.49 N/A N/A $97.38 N/A N/A $119.80 N/A N/A $174.42 N/A N/A $101.75 N/A N/A $188.96 N/A N/A $87.21 N/A N/A $174.42 N/A N/A $203.49 N/A N/A $87.21 N/A N/A $87.21 N/A N/A $87.21 N/A N/A $87.21 N/A N/A $87.21 N/A N/A $87.21 N/A N/A $139.20 9.60992E+11 Evaluation and Management INITIAL HOSPITAL CARE - 99223 99223 960 $- $- $- $110.55 $- $- $340.17 N/A N/A $110.55 N/A N/A $160.73 N/A N/A $255.13 N/A N/A $212.61 N/A N/A $176.38 N/A N/A $289.14 N/A N/A $263.63 N/A N/A $167.96 N/A N/A $297.65 N/A N/A $340.17 N/A N/A $233.87 N/A N/A $297.65 N/A N/A $142.45 N/A N/A $176.38 N/A N/A $255.13 N/A N/A $148.82 N/A N/A $276.39 N/A N/A $127.56 N/A N/A $255.13 N/A N/A $297.65 N/A N/A $127.56 N/A N/A $127.56 N/A N/A $127.56 N/A N/A $127.56 N/A N/A $127.56 N/A N/A $127.56 N/A N/A $- 9.60992E+11 Evaluation and Management SUBSEQ HOSPITAL CARE - 99231 99231 960 $- $- $- $21.70 $- $- $66.76 N/A N/A $21.70 N/A N/A $31.54 N/A N/A $50.07 N/A N/A $41.73 N/A N/A $34.01 N/A N/A $56.75 N/A N/A $51.74 N/A N/A $32.96 N/A N/A $58.42 N/A N/A $66.76 N/A N/A $45.90 N/A N/A $58.42 N/A N/A $27.96 N/A N/A $34.01 N/A N/A $50.07 N/A N/A $29.21 N/A N/A $54.24 N/A N/A $25.04 N/A N/A $50.07 N/A N/A $58.42 N/A N/A $25.04 N/A N/A $25.04 N/A N/A $25.04 N/A N/A $25.04 N/A N/A $25.04 N/A N/A $25.04 N/A N/A $- 9.60992E+11 Evaluation and Management SUBSEQ HOSP CARE LEVEL 2 - 99232 99232 960 $- $- $- $39.72 $- $- $122.20 N/A N/A $39.72 N/A N/A $57.74 N/A N/A $91.65 N/A N/A $76.38 N/A N/A $62.44 N/A N/A $103.87 N/A N/A $94.71 N/A N/A $60.34 N/A N/A $106.93 N/A N/A $122.20 N/A N/A $84.01 N/A N/A $106.93 N/A N/A $51.17 N/A N/A $62.44 N/A N/A $91.65 N/A N/A $53.46 N/A N/A $99.29 N/A N/A $45.83 N/A N/A $91.65 N/A N/A $106.93 N/A N/A $45.83 N/A N/A $45.83 N/A N/A $45.83 N/A N/A $45.83 N/A N/A $45.83 N/A N/A $45.83 N/A N/A $- 9.60992E+11 Evaluation and Management SUBSEQUENT HOSP CARE - 99233 99233 960 $- $- $- $57.05 $- $- $175.53 N/A N/A $57.05 N/A N/A $82.94 N/A N/A $131.65 N/A N/A $109.71 N/A N/A $89.94 N/A N/A $149.20 N/A N/A $136.03 N/A N/A $86.67 N/A N/A $153.59 N/A N/A $175.53 N/A N/A $120.68 N/A N/A $153.59 N/A N/A $73.50 N/A N/A $89.94 N/A N/A $131.65 N/A N/A $76.79 N/A N/A $142.62 N/A N/A $65.82 N/A N/A $131.65 N/A N/A $153.59 N/A N/A $65.82 N/A N/A $65.82 N/A N/A $65.82 N/A N/A $65.82 N/A N/A $65.82 N/A N/A $65.82 N/A N/A $- 82530 General Lab "Cortisol, Urine QLS" 82530 301 $320.00 $- $10.72 $- $- $256.00 $- N/A $83.20 N/A N/A $17.92 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $10.72 N/A N/A $217.60 N/A N/A $156.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $10.72 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 787335 General Lab Inflammatory Bowel Panel QST 86021 302 $209.00 $- $7.28 $- $- $167.20 $- N/A $54.34 N/A N/A $12.16 N/A N/A $125.40 N/A N/A $104.50 N/A N/A $7.28 N/A N/A $142.12 N/A N/A $102.41 N/A N/A $81.51 N/A N/A $146.30 N/A N/A $167.20 N/A N/A $114.95 N/A N/A $146.30 N/A N/A $70.02 N/A N/A $7.28 N/A N/A $125.40 N/A N/A $73.15 N/A N/A $135.85 N/A N/A $62.70 N/A N/A $125.40 N/A N/A $146.30 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A $209.00 $209.00 N/A 787335 General Lab Inflammatory Bowel Panel QST 86671 302 $209.00 $- $7.86 $- $- $167.20 $- N/A $54.34 N/A N/A $13.14 N/A N/A $125.40 N/A N/A $104.50 N/A N/A $7.86 N/A N/A $142.12 N/A N/A $102.41 N/A N/A $81.51 N/A N/A $146.30 N/A N/A $167.20 N/A N/A $114.95 N/A N/A $146.30 N/A N/A $70.02 N/A N/A $7.86 N/A N/A $125.40 N/A N/A $73.15 N/A N/A $135.85 N/A N/A $62.70 N/A N/A $125.40 N/A N/A $146.30 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A $209.00 $209.00 N/A 1000244 General Lab Amikacin Peak QLS 80150 301 $478.00 $- $9.67 $- $- $382.40 $- N/A $124.28 N/A N/A $16.16 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $9.67 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $9.67 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 1000244 General Lab "Amikacin, Peak QST" 80150 301 $478.00 $- $9.67 $- $- $382.40 $- N/A $124.28 N/A N/A $16.16 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $9.67 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $9.67 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 1000615 General Lab Cardio IQ Lipid Panel QLS 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 1000615 General Lab Cardio IQ® Lipid Panel w/ Reflex to Direct LDL QST 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 1000651 General Lab "PSA, Total w/ Rflx to PSA, FREE QST" 84153 G0103 301 $292.00 $- $11.80 $- $- $233.60 $- N/A $75.92 N/A N/A $19.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $11.80 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $11.80 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 1000651 General Lab "Prostate Specific Antigen (PSA), Total w/Reflex to Free QLS" 84153 G0103 301 $292.00 $- $11.80 $- $- $233.60 $- N/A $75.92 N/A N/A $19.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $11.80 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $11.80 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4000002 General Lab UA Complete 1 81003 307 $44.00 $- $1.44 $- $- $35.20 $- N/A $11.44 N/A N/A $2.41 N/A N/A $26.40 N/A N/A $22.00 N/A N/A $1.44 N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A $1.44 N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 4000002 General Lab UA Complete 2 81003 307 $44.00 $- $1.44 $- $- $35.20 $- N/A $11.44 N/A N/A $2.41 N/A N/A $26.40 N/A N/A $22.00 N/A N/A $1.44 N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A $1.44 N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 4000002 General Lab UA Complete w/ Culture if indicated 81001 307 $44.00 $- $2.04 $- $- $35.20 $- N/A $11.44 N/A N/A $3.40 N/A N/A $26.40 N/A N/A $22.00 N/A N/A $2.04 N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A $2.04 N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 4000002 General Lab UA Complete 81003 307 $44.00 $- $1.44 $- $- $35.20 $- N/A $11.44 N/A N/A $2.41 N/A N/A $26.40 N/A N/A $22.00 N/A N/A $1.44 N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A $1.44 N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 4000002 General Lab UA Complete 81003 307 $44.00 $- $1.44 $- $- $35.20 $- N/A $11.44 N/A N/A $2.41 N/A N/A $26.40 N/A N/A $22.00 N/A N/A $1.44 N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A $1.44 N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 4000003 General Lab "Uric Acid, Synovial Fluid QST" 84550 301 $86.00 $- $2.90 $- $- $68.80 $- N/A $22.36 N/A N/A $4.85 N/A N/A $51.60 N/A N/A $43.00 N/A N/A $2.90 N/A N/A $58.48 N/A N/A $42.14 N/A N/A $33.54 N/A N/A $60.20 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $60.20 N/A N/A $28.81 N/A N/A $2.90 N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $60.20 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 4000003 General Lab "Uric Acid, Synovial Fluid QLS" 301 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A $42.14 N/A N/A $33.54 N/A N/A $60.20 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $60.20 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $60.20 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 4000010 General Lab Respiratory Culture QLS 87070 306 $171.00 $- $5.53 $- $- $136.80 $- N/A $44.46 N/A N/A $9.24 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $5.53 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $5.53 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4000011 General Lab Carboxy Hgb 82375 301 $584.00 $- $7.91 $- $- $467.20 $- N/A $151.84 N/A N/A $13.21 N/A N/A $350.40 N/A N/A $292.00 N/A N/A $7.91 N/A N/A $397.12 N/A N/A $286.16 N/A N/A $227.76 N/A N/A $408.80 N/A N/A $467.20 N/A N/A $321.20 N/A N/A $408.80 N/A N/A $195.64 N/A N/A $7.91 N/A N/A $350.40 N/A N/A $204.40 N/A N/A $379.60 N/A N/A $175.20 N/A N/A $350.40 N/A N/A $408.80 N/A N/A $175.20 N/A N/A $175.20 N/A N/A $175.20 N/A N/A $175.20 N/A N/A $175.20 N/A N/A $175.20 N/A $584.00 $584.00 N/A 4000013 General Lab PTH-Related Protein QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4000013 General Lab PTH-Related Protein (PTH-rP) QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4000016 General Lab "Histoplasma Ab, ID QST" 86698 302 $81.00 $- $8.02 $- $- $64.80 $- N/A $21.06 N/A N/A $13.40 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $8.02 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $8.02 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4000016 General Lab "Histoplasma Ab, Immunodiffusion, Serum QLS" 86698 302 $81.00 $- $8.02 $- $- $64.80 $- N/A $21.06 N/A N/A $13.40 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $8.02 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $8.02 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4000016 General Lab Mycelial Phase Ab QST 86698 302 $81.00 $- $8.02 $- $- $64.80 $- N/A $21.06 N/A N/A $13.40 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $8.02 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $8.02 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4000016 General Lab Yeast Phase Ab QST 86698 302 $81.00 $- $8.02 $- $- $64.80 $- N/A $21.06 N/A N/A $13.40 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $8.02 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $8.02 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4000017 General Lab "Coccidioides Antibodies, IgG, IgM QLS" 86635 302 $223.00 $- $7.37 $- $- $178.40 $- N/A $57.98 N/A N/A $12.30 N/A N/A $133.80 N/A N/A $111.50 N/A N/A $7.37 N/A N/A $151.64 N/A N/A $109.27 N/A N/A $86.97 N/A N/A $156.10 N/A N/A $178.40 N/A N/A $122.65 N/A N/A $156.10 N/A N/A $74.71 N/A N/A $7.37 N/A N/A $133.80 N/A N/A $78.05 N/A N/A $144.95 N/A N/A $66.90 N/A N/A $133.80 N/A N/A $156.10 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A $223.00 $223.00 N/A 4000018 General Lab FSH QLS 83001 301 $322.00 $- $11.92 $- $- $257.60 $- N/A $83.72 N/A N/A $19.92 N/A N/A $193.20 N/A N/A $161.00 N/A N/A $11.92 N/A N/A $218.96 N/A N/A $157.78 N/A N/A $125.58 N/A N/A $225.40 N/A N/A $257.60 N/A N/A $177.10 N/A N/A $225.40 N/A N/A $107.87 N/A N/A $11.92 N/A N/A $193.20 N/A N/A $112.70 N/A N/A $209.30 N/A N/A $96.60 N/A N/A $193.20 N/A N/A $225.40 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A $322.00 $322.00 N/A 4000018 General Lab Follicle Stimulating Hormone QST 83001 301 $322.00 $- $11.92 $- $- $257.60 $- N/A $83.72 N/A N/A $19.92 N/A N/A $193.20 N/A N/A $161.00 N/A N/A $11.92 N/A N/A $218.96 N/A N/A $157.78 N/A N/A $125.58 N/A N/A $225.40 N/A N/A $257.60 N/A N/A $177.10 N/A N/A $225.40 N/A N/A $107.87 N/A N/A $11.92 N/A N/A $193.20 N/A N/A $112.70 N/A N/A $209.30 N/A N/A $96.60 N/A N/A $193.20 N/A N/A $225.40 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A $322.00 $322.00 N/A 4000022 General Lab Inhibin-A QLS 86336 302 $238.00 $- $8.31 $- $- $190.40 $- N/A $61.88 N/A N/A $13.88 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $8.31 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $8.31 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4000023 General Lab Inhibin-B QLS 82397 301 $308.00 $- $9.07 $- $- $246.40 $- N/A $80.08 N/A N/A $15.14 N/A N/A $184.80 N/A N/A $154.00 N/A N/A $9.07 N/A N/A $209.44 N/A N/A $150.92 N/A N/A $120.12 N/A N/A $215.60 N/A N/A $246.40 N/A N/A $169.40 N/A N/A $215.60 N/A N/A $103.18 N/A N/A $9.07 N/A N/A $184.80 N/A N/A $107.80 N/A N/A $200.20 N/A N/A $92.40 N/A N/A $184.80 N/A N/A $215.60 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A $308.00 $308.00 N/A 4000026 General Lab LH QLS 83002 301 $303.00 $- $11.88 $- $- $242.40 $- N/A $78.78 N/A N/A $19.86 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $11.88 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $11.88 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000026 General Lab LH. Qst 83002 301 $303.00 $- $11.88 $- $- $242.40 $- N/A $78.78 N/A N/A $19.86 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $11.88 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $11.88 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000027 General Lab ANCA Vasculitides QLS 86021 302 $219.00 $- $7.28 $- $- $175.20 $- N/A $56.94 N/A N/A $12.16 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $7.28 N/A N/A $148.92 N/A N/A $107.31 N/A N/A $85.41 N/A N/A $153.30 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $153.30 N/A N/A $73.37 N/A N/A $7.28 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $153.30 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 4000031 General Lab "Culture, Fluid W/ Gram Stain QLS" 87070 306 $169.00 $- $5.53 $- $- $135.20 $- N/A $43.94 N/A N/A $9.24 N/A N/A $101.40 N/A N/A $84.50 N/A N/A $5.53 N/A N/A $114.92 N/A N/A $82.81 N/A N/A $65.91 N/A N/A $118.30 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $118.30 N/A N/A $56.62 N/A N/A $5.53 N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $118.30 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 4000031 General Lab "Culture, Fluid W/ Gram Stain QLS" 87205 306 $169.00 $- $2.74 $- $- $135.20 $- N/A $43.94 N/A N/A $4.58 N/A N/A $101.40 N/A N/A $84.50 N/A N/A $2.74 N/A N/A $114.92 N/A N/A $82.81 N/A N/A $65.91 N/A N/A $118.30 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $118.30 N/A N/A $56.62 N/A N/A $2.74 N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $118.30 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 4000032 General Lab "Glucose, Pleural Fl QST" 82945 301 $229.00 $- $2.52 $- $- $183.20 $- N/A $59.54 N/A N/A $4.20 N/A N/A $137.40 N/A N/A $114.50 N/A N/A $2.52 N/A N/A $155.72 N/A N/A $112.21 N/A N/A $89.31 N/A N/A $160.30 N/A N/A $183.20 N/A N/A $125.95 N/A N/A $160.30 N/A N/A $76.72 N/A N/A $2.52 N/A N/A $137.40 N/A N/A $80.15 N/A N/A $148.85 N/A N/A $68.70 N/A N/A $137.40 N/A N/A $160.30 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A $229.00 $229.00 N/A 4000032 General Lab "Glucose, Pleural Fluid QLS" 82945 301 $229.00 $- $2.52 $- $- $183.20 $- N/A $59.54 N/A N/A $4.20 N/A N/A $137.40 N/A N/A $114.50 N/A N/A $2.52 N/A N/A $155.72 N/A N/A $112.21 N/A N/A $89.31 N/A N/A $160.30 N/A N/A $183.20 N/A N/A $125.95 N/A N/A $160.30 N/A N/A $76.72 N/A N/A $2.52 N/A N/A $137.40 N/A N/A $80.15 N/A N/A $148.85 N/A N/A $68.70 N/A N/A $137.40 N/A N/A $160.30 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A N/A $68.70 N/A $229.00 $229.00 N/A 4000037 General Lab Electrolyte Panel QST 80051 300 $130.00 $- $4.51 $- $- $104.00 $- N/A $33.80 N/A N/A $7.52 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.51 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.51 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4000037 General Lab Electrolytes 80051 300 $130.00 $- $4.51 $- $- $104.00 $- N/A $33.80 N/A N/A $7.52 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.51 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.51 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4000051 General Lab UA Dipstick 81005 307 $43.00 $- $1.40 $- $- $34.40 $- N/A $11.18 N/A N/A $2.33 N/A N/A $25.80 N/A N/A $21.50 N/A N/A $1.40 N/A N/A $29.24 N/A N/A $21.07 N/A N/A $16.77 N/A N/A $30.10 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $30.10 N/A N/A $14.41 N/A N/A $1.40 N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $30.10 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 4000051 General Lab UA Dipstick 81005 307 $43.00 $- $1.40 $- $- $34.40 $- N/A $11.18 N/A N/A $2.33 N/A N/A $25.80 N/A N/A $21.50 N/A N/A $1.40 N/A N/A $29.24 N/A N/A $21.07 N/A N/A $16.77 N/A N/A $30.10 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $30.10 N/A N/A $14.41 N/A N/A $1.40 N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $30.10 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 4000061 General Lab Basic Metabolic Panel 9 80048 301 $167.00 $- $5.43 $- $- $133.60 $- N/A $43.42 N/A N/A $9.07 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $5.43 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $5.43 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4000061 General Lab Basic Metabolic 982 QLS 80048 301 $167.00 $- $5.43 $- $- $133.60 $- N/A $43.42 N/A N/A $9.07 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $5.43 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $5.43 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4000061 General Lab Basic Metabolic Panel QST 80048 301 $167.00 $- $5.43 $- $- $133.60 $- N/A $43.42 N/A N/A $9.07 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $5.43 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $5.43 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4000073 General Lab Manual Diff 85007 305 $69.00 $- $2.21 $- $- $55.20 $- N/A $17.94 N/A N/A $3.68 N/A N/A $41.40 N/A N/A $34.50 N/A N/A $2.21 N/A N/A $46.92 N/A N/A $33.81 N/A N/A $26.91 N/A N/A $48.30 N/A N/A $55.20 N/A N/A $37.95 N/A N/A $48.30 N/A N/A $23.12 N/A N/A $2.21 N/A N/A $41.40 N/A N/A $24.15 N/A N/A $44.85 N/A N/A $20.70 N/A N/A $41.40 N/A N/A $48.30 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A $69.00 $69.00 N/A 4000073 General Lab Manual Diff 85007 305 $69.00 $- $2.21 $- $- $55.20 $- N/A $17.94 N/A N/A $3.68 N/A N/A $41.40 N/A N/A $34.50 N/A N/A $2.21 N/A N/A $46.92 N/A N/A $33.81 N/A N/A $26.91 N/A N/A $48.30 N/A N/A $55.20 N/A N/A $37.95 N/A N/A $48.30 N/A N/A $23.12 N/A N/A $2.21 N/A N/A $41.40 N/A N/A $24.15 N/A N/A $44.85 N/A N/A $20.70 N/A N/A $41.40 N/A N/A $48.30 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A $69.00 $69.00 N/A 4000078 General Lab 82962 - ACCUCHECK 82962 301 $38.00 $- $1.16 $- $- $30.40 $- N/A $9.88 N/A N/A $1.93 N/A N/A $22.80 N/A N/A $19.00 N/A N/A $1.16 N/A N/A $25.84 N/A N/A $18.62 N/A N/A $14.82 N/A N/A $26.60 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $26.60 N/A N/A $12.73 N/A N/A $1.16 N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $26.60 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 4000083 General Lab Bill Snaptophysin Stain 88342 310 $387.00 $- $52.52 $- $- $309.60 $- N/A $100.62 N/A N/A $94.06 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $52.52 N/A N/A $263.16 N/A N/A $189.63 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $212.85 N/A N/A $270.90 N/A N/A $129.65 N/A N/A $52.52 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $251.55 N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4000085 General Lab Scl-70 Ab QST 86235 302 $65.00 $- $10.74 $- $- $52.00 $- N/A $16.90 N/A N/A $17.95 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $10.74 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $10.74 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4000085 General Lab Scleroderma Abs (Scl-70) QLS 86235 302 $65.00 $- $10.74 $- $- $52.00 $- N/A $16.90 N/A N/A $17.95 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $10.74 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $10.74 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4000100 General Lab "Acetone, Serum" 82009 301 $91.00 $- $2.90 $- $- $72.80 $- N/A $23.66 N/A N/A $4.85 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $2.90 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $2.90 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4000105 General Lab "IgE, Total QLS" 82785 302 $137.00 $- $10.57 $- $- $109.60 $- N/A $35.62 N/A N/A $17.66 N/A N/A $82.20 N/A N/A $68.50 N/A N/A $10.57 N/A N/A $93.16 N/A N/A $67.13 N/A N/A $53.43 N/A N/A $95.90 N/A N/A $109.60 N/A N/A $75.35 N/A N/A $95.90 N/A N/A $45.90 N/A N/A $10.57 N/A N/A $82.20 N/A N/A $47.95 N/A N/A $89.05 N/A N/A $41.10 N/A N/A $82.20 N/A N/A $95.90 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A $137.00 $137.00 N/A 4000105 General Lab Immunoglobulin E QST 82785 302 $137.00 $- $10.57 $- $- $109.60 $- N/A $35.62 N/A N/A $17.66 N/A N/A $82.20 N/A N/A $68.50 N/A N/A $10.57 N/A N/A $93.16 N/A N/A $67.13 N/A N/A $53.43 N/A N/A $95.90 N/A N/A $109.60 N/A N/A $75.35 N/A N/A $95.90 N/A N/A $45.90 N/A N/A $10.57 N/A N/A $82.20 N/A N/A $47.95 N/A N/A $89.05 N/A N/A $41.10 N/A N/A $82.20 N/A N/A $95.90 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A $137.00 $137.00 N/A 4000109 General Lab Haptoglobin QST 83010 301 $292.00 $- $8.07 $- $- $233.60 $- N/A $75.92 N/A N/A $13.49 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $8.07 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $8.07 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4000109 General Lab Haptoglobin QLS 83010 301 $292.00 $- $8.07 $- $- $233.60 $- N/A $75.92 N/A N/A $13.49 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $8.07 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $8.07 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4000111 General Lab Heavy Metals Panel QST 82175 301 $150.00 $- $12.18 $- $- $120.00 $- N/A $39.00 N/A N/A $20.34 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $12.18 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $12.18 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4000111 General Lab "Heavy Metals Panel, Blood QST" 82175 301 $150.00 $- $12.18 $- $- $120.00 $- N/A $39.00 N/A N/A $20.34 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $12.18 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $12.18 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4000125 General Lab Gentamicin Level Trough QST 80170 301 $301.00 $- $10.51 $- $- $240.80 $- N/A $78.26 N/A N/A $17.57 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $10.51 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $10.51 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4000125 General Lab "Gentamicin, Trough QLS" 80170 301 $301.00 $- $10.51 $- $- $240.80 $- N/A $78.26 N/A N/A $17.57 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $10.51 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $10.51 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4000127 General Lab "Tobramycin, Trough QLS" 80200 301 $446.00 $- $10.34 $- $- $356.80 $- N/A $115.96 N/A N/A $17.28 N/A N/A $267.60 N/A N/A $223.00 N/A N/A $10.34 N/A N/A $303.28 N/A N/A $218.54 N/A N/A $173.94 N/A N/A $312.20 N/A N/A $356.80 N/A N/A $245.30 N/A N/A $312.20 N/A N/A $149.41 N/A N/A $10.34 N/A N/A $267.60 N/A N/A $156.10 N/A N/A $289.90 N/A N/A $133.80 N/A N/A $267.60 N/A N/A $312.20 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A $446.00 $446.00 N/A 4000127 General Lab "Tobramycin, Trough QST" 80200 301 $446.00 $- $10.34 $- $- $356.80 $- N/A $115.96 N/A N/A $17.28 N/A N/A $267.60 N/A N/A $223.00 N/A N/A $10.34 N/A N/A $303.28 N/A N/A $218.54 N/A N/A $173.94 N/A N/A $312.20 N/A N/A $356.80 N/A N/A $245.30 N/A N/A $312.20 N/A N/A $149.41 N/A N/A $10.34 N/A N/A $267.60 N/A N/A $156.10 N/A N/A $289.90 N/A N/A $133.80 N/A N/A $267.60 N/A N/A $312.20 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A $446.00 $446.00 N/A 4000128 General Lab Vancomycin Peak 80202 301 $470.00 $- $8.70 $- $- $376.00 $- N/A $122.20 N/A N/A $14.53 N/A N/A $282.00 N/A N/A $235.00 N/A N/A $8.70 N/A N/A $319.60 N/A N/A $230.30 N/A N/A $183.30 N/A N/A $329.00 N/A N/A $376.00 N/A N/A $258.50 N/A N/A $329.00 N/A N/A $157.45 N/A N/A $8.70 N/A N/A $282.00 N/A N/A $164.50 N/A N/A $305.50 N/A N/A $141.00 N/A N/A $282.00 N/A N/A $329.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A $470.00 $470.00 N/A 4000129 General Lab Vancomycin Level Trough QST 80202 301 $447.00 $- $8.70 $- $- $357.60 $- N/A $116.22 N/A N/A $14.53 N/A N/A $268.20 N/A N/A $223.50 N/A N/A $8.70 N/A N/A $303.96 N/A N/A $219.03 N/A N/A $174.33 N/A N/A $312.90 N/A N/A $357.60 N/A N/A $245.85 N/A N/A $312.90 N/A N/A $149.75 N/A N/A $8.70 N/A N/A $268.20 N/A N/A $156.45 N/A N/A $290.55 N/A N/A $134.10 N/A N/A $268.20 N/A N/A $312.90 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A $447.00 $447.00 N/A 4000129 General Lab Vancomycin Trough 80202 301 $447.00 $- $8.70 $- $- $357.60 $- N/A $116.22 N/A N/A $14.53 N/A N/A $268.20 N/A N/A $223.50 N/A N/A $8.70 N/A N/A $303.96 N/A N/A $219.03 N/A N/A $174.33 N/A N/A $312.90 N/A N/A $357.60 N/A N/A $245.85 N/A N/A $312.90 N/A N/A $149.75 N/A N/A $8.70 N/A N/A $268.20 N/A N/A $156.45 N/A N/A $290.55 N/A N/A $134.10 N/A N/A $268.20 N/A N/A $312.90 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A N/A $134.10 N/A $447.00 $447.00 N/A 4000131 General Lab "Collagen Cross-Linked N-Telopeptide, Random QLS" 82523 301 $651.00 $- $11.99 $- $- $520.80 $- N/A $169.26 N/A N/A $20.04 N/A N/A $390.60 N/A N/A $325.50 N/A N/A $11.99 N/A N/A $442.68 N/A N/A $318.99 N/A N/A $253.89 N/A N/A $455.70 N/A N/A $520.80 N/A N/A $358.05 N/A N/A $455.70 N/A N/A $218.09 N/A N/A $11.99 N/A N/A $390.60 N/A N/A $227.85 N/A N/A $423.15 N/A N/A $195.30 N/A N/A $390.60 N/A N/A $455.70 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A $651.00 $651.00 N/A 4000131 General Lab "Collagen Cross-Linked N-Telopeptide, Random QLS" 82570 301 $651.00 $- $3.32 $- $- $520.80 $- N/A $169.26 N/A N/A $5.54 N/A N/A $390.60 N/A N/A $325.50 N/A N/A $3.32 N/A N/A $442.68 N/A N/A $318.99 N/A N/A $253.89 N/A N/A $455.70 N/A N/A $520.80 N/A N/A $358.05 N/A N/A $455.70 N/A N/A $218.09 N/A N/A $3.32 N/A N/A $390.60 N/A N/A $227.85 N/A N/A $423.15 N/A N/A $195.30 N/A N/A $390.60 N/A N/A $455.70 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A $651.00 $651.00 N/A 4000143 General Lab Intrinsic Factor Blocking Antibody QLS 86340 302 $375.00 $- $9.67 $- $- $300.00 $- N/A $97.50 N/A N/A $16.16 N/A N/A $225.00 N/A N/A $187.50 N/A N/A $9.67 N/A N/A $255.00 N/A N/A $183.75 N/A N/A $146.25 N/A N/A $262.50 N/A N/A $300.00 N/A N/A $206.25 N/A N/A $262.50 N/A N/A $125.63 N/A N/A $9.67 N/A N/A $225.00 N/A N/A $131.25 N/A N/A $243.75 N/A N/A $112.50 N/A N/A $225.00 N/A N/A $262.50 N/A N/A $112.50 N/A N/A $112.50 N/A N/A $112.50 N/A N/A $112.50 N/A N/A $112.50 N/A N/A $112.50 N/A $375.00 $375.00 N/A 4000149 General Lab Hematocrit 85014 305 $47.00 $- $1.53 $- $- $37.60 $- N/A $12.22 N/A N/A $2.54 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $1.53 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $1.53 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4000149 General Lab Hematocrit 85014 305 $47.00 $- $1.53 $- $- $37.60 $- N/A $12.22 N/A N/A $2.54 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $1.53 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $1.53 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4000163 General Lab Antibody Screen 86850 302 $179.00 $- $2.46 $- $- $143.20 $- N/A $46.54 N/A N/A $14.04 N/A N/A $107.40 N/A N/A $89.50 N/A N/A $2.46 N/A N/A $121.72 N/A N/A $87.71 N/A N/A $69.81 N/A N/A $125.30 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $125.30 N/A N/A $59.97 N/A N/A $2.46 N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $125.30 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 4000174 General Lab "Urea Nitrogen, Urine QLS" 84540 301 $93.00 $- $3.05 $- $- $74.40 $- N/A $24.18 N/A N/A $5.09 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $3.05 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $3.05 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4000180 General Lab Hemoglobin 85018 305 $47.00 $- $1.53 $- $- $37.60 $- N/A $12.22 N/A N/A $2.54 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $1.53 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $1.53 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4000180 General Lab Hemoglobin 85018 305 $47.00 $- $1.53 $- $- $37.60 $- N/A $12.22 N/A N/A $2.54 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $1.53 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $1.53 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4000180 General Lab Hemoglobin QST 85018 305 $47.00 $- $1.53 $- $- $37.60 $- N/A $12.22 N/A N/A $2.54 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $1.53 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $1.53 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4000192 General Lab Bill Epith Mem Ag Stain 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4000194 General Lab Comprehensive Metabolic Panel 12 80053 301 $830.00 $- $6.78 $- $- $664.00 $- N/A $215.80 N/A N/A $11.33 N/A N/A $498.00 N/A N/A $415.00 N/A N/A $6.78 N/A N/A $564.40 N/A N/A $406.70 N/A N/A $323.70 N/A N/A $581.00 N/A N/A $664.00 N/A N/A $456.50 N/A N/A $581.00 N/A N/A $278.05 N/A N/A $6.78 N/A N/A $498.00 N/A N/A $290.50 N/A N/A $539.50 N/A N/A $249.00 N/A N/A $498.00 N/A N/A $581.00 N/A N/A $249.00 N/A N/A $249.00 N/A N/A $249.00 N/A N/A $249.00 N/A N/A $249.00 N/A N/A $249.00 N/A $830.00 $830.00 N/A 4000198 General Lab Selenium QLS 84255 301 $152.00 $- $16.38 $- $- $121.60 $- N/A $39.52 N/A N/A $27.38 N/A N/A $91.20 N/A N/A $76.00 N/A N/A $16.38 N/A N/A $103.36 N/A N/A $74.48 N/A N/A $59.28 N/A N/A $106.40 N/A N/A $121.60 N/A N/A $83.60 N/A N/A $106.40 N/A N/A $50.92 N/A N/A $16.38 N/A N/A $91.20 N/A N/A $53.20 N/A N/A $98.80 N/A N/A $45.60 N/A N/A $91.20 N/A N/A $106.40 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A $152.00 $152.00 N/A 4000198 General Lab Selenium QST 84255 301 $152.00 $- $16.38 $- $- $121.60 $- N/A $39.52 N/A N/A $27.38 N/A N/A $91.20 N/A N/A $76.00 N/A N/A $16.38 N/A N/A $103.36 N/A N/A $74.48 N/A N/A $59.28 N/A N/A $106.40 N/A N/A $121.60 N/A N/A $83.60 N/A N/A $106.40 N/A N/A $50.92 N/A N/A $16.38 N/A N/A $91.20 N/A N/A $53.20 N/A N/A $98.80 N/A N/A $45.60 N/A N/A $91.20 N/A N/A $106.40 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A $152.00 $152.00 N/A 4000204 General Lab Leukemia/Lymphoma Evaluation QST 88189 300 $208.00 $- $52.96 $- $- $166.40 $- N/A $54.08 N/A N/A $85.01 N/A N/A $124.80 N/A N/A $104.00 N/A N/A $52.96 N/A N/A $141.44 N/A N/A $101.92 N/A N/A $81.12 N/A N/A $145.60 N/A N/A $166.40 N/A N/A $114.40 N/A N/A $145.60 N/A N/A $69.68 N/A N/A $52.96 N/A N/A $124.80 N/A N/A $72.80 N/A N/A $135.20 N/A N/A $62.40 N/A N/A $124.80 N/A N/A $145.60 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A $208.00 $208.00 N/A 4000204 General Lab Leukemia/Lymphoma Evaluation QLS 88184 300 $208.00 $- $43.54 $- $- $166.40 $- N/A $54.08 N/A N/A $73.33 N/A N/A $124.80 N/A N/A $104.00 N/A N/A $43.54 N/A N/A $141.44 N/A N/A $101.92 N/A N/A $81.12 N/A N/A $145.60 N/A N/A $166.40 N/A N/A $114.40 N/A N/A $145.60 N/A N/A $69.68 N/A N/A $43.54 N/A N/A $124.80 N/A N/A $72.80 N/A N/A $135.20 N/A N/A $62.40 N/A N/A $124.80 N/A N/A $145.60 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A $208.00 $208.00 N/A 4000204 General Lab Leukemia/Lymphoma Evaluation QLS 88189 300 $208.00 $- $52.96 $- $- $166.40 $- N/A $54.08 N/A N/A $85.01 N/A N/A $124.80 N/A N/A $104.00 N/A N/A $52.96 N/A N/A $141.44 N/A N/A $101.92 N/A N/A $81.12 N/A N/A $145.60 N/A N/A $166.40 N/A N/A $114.40 N/A N/A $145.60 N/A N/A $69.68 N/A N/A $52.96 N/A N/A $124.80 N/A N/A $72.80 N/A N/A $135.20 N/A N/A $62.40 N/A N/A $124.80 N/A N/A $145.60 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A $208.00 $208.00 N/A 4000207 General Lab Chromogranin A QST 86316 302 $565.00 $- $13.35 $- $- $452.00 $- N/A $146.90 N/A N/A $22.32 N/A N/A $339.00 N/A N/A $282.50 N/A N/A $13.35 N/A N/A $384.20 N/A N/A $276.85 N/A N/A $220.35 N/A N/A $395.50 N/A N/A $452.00 N/A N/A $310.75 N/A N/A $395.50 N/A N/A $189.28 N/A N/A $13.35 N/A N/A $339.00 N/A N/A $197.75 N/A N/A $367.25 N/A N/A $169.50 N/A N/A $339.00 N/A N/A $395.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4000207 General Lab "Chromogranin A, Electrochemiluminescence QLS" 86316 302 $565.00 $- $13.35 $- $- $452.00 $- N/A $146.90 N/A N/A $22.32 N/A N/A $339.00 N/A N/A $282.50 N/A N/A $13.35 N/A N/A $384.20 N/A N/A $276.85 N/A N/A $220.35 N/A N/A $395.50 N/A N/A $452.00 N/A N/A $310.75 N/A N/A $395.50 N/A N/A $189.28 N/A N/A $13.35 N/A N/A $339.00 N/A N/A $197.75 N/A N/A $367.25 N/A N/A $169.50 N/A N/A $339.00 N/A N/A $395.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4000222 General Lab CBC w/ Auto Diff 6 85027 305 $264.00 $- $4.16 $- $- $211.20 $- N/A $68.64 N/A N/A $6.94 N/A N/A $158.40 N/A N/A $132.00 N/A N/A $4.16 N/A N/A $179.52 N/A N/A $129.36 N/A N/A $102.96 N/A N/A $184.80 N/A N/A $211.20 N/A N/A $145.20 N/A N/A $184.80 N/A N/A $88.44 N/A N/A $4.16 N/A N/A $158.40 N/A N/A $92.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $158.40 N/A N/A $184.80 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A $264.00 $264.00 N/A 4000222 General Lab CBC w/ Auto Diff 10 85025 305 $264.00 $- $5.00 $- $- $211.20 $- N/A $68.64 N/A N/A $8.34 N/A N/A $158.40 N/A N/A $132.00 N/A N/A $5.00 N/A N/A $179.52 N/A N/A $129.36 N/A N/A $102.96 N/A N/A $184.80 N/A N/A $211.20 N/A N/A $145.20 N/A N/A $184.80 N/A N/A $88.44 N/A N/A $5.00 N/A N/A $158.40 N/A N/A $92.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $158.40 N/A N/A $184.80 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A $264.00 $264.00 N/A 4000224 General Lab 88305 310 $317.00 $- $34.33 $- $- $253.60 $- N/A $82.42 N/A N/A $56.77 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $34.33 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $34.33 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000224 General Lab Tissue Exam QST 88305 310 $317.00 $- $34.33 $- $- $253.60 $- N/A $82.42 N/A N/A $56.77 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $34.33 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $34.33 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000224 General Lab 88305 310 $317.00 $- $34.33 $- $- $253.60 $- N/A $82.42 N/A N/A $56.77 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $34.33 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $34.33 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000227 General Lab Kappa Lambda Light Chains w/ Calc 24-Hr Urine QST 83883 301 $78.00 $- $8.72 $- $- $62.40 $- N/A $20.28 N/A N/A $14.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $8.72 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $8.72 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4000227 General Lab "Kappa/Lambda Lt Chains, Free w/ Ratio QST" 83883 301 $78.00 $- $8.72 $- $- $62.40 $- N/A $20.28 N/A N/A $14.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $8.72 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $8.72 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4000227 General Lab "Kappa/Lambda Light Chains, Free W/ Ratio QLS" 83883 301 $78.00 $- $8.72 $- $- $62.40 $- N/A $20.28 N/A N/A $14.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $8.72 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $8.72 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4000227 General Lab "Kappa/Lambda Light Chains Total, Serum QST" 83883 301 $78.00 $- $8.72 $- $- $62.40 $- N/A $20.28 N/A N/A $14.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $8.72 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $8.72 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4000227 General Lab "Kappa/Lambda Light Chains Total, Urine QST" 83883 301 $78.00 $- $8.72 $- $- $62.40 $- N/A $20.28 N/A N/A $14.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $8.72 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $8.72 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4000232 General Lab Influenza B 87804 306 $84.00 $- $7.69 $- $- $67.20 $- N/A $21.84 N/A N/A $12.86 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $7.69 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $7.69 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4000233 General Lab Influenza A 87804 306 $84.00 $- $7.69 $- $- $67.20 $- N/A $21.84 N/A N/A $12.86 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $7.69 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $7.69 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4000233 General Lab Influenza A 87804 306 $84.00 $- $7.69 $- $- $67.20 $- N/A $21.84 N/A N/A $12.86 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $7.69 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $7.69 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4000234 General Lab 88305 311 $373.00 $- $34.33 $- $- $298.40 $- N/A $96.98 N/A N/A $56.77 N/A N/A $223.80 N/A N/A $186.50 N/A N/A $34.33 N/A N/A $253.64 N/A N/A $182.77 N/A N/A $145.47 N/A N/A $261.10 N/A N/A $298.40 N/A N/A $205.15 N/A N/A $261.10 N/A N/A $124.96 N/A N/A $34.33 N/A N/A $223.80 N/A N/A $130.55 N/A N/A $242.45 N/A N/A $111.90 N/A N/A $223.80 N/A N/A $261.10 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A $373.00 $373.00 N/A 4000241 General Lab Adrenocorticotropic Hormone (ACTH) QST 82024 301 $680.00 $- $24.77 $- $- $544.00 $- N/A $176.80 N/A N/A $41.42 N/A N/A $408.00 N/A N/A $340.00 N/A N/A $24.77 N/A N/A $462.40 N/A N/A $333.20 N/A N/A $265.20 N/A N/A $476.00 N/A N/A $544.00 N/A N/A $374.00 N/A N/A $476.00 N/A N/A $227.80 N/A N/A $24.77 N/A N/A $408.00 N/A N/A $238.00 N/A N/A $442.00 N/A N/A $204.00 N/A N/A $408.00 N/A N/A $476.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A $680.00 $680.00 N/A 4000244 General Lab "Amikacin, Trough Level QLS" 80150 301 $478.00 $- $9.67 $- $- $382.40 $- N/A $124.28 N/A N/A $16.16 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $9.67 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $9.67 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 4000244 General Lab "Amikacin, Trough QST" 80150 301 $478.00 $- $9.67 $- $- $382.40 $- N/A $124.28 N/A N/A $16.16 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $9.67 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $9.67 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 4000249 General Lab "H. Pylori Ag, Stool QST" 87338 306 $646.00 $- $7.70 $- $- $516.80 $- N/A $167.96 N/A N/A $12.86 N/A N/A $387.60 N/A N/A $323.00 N/A N/A $7.70 N/A N/A $439.28 N/A N/A $316.54 N/A N/A $251.94 N/A N/A $452.20 N/A N/A $516.80 N/A N/A $355.30 N/A N/A $452.20 N/A N/A $216.41 N/A N/A $7.70 N/A N/A $387.60 N/A N/A $226.10 N/A N/A $419.90 N/A N/A $193.80 N/A N/A $387.60 N/A N/A $452.20 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A $646.00 $646.00 N/A 4000249 General Lab "Helicobacter Pylori Antigen, EIA, Stool QLS" 87338 306 $646.00 $- $7.70 $- $- $516.80 $- N/A $167.96 N/A N/A $12.86 N/A N/A $387.60 N/A N/A $323.00 N/A N/A $7.70 N/A N/A $439.28 N/A N/A $316.54 N/A N/A $251.94 N/A N/A $452.20 N/A N/A $516.80 N/A N/A $355.30 N/A N/A $452.20 N/A N/A $216.41 N/A N/A $7.70 N/A N/A $387.60 N/A N/A $226.10 N/A N/A $419.90 N/A N/A $193.80 N/A N/A $387.60 N/A N/A $452.20 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A $646.00 $646.00 N/A 4000250 General Lab "HTLV -I/II Ab,EIA w/Rfl Wb QLS" 86790 302 $345.00 $- $8.27 $- $- $276.00 $- N/A $89.70 N/A N/A $13.81 N/A N/A $207.00 N/A N/A $172.50 N/A N/A $8.27 N/A N/A $234.60 N/A N/A $169.05 N/A N/A $134.55 N/A N/A $241.50 N/A N/A $276.00 N/A N/A $189.75 N/A N/A $241.50 N/A N/A $115.58 N/A N/A $8.27 N/A N/A $207.00 N/A N/A $120.75 N/A N/A $224.25 N/A N/A $103.50 N/A N/A $207.00 N/A N/A $241.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A $345.00 $345.00 N/A 4000252 General Lab Extended Phenotype 86905 302 $72.00 $- $2.46 $- $- $57.60 $- N/A $18.72 N/A N/A $4.09 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $2.46 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $2.46 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4000253 General Lab Elution 86860 302 $272.00 $- $15.18 $- $- $217.60 $- N/A $70.72 N/A N/A $17.96 N/A N/A $163.20 N/A N/A $136.00 N/A N/A $15.18 N/A N/A $184.96 N/A N/A $133.28 N/A N/A $106.08 N/A N/A $190.40 N/A N/A $217.60 N/A N/A $149.60 N/A N/A $190.40 N/A N/A $91.12 N/A N/A $15.18 N/A N/A $163.20 N/A N/A $95.20 N/A N/A $176.80 N/A N/A $81.60 N/A N/A $163.20 N/A N/A $190.40 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A $272.00 $272.00 N/A 4000255 General Lab Direct Antiglobulin Test 86880 302 $100.00 $- $3.45 $- $- $80.00 $- N/A $26.00 N/A N/A $5.76 N/A N/A $60.00 N/A N/A $50.00 N/A N/A $3.45 N/A N/A $68.00 N/A N/A $49.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A $3.45 N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4000257 General Lab Adsorption 86978 302 $272.00 $- $16.75 $- $- $217.60 $- N/A $70.72 N/A N/A $19.93 N/A N/A $163.20 N/A N/A $136.00 N/A N/A $16.75 N/A N/A $184.96 N/A N/A $133.28 N/A N/A $106.08 N/A N/A $190.40 N/A N/A $217.60 N/A N/A $149.60 N/A N/A $190.40 N/A N/A $91.12 N/A N/A $16.75 N/A N/A $163.20 N/A N/A $95.20 N/A N/A $176.80 N/A N/A $81.60 N/A N/A $163.20 N/A N/A $190.40 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A N/A $81.60 N/A $272.00 $272.00 N/A 4000259 General Lab Bill AE1/AE3 Stain 88342 310 $387.00 $- $52.52 $- $- $309.60 $- N/A $100.62 N/A N/A $94.06 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $52.52 N/A N/A $263.16 N/A N/A $189.63 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $212.85 N/A N/A $270.90 N/A N/A $129.65 N/A N/A $52.52 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $251.55 N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4000261 General Lab Bill TTF-1 Stain 88342 310 $408.00 $- $52.52 $- $- $326.40 $- N/A $106.08 N/A N/A $94.06 N/A N/A $244.80 N/A N/A $204.00 N/A N/A $52.52 N/A N/A $277.44 N/A N/A $199.92 N/A N/A $159.12 N/A N/A $285.60 N/A N/A $326.40 N/A N/A $224.40 N/A N/A $285.60 N/A N/A $136.68 N/A N/A $52.52 N/A N/A $244.80 N/A N/A $142.80 N/A N/A $265.20 N/A N/A $122.40 N/A N/A $244.80 N/A N/A $285.60 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A N/A $122.40 N/A $408.00 $408.00 N/A 4000262 General Lab Bill Wilm's Tumor Stain 88342 310 $317.00 $- $52.52 $- $- $253.60 $- N/A $82.42 N/A N/A $94.06 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $52.52 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $52.52 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000263 General Lab Bill Ber-Ep4 Stain 88342 310 $317.00 $- $52.52 $- $- $253.60 $- N/A $82.42 N/A N/A $94.06 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $52.52 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $52.52 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000264 General Lab Bill Cytokeratin 20 Stain 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4000266 General Lab Bill MOC 31 Stain 88342 310 $387.00 $- $52.52 $- $- $309.60 $- N/A $100.62 N/A N/A $94.06 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $52.52 N/A N/A $263.16 N/A N/A $189.63 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $212.85 N/A N/A $270.90 N/A N/A $129.65 N/A N/A $52.52 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $251.55 N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4000270 General Lab "Folate, RBC (No Serum) QLS" 82747 301 $317.00 $- $11.12 $- $- $253.60 $- N/A $82.42 N/A N/A $18.58 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $11.12 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $11.12 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000270 General Lab "Folate, RBC QST" 82747 301 $317.00 $- $11.12 $- $- $253.60 $- N/A $82.42 N/A N/A $18.58 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $11.12 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $11.12 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4000273 General Lab "Norovirus, EIA, Stool QST" 87449 306 $196.00 $- $7.69 $- $- $156.80 $- N/A $50.96 N/A N/A $12.86 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $7.69 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $7.69 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 4000273 General Lab "Norovirus, Stool QLS" 87449 306 $196.00 $- $7.69 $- $- $156.80 $- N/A $50.96 N/A N/A $12.86 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $7.69 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $7.69 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 4000280 General Lab Centromere Antibody QST 86235 302 $162.00 $- $10.74 $- $- $129.60 $- N/A $42.12 N/A N/A $17.95 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $10.74 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $10.74 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4000280 General Lab Centromere B Antibody QLS 86038 300 $162.00 $- $7.76 $- $- $129.60 $- N/A $42.12 N/A N/A $12.96 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $7.76 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $7.76 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4000282 General Lab Antibody ID 86077 302 $391.00 $- $24.60 $- $- $312.80 $- N/A $101.66 N/A N/A $39.78 N/A N/A $234.60 N/A N/A $195.50 N/A N/A $24.60 N/A N/A $265.88 N/A N/A $191.59 N/A N/A $152.49 N/A N/A $273.70 N/A N/A $312.80 N/A N/A $215.05 N/A N/A $273.70 N/A N/A $130.99 N/A N/A $24.60 N/A N/A $234.60 N/A N/A $136.85 N/A N/A $254.15 N/A N/A $117.30 N/A N/A $234.60 N/A N/A $273.70 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A $391.00 $391.00 N/A 4000287 General Lab Quantiferon (r) TB Gold QLS 86480 302 $368.00 $- $39.75 $- $- $294.40 $- N/A $95.68 N/A N/A $66.46 N/A N/A $220.80 N/A N/A $184.00 N/A N/A $39.75 N/A N/A $250.24 N/A N/A $180.32 N/A N/A $143.52 N/A N/A $257.60 N/A N/A $294.40 N/A N/A $202.40 N/A N/A $257.60 N/A N/A $123.28 N/A N/A $39.75 N/A N/A $220.80 N/A N/A $128.80 N/A N/A $239.20 N/A N/A $110.40 N/A N/A $220.80 N/A N/A $257.60 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A $368.00 $368.00 N/A 4000287 General Lab Quantiferon(R)-TB Gold QST 86480 302 $368.00 $- $39.75 $- $- $294.40 $- N/A $95.68 N/A N/A $66.46 N/A N/A $220.80 N/A N/A $184.00 N/A N/A $39.75 N/A N/A $250.24 N/A N/A $180.32 N/A N/A $143.52 N/A N/A $257.60 N/A N/A $294.40 N/A N/A $202.40 N/A N/A $257.60 N/A N/A $123.28 N/A N/A $39.75 N/A N/A $220.80 N/A N/A $128.80 N/A N/A $239.20 N/A N/A $110.40 N/A N/A $220.80 N/A N/A $257.60 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A $368.00 $368.00 N/A 4000288 General Lab "CMV DNA, QNT, RT PCR QST" 87497 306 "$1,517.00 " $- $27.47 $- $- "$1,213.60 " $- N/A $394.42 N/A N/A $45.92 N/A N/A $910.20 N/A N/A $758.50 N/A N/A $27.47 N/A N/A "$1,031.56 " N/A N/A $743.33 N/A N/A $591.63 N/A N/A "$1,061.90 " N/A N/A "$1,213.60 " N/A N/A $834.35 N/A N/A "$1,061.90 " N/A N/A $508.20 N/A N/A $27.47 N/A N/A $910.20 N/A N/A $530.95 N/A N/A $986.05 N/A N/A $455.10 N/A N/A $910.20 N/A N/A "$1,061.90 " N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A "$1,517.00 " "$1,517.00 " N/A 4000288 General Lab "Cytomegalovirus DNA, Quantittive, Real-Time PCR QLS" 87497 306 "$1,517.00 " $- $27.47 $- $- "$1,213.60 " $- N/A $394.42 N/A N/A $45.92 N/A N/A $910.20 N/A N/A $758.50 N/A N/A $27.47 N/A N/A "$1,031.56 " N/A N/A $743.33 N/A N/A $591.63 N/A N/A "$1,061.90 " N/A N/A "$1,213.60 " N/A N/A $834.35 N/A N/A "$1,061.90 " N/A N/A $508.20 N/A N/A $27.47 N/A N/A $910.20 N/A N/A $530.95 N/A N/A $986.05 N/A N/A $455.10 N/A N/A $910.20 N/A N/A "$1,061.90 " N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A N/A $455.10 N/A "$1,517.00 " "$1,517.00 " N/A 4000292 General Lab Pregnenolone QST 84140 301 $480.00 $- $13.27 $- $- $384.00 $- N/A $124.80 N/A N/A $22.16 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $13.27 N/A N/A $326.40 N/A N/A $235.20 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $13.27 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4000292 General Lab Pregnenolone QLS 84140 301 $480.00 $- $13.27 $- $- $384.00 $- N/A $124.80 N/A N/A $22.16 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $13.27 N/A N/A $326.40 N/A N/A $235.20 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $13.27 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4000292 General Lab Pregnenolone QST 84140 301 $480.00 $- $13.27 $- $- $384.00 $- N/A $124.80 N/A N/A $22.16 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $13.27 N/A N/A $326.40 N/A N/A $235.20 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $13.27 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4000301 General Lab Valproic Acid Level 80164 301 $247.00 $- $8.70 $- $- $197.60 $- N/A $64.22 N/A N/A $14.53 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $8.70 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $8.70 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4000330 General Lab H. Pylori Urea Breath Test QLS 83013 301 "$1,361.00 " $- $43.20 $- $- "$1,088.80 " $- N/A $353.86 N/A N/A $72.22 N/A N/A $816.60 N/A N/A $680.50 N/A N/A $43.20 N/A N/A $925.48 N/A N/A $666.89 N/A N/A $530.79 N/A N/A $952.70 N/A N/A "$1,088.80 " N/A N/A $748.55 N/A N/A $952.70 N/A N/A $455.94 N/A N/A $43.20 N/A N/A $816.60 N/A N/A $476.35 N/A N/A $884.65 N/A N/A $408.30 N/A N/A $816.60 N/A N/A $952.70 N/A N/A $408.30 N/A N/A $408.30 N/A N/A $408.30 N/A N/A $408.30 N/A N/A $408.30 N/A N/A $408.30 N/A "$1,361.00 " "$1,361.00 " N/A 4000331 General Lab Bill DNA/RNA Direct Probe 87149 306 $193.00 $- $12.86 $- $- $154.40 $- N/A $50.18 N/A N/A $21.50 N/A N/A $115.80 N/A N/A $96.50 N/A N/A $12.86 N/A N/A $131.24 N/A N/A $94.57 N/A N/A $75.27 N/A N/A $135.10 N/A N/A $154.40 N/A N/A $106.15 N/A N/A $135.10 N/A N/A $64.66 N/A N/A $12.86 N/A N/A $115.80 N/A N/A $67.55 N/A N/A $125.45 N/A N/A $57.90 N/A N/A $115.80 N/A N/A $135.10 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A $193.00 $193.00 N/A 4000332 General Lab Thyroid Stimulating Immunoglobulin QST 84445 301 "$1,269.00 " $- $32.61 $- $- "$1,015.20 " $- N/A $329.94 N/A N/A $54.53 N/A N/A $761.40 N/A N/A $634.50 N/A N/A $32.61 N/A N/A $862.92 N/A N/A $621.81 N/A N/A $494.91 N/A N/A $888.30 N/A N/A "$1,015.20 " N/A N/A $697.95 N/A N/A $888.30 N/A N/A $425.12 N/A N/A $32.61 N/A N/A $761.40 N/A N/A $444.15 N/A N/A $824.85 N/A N/A $380.70 N/A N/A $761.40 N/A N/A $888.30 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A "$1,269.00 " "$1,269.00 " N/A 4000332 General Lab Thyroid Stimulating Immunoglobulin QLS 84445 301 "$1,269.00 " $- $32.61 $- $- "$1,015.20 " $- N/A $329.94 N/A N/A $54.53 N/A N/A $761.40 N/A N/A $634.50 N/A N/A $32.61 N/A N/A $862.92 N/A N/A $621.81 N/A N/A $494.91 N/A N/A $888.30 N/A N/A "$1,015.20 " N/A N/A $697.95 N/A N/A $888.30 N/A N/A $425.12 N/A N/A $32.61 N/A N/A $761.40 N/A N/A $444.15 N/A N/A $824.85 N/A N/A $380.70 N/A N/A $761.40 N/A N/A $888.30 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A N/A $380.70 N/A "$1,269.00 " "$1,269.00 " N/A 4000333 General Lab "Metanephrines, Fract, Free, lc/ms/ms, Plasma QST" 83835 300 $823.00 $- $10.87 $- $- $658.40 $- N/A $213.98 N/A N/A $18.17 N/A N/A $493.80 N/A N/A $411.50 N/A N/A $10.87 N/A N/A $559.64 N/A N/A $403.27 N/A N/A $320.97 N/A N/A $576.10 N/A N/A $658.40 N/A N/A $452.65 N/A N/A $576.10 N/A N/A $275.71 N/A N/A $10.87 N/A N/A $493.80 N/A N/A $288.05 N/A N/A $534.95 N/A N/A $246.90 N/A N/A $493.80 N/A N/A $576.10 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A N/A $246.90 N/A $823.00 $823.00 N/A 4000345 General Lab C Diff Tox Panel QST 87493 306 $237.00 $- $22.51 $- $- $189.60 $- N/A $61.62 N/A N/A $37.63 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $22.51 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $22.51 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000345 General Lab "Clostridium Difficile Toxin B, Qual Real-Time PCR QLS" 87493 306 $237.00 $- $22.51 $- $- $189.60 $- N/A $61.62 N/A N/A $37.63 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $22.51 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $22.51 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000355 General Lab "Hepatitis Panel, Acute w/ Confirm QST" 80074 300 $704.00 $- $30.55 $- $- $563.20 $- N/A $183.04 N/A N/A $51.07 N/A N/A $422.40 N/A N/A $352.00 N/A N/A $30.55 N/A N/A $478.72 N/A N/A $344.96 N/A N/A $274.56 N/A N/A $492.80 N/A N/A $563.20 N/A N/A $387.20 N/A N/A $492.80 N/A N/A $235.84 N/A N/A $30.55 N/A N/A $422.40 N/A N/A $246.40 N/A N/A $457.60 N/A N/A $211.20 N/A N/A $422.40 N/A N/A $492.80 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A $704.00 $704.00 N/A 4000355 General Lab "Hepatitis Panel, Acute QLS" 80074 300 $704.00 $- $30.55 $- $- $563.20 $- N/A $183.04 N/A N/A $51.07 N/A N/A $422.40 N/A N/A $352.00 N/A N/A $30.55 N/A N/A $478.72 N/A N/A $344.96 N/A N/A $274.56 N/A N/A $492.80 N/A N/A $563.20 N/A N/A $387.20 N/A N/A $492.80 N/A N/A $235.84 N/A N/A $30.55 N/A N/A $422.40 N/A N/A $246.40 N/A N/A $457.60 N/A N/A $211.20 N/A N/A $422.40 N/A N/A $492.80 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A N/A $211.20 N/A $704.00 $704.00 N/A 4000364 General Lab Hemoglobin A1c 83036 301 $237.00 $- $6.23 $- $- $189.60 $- N/A $61.62 N/A N/A $10.40 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $6.23 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $6.23 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000364 General Lab Hemoglobin A1c QLS 83036 301 $237.00 $- $6.23 $- $- $189.60 $- N/A $61.62 N/A N/A $10.40 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $6.23 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $6.23 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000364 General Lab Hemoglobin A1C QST 83036 301 $237.00 $- $6.23 $- $- $189.60 $- N/A $61.62 N/A N/A $10.40 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $6.23 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $6.23 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000364 General Lab Glycohemoglobin 83036 301 $237.00 $- $6.23 $- $- $189.60 $- N/A $61.62 N/A N/A $10.40 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $6.23 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $6.23 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4000375 General Lab "Culture, Aerobic QLS" 87070 306 $168.00 $- $5.53 $- $- $134.40 $- N/A $43.68 N/A N/A $9.24 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $5.53 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $5.53 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4000387 General Lab ANA Scr IFAw/Refl Titer/Pattern/MPX Ab Cascade QST 86038 302 $174.00 $- $7.76 $- $- $139.20 $- N/A $45.24 N/A N/A $12.96 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $7.76 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $7.76 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000387 General Lab ANA Screen (IFA) Cascading Reflex QLS 86038 302 $174.00 $- $7.76 $- $- $139.20 $- N/A $45.24 N/A N/A $12.96 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $7.76 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $7.76 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000387 General Lab "ANA Scrn, IFA w/ Rfl Titer/Pattern/RA Panel 1 QST" 86038 302 $174.00 $- $7.76 $- $- $139.20 $- N/A $45.24 N/A N/A $12.96 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $7.76 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $7.76 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000387 General Lab Antinuclear Antibody Screen QST 86038 302 $174.00 $- $7.76 $- $- $139.20 $- N/A $45.24 N/A N/A $12.96 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $7.76 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $7.76 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000388 General Lab ANCA Screen with Reflex to Titer QST 86021 300 $72.00 $- $7.28 $- $- $57.60 $- N/A $18.72 N/A N/A $12.16 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $7.28 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $7.28 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4000388 General Lab ANCA Screen w/ MPO and PR3 w/Rlf to ANCA Titer QLS 86021 300 $72.00 $- $7.28 $- $- $57.60 $- N/A $18.72 N/A N/A $12.16 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $7.28 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $7.28 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4000388 General Lab ANCA Screen w/ Rfl to ANCA Titer QLS 86021 300 $72.00 $- $7.28 $- $- $57.60 $- N/A $18.72 N/A N/A $12.16 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $7.28 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $7.28 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4000402 General Lab "Culture, Blood QST" 87040 306 $738.00 $- $6.63 $- $- $590.40 $- N/A $191.88 N/A N/A $11.06 N/A N/A $442.80 N/A N/A $369.00 N/A N/A $6.63 N/A N/A $501.84 N/A N/A $361.62 N/A N/A $287.82 N/A N/A $516.60 N/A N/A $590.40 N/A N/A $405.90 N/A N/A $516.60 N/A N/A $247.23 N/A N/A $6.63 N/A N/A $442.80 N/A N/A $258.30 N/A N/A $479.70 N/A N/A $221.40 N/A N/A $442.80 N/A N/A $516.60 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A $738.00 $738.00 N/A 4000402 General Lab "Culture, Blood QLS" 87040 306 $738.00 $- $6.63 $- $- $590.40 $- N/A $191.88 N/A N/A $11.06 N/A N/A $442.80 N/A N/A $369.00 N/A N/A $6.63 N/A N/A $501.84 N/A N/A $361.62 N/A N/A $287.82 N/A N/A $516.60 N/A N/A $590.40 N/A N/A $405.90 N/A N/A $516.60 N/A N/A $247.23 N/A N/A $6.63 N/A N/A $442.80 N/A N/A $258.30 N/A N/A $479.70 N/A N/A $221.40 N/A N/A $442.80 N/A N/A $516.60 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A N/A $221.40 N/A $738.00 $738.00 N/A 4000407 General Lab Albumin Level 82040 301 $98.00 $- $3.18 $- $- $78.40 $- N/A $25.48 N/A N/A $5.30 N/A N/A $58.80 N/A N/A $49.00 N/A N/A $3.18 N/A N/A $66.64 N/A N/A $48.02 N/A N/A $38.22 N/A N/A $68.60 N/A N/A $78.40 N/A N/A $53.90 N/A N/A $68.60 N/A N/A $32.83 N/A N/A $3.18 N/A N/A $58.80 N/A N/A $34.30 N/A N/A $63.70 N/A N/A $29.40 N/A N/A $58.80 N/A N/A $68.60 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A $98.00 $98.00 N/A 4000407 General Lab "Albumin, Serum QLS" 82040 301 $98.00 $- $3.18 $- $- $78.40 $- N/A $25.48 N/A N/A $5.30 N/A N/A $58.80 N/A N/A $49.00 N/A N/A $3.18 N/A N/A $66.64 N/A N/A $48.02 N/A N/A $38.22 N/A N/A $68.60 N/A N/A $78.40 N/A N/A $53.90 N/A N/A $68.60 N/A N/A $32.83 N/A N/A $3.18 N/A N/A $58.80 N/A N/A $34.30 N/A N/A $63.70 N/A N/A $29.40 N/A N/A $58.80 N/A N/A $68.60 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A $98.00 $98.00 N/A 4000412 General Lab RBC Count 85041 305 $62.00 $- $1.94 $- $- $49.60 $- N/A $16.12 N/A N/A $3.23 N/A N/A $37.20 N/A N/A $31.00 N/A N/A $1.94 N/A N/A $42.16 N/A N/A $30.38 N/A N/A $24.18 N/A N/A $43.40 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $43.40 N/A N/A $20.77 N/A N/A $1.94 N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $43.40 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 4000425 General Lab Renal Function Panel 80069 301 $365.00 $- $5.58 $- $- $292.00 $- N/A $94.90 N/A N/A $9.31 N/A N/A $219.00 N/A N/A $182.50 N/A N/A $5.58 N/A N/A $248.20 N/A N/A $178.85 N/A N/A $142.35 N/A N/A $255.50 N/A N/A $292.00 N/A N/A $200.75 N/A N/A $255.50 N/A N/A $122.28 N/A N/A $5.58 N/A N/A $219.00 N/A N/A $127.75 N/A N/A $237.25 N/A N/A $109.50 N/A N/A $219.00 N/A N/A $255.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A $365.00 $365.00 N/A 4000425 General Lab Renal Function Panel QST 80069 301 $365.00 $- $5.58 $- $- $292.00 $- N/A $94.90 N/A N/A $9.31 N/A N/A $219.00 N/A N/A $182.50 N/A N/A $5.58 N/A N/A $248.20 N/A N/A $178.85 N/A N/A $142.35 N/A N/A $255.50 N/A N/A $292.00 N/A N/A $200.75 N/A N/A $255.50 N/A N/A $122.28 N/A N/A $5.58 N/A N/A $219.00 N/A N/A $127.75 N/A N/A $237.25 N/A N/A $109.50 N/A N/A $219.00 N/A N/A $255.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A $365.00 $365.00 N/A 4000431 General Lab Keppra (Levetiracetam) QST 80177 301 $243.00 $- $8.51 $- $- $194.40 $- N/A $63.18 N/A N/A $14.11 N/A N/A $145.80 N/A N/A $121.50 N/A N/A $8.51 N/A N/A $165.24 N/A N/A $119.07 N/A N/A $94.77 N/A N/A $170.10 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $170.10 N/A N/A $81.41 N/A N/A $8.51 N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $170.10 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 4000431 General Lab Levetiracetam (Keppra) PML 80177 301 $243.00 $- $8.51 $- $- $194.40 $- N/A $63.18 N/A N/A $14.11 N/A N/A $145.80 N/A N/A $121.50 N/A N/A $8.51 N/A N/A $165.24 N/A N/A $119.07 N/A N/A $94.77 N/A N/A $170.10 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $170.10 N/A N/A $81.41 N/A N/A $8.51 N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $170.10 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 4000431 General Lab Levetiracetam QLS 80177 301 $243.00 $- $8.51 $- $- $194.40 $- N/A $63.18 N/A N/A $14.11 N/A N/A $145.80 N/A N/A $121.50 N/A N/A $8.51 N/A N/A $165.24 N/A N/A $119.07 N/A N/A $94.77 N/A N/A $170.10 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $170.10 N/A N/A $81.41 N/A N/A $8.51 N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $170.10 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 4000435 General Lab "MTHFR, DNA Mutation Analysis QST" 81291 300 $793.00 $- $93.00 $- $- $634.40 $- N/A $206.18 N/A N/A $93.00 N/A N/A $475.80 N/A N/A $396.50 N/A N/A N/A N/A N/A $539.24 N/A N/A $388.57 N/A N/A $309.27 N/A N/A $555.10 N/A N/A $634.40 N/A N/A $436.15 N/A N/A $555.10 N/A N/A $265.66 N/A N/A N/A N/A N/A $475.80 N/A N/A $277.55 N/A N/A $515.45 N/A N/A $237.90 N/A N/A $475.80 N/A N/A $555.10 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A $793.00 $793.00 N/A 4000441 General Lab "SureSwab Trichomonas Vaginalis RNA, Qualitative, TMA QLS" 87798 306 $672.00 $- $22.51 $- $- $537.60 $- N/A $174.72 N/A N/A $37.63 N/A N/A $403.20 N/A N/A $336.00 N/A N/A $22.51 N/A N/A $456.96 N/A N/A $329.28 N/A N/A $262.08 N/A N/A $470.40 N/A N/A $537.60 N/A N/A $369.60 N/A N/A $470.40 N/A N/A $225.12 N/A N/A $22.51 N/A N/A $403.20 N/A N/A $235.20 N/A N/A $436.80 N/A N/A $201.60 N/A N/A $403.20 N/A N/A $470.40 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A $672.00 $672.00 N/A 4000441 General Lab "Trich Vaginalis RNA, Qual TMA QST" 87798 306 $672.00 $- $22.51 $- $- $537.60 $- N/A $174.72 N/A N/A $37.63 N/A N/A $403.20 N/A N/A $336.00 N/A N/A $22.51 N/A N/A $456.96 N/A N/A $329.28 N/A N/A $262.08 N/A N/A $470.40 N/A N/A $537.60 N/A N/A $369.60 N/A N/A $470.40 N/A N/A $225.12 N/A N/A $22.51 N/A N/A $403.20 N/A N/A $235.20 N/A N/A $436.80 N/A N/A $201.60 N/A N/A $403.20 N/A N/A $470.40 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A $672.00 $672.00 N/A 4000446 General Lab Reticulocyte Count QLS 85045 305 $142.00 $- $2.57 $- $- $113.60 $- N/A $36.92 N/A N/A $4.30 N/A N/A $85.20 N/A N/A $71.00 N/A N/A $2.57 N/A N/A $96.56 N/A N/A $69.58 N/A N/A $55.38 N/A N/A $99.40 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $99.40 N/A N/A $47.57 N/A N/A $2.57 N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $99.40 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 4000451 General Lab "Culture, Campylobacter QST" 87046 306 $303.00 $- $6.06 $- $- $242.40 $- N/A $78.78 N/A N/A $10.12 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $6.06 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $6.06 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000451 General Lab "Culture, Salmonella Shigella QST" 87045 306 $303.00 $- $6.06 $- $- $242.40 $- N/A $78.78 N/A N/A $10.12 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $6.06 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $6.06 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000451 General Lab "Culture, Stool QST" 87046 306 $303.00 $- $6.06 $- $- $242.40 $- N/A $78.78 N/A N/A $10.12 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $6.06 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $6.06 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000451 General Lab "Culture, Stool QLS" 87045 306 $303.00 $- $6.06 $- $- $242.40 $- N/A $78.78 N/A N/A $10.12 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $6.06 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $6.06 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000451 General Lab "Culture, Stool QLS" 87046 306 $303.00 $- $6.06 $- $- $242.40 $- N/A $78.78 N/A N/A $10.12 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $6.06 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $6.06 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000454 General Lab Dilantin Level 2 80185 301 $259.00 $- $8.51 $- $- $207.20 $- N/A $67.34 N/A N/A $14.21 N/A N/A $155.40 N/A N/A $129.50 N/A N/A $8.51 N/A N/A $176.12 N/A N/A $126.91 N/A N/A $101.01 N/A N/A $181.30 N/A N/A $207.20 N/A N/A $142.45 N/A N/A $181.30 N/A N/A $86.77 N/A N/A $8.51 N/A N/A $155.40 N/A N/A $90.65 N/A N/A $168.35 N/A N/A $77.70 N/A N/A $155.40 N/A N/A $181.30 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A $259.00 $259.00 N/A 4000458 General Lab Von Willebrand Comprehensive Panel QLS 85246 305 "$1,856.00 " $- $14.72 $- $- "$1,484.80 " $- N/A $482.56 N/A N/A $24.60 N/A N/A "$1,113.60 " N/A N/A $928.00 N/A N/A $14.72 N/A N/A "$1,262.08 " N/A N/A $909.44 N/A N/A $723.84 N/A N/A "$1,299.20 " N/A N/A "$1,484.80 " N/A N/A "$1,020.80 " N/A N/A "$1,299.20 " N/A N/A $621.76 N/A N/A $14.72 N/A N/A "$1,113.60 " N/A N/A $649.60 N/A N/A "$1,206.40 " N/A N/A $556.80 N/A N/A "$1,113.60 " N/A N/A "$1,299.20 " N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A "$1,856.00 " "$1,856.00 " N/A 4000458 General Lab Von Willebrand Comprehensive Panel QLS 85730 305 "$1,856.00 " $- $3.86 $- $- "$1,484.80 " $- N/A $482.56 N/A N/A $6.43 N/A N/A "$1,113.60 " N/A N/A $928.00 N/A N/A $3.86 N/A N/A "$1,262.08 " N/A N/A $909.44 N/A N/A $723.84 N/A N/A "$1,299.20 " N/A N/A "$1,484.80 " N/A N/A "$1,020.80 " N/A N/A "$1,299.20 " N/A N/A $621.76 N/A N/A $3.86 N/A N/A "$1,113.60 " N/A N/A $649.60 N/A N/A "$1,206.40 " N/A N/A $556.80 N/A N/A "$1,113.60 " N/A N/A "$1,299.20 " N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A "$1,856.00 " "$1,856.00 " N/A 4000458 General Lab Von Willebrand Comprehensive Panel QLS 85240 305 "$1,856.00 " $- $11.49 $- $- "$1,484.80 " $- N/A $482.56 N/A N/A $19.20 N/A N/A "$1,113.60 " N/A N/A $928.00 N/A N/A $11.49 N/A N/A "$1,262.08 " N/A N/A $909.44 N/A N/A $723.84 N/A N/A "$1,299.20 " N/A N/A "$1,484.80 " N/A N/A "$1,020.80 " N/A N/A "$1,299.20 " N/A N/A $621.76 N/A N/A $11.49 N/A N/A "$1,113.60 " N/A N/A $649.60 N/A N/A "$1,206.40 " N/A N/A $556.80 N/A N/A "$1,113.60 " N/A N/A "$1,299.20 " N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A "$1,856.00 " "$1,856.00 " N/A 4000458 General Lab Von Willebrand Comprehensive Panel QLS 85245 305 "$1,856.00 " $- $14.72 $- $- "$1,484.80 " $- N/A $482.56 N/A N/A $24.60 N/A N/A "$1,113.60 " N/A N/A $928.00 N/A N/A $14.72 N/A N/A "$1,262.08 " N/A N/A $909.44 N/A N/A $723.84 N/A N/A "$1,299.20 " N/A N/A "$1,484.80 " N/A N/A "$1,020.80 " N/A N/A "$1,299.20 " N/A N/A $621.76 N/A N/A $14.72 N/A N/A "$1,113.60 " N/A N/A $649.60 N/A N/A "$1,206.40 " N/A N/A $556.80 N/A N/A "$1,113.60 " N/A N/A "$1,299.20 " N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A "$1,856.00 " "$1,856.00 " N/A 4000458 General Lab Von Willebrand Comprehensive Panel QLS 85247 305 "$1,856.00 " $- $14.72 $- $- "$1,484.80 " $- N/A $482.56 N/A N/A $24.60 N/A N/A "$1,113.60 " N/A N/A $928.00 N/A N/A $14.72 N/A N/A "$1,262.08 " N/A N/A $909.44 N/A N/A $723.84 N/A N/A "$1,299.20 " N/A N/A "$1,484.80 " N/A N/A "$1,020.80 " N/A N/A "$1,299.20 " N/A N/A $621.76 N/A N/A $14.72 N/A N/A "$1,113.60 " N/A N/A $649.60 N/A N/A "$1,206.40 " N/A N/A $556.80 N/A N/A "$1,113.60 " N/A N/A "$1,299.20 " N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A N/A $556.80 N/A "$1,856.00 " "$1,856.00 " N/A 4000464 General Lab "Lambda Light Chains, Free, Serum QLS" 83883 301 $303.00 $- $8.72 $- $- $242.40 $- N/A $78.78 N/A N/A $14.58 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $8.72 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $8.72 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000464 General Lab "Lambda Light Chain, Free QST" 83883 301 $303.00 $- $8.72 $- $- $242.40 $- N/A $78.78 N/A N/A $14.58 N/A N/A $181.80 N/A N/A $151.50 N/A N/A $8.72 N/A N/A $206.04 N/A N/A $148.47 N/A N/A $118.17 N/A N/A $212.10 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $212.10 N/A N/A $101.51 N/A N/A $8.72 N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $212.10 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 4000475 General Lab JAK2 Mutation Quant QST 81270 310 "$1,660.00 " $- $69.06 $- $- "$1,328.00 " $- N/A $431.60 N/A N/A $69.06 N/A N/A $996.00 N/A N/A $830.00 N/A N/A N/A N/A N/A "$1,128.80 " N/A N/A $813.40 N/A N/A $647.40 N/A N/A "$1,162.00 " N/A N/A "$1,328.00 " N/A N/A $913.00 N/A N/A "$1,162.00 " N/A N/A $556.10 N/A N/A N/A N/A N/A $996.00 N/A N/A $581.00 N/A N/A "$1,079.00 " N/A N/A $498.00 N/A N/A $996.00 N/A N/A "$1,162.00 " N/A N/A $498.00 N/A N/A $498.00 N/A N/A $498.00 N/A N/A $498.00 N/A N/A $498.00 N/A N/A $498.00 N/A "$1,660.00 " "$1,660.00 " N/A 4000487 General Lab White Blood Count 85048 300 $22.00 $- $1.63 $- $- $17.60 $- N/A $5.72 N/A N/A $2.72 N/A N/A $13.20 N/A N/A $11.00 N/A N/A $1.63 N/A N/A $14.96 N/A N/A $10.78 N/A N/A $8.58 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A $1.63 N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $15.40 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 4000509 General Lab "Cell Count and Differential, Fluid QLS" 89051 305 $238.00 $- $3.54 $- $- $190.40 $- N/A $61.88 N/A N/A $5.90 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $3.54 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $3.54 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4000555 General Lab Alcohol Level 1 80320 G0480 301 $350.00 $- $0.01 $- $- $280.00 $- N/A $91.00 N/A N/A $0.01 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4000570 General Lab Cystatin C QLS 82610 301 $263.00 $- $8.72 $- $- $210.40 $- N/A $68.38 N/A N/A $14.58 N/A N/A $157.80 N/A N/A $131.50 N/A N/A $8.72 N/A N/A $178.84 N/A N/A $128.87 N/A N/A $102.57 N/A N/A $184.10 N/A N/A $210.40 N/A N/A $144.65 N/A N/A $184.10 N/A N/A $88.11 N/A N/A $8.72 N/A N/A $157.80 N/A N/A $92.05 N/A N/A $170.95 N/A N/A $78.90 N/A N/A $157.80 N/A N/A $184.10 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A $263.00 $263.00 N/A 4000570 General Lab Cystatin C QST 82610 301 $263.00 $- $8.72 $- $- $210.40 $- N/A $68.38 N/A N/A $14.58 N/A N/A $157.80 N/A N/A $131.50 N/A N/A $8.72 N/A N/A $178.84 N/A N/A $128.87 N/A N/A $102.57 N/A N/A $184.10 N/A N/A $210.40 N/A N/A $144.65 N/A N/A $184.10 N/A N/A $88.11 N/A N/A $8.72 N/A N/A $157.80 N/A N/A $92.05 N/A N/A $170.95 N/A N/A $78.90 N/A N/A $157.80 N/A N/A $184.10 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A N/A $78.90 N/A $263.00 $263.00 N/A 4000581 General Lab Hepatic Panel 1 80076 301 $160.00 $- $5.24 $- $- $128.00 $- N/A $41.60 N/A N/A $8.76 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $5.24 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $5.24 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4000608 General Lab Crystals Body Fluid QST 89060 305 $103.00 $- $4.59 $- $- $82.40 $- N/A $26.78 N/A N/A $7.67 N/A N/A $61.80 N/A N/A $51.50 N/A N/A $4.59 N/A N/A $70.04 N/A N/A $50.47 N/A N/A $40.17 N/A N/A $72.10 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $72.10 N/A N/A $34.51 N/A N/A $4.59 N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $72.10 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 4000608 General Lab "Crystals, Fluid QLS" 89060 305 $103.00 $- $4.59 $- $- $82.40 $- N/A $26.78 N/A N/A $7.67 N/A N/A $61.80 N/A N/A $51.50 N/A N/A $4.59 N/A N/A $70.04 N/A N/A $50.47 N/A N/A $40.17 N/A N/A $72.10 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $72.10 N/A N/A $34.51 N/A N/A $4.59 N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $72.10 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 4000615 General Lab Lipid Panel 3 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4000615 General Lab Lipid Profile 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4000651 General Lab PSA Screen 84153 G0103 301 $292.00 $- $11.80 $- $- $233.60 $- N/A $75.92 N/A N/A $19.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $11.80 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $11.80 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4000663 General Lab Malaria/Babesia/Other Blood Parasite QLS 87207 306 $185.00 $- $3.85 $- $- $148.00 $- N/A $48.10 N/A N/A $6.43 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $3.85 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $3.85 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4000663 General Lab Malaria/Babesia/Other Blood Parasites QST 87207 306 $185.00 $- $3.85 $- $- $148.00 $- N/A $48.10 N/A N/A $6.43 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $3.85 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $3.85 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4000665 General Lab "C. psittaci Abs IgG, IgA, IgM QST" 86331 302 $203.00 $- $7.69 $- $- $162.40 $- N/A $52.78 N/A N/A $12.85 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $7.69 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $7.69 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4000665 General Lab "Chlamydophila Psittaci Antibodies (IgG, IgA, IgM) QLS" 86331 302 $203.00 $- $7.69 $- $- $162.40 $- N/A $52.78 N/A N/A $12.85 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $7.69 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $7.69 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4000751 General Lab Alkaline Phosphatase 84075 301 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4000758 General Lab "Culture, Aerobic Bacteria With Gram Stain QST" 87075 306 $174.00 $- $6.08 $- $- $139.20 $- N/A $45.24 N/A N/A $10.15 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $6.08 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $6.08 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000758 General Lab "Culture, Anaerobic Bacteria w/ Gram Stain QLS" 87075 306 $174.00 $- $6.08 $- $- $139.20 $- N/A $45.24 N/A N/A $10.15 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $6.08 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $6.08 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000758 General Lab "Culture, Anaerobic Bacteria w/ Gram Stain QLS" 87205 306 $174.00 $- $2.74 $- $- $139.20 $- N/A $45.24 N/A N/A $4.58 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $2.74 N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A $2.74 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 4000816 General Lab Rapid Strep A Screen 1 86063 302 $182.00 $- $3.71 $- $- $145.60 $- N/A $47.32 N/A N/A $6.18 N/A N/A $109.20 N/A N/A $91.00 N/A N/A $3.71 N/A N/A $123.76 N/A N/A $89.18 N/A N/A $70.98 N/A N/A $127.40 N/A N/A $145.60 N/A N/A $100.10 N/A N/A $127.40 N/A N/A $60.97 N/A N/A $3.71 N/A N/A $109.20 N/A N/A $63.70 N/A N/A $118.30 N/A N/A $54.60 N/A N/A $109.20 N/A N/A $127.40 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A $182.00 $182.00 N/A 4000852 General Lab Aldolase QLS 82085 301 $333.00 $- $6.23 $- $- $266.40 $- N/A $86.58 N/A N/A $10.40 N/A N/A $199.80 N/A N/A $166.50 N/A N/A $6.23 N/A N/A $226.44 N/A N/A $163.17 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $6.23 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 4000852 General Lab Aldolase QST 82085 301 $333.00 $- $6.23 $- $- $266.40 $- N/A $86.58 N/A N/A $10.40 N/A N/A $199.80 N/A N/A $166.50 N/A N/A $6.23 N/A N/A $226.44 N/A N/A $163.17 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $6.23 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 4000854 General Lab Cyclosporine Whole Molecule QLS 80158 301 $333.00 $- $11.59 $- $- $266.40 $- N/A $86.58 N/A N/A $19.36 N/A N/A $199.80 N/A N/A $166.50 N/A N/A $11.59 N/A N/A $226.44 N/A N/A $163.17 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $11.59 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 4000857 General Lab "Culture, Urine QST" 87086 306 $301.00 $- $5.18 $- $- $240.80 $- N/A $78.26 N/A N/A $8.66 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $5.18 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $5.18 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4000857 General Lab "Culture, Urine, Routine QLS" 87086 306 $301.00 $- $5.18 $- $- $240.80 $- N/A $78.26 N/A N/A $8.66 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $5.18 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $5.18 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4000886 General Lab Aldosterone QST 82088 301 $852.00 $- $26.14 $- $- $681.60 $- N/A $221.52 N/A N/A $43.69 N/A N/A $511.20 N/A N/A $426.00 N/A N/A $26.14 N/A N/A $579.36 N/A N/A $417.48 N/A N/A $332.28 N/A N/A $596.40 N/A N/A $681.60 N/A N/A $468.60 N/A N/A $596.40 N/A N/A $285.42 N/A N/A $26.14 N/A N/A $511.20 N/A N/A $298.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $511.20 N/A N/A $596.40 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A $852.00 $852.00 N/A 4000886 General Lab Aldosterone QLS 82088 301 $852.00 $- $26.14 $- $- $681.60 $- N/A $221.52 N/A N/A $43.69 N/A N/A $511.20 N/A N/A $426.00 N/A N/A $26.14 N/A N/A $579.36 N/A N/A $417.48 N/A N/A $332.28 N/A N/A $596.40 N/A N/A $681.60 N/A N/A $468.60 N/A N/A $596.40 N/A N/A $285.42 N/A N/A $26.14 N/A N/A $511.20 N/A N/A $298.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $511.20 N/A N/A $596.40 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A $852.00 $852.00 N/A 4001007 General Lab Phosphorus Level 84100 301 $96.00 $- $3.04 $- $- $76.80 $- N/A $24.96 N/A N/A $5.09 N/A N/A $57.60 N/A N/A $48.00 N/A N/A $3.04 N/A N/A $65.28 N/A N/A $47.04 N/A N/A $37.44 N/A N/A $67.20 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $67.20 N/A N/A $32.16 N/A N/A $3.04 N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $67.20 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 4001061 General Lab "Culture, Fungus, Other QLS" 87102 306 $318.00 $- $5.39 $- $- $254.40 $- N/A $82.68 N/A N/A $9.01 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $5.39 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $5.39 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4001061 General Lab "Culture, Fungus, Other QLS" 87206 306 $318.00 $- $3.45 $- $- $254.40 $- N/A $82.68 N/A N/A $5.76 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $3.45 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $3.45 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4001122 General Lab COLLECTION: Capillary 36415 300 $42.00 $- $2.51 $- $- $33.60 $- N/A $10.92 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $2.51 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $2.51 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 4001200 General Lab "Protein, Ur (mg/dl) QLS" 84156 301 $171.00 $- $2.35 $- $- $136.80 $- N/A $44.46 N/A N/A $3.94 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $2.35 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $2.35 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4001200 General Lab "Protein,Total,24hr Urine(w/Creat) QLS" 84156 300 $171.00 $- $2.35 $- $- $136.80 $- N/A $44.46 N/A N/A $3.94 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $2.35 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $2.35 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4001200 General Lab "Protein,Total,24hr Urine(w/Creat) QLS" 82570 300 $171.00 $- $3.32 $- $- $136.80 $- N/A $44.46 N/A N/A $5.54 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $3.32 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $3.32 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4001200 General Lab "Protein/Creat Ratio, Urine QLS" 82570 300 $171.00 $- $3.32 $- $- $136.80 $- N/A $44.46 N/A N/A $5.54 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $3.32 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $3.32 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4001200 General Lab "Protein/Creat Ratio, Urine QLS" 84156 300 $171.00 $- $2.35 $- $- $136.80 $- N/A $44.46 N/A N/A $3.94 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $2.35 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $2.35 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 4001213 General Lab Coenzyme Q10 QST 82542 301 $285.00 $- $11.59 $- $- $228.00 $- N/A $74.10 N/A N/A $19.36 N/A N/A $171.00 N/A N/A $142.50 N/A N/A $11.59 N/A N/A $193.80 N/A N/A $139.65 N/A N/A $111.15 N/A N/A $199.50 N/A N/A $228.00 N/A N/A $156.75 N/A N/A $199.50 N/A N/A $95.48 N/A N/A $11.59 N/A N/A $171.00 N/A N/A $99.75 N/A N/A $185.25 N/A N/A $85.50 N/A N/A $171.00 N/A N/A $199.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A $285.00 $285.00 N/A 4001213 General Lab "Porphyrins, Total, Plasma QLS" 82542 301 $285.00 $- $11.59 $- $- $228.00 $- N/A $74.10 N/A N/A $19.36 N/A N/A $171.00 N/A N/A $142.50 N/A N/A $11.59 N/A N/A $193.80 N/A N/A $139.65 N/A N/A $111.15 N/A N/A $199.50 N/A N/A $228.00 N/A N/A $156.75 N/A N/A $199.50 N/A N/A $95.48 N/A N/A $11.59 N/A N/A $171.00 N/A N/A $99.75 N/A N/A $185.25 N/A N/A $85.50 N/A N/A $171.00 N/A N/A $199.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A $285.00 $285.00 N/A 4001230 General Lab "Cardio IQ® Lipoprotein Fractionation, Ion Mobility QLS" 83704 301 $603.00 $- $20.23 $- $- $482.40 $- N/A $156.78 N/A N/A $33.82 N/A N/A $361.80 N/A N/A $301.50 N/A N/A $20.23 N/A N/A $410.04 N/A N/A $295.47 N/A N/A $235.17 N/A N/A $422.10 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $422.10 N/A N/A $202.01 N/A N/A $20.23 N/A N/A $361.80 N/A N/A $211.05 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $422.10 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 4001230 General Lab Lipoprotein Fractation Ion Mobility QST 83704 301 $603.00 $- $20.23 $- $- $482.40 $- N/A $156.78 N/A N/A $33.82 N/A N/A $361.80 N/A N/A $301.50 N/A N/A $20.23 N/A N/A $410.04 N/A N/A $295.47 N/A N/A $235.17 N/A N/A $422.10 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $422.10 N/A N/A $202.01 N/A N/A $20.23 N/A N/A $361.80 N/A N/A $211.05 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $422.10 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 4001250 General Lab Fecal Leukocytes QST 89055 301 $78.00 $- $2.74 $- $- $62.40 $- N/A $20.28 N/A N/A $4.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.74 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.74 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4001250 General Lab Stool For WBC QLS 89055 301 $78.00 $- $2.74 $- $- $62.40 $- N/A $20.28 N/A N/A $4.58 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.74 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.74 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4001289 General Lab Beta-2-Microglobulin QST 82232 301 $301.00 $- $10.38 $- $- $240.80 $- N/A $78.26 N/A N/A $17.35 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $10.38 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $10.38 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4001289 General Lab "Beta-2-Microglobulin, Blood QLS" 82232 301 $301.00 $- $10.38 $- $- $240.80 $- N/A $78.26 N/A N/A $17.35 N/A N/A $180.60 N/A N/A $150.50 N/A N/A $10.38 N/A N/A $204.68 N/A N/A $147.49 N/A N/A $117.39 N/A N/A $210.70 N/A N/A $240.80 N/A N/A $165.55 N/A N/A $210.70 N/A N/A $100.84 N/A N/A $10.38 N/A N/A $180.60 N/A N/A $105.35 N/A N/A $195.65 N/A N/A $90.30 N/A N/A $180.60 N/A N/A $210.70 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A N/A $90.30 N/A $301.00 $301.00 N/A 4001290 General Lab Fecal Globin by Immunochem QST 82274 301 $180.00 $- $10.20 $- $- $144.00 $- N/A $46.80 N/A N/A $17.05 N/A N/A $108.00 N/A N/A $90.00 N/A N/A $10.20 N/A N/A $122.40 N/A N/A $88.20 N/A N/A $70.20 N/A N/A $126.00 N/A N/A $144.00 N/A N/A $99.00 N/A N/A $126.00 N/A N/A $60.30 N/A N/A $10.20 N/A N/A $108.00 N/A N/A $63.00 N/A N/A $117.00 N/A N/A $54.00 N/A N/A $108.00 N/A N/A $126.00 N/A N/A $54.00 N/A N/A $54.00 N/A N/A $54.00 N/A N/A $54.00 N/A N/A $54.00 N/A N/A $54.00 N/A $180.00 $180.00 N/A 4001300 General Lab Homocysteine Cardiovascular QST 83090 301 $362.00 $- $10.82 $- $- $289.60 $- N/A $94.12 N/A N/A $18.08 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $10.82 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $10.82 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4001300 General Lab "Homocysteine, Cardiovascular QLS" 83090 301 $362.00 $- $10.82 $- $- $289.60 $- N/A $94.12 N/A N/A $18.08 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $10.82 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $10.82 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4001320 General Lab CA 15-3 QST 86300 302 $529.00 $- $13.35 $- $- $423.20 $- N/A $137.54 N/A N/A $22.32 N/A N/A $317.40 N/A N/A $264.50 N/A N/A $13.35 N/A N/A $359.72 N/A N/A $259.21 N/A N/A $206.31 N/A N/A $370.30 N/A N/A $423.20 N/A N/A $290.95 N/A N/A $370.30 N/A N/A $177.22 N/A N/A $13.35 N/A N/A $317.40 N/A N/A $185.15 N/A N/A $343.85 N/A N/A $158.70 N/A N/A $317.40 N/A N/A $370.30 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A $529.00 $529.00 N/A 4001320 General Lab CA 27.29 QLS 86300 302 $529.00 $- $13.35 $- $- $423.20 $- N/A $137.54 N/A N/A $22.32 N/A N/A $317.40 N/A N/A $264.50 N/A N/A $13.35 N/A N/A $359.72 N/A N/A $259.21 N/A N/A $206.31 N/A N/A $370.30 N/A N/A $423.20 N/A N/A $290.95 N/A N/A $370.30 N/A N/A $177.22 N/A N/A $13.35 N/A N/A $317.40 N/A N/A $185.15 N/A N/A $343.85 N/A N/A $158.70 N/A N/A $317.40 N/A N/A $370.30 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A $529.00 $529.00 N/A 4001320 General Lab CA 27.29 QST 86300 302 $529.00 $- $13.35 $- $- $423.20 $- N/A $137.54 N/A N/A $22.32 N/A N/A $317.40 N/A N/A $264.50 N/A N/A $13.35 N/A N/A $359.72 N/A N/A $259.21 N/A N/A $206.31 N/A N/A $370.30 N/A N/A $423.20 N/A N/A $290.95 N/A N/A $370.30 N/A N/A $177.22 N/A N/A $13.35 N/A N/A $317.40 N/A N/A $185.15 N/A N/A $343.85 N/A N/A $158.70 N/A N/A $317.40 N/A N/A $370.30 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A $529.00 $529.00 N/A 4001330 General Lab Tacrolimus QST 80197 301 $437.00 $- $8.81 $- $- $349.60 $- N/A $113.62 N/A N/A $14.72 N/A N/A $262.20 N/A N/A $218.50 N/A N/A $8.81 N/A N/A $297.16 N/A N/A $214.13 N/A N/A $170.43 N/A N/A $305.90 N/A N/A $349.60 N/A N/A $240.35 N/A N/A $305.90 N/A N/A $146.40 N/A N/A $8.81 N/A N/A $262.20 N/A N/A $152.95 N/A N/A $284.05 N/A N/A $131.10 N/A N/A $262.20 N/A N/A $305.90 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A $437.00 $437.00 N/A 4001330 General Lab "Tacrolimus, Highly Sensitive QLS" 80197 301 $437.00 $- $8.81 $- $- $349.60 $- N/A $113.62 N/A N/A $14.72 N/A N/A $262.20 N/A N/A $218.50 N/A N/A $8.81 N/A N/A $297.16 N/A N/A $214.13 N/A N/A $170.43 N/A N/A $305.90 N/A N/A $349.60 N/A N/A $240.35 N/A N/A $305.90 N/A N/A $146.40 N/A N/A $8.81 N/A N/A $262.20 N/A N/A $152.95 N/A N/A $284.05 N/A N/A $131.10 N/A N/A $262.20 N/A N/A $305.90 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A $437.00 $437.00 N/A 4001341 General Lab Pre-Albumin QLS 84134 301 $300.00 $- $9.36 $- $- $240.00 $- N/A $78.00 N/A N/A $15.64 N/A N/A $180.00 N/A N/A $150.00 N/A N/A $9.36 N/A N/A $204.00 N/A N/A $147.00 N/A N/A $117.00 N/A N/A $210.00 N/A N/A $240.00 N/A N/A $165.00 N/A N/A $210.00 N/A N/A $100.50 N/A N/A $9.36 N/A N/A $180.00 N/A N/A $105.00 N/A N/A $195.00 N/A N/A $90.00 N/A N/A $180.00 N/A N/A $210.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A $300.00 $300.00 N/A 4001341 General Lab Prealbumin QST 84134 301 $300.00 $- $9.36 $- $- $240.00 $- N/A $78.00 N/A N/A $15.64 N/A N/A $180.00 N/A N/A $150.00 N/A N/A $9.36 N/A N/A $204.00 N/A N/A $147.00 N/A N/A $117.00 N/A N/A $210.00 N/A N/A $240.00 N/A N/A $165.00 N/A N/A $210.00 N/A N/A $100.50 N/A N/A $9.36 N/A N/A $180.00 N/A N/A $105.00 N/A N/A $195.00 N/A N/A $90.00 N/A N/A $180.00 N/A N/A $210.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A $300.00 $300.00 N/A 4001345 General Lab "HSV 1 IgG, Type Specific Ab QST" 86695 302 $185.00 $- $8.46 $- $- $148.00 $- N/A $48.10 N/A N/A $14.14 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $8.46 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $8.46 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001345 General Lab "HSV 1/2 Ab IgM, IFA w/ Rflx to Titer QST" 86696 302 $185.00 $- $12.41 $- $- $148.00 $- N/A $48.10 N/A N/A $20.75 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $12.41 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $12.41 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001345 General Lab HSV 1/2 IgG Ab QST 86696 302 $185.00 $- $12.41 $- $- $148.00 $- N/A $48.10 N/A N/A $20.75 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $12.41 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $12.41 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001345 General Lab HSV Virus 1/2(IgG) Type-Specific Ab (Herpeselect) QLS 86695 302 $185.00 $- $8.46 $- $- $148.00 $- N/A $48.10 N/A N/A $14.14 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $8.46 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $8.46 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001345 General Lab HSV Virus 1/2(IgG) Type-Specific Ab (Herpeselect) QLS 86696 302 $185.00 $- $12.41 $- $- $148.00 $- N/A $48.10 N/A N/A $20.75 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $12.41 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $12.41 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001371 General Lab Theophylline QST 80198 301 $261.00 $- $9.08 $- $- $208.80 $- N/A $67.86 N/A N/A $15.17 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $9.08 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $9.08 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4001371 General Lab Theophylline (Aminophylline) QLS 80198 301 $261.00 $- $9.08 $- $- $208.80 $- N/A $67.86 N/A N/A $15.17 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $9.08 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $9.08 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4001402 General Lab "C Reactive Protein, Quantitative QLS" 86140 302 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001402 General Lab C-Reactive Protein QST 86140 302 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001405 General Lab Ammonia Level 82140 301 $350.00 $- $9.35 $- $- $280.00 $- N/A $91.00 N/A N/A $15.62 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $9.35 N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A $9.35 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4001430 General Lab Free T3 QST 84481 301 $261.00 $- $10.87 $- $- $208.80 $- N/A $67.86 N/A N/A $18.17 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $10.87 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $10.87 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4001430 General Lab "T3, Free QLS" 84481 301 $261.00 $- $10.87 $- $- $208.80 $- N/A $67.86 N/A N/A $18.17 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $10.87 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $10.87 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4001445 General Lab Progesterone Level QST 84144 301 $366.00 $- $13.38 $- $- $292.80 $- N/A $95.16 N/A N/A $22.37 N/A N/A $219.60 N/A N/A $183.00 N/A N/A $13.38 N/A N/A $248.88 N/A N/A $179.34 N/A N/A $142.74 N/A N/A $256.20 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $256.20 N/A N/A $122.61 N/A N/A $13.38 N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $256.20 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 4001445 General Lab Progesterone QLS 84144 301 $366.00 $- $13.38 $- $- $292.80 $- N/A $95.16 N/A N/A $22.37 N/A N/A $219.60 N/A N/A $183.00 N/A N/A $13.38 N/A N/A $248.88 N/A N/A $179.34 N/A N/A $142.74 N/A N/A $256.20 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $256.20 N/A N/A $122.61 N/A N/A $13.38 N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $256.20 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 4001445 General Lab "Progesterone, LC/MS QST" 84144 301 $366.00 $- $13.38 $- $- $292.80 $- N/A $95.16 N/A N/A $22.37 N/A N/A $219.60 N/A N/A $183.00 N/A N/A $13.38 N/A N/A $248.88 N/A N/A $179.34 N/A N/A $142.74 N/A N/A $256.20 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $256.20 N/A N/A $122.61 N/A N/A $13.38 N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $256.20 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 4001460 General Lab Prolactin Level QST 84146 301 $192.00 $- $12.43 $- $- $153.60 $- N/A $49.92 N/A N/A $20.78 N/A N/A $115.20 N/A N/A $96.00 N/A N/A $12.43 N/A N/A $130.56 N/A N/A $94.08 N/A N/A $74.88 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A $12.43 N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $57.60 N/A N/A $115.20 N/A N/A $134.40 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A $192.00 $192.00 N/A 4001460 General Lab Prolactin QLS 84146 301 $192.00 $- $12.43 $- $- $153.60 $- N/A $49.92 N/A N/A $20.78 N/A N/A $115.20 N/A N/A $96.00 N/A N/A $12.43 N/A N/A $130.56 N/A N/A $94.08 N/A N/A $74.88 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A $12.43 N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $57.60 N/A N/A $115.20 N/A N/A $134.40 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A $192.00 $192.00 N/A 4001460 General Lab "Prolactin, Diluted QLS" 84146 301 $192.00 $- $12.43 $- $- $153.60 $- N/A $49.92 N/A N/A $20.78 N/A N/A $115.20 N/A N/A $96.00 N/A N/A $12.43 N/A N/A $130.56 N/A N/A $94.08 N/A N/A $74.88 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A $12.43 N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $57.60 N/A N/A $115.20 N/A N/A $134.40 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A $192.00 $192.00 N/A 4001464 General Lab Chloride Level Urine 82436 301 $68.00 $- $3.23 $- $- $54.40 $- N/A $17.68 N/A N/A $5.39 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $3.23 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $3.23 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001464 General Lab "Chlroide, Random Urine w/o Creat QLS" 82436 301 $68.00 $- $3.23 $- $- $54.40 $- N/A $17.68 N/A N/A $5.39 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $3.23 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $3.23 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001465 General Lab Potassium Level Urine 84133 301 $47.00 $- $2.77 $- $- $37.60 $- N/A $12.22 N/A N/A $4.61 N/A N/A $28.20 N/A N/A $23.50 N/A N/A $2.77 N/A N/A $31.96 N/A N/A $23.03 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A $2.77 N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4001466 General Lab Sodium Level Urine 84300 301 $92.00 $- $3.13 $- $- $73.60 $- N/A $23.92 N/A N/A $5.22 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.13 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.13 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4001466 General Lab "Sodium, Random Urine w/o Creat QLS" 82436 301 $92.00 $- $3.23 $- $- $73.60 $- N/A $23.92 N/A N/A $5.39 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.23 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.23 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4001470 General Lab "Delta-Aminolevulinic Acid, 24 Hr Urine QLS" 82135 301 $322.00 $- $10.56 $- $- $257.60 $- N/A $83.72 N/A N/A $17.64 N/A N/A $193.20 N/A N/A $161.00 N/A N/A $10.56 N/A N/A $218.96 N/A N/A $157.78 N/A N/A $125.58 N/A N/A $225.40 N/A N/A $257.60 N/A N/A $177.10 N/A N/A $225.40 N/A N/A $107.87 N/A N/A $10.56 N/A N/A $193.20 N/A N/A $112.70 N/A N/A $209.30 N/A N/A $96.60 N/A N/A $193.20 N/A N/A $225.40 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A $322.00 $322.00 N/A 4001493 General Lab CEA (Carcinoembryonic Antigen) QLS 82378 302 $366.00 $- $12.17 $- $- $292.80 $- N/A $95.16 N/A N/A $20.34 N/A N/A $219.60 N/A N/A $183.00 N/A N/A $12.17 N/A N/A $248.88 N/A N/A $179.34 N/A N/A $142.74 N/A N/A $256.20 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $256.20 N/A N/A $122.61 N/A N/A $12.17 N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $256.20 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 4001493 General Lab Carcinoembryonic Antigen QST 82378 302 $366.00 $- $12.17 $- $- $292.80 $- N/A $95.16 N/A N/A $20.34 N/A N/A $219.60 N/A N/A $183.00 N/A N/A $12.17 N/A N/A $248.88 N/A N/A $179.34 N/A N/A $142.74 N/A N/A $256.20 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $256.20 N/A N/A $122.61 N/A N/A $12.17 N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $256.20 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 4001504 General Lab Amylase Level 82150 301 $139.00 $- $4.16 $- $- $111.20 $- N/A $36.14 N/A N/A $6.95 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $4.16 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $4.16 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4001504 General Lab Amylase QLS 82150 301 $139.00 $- $4.16 $- $- $111.20 $- N/A $36.14 N/A N/A $6.95 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $4.16 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $4.16 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4001543 General Lab Vitamin B2 QLS 84252 301 $646.00 $- $12.99 $- $- $516.80 $- N/A $167.96 N/A N/A $21.70 N/A N/A $387.60 N/A N/A $323.00 N/A N/A $12.99 N/A N/A $439.28 N/A N/A $316.54 N/A N/A $251.94 N/A N/A $452.20 N/A N/A $516.80 N/A N/A $355.30 N/A N/A $452.20 N/A N/A $216.41 N/A N/A $12.99 N/A N/A $387.60 N/A N/A $226.10 N/A N/A $419.90 N/A N/A $193.80 N/A N/A $387.60 N/A N/A $452.20 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A N/A $193.80 N/A $646.00 $646.00 N/A 4001544 General Lab Eosinophil Count U QST 85999 300 $101.00 $- $26.26 $- $- $80.80 $- N/A $26.26 N/A N/A N/A N/A N/A $60.60 N/A N/A $50.50 N/A N/A N/A N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A N/A N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophil Count, Blood QST" 85004 300 $101.00 $- $4.16 $- $- $80.80 $- N/A $26.26 N/A N/A $6.94 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $4.16 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $4.16 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophil Count, Blood QST" 85048 300 $101.00 $- $1.63 $- $- $80.80 $- N/A $26.26 N/A N/A $2.72 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $1.63 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $1.63 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophil Count, Nasal QST" 89190 300 $101.00 $- $3.05 $- $- $80.80 $- N/A $26.26 N/A N/A $5.09 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.05 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.05 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophil Count, Sputum QST" 85999 300 $101.00 $- $26.26 $- $- $80.80 $- N/A $26.26 N/A N/A N/A N/A N/A $60.60 N/A N/A $50.50 N/A N/A N/A N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A N/A N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophil Count, Feces QST" 85999 300 $101.00 $- $26.26 $- $- $80.80 $- N/A $26.26 N/A N/A N/A N/A N/A $60.60 N/A N/A $50.50 N/A N/A N/A N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A N/A N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001544 General Lab "Eosinophils, Nasal, Urine, and Other QLS" 85999 300 $101.00 $- $26.26 $- $- $80.80 $- N/A $26.26 N/A N/A N/A N/A N/A $60.60 N/A N/A $50.50 N/A N/A N/A N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A N/A N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4001549 General Lab Actin (Smooth Muscle) Antibody (IgG) QLS 83516 301 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Myositis Assessr Plus Jo-1 AutoAntibodies QLS 83516 302 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Myositis Assessr plus Jo-1 Ab QST 83516 302 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Smooth Muscle Ab QST 83516 301 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Tissue Transglutaminase Ab IgA QLS 83516 301 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Tissue transglutaminase IgG QST 83516 301 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001549 General Lab Tissue transglutaminase IgA QST 83516 301 $93.00 $- $7.40 $- $- $74.40 $- N/A $24.18 N/A N/A $12.37 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.40 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.40 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4001551 General Lab Protein Total 84155 301 $72.00 $- $2.35 $- $- $57.60 $- N/A $18.72 N/A N/A $3.94 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $2.35 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $2.35 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4001552 General Lab CSF Protein 84157 301 $196.00 $- $2.35 $- $- $156.80 $- N/A $50.96 N/A N/A $3.94 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $2.35 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $2.35 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 4001605 General Lab Cytology QLS 88160 311 $160.00 $- $31.54 $- $- $128.00 $- N/A $41.60 N/A N/A $51.83 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $31.54 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $31.54 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4001605 General Lab "Cytology, Non-Gyn QST" 88160 311 $160.00 $- $31.54 $- $- $128.00 $- N/A $41.60 N/A N/A $51.83 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $31.54 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $31.54 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4001607 General Lab Bill Giemsa Stain 87207 306 $185.00 $- $3.85 $- $- $148.00 $- N/A $48.10 N/A N/A $6.43 N/A N/A $111.00 N/A N/A $92.50 N/A N/A $3.85 N/A N/A $125.80 N/A N/A $90.65 N/A N/A $72.15 N/A N/A $129.50 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $129.50 N/A N/A $61.98 N/A N/A $3.85 N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $129.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 4001608 General Lab Aspirin Resistance (11-Dehydrothromboxane B2) QLS 83520 305 $397.00 $- $8.31 $- $- $317.60 $- N/A $103.22 N/A N/A $13.88 N/A N/A $238.20 N/A N/A $198.50 N/A N/A $8.31 N/A N/A $269.96 N/A N/A $194.53 N/A N/A $154.83 N/A N/A $277.90 N/A N/A $317.60 N/A N/A $218.35 N/A N/A $277.90 N/A N/A $133.00 N/A N/A $8.31 N/A N/A $238.20 N/A N/A $138.95 N/A N/A $258.05 N/A N/A $119.10 N/A N/A $238.20 N/A N/A $277.90 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A $397.00 $397.00 N/A 4001608 General Lab Aspirin Resistance (11-Dehydrothromboxane B2) QLS 82570 305 $397.00 $- $3.32 $- $- $317.60 $- N/A $103.22 N/A N/A $5.54 N/A N/A $238.20 N/A N/A $198.50 N/A N/A $3.32 N/A N/A $269.96 N/A N/A $194.53 N/A N/A $154.83 N/A N/A $277.90 N/A N/A $317.60 N/A N/A $218.35 N/A N/A $277.90 N/A N/A $133.00 N/A N/A $3.32 N/A N/A $238.20 N/A N/A $138.95 N/A N/A $258.05 N/A N/A $119.10 N/A N/A $238.20 N/A N/A $277.90 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A $397.00 $397.00 N/A 4001608 General Lab Aspirin Resistance QST 82570 305 $397.00 $- $3.32 $- $- $317.60 $- N/A $103.22 N/A N/A $5.54 N/A N/A $238.20 N/A N/A $198.50 N/A N/A $3.32 N/A N/A $269.96 N/A N/A $194.53 N/A N/A $154.83 N/A N/A $277.90 N/A N/A $317.60 N/A N/A $218.35 N/A N/A $277.90 N/A N/A $133.00 N/A N/A $3.32 N/A N/A $238.20 N/A N/A $138.95 N/A N/A $258.05 N/A N/A $119.10 N/A N/A $238.20 N/A N/A $277.90 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A N/A $119.10 N/A $397.00 $397.00 N/A 4001614 General Lab "ANA IFA Screen w/ Rfl to Titer, Pattern, IFA QLS" 86038 302 $443.00 $- $7.76 $- $- $354.40 $- N/A $115.18 N/A N/A $12.96 N/A N/A $265.80 N/A N/A $221.50 N/A N/A $7.76 N/A N/A $301.24 N/A N/A $217.07 N/A N/A $172.77 N/A N/A $310.10 N/A N/A $354.40 N/A N/A $243.65 N/A N/A $310.10 N/A N/A $148.41 N/A N/A $7.76 N/A N/A $265.80 N/A N/A $155.05 N/A N/A $287.95 N/A N/A $132.90 N/A N/A $265.80 N/A N/A $310.10 N/A N/A $132.90 N/A N/A $132.90 N/A N/A $132.90 N/A N/A $132.90 N/A N/A $132.90 N/A N/A $132.90 N/A $443.00 $443.00 N/A 4001626 General Lab Complement Total CH50 QST 86162 302 $423.00 $- $13.03 $- $- $338.40 $- N/A $109.98 N/A N/A $21.78 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $13.03 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $13.03 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4001626 General Lab "Complement, Total (CH50) QLS" 86162 302 $423.00 $- $13.03 $- $- $338.40 $- N/A $109.98 N/A N/A $21.78 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $13.03 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $13.03 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4001650 General Lab Protein Electrophoresis QST 84155 301 $91.00 $- $2.35 $- $- $72.80 $- N/A $23.66 N/A N/A $3.94 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $2.35 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $2.35 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4001650 General Lab "Protein Electrophoresis, Serum QLS" 84165 305 $91.00 $- $6.90 $- $- $72.80 $- N/A $23.66 N/A N/A $11.51 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $6.90 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $6.90 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4001650 General Lab "Protein Electrophoresis, Serum QLS" 84155 305 $91.00 $- $2.35 $- $- $72.80 $- N/A $23.66 N/A N/A $3.94 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $2.35 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $2.35 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4001659 General Lab "Protein S, Total Antigen QLS" 85305 305 $247.00 $- $7.45 $- $- $197.60 $- N/A $64.22 N/A N/A $12.44 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $7.45 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $7.45 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4001735 General Lab Gastric Parietal Cell Antibody QLS 83516 301 $246.00 $- $7.40 $- $- $196.80 $- N/A $63.96 N/A N/A $12.37 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $7.40 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $7.40 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4001743 General Lab PSA (Free and Total) QST 84153 G0103 301 $170.00 $- $11.80 $- $- $136.00 $- N/A $44.20 N/A N/A $19.73 N/A N/A $102.00 N/A N/A $85.00 N/A N/A $11.80 N/A N/A $115.60 N/A N/A $83.30 N/A N/A $66.30 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A $11.80 N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $119.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 4001743 General Lab PSA Free and Total QLS 84153 G0103 301 $170.00 $- $11.80 $- $- $136.00 $- N/A $44.20 N/A N/A $19.73 N/A N/A $102.00 N/A N/A $85.00 N/A N/A $11.80 N/A N/A $115.60 N/A N/A $83.30 N/A N/A $66.30 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A $11.80 N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $119.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 4001743 General Lab PSA Free and Total QLS 84154 G0103 301 $170.00 $- $11.80 $- $- $136.00 $- N/A $44.20 N/A N/A $19.73 N/A N/A $102.00 N/A N/A $85.00 N/A N/A $11.80 N/A N/A $115.60 N/A N/A $83.30 N/A N/A $66.30 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A $11.80 N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $119.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 4001743 General Lab "PSA, Free QST" 84154 301 $170.00 $- $11.80 $- $- $136.00 $- N/A $44.20 N/A N/A $19.73 N/A N/A $102.00 N/A N/A $85.00 N/A N/A $11.80 N/A N/A $115.60 N/A N/A $83.30 N/A N/A $66.30 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A $11.80 N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $119.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 4001743 General Lab Prostate Specific Antigen QST 84153 G0103 301 $170.00 $- $11.80 $- $- $136.00 $- N/A $44.20 N/A N/A $19.73 N/A N/A $102.00 N/A N/A $85.00 N/A N/A $11.80 N/A N/A $115.60 N/A N/A $83.30 N/A N/A $66.30 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A $11.80 N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $119.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 4001772 General Lab Ova Parasite Concentration Identification QST 87209 306 $76.00 $- $11.53 $- $- $60.80 $- N/A $19.76 N/A N/A $19.27 N/A N/A $45.60 N/A N/A $38.00 N/A N/A $11.53 N/A N/A $51.68 N/A N/A $37.24 N/A N/A $29.64 N/A N/A $53.20 N/A N/A $60.80 N/A N/A $41.80 N/A N/A $53.20 N/A N/A $25.46 N/A N/A $11.53 N/A N/A $45.60 N/A N/A $26.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $45.60 N/A N/A $53.20 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A $76.00 $76.00 N/A 4001772 General Lab "Ova and Parasites, Concentrate Permanent Smear QLS" 87177 306 $76.00 $- $5.71 $- $- $60.80 $- N/A $19.76 N/A N/A $9.54 N/A N/A $45.60 N/A N/A $38.00 N/A N/A $5.71 N/A N/A $51.68 N/A N/A $37.24 N/A N/A $29.64 N/A N/A $53.20 N/A N/A $60.80 N/A N/A $41.80 N/A N/A $53.20 N/A N/A $25.46 N/A N/A $5.71 N/A N/A $45.60 N/A N/A $26.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $45.60 N/A N/A $53.20 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A $76.00 $76.00 N/A 4001772 General Lab "Ova and Parasites, Concentrate Permanent Smear QLS" 87209 306 $76.00 $- $11.53 $- $- $60.80 $- N/A $19.76 N/A N/A $19.27 N/A N/A $45.60 N/A N/A $38.00 N/A N/A $11.53 N/A N/A $51.68 N/A N/A $37.24 N/A N/A $29.64 N/A N/A $53.20 N/A N/A $60.80 N/A N/A $41.80 N/A N/A $53.20 N/A N/A $25.46 N/A N/A $11.53 N/A N/A $45.60 N/A N/A $26.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $45.60 N/A N/A $53.20 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A $76.00 $76.00 N/A 4001786 General Lab IGF Binding Protein-1 QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4001809 General Lab "Protein, Total w/Creat, Random, Urine QST" 84156 301 $68.00 $- $2.35 $- $- $54.40 $- N/A $17.68 N/A N/A $3.94 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $2.35 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $2.35 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001809 General Lab "Protein, Total, 24 Hr Urine w/o Creat QST" 84156 301 $68.00 $- $2.35 $- $- $54.40 $- N/A $17.68 N/A N/A $3.94 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $2.35 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $2.35 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001809 General Lab "Protein, Total, Random Urine QLS" 84156 301 $68.00 $- $2.35 $- $- $54.40 $- N/A $17.68 N/A N/A $3.94 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $2.35 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $2.35 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001809 General Lab "Urine Protein, Total (w/o Creat) QST" 84156 301 $68.00 $- $2.35 $- $- $54.40 $- N/A $17.68 N/A N/A $3.94 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $2.35 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $2.35 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4001863 General Lab Bill Sensitivity MIC 87186 306 $137.00 $- $5.55 $- $- $109.60 $- N/A $35.62 N/A N/A $9.26 N/A N/A $82.20 N/A N/A $68.50 N/A N/A $5.55 N/A N/A $93.16 N/A N/A $67.13 N/A N/A $53.43 N/A N/A $95.90 N/A N/A $109.60 N/A N/A $75.35 N/A N/A $95.90 N/A N/A $45.90 N/A N/A $5.55 N/A N/A $82.20 N/A N/A $47.95 N/A N/A $89.05 N/A N/A $41.10 N/A N/A $82.20 N/A N/A $95.90 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A $137.00 $137.00 N/A 4001864 General Lab Protein C Activity QLS 85303 305 $140.00 $- $8.88 $- $- $112.00 $- N/A $36.40 N/A N/A $14.83 N/A N/A $84.00 N/A N/A $70.00 N/A N/A $8.88 N/A N/A $95.20 N/A N/A $68.60 N/A N/A $54.60 N/A N/A $98.00 N/A N/A $112.00 N/A N/A $77.00 N/A N/A $98.00 N/A N/A $46.90 N/A N/A $8.88 N/A N/A $84.00 N/A N/A $49.00 N/A N/A $91.00 N/A N/A $42.00 N/A N/A $84.00 N/A N/A $98.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A $140.00 $140.00 N/A 4001864 General Lab "Protein C, Activity QST" 85303 305 $140.00 $- $8.88 $- $- $112.00 $- N/A $36.40 N/A N/A $14.83 N/A N/A $84.00 N/A N/A $70.00 N/A N/A $8.88 N/A N/A $95.20 N/A N/A $68.60 N/A N/A $54.60 N/A N/A $98.00 N/A N/A $112.00 N/A N/A $77.00 N/A N/A $98.00 N/A N/A $46.90 N/A N/A $8.88 N/A N/A $84.00 N/A N/A $49.00 N/A N/A $91.00 N/A N/A $42.00 N/A N/A $84.00 N/A N/A $98.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A $140.00 $140.00 N/A 4001902 General Lab "Vitamin D 1,25-Dihydroxy QLS" 82652 301 $344.00 $- $24.70 $- $- $275.20 $- N/A $89.44 N/A N/A $41.28 N/A N/A $206.40 N/A N/A $172.00 N/A N/A $24.70 N/A N/A $233.92 N/A N/A $168.56 N/A N/A $134.16 N/A N/A $240.80 N/A N/A $275.20 N/A N/A $189.20 N/A N/A $240.80 N/A N/A $115.24 N/A N/A $24.70 N/A N/A $206.40 N/A N/A $120.40 N/A N/A $223.60 N/A N/A $103.20 N/A N/A $206.40 N/A N/A $240.80 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A $344.00 $344.00 N/A 4001902 General Lab "Vitamin D, 1,25 Dihydroxy QST" 82652 301 $344.00 $- $24.70 $- $- $275.20 $- N/A $89.44 N/A N/A $41.28 N/A N/A $206.40 N/A N/A $172.00 N/A N/A $24.70 N/A N/A $233.92 N/A N/A $168.56 N/A N/A $134.16 N/A N/A $240.80 N/A N/A $275.20 N/A N/A $189.20 N/A N/A $240.80 N/A N/A $115.24 N/A N/A $24.70 N/A N/A $206.40 N/A N/A $120.40 N/A N/A $223.60 N/A N/A $103.20 N/A N/A $206.40 N/A N/A $240.80 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A $344.00 $344.00 N/A 4001944 General Lab Jo-1 Ab QST 86235 302 $247.00 $- $10.74 $- $- $197.60 $- N/A $64.22 N/A N/A $17.95 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $10.74 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $10.74 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4001944 General Lab Jo-1 Antibody QLS 86235 302 $247.00 $- $10.74 $- $- $197.60 $- N/A $64.22 N/A N/A $17.95 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $10.74 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $10.74 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4001944 General Lab SM Ab QLS 86235 302 $247.00 $- $10.74 $- $- $197.60 $- N/A $64.22 N/A N/A $17.95 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $10.74 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $10.74 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4001984 General Lab Sickle Cell Screen QST 85660 305 $102.00 $- $3.55 $- $- $81.60 $- N/A $26.52 N/A N/A $5.92 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $3.55 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $3.55 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4002026 General Lab Bill Special Stain S-100 88342 310 $362.00 $- $52.52 $- $- $289.60 $- N/A $94.12 N/A N/A $94.06 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $52.52 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $52.52 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4002035 General Lab Bill KI-1 Stain 88342 310 $470.00 $- $52.52 $- $- $376.00 $- N/A $122.20 N/A N/A $94.06 N/A N/A $282.00 N/A N/A $235.00 N/A N/A $52.52 N/A N/A $319.60 N/A N/A $230.30 N/A N/A $183.30 N/A N/A $329.00 N/A N/A $376.00 N/A N/A $258.50 N/A N/A $329.00 N/A N/A $157.45 N/A N/A $52.52 N/A N/A $282.00 N/A N/A $164.50 N/A N/A $305.50 N/A N/A $141.00 N/A N/A $282.00 N/A N/A $329.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A $470.00 $470.00 N/A 4002036 General Lab Bill CD15 Stain 88342 310 $317.00 $- $52.52 $- $- $253.60 $- N/A $82.42 N/A N/A $94.06 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $52.52 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $52.52 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4002048 General Lab Bill SS CD68 88342 310 $518.00 $- $52.52 $- $- $414.40 $- N/A $134.68 N/A N/A $94.06 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $52.52 N/A N/A $352.24 N/A N/A $253.82 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $52.52 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4002051 General Lab Amylase CPL 87205 306 $81.00 $- $2.74 $- $- $64.80 $- N/A $21.06 N/A N/A $4.58 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $2.74 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $2.74 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4002051 General Lab Gram Stain 3 87205 306 $81.00 $- $2.74 $- $- $64.80 $- N/A $21.06 N/A N/A $4.58 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $2.74 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $2.74 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4002051 General Lab Gram Stain QLS 87205 306 $81.00 $- $2.74 $- $- $64.80 $- N/A $21.06 N/A N/A $4.58 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $2.74 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $2.74 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4002051 General Lab Gram Stain Send Out QST 87205 306 $81.00 $- $2.74 $- $- $64.80 $- N/A $21.06 N/A N/A $4.58 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $2.74 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $2.74 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4002059 General Lab Occult Blood Diagnostic 1 82270 301 $65.00 $- $2.09 $- $- $52.00 $- N/A $16.90 N/A N/A $3.49 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $2.09 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $2.09 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4002059 General Lab Occult Blood Screen 1-3 82270 301 $65.00 $- $2.09 $- $- $52.00 $- N/A $16.90 N/A N/A $3.49 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $2.09 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $2.09 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4002059 General Lab Occult Blood Diagnostic 1-3 82270 301 $65.00 $- $2.09 $- $- $52.00 $- N/A $16.90 N/A N/A $3.49 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $2.09 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $2.09 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4002059 General Lab Occult Blood Screening 1-3 BCH 82270 301 $65.00 $- $2.09 $- $- $52.00 $- N/A $16.90 N/A N/A $3.49 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $2.09 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $2.09 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4002059 General Lab Occult Blood Diagnostic 1-3 BCH 82270 301 $65.00 $- $2.09 $- $- $52.00 $- N/A $16.90 N/A N/A $3.49 N/A N/A $39.00 N/A N/A $32.50 N/A N/A $2.09 N/A N/A $44.20 N/A N/A $31.85 N/A N/A $25.35 N/A N/A $45.50 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $45.50 N/A N/A $21.78 N/A N/A $2.09 N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $45.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 4002071 General Lab Vitamin B6 Level QST 84207 301 $393.00 $- $18.02 $- $- $314.40 $- N/A $102.18 N/A N/A $30.12 N/A N/A $235.80 N/A N/A $196.50 N/A N/A $18.02 N/A N/A $267.24 N/A N/A $192.57 N/A N/A $153.27 N/A N/A $275.10 N/A N/A $314.40 N/A N/A $216.15 N/A N/A $275.10 N/A N/A $131.66 N/A N/A $18.02 N/A N/A $235.80 N/A N/A $137.55 N/A N/A $255.45 N/A N/A $117.90 N/A N/A $235.80 N/A N/A $275.10 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A $393.00 $393.00 N/A 4002071 General Lab Vitamin B6 QLS 84207 301 $393.00 $- $18.02 $- $- $314.40 $- N/A $102.18 N/A N/A $30.12 N/A N/A $235.80 N/A N/A $196.50 N/A N/A $18.02 N/A N/A $267.24 N/A N/A $192.57 N/A N/A $153.27 N/A N/A $275.10 N/A N/A $314.40 N/A N/A $216.15 N/A N/A $275.10 N/A N/A $131.66 N/A N/A $18.02 N/A N/A $235.80 N/A N/A $137.55 N/A N/A $255.45 N/A N/A $117.90 N/A N/A $235.80 N/A N/A $275.10 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A $393.00 $393.00 N/A 4002073 General Lab "Beta 2 GlycoProtein I (IgG,A,M) QLS" 86146 302 $371.00 $- $16.32 $- $- $296.80 $- N/A $96.46 N/A N/A $27.28 N/A N/A $222.60 N/A N/A $185.50 N/A N/A $16.32 N/A N/A $252.28 N/A N/A $181.79 N/A N/A $144.69 N/A N/A $259.70 N/A N/A $296.80 N/A N/A $204.05 N/A N/A $259.70 N/A N/A $124.29 N/A N/A $16.32 N/A N/A $222.60 N/A N/A $129.85 N/A N/A $241.15 N/A N/A $111.30 N/A N/A $222.60 N/A N/A $259.70 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A $371.00 $371.00 N/A 4002073 General Lab "zzBeta 2 Glycoprotein I Ab (IgG, IgA, IgM)" 86146 302 $371.00 $- $16.32 $- $- $296.80 $- N/A $96.46 N/A N/A $27.28 N/A N/A $222.60 N/A N/A $185.50 N/A N/A $16.32 N/A N/A $252.28 N/A N/A $181.79 N/A N/A $144.69 N/A N/A $259.70 N/A N/A $296.80 N/A N/A $204.05 N/A N/A $259.70 N/A N/A $124.29 N/A N/A $16.32 N/A N/A $222.60 N/A N/A $129.85 N/A N/A $241.15 N/A N/A $111.30 N/A N/A $222.60 N/A N/A $259.70 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A $371.00 $371.00 N/A 4002077 General Lab Acid Fast Bacilli Smear Send Out QST 87206 306 $101.00 $- $3.45 $- $- $80.80 $- N/A $26.26 N/A N/A $5.76 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.45 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.45 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4002077 General Lab Acid-Fast Bacilli Stain QLS 87206 306 $101.00 $- $3.45 $- $- $80.80 $- N/A $26.26 N/A N/A $5.76 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.45 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.45 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4002101 General Lab Wet Mount 5 87210 306 $190.00 $- $2.74 $- $- $152.00 $- N/A $49.40 N/A N/A $4.58 N/A N/A $114.00 N/A N/A $95.00 N/A N/A $2.74 N/A N/A $129.20 N/A N/A $93.10 N/A N/A $74.10 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A $2.74 N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A $57.00 N/A N/A $114.00 N/A N/A $133.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A $190.00 $190.00 N/A 4002180 General Lab Ascorbic Acid (Vitamin C) QLS 82180 301 $528.00 $- $6.34 $- $- $422.40 $- N/A $137.28 N/A N/A $10.60 N/A N/A $316.80 N/A N/A $264.00 N/A N/A $6.34 N/A N/A $359.04 N/A N/A $258.72 N/A N/A $205.92 N/A N/A $369.60 N/A N/A $422.40 N/A N/A $290.40 N/A N/A $369.60 N/A N/A $176.88 N/A N/A $6.34 N/A N/A $316.80 N/A N/A $184.80 N/A N/A $343.20 N/A N/A $158.40 N/A N/A $316.80 N/A N/A $369.60 N/A N/A $158.40 N/A N/A $158.40 N/A N/A $158.40 N/A N/A $158.40 N/A N/A $158.40 N/A N/A $158.40 N/A $528.00 $528.00 N/A 4002197 General Lab Ethylene Glycol (Serum) QLS 82693 301 $55.00 $- $9.56 $- $- $44.00 $- N/A $14.30 N/A N/A $15.97 N/A N/A $33.00 N/A N/A $27.50 N/A N/A $9.56 N/A N/A $37.40 N/A N/A $26.95 N/A N/A $21.45 N/A N/A $38.50 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $38.50 N/A N/A $18.43 N/A N/A $9.56 N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $38.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 4002200 General Lab "Culture, Fungus, Skin,Hair,Nail w/ KOH QLS" 87220 306 $132.00 $- $2.74 $- $- $105.60 $- N/A $34.32 N/A N/A $4.58 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.74 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.74 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4002200 General Lab "Fungal Smear, Skin, Hair, Nail QLS" 87220 306 $132.00 $- $2.74 $- $- $105.60 $- N/A $34.32 N/A N/A $4.58 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.74 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.74 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4002200 General Lab "Fungal Smear, Skin/Hair/Nail QST" 87220 306 $132.00 $- $2.74 $- $- $105.60 $- N/A $34.32 N/A N/A $4.58 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.74 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.74 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4002200 General Lab KOH Prep 3 87220 306 $132.00 $- $2.74 $- $- $105.60 $- N/A $34.32 N/A N/A $4.58 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.74 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.74 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4002202 General Lab Factor V (Leiden) Mutation Analysis w/Rlf QLS 81241 305 $340.00 $- $54.38 $- $- $272.00 $- N/A $88.40 N/A N/A $54.38 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A $166.60 N/A N/A $132.60 N/A N/A $238.00 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $238.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $238.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 4002202 General Lab Factor V Leiden Mutation w/ Reflex QST 81241 305 $340.00 $- $54.38 $- $- $272.00 $- N/A $88.40 N/A N/A $54.38 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A $166.60 N/A N/A $132.60 N/A N/A $238.00 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $238.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $238.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 4002225 General Lab Cardio IQ Advance Lipid Panel QLS 80061 301 $150.00 $- $8.60 $- $- $120.00 $- N/A $39.00 N/A N/A $14.36 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $8.60 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $8.60 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4002225 General Lab Cardio IQ(R) Advanced Lipid Panel QST 80061 301 $150.00 $- $8.60 $- $- $120.00 $- N/A $39.00 N/A N/A $14.36 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $8.60 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $8.60 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4002309 General Lab Clostridium Difficile Toxin/GDH w/Rfl to PCR QLS 87324 306 $591.00 $- $7.69 $- $- $472.80 $- N/A $153.66 N/A N/A $12.86 N/A N/A $354.60 N/A N/A $295.50 N/A N/A $7.69 N/A N/A $401.88 N/A N/A $289.59 N/A N/A $230.49 N/A N/A $413.70 N/A N/A $472.80 N/A N/A $325.05 N/A N/A $413.70 N/A N/A $197.99 N/A N/A $7.69 N/A N/A $354.60 N/A N/A $206.85 N/A N/A $384.15 N/A N/A $177.30 N/A N/A $354.60 N/A N/A $413.70 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A N/A $177.30 N/A $591.00 $591.00 N/A 4002313 General Lab Bill SS E-Cad 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4002318 General Lab Bill SS Panmel 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4002319 General Lab Bill SS Brst-2 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4002350 General Lab "Culture, Sputum W/ Gram Stain QLS" 87070 306 $739.00 $- $5.53 $- $- $591.20 $- N/A $192.14 N/A N/A $9.24 N/A N/A $443.40 N/A N/A $369.50 N/A N/A $5.53 N/A N/A $502.52 N/A N/A $362.11 N/A N/A $288.21 N/A N/A $517.30 N/A N/A $591.20 N/A N/A $406.45 N/A N/A $517.30 N/A N/A $247.57 N/A N/A $5.53 N/A N/A $443.40 N/A N/A $258.65 N/A N/A $480.35 N/A N/A $221.70 N/A N/A $443.40 N/A N/A $517.30 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A $739.00 $739.00 N/A 4002350 General Lab "Culture, Sputum W/ Gram Stain QLS" 87205 306 $739.00 $- $2.74 $- $- $591.20 $- N/A $192.14 N/A N/A $4.58 N/A N/A $443.40 N/A N/A $369.50 N/A N/A $2.74 N/A N/A $502.52 N/A N/A $362.11 N/A N/A $288.21 N/A N/A $517.30 N/A N/A $591.20 N/A N/A $406.45 N/A N/A $517.30 N/A N/A $247.57 N/A N/A $2.74 N/A N/A $443.40 N/A N/A $258.65 N/A N/A $480.35 N/A N/A $221.70 N/A N/A $443.40 N/A N/A $517.30 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A $739.00 $739.00 N/A 4002350 General Lab Sputum Culture Send QST 87070 306 $739.00 $- $5.53 $- $- $591.20 $- N/A $192.14 N/A N/A $9.24 N/A N/A $443.40 N/A N/A $369.50 N/A N/A $5.53 N/A N/A $502.52 N/A N/A $362.11 N/A N/A $288.21 N/A N/A $517.30 N/A N/A $591.20 N/A N/A $406.45 N/A N/A $517.30 N/A N/A $247.57 N/A N/A $5.53 N/A N/A $443.40 N/A N/A $258.65 N/A N/A $480.35 N/A N/A $221.70 N/A N/A $443.40 N/A N/A $517.30 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A N/A $221.70 N/A $739.00 $739.00 N/A 4002441 General Lab Alpha Fetoprotein Tumor Marker QST 82105 302 $308.00 $- $10.74 $- $- $246.40 $- N/A $80.08 N/A N/A $17.95 N/A N/A $184.80 N/A N/A $154.00 N/A N/A $10.74 N/A N/A $209.44 N/A N/A $150.92 N/A N/A $120.12 N/A N/A $215.60 N/A N/A $246.40 N/A N/A $169.40 N/A N/A $215.60 N/A N/A $103.18 N/A N/A $10.74 N/A N/A $184.80 N/A N/A $107.80 N/A N/A $200.20 N/A N/A $92.40 N/A N/A $184.80 N/A N/A $215.60 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A $308.00 $308.00 N/A 4002441 General Lab "Alpha-FetoProtein,Tumor Marker QLS" 82105 302 $308.00 $- $10.74 $- $- $246.40 $- N/A $80.08 N/A N/A $17.95 N/A N/A $184.80 N/A N/A $154.00 N/A N/A $10.74 N/A N/A $209.44 N/A N/A $150.92 N/A N/A $120.12 N/A N/A $215.60 N/A N/A $246.40 N/A N/A $169.40 N/A N/A $215.60 N/A N/A $103.18 N/A N/A $10.74 N/A N/A $184.80 N/A N/A $107.80 N/A N/A $200.20 N/A N/A $92.40 N/A N/A $184.80 N/A N/A $215.60 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A $308.00 $308.00 N/A 4002443 General Lab Plasma Renin Activity (PRA) QST 84244 300 $449.00 $- $14.11 $- $- $359.20 $- N/A $116.74 N/A N/A $23.59 N/A N/A $269.40 N/A N/A $224.50 N/A N/A $14.11 N/A N/A $305.32 N/A N/A $220.01 N/A N/A $175.11 N/A N/A $314.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $314.30 N/A N/A $150.42 N/A N/A $14.11 N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $314.30 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 4002502 General Lab Bilirubin Total 82247 301 $99.00 $- $3.22 $- $- $79.20 $- N/A $25.74 N/A N/A $5.39 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $3.22 N/A N/A $67.32 N/A N/A $48.51 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $69.30 N/A N/A $33.17 N/A N/A $3.22 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4002510 General Lab Bilirubin Direct 82248 301 $99.00 $- $3.22 $- $- $79.20 $- N/A $25.74 N/A N/A $5.39 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $3.22 N/A N/A $67.32 N/A N/A $48.51 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $69.30 N/A N/A $33.17 N/A N/A $3.22 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4002566 General Lab Mitochondrial Ab w/Refl Titer QST 86255 302 $62.00 $- $7.73 $- $- $49.60 $- N/A $16.12 N/A N/A $12.92 N/A N/A $37.20 N/A N/A $31.00 N/A N/A $7.73 N/A N/A $42.16 N/A N/A $30.38 N/A N/A $24.18 N/A N/A $43.40 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $43.40 N/A N/A $20.77 N/A N/A $7.73 N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $43.40 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 4002566 General Lab Mitochondrial Antibody W/ Reflex to Titer QLS 86255 302 $62.00 $- $7.73 $- $- $49.60 $- N/A $16.12 N/A N/A $12.92 N/A N/A $37.20 N/A N/A $31.00 N/A N/A $7.73 N/A N/A $42.16 N/A N/A $30.38 N/A N/A $24.18 N/A N/A $43.40 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $43.40 N/A N/A $20.77 N/A N/A $7.73 N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $43.40 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 4002567 General Lab HU Ab Screen w/Rlf to Titer and WB QLS 86255 301 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab HU Ab Screen w/Rlf to Titer and WB QLS 86255 301 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab HU and Yo AutoAntibodies w/Rlf QLS 86255 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab Hu and Yo Autoantibodies w/ Reflex QST 86255 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab Neuronal Nuclear Ab w/ Reflex to Titer QST 86255 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab Yo Ab Screen w/ Rflx to Titer and WB QST 86255 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002567 General Lab Yo Antibody Screen w/Rflx to Titer and WB QLS 86255 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4002568 General Lab Bill Panlympoid Stain 88342 310 $225.00 $- $52.52 $- $- $180.00 $- N/A $58.50 N/A N/A $94.06 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $52.52 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $52.52 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4002569 General Lab Anti-Myocardial Ab Screen w/Rlf Titer QLS 86256 302 $362.00 $- $7.73 $- $- $289.60 $- N/A $94.12 N/A N/A $12.92 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $7.73 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $7.73 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4002569 General Lab Anti-Myocardial Ab w/ Reflex Titer QST 86256 302 $362.00 $- $7.73 $- $- $289.60 $- N/A $94.12 N/A N/A $12.92 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $7.73 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $7.73 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4002800 General Lab "Culture, Genital QLS" 87070 306 $705.00 $- $5.53 $- $- $564.00 $- N/A $183.30 N/A N/A $9.24 N/A N/A $423.00 N/A N/A $352.50 N/A N/A $5.53 N/A N/A $479.40 N/A N/A $345.45 N/A N/A $274.95 N/A N/A $493.50 N/A N/A $564.00 N/A N/A $387.75 N/A N/A $493.50 N/A N/A $236.18 N/A N/A $5.53 N/A N/A $423.00 N/A N/A $246.75 N/A N/A $458.25 N/A N/A $211.50 N/A N/A $423.00 N/A N/A $493.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A $705.00 $705.00 N/A 4002800 General Lab "Culture, Genital QLS" 87210 306 $705.00 $- $2.74 $- $- $564.00 $- N/A $183.30 N/A N/A $4.58 N/A N/A $423.00 N/A N/A $352.50 N/A N/A $2.74 N/A N/A $479.40 N/A N/A $345.45 N/A N/A $274.95 N/A N/A $493.50 N/A N/A $564.00 N/A N/A $387.75 N/A N/A $493.50 N/A N/A $236.18 N/A N/A $2.74 N/A N/A $423.00 N/A N/A $246.75 N/A N/A $458.25 N/A N/A $211.50 N/A N/A $423.00 N/A N/A $493.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A $705.00 $705.00 N/A 4002800 General Lab "Culture, Genital QST" 87070 306 $705.00 $- $5.53 $- $- $564.00 $- N/A $183.30 N/A N/A $9.24 N/A N/A $423.00 N/A N/A $352.50 N/A N/A $5.53 N/A N/A $479.40 N/A N/A $345.45 N/A N/A $274.95 N/A N/A $493.50 N/A N/A $564.00 N/A N/A $387.75 N/A N/A $493.50 N/A N/A $236.18 N/A N/A $5.53 N/A N/A $423.00 N/A N/A $246.75 N/A N/A $458.25 N/A N/A $211.50 N/A N/A $423.00 N/A N/A $493.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A N/A $211.50 N/A $705.00 $705.00 N/A 4002805 General Lab Rubella Immune Status QST 86762 302 $757.00 $- $9.24 $- $- $605.60 $- N/A $196.82 N/A N/A $15.43 N/A N/A $454.20 N/A N/A $378.50 N/A N/A $9.24 N/A N/A $514.76 N/A N/A $370.93 N/A N/A $295.23 N/A N/A $529.90 N/A N/A $605.60 N/A N/A $416.35 N/A N/A $529.90 N/A N/A $253.60 N/A N/A $9.24 N/A N/A $454.20 N/A N/A $264.95 N/A N/A $492.05 N/A N/A $227.10 N/A N/A $454.20 N/A N/A $529.90 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A $757.00 $757.00 N/A 4002805 General Lab Rubella Immune Status QLS 86762 302 $757.00 $- $9.24 $- $- $605.60 $- N/A $196.82 N/A N/A $15.43 N/A N/A $454.20 N/A N/A $378.50 N/A N/A $9.24 N/A N/A $514.76 N/A N/A $370.93 N/A N/A $295.23 N/A N/A $529.90 N/A N/A $605.60 N/A N/A $416.35 N/A N/A $529.90 N/A N/A $253.60 N/A N/A $9.24 N/A N/A $454.20 N/A N/A $264.95 N/A N/A $492.05 N/A N/A $227.10 N/A N/A $454.20 N/A N/A $529.90 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A N/A $227.10 N/A $757.00 $757.00 N/A 4002821 General Lab Complement C3 QLS 86160 302 $203.00 $- $7.70 $- $- $162.40 $- N/A $52.78 N/A N/A $12.88 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $7.70 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $7.70 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4002821 General Lab Complement Component C3 QST 86160 302 $203.00 $- $7.70 $- $- $162.40 $- N/A $52.78 N/A N/A $12.88 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $7.70 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $7.70 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4002870 General Lab Hepatitis B Surface Ag w/ Confirm QST 87340 302 $152.00 $- $6.63 $- $- $121.60 $- N/A $39.52 N/A N/A $11.08 N/A N/A $91.20 N/A N/A $76.00 N/A N/A $6.63 N/A N/A $103.36 N/A N/A $74.48 N/A N/A $59.28 N/A N/A $106.40 N/A N/A $121.60 N/A N/A $83.60 N/A N/A $106.40 N/A N/A $50.92 N/A N/A $6.63 N/A N/A $91.20 N/A N/A $53.20 N/A N/A $98.80 N/A N/A $45.60 N/A N/A $91.20 N/A N/A $106.40 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A $152.00 $152.00 N/A 4002870 General Lab Hepatitis B Surface Antigen QLS 87340 302 $152.00 $- $6.63 $- $- $121.60 $- N/A $39.52 N/A N/A $11.08 N/A N/A $91.20 N/A N/A $76.00 N/A N/A $6.63 N/A N/A $103.36 N/A N/A $74.48 N/A N/A $59.28 N/A N/A $106.40 N/A N/A $121.60 N/A N/A $83.60 N/A N/A $106.40 N/A N/A $50.92 N/A N/A $6.63 N/A N/A $91.20 N/A N/A $53.20 N/A N/A $98.80 N/A N/A $45.60 N/A N/A $91.20 N/A N/A $106.40 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A N/A $45.60 N/A $152.00 $152.00 N/A 4002912 General Lab Hepatitis B Surface Ab Qual QST 86706 302 $92.00 $- $6.90 $- $- $73.60 $- N/A $23.92 N/A N/A $11.51 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $6.90 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $6.90 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4002912 General Lab "Hepatitis B Surface Ab, Qual QLS" 86706 302 $92.00 $- $6.90 $- $- $73.60 $- N/A $23.92 N/A N/A $11.51 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $6.90 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $6.90 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4002955 General Lab Sodium Level 84295 301 $92.00 $- $3.09 $- $- $73.60 $- N/A $23.92 N/A N/A $5.16 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.09 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.09 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4002955 General Lab Sodium QST 84295 301 $92.00 $- $3.09 $- $- $73.60 $- N/A $23.92 N/A N/A $5.16 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.09 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.09 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4002961 General Lab "Hepatitis A Ab, Total QLS" 86708 302 $130.00 $- $7.95 $- $- $104.00 $- N/A $33.80 N/A N/A $13.28 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $7.95 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $7.95 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4002961 General Lab "Hepatitis A Ab, Total w/Refl IgM QST" 86708 302 $130.00 $- $7.95 $- $- $104.00 $- N/A $33.80 N/A N/A $13.28 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $7.95 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $7.95 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4003001 General Lab Mono Screen 86308 302 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4003001 General Lab Mono Screen 1 86308 302 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4003010 General Lab Anti-Double-Stranded/Native DNA Antibody QST 86225 302 $56.00 $- $8.81 $- $- $44.80 $- N/A $14.56 N/A N/A $14.72 N/A N/A $33.60 N/A N/A $28.00 N/A N/A $8.81 N/A N/A $38.08 N/A N/A $27.44 N/A N/A $21.84 N/A N/A $39.20 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $39.20 N/A N/A $18.76 N/A N/A $8.81 N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $39.20 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 4003010 General Lab DNA (ds) Ab QLS 86225 302 $56.00 $- $8.81 $- $- $44.80 $- N/A $14.56 N/A N/A $14.72 N/A N/A $33.60 N/A N/A $28.00 N/A N/A $8.81 N/A N/A $38.08 N/A N/A $27.44 N/A N/A $21.84 N/A N/A $39.20 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $39.20 N/A N/A $18.76 N/A N/A $8.81 N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $39.20 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 4003022 General Lab Sjogren's Ab (SS-B) QLS 86235 302 $75.00 $- $10.74 $- $- $60.00 $- N/A $19.50 N/A N/A $17.95 N/A N/A $45.00 N/A N/A $37.50 N/A N/A $10.74 N/A N/A $51.00 N/A N/A $36.75 N/A N/A $29.25 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A $10.74 N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $52.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 4003022 General Lab Sjogren's Antibody (SS-A) QST 86235 302 $75.00 $- $10.74 $- $- $60.00 $- N/A $19.50 N/A N/A $17.95 N/A N/A $45.00 N/A N/A $37.50 N/A N/A $10.74 N/A N/A $51.00 N/A N/A $36.75 N/A N/A $29.25 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A $10.74 N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $52.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 4003023 General Lab Hepatitis C Antibody (HCV) (2.0) QLS 86803 300 $477.00 $- $9.16 $- $- $381.60 $- N/A $124.02 N/A N/A $15.30 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $9.16 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $9.16 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4003023 General Lab Hepatitis C Antibody (HCV) (2.0) QLS 87522 300 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4003023 General Lab Hepatitis C Antibody QST 86803 302 $477.00 $- $9.16 $- $- $381.60 $- N/A $124.02 N/A N/A $15.30 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $9.16 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $9.16 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4003041 General Lab "Calcium, U24 (W/ Creatinine) QST" 82340 301 $87.00 $- $3.88 $- $- $69.60 $- N/A $22.62 N/A N/A $6.47 N/A N/A $52.20 N/A N/A $43.50 N/A N/A $3.88 N/A N/A $59.16 N/A N/A $42.63 N/A N/A $33.93 N/A N/A $60.90 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $60.90 N/A N/A $29.15 N/A N/A $3.88 N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $60.90 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 4003051 General Lab Protein S Activity QST 85306 305 $792.00 $- $9.84 $- $- $633.60 $- N/A $205.92 N/A N/A $16.43 N/A N/A $475.20 N/A N/A $396.00 N/A N/A $9.84 N/A N/A $538.56 N/A N/A $388.08 N/A N/A $308.88 N/A N/A $554.40 N/A N/A $633.60 N/A N/A $435.60 N/A N/A $554.40 N/A N/A $265.32 N/A N/A $9.84 N/A N/A $475.20 N/A N/A $277.20 N/A N/A $514.80 N/A N/A $237.60 N/A N/A $475.20 N/A N/A $554.40 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A $792.00 $792.00 N/A 4003051 General Lab Protein S Activity QLS 85306 305 $792.00 $- $9.84 $- $- $633.60 $- N/A $205.92 N/A N/A $16.43 N/A N/A $475.20 N/A N/A $396.00 N/A N/A $9.84 N/A N/A $538.56 N/A N/A $388.08 N/A N/A $308.88 N/A N/A $554.40 N/A N/A $633.60 N/A N/A $435.60 N/A N/A $554.40 N/A N/A $265.32 N/A N/A $9.84 N/A N/A $475.20 N/A N/A $277.20 N/A N/A $514.80 N/A N/A $237.60 N/A N/A $475.20 N/A N/A $554.40 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A N/A $237.60 N/A $792.00 $792.00 N/A 4003060 General Lab Thyroid Peroxidase Ab QST 86376 302 $239.00 $- $9.34 $- $- $191.20 $- N/A $62.14 N/A N/A $15.59 N/A N/A $143.40 N/A N/A $119.50 N/A N/A $9.34 N/A N/A $162.52 N/A N/A $117.11 N/A N/A $93.21 N/A N/A $167.30 N/A N/A $191.20 N/A N/A $131.45 N/A N/A $167.30 N/A N/A $80.07 N/A N/A $9.34 N/A N/A $143.40 N/A N/A $83.65 N/A N/A $155.35 N/A N/A $71.70 N/A N/A $143.40 N/A N/A $167.30 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A $239.00 $239.00 N/A 4003060 General Lab Thyroid Peroxidase Antibody QLS 86376 302 $239.00 $- $9.34 $- $- $191.20 $- N/A $62.14 N/A N/A $15.59 N/A N/A $143.40 N/A N/A $119.50 N/A N/A $9.34 N/A N/A $162.52 N/A N/A $117.11 N/A N/A $93.21 N/A N/A $167.30 N/A N/A $191.20 N/A N/A $131.45 N/A N/A $167.30 N/A N/A $80.07 N/A N/A $9.34 N/A N/A $143.40 N/A N/A $83.65 N/A N/A $155.35 N/A N/A $71.70 N/A N/A $143.40 N/A N/A $167.30 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A $239.00 $239.00 N/A 4003062 General Lab "Hydroxyvitamin D(D2,D3) QLS" 82306 301 $657.00 $- $18.80 $- $- $525.60 $- N/A $170.82 N/A N/A $31.43 N/A N/A $394.20 N/A N/A $328.50 N/A N/A $18.80 N/A N/A $446.76 N/A N/A $321.93 N/A N/A $256.23 N/A N/A $459.90 N/A N/A $525.60 N/A N/A $361.35 N/A N/A $459.90 N/A N/A $220.10 N/A N/A $18.80 N/A N/A $394.20 N/A N/A $229.95 N/A N/A $427.05 N/A N/A $197.10 N/A N/A $394.20 N/A N/A $459.90 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A $657.00 $657.00 N/A 4003062 General Lab "Vit D 25-Hydroxy w/D2, D3, LC/MS/MS QST" 82306 301 $657.00 $- $18.80 $- $- $525.60 $- N/A $170.82 N/A N/A $31.43 N/A N/A $394.20 N/A N/A $328.50 N/A N/A $18.80 N/A N/A $446.76 N/A N/A $321.93 N/A N/A $256.23 N/A N/A $459.90 N/A N/A $525.60 N/A N/A $361.35 N/A N/A $459.90 N/A N/A $220.10 N/A N/A $18.80 N/A N/A $394.20 N/A N/A $229.95 N/A N/A $427.05 N/A N/A $197.10 N/A N/A $394.20 N/A N/A $459.90 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A $657.00 $657.00 N/A 4003062 General Lab "Vitamin D 25(OH), Total" 82306 301 $657.00 $- $18.80 $- $- $525.60 $- N/A $170.82 N/A N/A $31.43 N/A N/A $394.20 N/A N/A $328.50 N/A N/A $18.80 N/A N/A $446.76 N/A N/A $321.93 N/A N/A $256.23 N/A N/A $459.90 N/A N/A $525.60 N/A N/A $361.35 N/A N/A $459.90 N/A N/A $220.10 N/A N/A $18.80 N/A N/A $394.20 N/A N/A $229.95 N/A N/A $427.05 N/A N/A $197.10 N/A N/A $394.20 N/A N/A $459.90 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A $657.00 $657.00 N/A 4003062 General Lab "Vitamin D, 25-Hydroxy QST" 82306 301 $657.00 $- $18.80 $- $- $525.60 $- N/A $170.82 N/A N/A $31.43 N/A N/A $394.20 N/A N/A $328.50 N/A N/A $18.80 N/A N/A $446.76 N/A N/A $321.93 N/A N/A $256.23 N/A N/A $459.90 N/A N/A $525.60 N/A N/A $361.35 N/A N/A $459.90 N/A N/A $220.10 N/A N/A $18.80 N/A N/A $394.20 N/A N/A $229.95 N/A N/A $427.05 N/A N/A $197.10 N/A N/A $394.20 N/A N/A $459.90 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A N/A $197.10 N/A $657.00 $657.00 N/A 4003088 General Lab "Histamine, Plasma QLS" 83088 301 $733.00 $- $18.95 $- $- $586.40 $- N/A $190.58 N/A N/A $31.67 N/A N/A $439.80 N/A N/A $366.50 N/A N/A $18.95 N/A N/A $498.44 N/A N/A $359.17 N/A N/A $285.87 N/A N/A $513.10 N/A N/A $586.40 N/A N/A $403.15 N/A N/A $513.10 N/A N/A $245.56 N/A N/A $18.95 N/A N/A $439.80 N/A N/A $256.55 N/A N/A $476.45 N/A N/A $219.90 N/A N/A $439.80 N/A N/A $513.10 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A $733.00 $733.00 N/A 4003104 General Lab Calcium Level 82310 301 $49.00 $- $3.31 $- $- $39.20 $- N/A $12.74 N/A N/A $5.53 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $3.31 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $3.31 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4003104 General Lab Calcium QLS 82310 301 $49.00 $- $3.31 $- $- $39.20 $- N/A $12.74 N/A N/A $5.53 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $3.31 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $3.31 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4003104 General Lab Calcium QST 82310 301 $49.00 $- $3.31 $- $- $39.20 $- N/A $12.74 N/A N/A $5.53 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $3.31 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $3.31 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4003121 General Lab Potassium Level 84132 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4003132 General Lab Bill Trichrome Stain 88313 310 $601.00 $- $32.49 $- $- $480.80 $- N/A $156.26 N/A N/A $55.60 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $32.49 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $32.49 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4003133 General Lab Bill SS CEA IM 88313 310 $601.00 $- $32.49 $- $- $480.80 $- N/A $156.26 N/A N/A $55.60 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $32.49 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $32.49 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4003134 General Lab Lupus Anticoagulant Evaluation w/ Reflex QST 85613 300 $113.00 $- $6.14 $- $- $90.40 $- N/A $29.38 N/A N/A $10.26 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $6.14 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $6.14 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4003134 General Lab Lupus Anticoagulant Evaluation w/ Reflex QST 85730 300 $113.00 $- $3.86 $- $- $90.40 $- N/A $29.38 N/A N/A $6.43 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $3.86 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $3.86 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4003135 General Lab Bill SS NSE IM 88313 310 $518.00 $- $32.49 $- $- $414.40 $- N/A $134.68 N/A N/A $55.60 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $32.49 N/A N/A $352.24 N/A N/A $253.82 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $32.49 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4003136 General Lab Bill SS Mucica 88313 310 $601.00 $- $32.49 $- $- $480.80 $- N/A $156.26 N/A N/A $55.60 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $32.49 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $32.49 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4003139 General Lab Bill SS Chromo 88313 310 $518.00 $- $32.49 $- $- $414.40 $- N/A $134.68 N/A N/A $55.60 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $32.49 N/A N/A $352.24 N/A N/A $253.82 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $32.49 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4003142 General Lab Cardiolipin Ab IgA QST 86147 302 $333.00 $- $16.32 $- $- $266.40 $- N/A $86.58 N/A N/A $27.28 N/A N/A $199.80 N/A N/A $166.50 N/A N/A $16.32 N/A N/A $226.44 N/A N/A $163.17 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $16.32 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 4003142 General Lab "Cardiolipin Antibody, IgA QLS" 86147 302 $333.00 $- $16.32 $- $- $266.40 $- N/A $86.58 N/A N/A $27.28 N/A N/A $199.80 N/A N/A $166.50 N/A N/A $16.32 N/A N/A $226.44 N/A N/A $163.17 N/A N/A $129.87 N/A N/A $233.10 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $233.10 N/A N/A $111.56 N/A N/A $16.32 N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $233.10 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 4003165 General Lab PTH Intact w/o Calcium QLS 83970 301 $560.00 $- $26.48 $- $- $448.00 $- N/A $145.60 N/A N/A $44.26 N/A N/A $336.00 N/A N/A $280.00 N/A N/A $26.48 N/A N/A $380.80 N/A N/A $274.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $26.48 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $364.00 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 4003165 General Lab "PTH, Intact w/o Calcium QST" 83970 301 $560.00 $- $26.48 $- $- $448.00 $- N/A $145.60 N/A N/A $44.26 N/A N/A $336.00 N/A N/A $280.00 N/A N/A $26.48 N/A N/A $380.80 N/A N/A $274.40 N/A N/A $218.40 N/A N/A $392.00 N/A N/A $448.00 N/A N/A $308.00 N/A N/A $392.00 N/A N/A $187.60 N/A N/A $26.48 N/A N/A $336.00 N/A N/A $196.00 N/A N/A $364.00 N/A N/A $168.00 N/A N/A $336.00 N/A N/A $392.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A N/A $168.00 N/A $560.00 $560.00 N/A 4003173 General Lab Bill Stain Diete 88342 310 $361.00 $- $52.52 $- $- $288.80 $- N/A $93.86 N/A N/A $94.06 N/A N/A $216.60 N/A N/A $180.50 N/A N/A $52.52 N/A N/A $245.48 N/A N/A $176.89 N/A N/A $140.79 N/A N/A $252.70 N/A N/A $288.80 N/A N/A $198.55 N/A N/A $252.70 N/A N/A $120.94 N/A N/A $52.52 N/A N/A $216.60 N/A N/A $126.35 N/A N/A $234.65 N/A N/A $108.30 N/A N/A $216.60 N/A N/A $252.70 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A $361.00 $361.00 N/A 4003175 General Lab "Lyme Disease Ab, Total w/Refl WB (IgG, IgM) QST" 86618 302 $179.00 $- $10.93 $- $- $143.20 $- N/A $46.54 N/A N/A $18.26 N/A N/A $107.40 N/A N/A $89.50 N/A N/A $10.93 N/A N/A $121.72 N/A N/A $87.71 N/A N/A $69.81 N/A N/A $125.30 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $125.30 N/A N/A $59.97 N/A N/A $10.93 N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $125.30 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 4003175 General Lab "Lyme Disease Antibody w/ Rfl To Blot(IgG,IgM) QLS" 86618 302 $179.00 $- $10.93 $- $- $143.20 $- N/A $46.54 N/A N/A $18.26 N/A N/A $107.40 N/A N/A $89.50 N/A N/A $10.93 N/A N/A $121.72 N/A N/A $87.71 N/A N/A $69.81 N/A N/A $125.30 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $125.30 N/A N/A $59.97 N/A N/A $10.93 N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $125.30 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 4003183 General Lab D-Dimer 85378 305 $225.00 $- $4.58 $- $- $180.00 $- N/A $58.50 N/A N/A $7.66 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $4.58 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $4.58 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4003183 General Lab D-Dimer QST 85378 305 $225.00 $- $4.58 $- $- $180.00 $- N/A $58.50 N/A N/A $7.66 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $4.58 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $4.58 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4003199 General Lab Bill SS Iron 88313 310 $601.00 $- $32.49 $- $- $480.80 $- N/A $156.26 N/A N/A $55.60 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $32.49 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $32.49 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4003214 General Lab EBV Panel QLS 86664 302 $497.00 $- $9.82 $- $- $397.60 $- N/A $129.22 N/A N/A $16.40 N/A N/A $298.20 N/A N/A $248.50 N/A N/A $9.82 N/A N/A $337.96 N/A N/A $243.53 N/A N/A $193.83 N/A N/A $347.90 N/A N/A $397.60 N/A N/A $273.35 N/A N/A $347.90 N/A N/A $166.50 N/A N/A $9.82 N/A N/A $298.20 N/A N/A $173.95 N/A N/A $323.05 N/A N/A $149.10 N/A N/A $298.20 N/A N/A $347.90 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A $497.00 $497.00 N/A 4003214 General Lab EBV Panel QLS 86665 302 $497.00 $- $11.64 $- $- $397.60 $- N/A $129.22 N/A N/A $19.45 N/A N/A $298.20 N/A N/A $248.50 N/A N/A $11.64 N/A N/A $337.96 N/A N/A $243.53 N/A N/A $193.83 N/A N/A $347.90 N/A N/A $397.60 N/A N/A $273.35 N/A N/A $347.90 N/A N/A $166.50 N/A N/A $11.64 N/A N/A $298.20 N/A N/A $173.95 N/A N/A $323.05 N/A N/A $149.10 N/A N/A $298.20 N/A N/A $347.90 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A N/A $149.10 N/A $497.00 $497.00 N/A 4003215 General Lab Bill Pas Stain 88312 310 $242.00 $- $46.42 $- $- $193.60 $- N/A $62.92 N/A N/A $79.85 N/A N/A $145.20 N/A N/A $121.00 N/A N/A $46.42 N/A N/A $164.56 N/A N/A $118.58 N/A N/A $94.38 N/A N/A $169.40 N/A N/A $193.60 N/A N/A $133.10 N/A N/A $169.40 N/A N/A $81.07 N/A N/A $46.42 N/A N/A $145.20 N/A N/A $84.70 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $145.20 N/A N/A $169.40 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A $242.00 $242.00 N/A 4003241 General Lab "Helicobacter Pylori Antibodies (IgG,IgA) QLS" 86677 302 "$1,028.00 " $- $9.31 $- $- $822.40 $- N/A $267.28 N/A N/A $15.56 N/A N/A $616.80 N/A N/A $514.00 N/A N/A $9.31 N/A N/A $699.04 N/A N/A $503.72 N/A N/A $400.92 N/A N/A $719.60 N/A N/A $822.40 N/A N/A $565.40 N/A N/A $719.60 N/A N/A $344.38 N/A N/A $9.31 N/A N/A $616.80 N/A N/A $359.80 N/A N/A $668.20 N/A N/A $308.40 N/A N/A $616.80 N/A N/A $719.60 N/A N/A $308.40 N/A N/A $308.40 N/A N/A $308.40 N/A N/A $308.40 N/A N/A $308.40 N/A N/A $308.40 N/A "$1,028.00 " "$1,028.00 " N/A 4003302 General Lab Calcium Ionized QST 82330 301 $163.00 $- $8.78 $- $- $130.40 $- N/A $42.38 N/A N/A $14.65 N/A N/A $97.80 N/A N/A $81.50 N/A N/A $8.78 N/A N/A $110.84 N/A N/A $79.87 N/A N/A $63.57 N/A N/A $114.10 N/A N/A $130.40 N/A N/A $89.65 N/A N/A $114.10 N/A N/A $54.61 N/A N/A $8.78 N/A N/A $97.80 N/A N/A $57.05 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $97.80 N/A N/A $114.10 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A $163.00 $163.00 N/A 4003302 General Lab "Calcium, Ionized QLS" 82330 301 $163.00 $- $8.78 $- $- $130.40 $- N/A $42.38 N/A N/A $14.65 N/A N/A $97.80 N/A N/A $81.50 N/A N/A $8.78 N/A N/A $110.84 N/A N/A $79.87 N/A N/A $63.57 N/A N/A $114.10 N/A N/A $130.40 N/A N/A $89.65 N/A N/A $114.10 N/A N/A $54.61 N/A N/A $8.78 N/A N/A $97.80 N/A N/A $57.05 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $97.80 N/A N/A $114.10 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A $163.00 $163.00 N/A 4003325 General Lab Coccidioides Antibodies to TP and F Ag QLS 86635 302 $146.00 $- $7.37 $- $- $116.80 $- N/A $37.96 N/A N/A $12.30 N/A N/A $87.60 N/A N/A $73.00 N/A N/A $7.37 N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A $7.37 N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4003325 General Lab Coccidioides Antibodies to TP and F Ag QLS 86335 302 $146.00 $- $18.82 $- $- $116.80 $- N/A $37.96 N/A N/A $31.46 N/A N/A $87.60 N/A N/A $73.00 N/A N/A $18.82 N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A $18.82 N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4003325 General Lab "Coccidioides Abs to TP and F Ag, ID QST" 86635 302 $146.00 $- $7.37 $- $- $116.80 $- N/A $37.96 N/A N/A $12.30 N/A N/A $87.60 N/A N/A $73.00 N/A N/A $7.37 N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A $7.37 N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4003345 General Lab "Influenza Virus Types A and B Antibody, CSF QLS" 86710 302 $470.00 $- $8.70 $- $- $376.00 $- N/A $122.20 N/A N/A $14.53 N/A N/A $282.00 N/A N/A $235.00 N/A N/A $8.70 N/A N/A $319.60 N/A N/A $230.30 N/A N/A $183.30 N/A N/A $329.00 N/A N/A $376.00 N/A N/A $258.50 N/A N/A $329.00 N/A N/A $157.45 N/A N/A $8.70 N/A N/A $282.00 N/A N/A $164.50 N/A N/A $305.50 N/A N/A $141.00 N/A N/A $282.00 N/A N/A $329.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A $470.00 $470.00 N/A 4003401 General Lab "Calcium, 24 Hour Urine QLS" 82340 301 $92.00 $- $3.88 $- $- $73.60 $- N/A $23.92 N/A N/A $6.47 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.88 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.88 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4003421 General Lab Bill SS Viment 88342 310 $518.00 $- $52.52 $- $- $414.40 $- N/A $134.68 N/A N/A $94.06 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $52.52 N/A N/A $352.24 N/A N/A $253.82 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $52.52 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4003516 General Lab Endomysial Ab IgA Screen w/ Reflex Titer QST 86255 301 $319.00 $- $7.73 $- $- $255.20 $- N/A $82.94 N/A N/A $12.92 N/A N/A $191.40 N/A N/A $159.50 N/A N/A $7.73 N/A N/A $216.92 N/A N/A $156.31 N/A N/A $124.41 N/A N/A $223.30 N/A N/A $255.20 N/A N/A $175.45 N/A N/A $223.30 N/A N/A $106.87 N/A N/A $7.73 N/A N/A $191.40 N/A N/A $111.65 N/A N/A $207.35 N/A N/A $95.70 N/A N/A $191.40 N/A N/A $223.30 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A $319.00 $319.00 N/A 4003516 General Lab Endomysial Ab Scr (IgA) w/Rfl Titer QLS 86255 301 $319.00 $- $7.73 $- $- $255.20 $- N/A $82.94 N/A N/A $12.92 N/A N/A $191.40 N/A N/A $159.50 N/A N/A $7.73 N/A N/A $216.92 N/A N/A $156.31 N/A N/A $124.41 N/A N/A $223.30 N/A N/A $255.20 N/A N/A $175.45 N/A N/A $223.30 N/A N/A $106.87 N/A N/A $7.73 N/A N/A $191.40 N/A N/A $111.65 N/A N/A $207.35 N/A N/A $95.70 N/A N/A $191.40 N/A N/A $223.30 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A N/A $95.70 N/A $319.00 $319.00 N/A 4003523 General Lab T3 Uptake (f) QLS 84479 301 $- $- $- $- $- $6.94 $- N/A $- N/A N/A $6.94 N/A N/A $- N/A N/A $- N/A N/A $4.16 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $4.16 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4003523 General Lab T3 Uptake QST 84479 301 $- $- $- $- $- $6.94 $- N/A $- N/A N/A $6.94 N/A N/A $- N/A N/A $- N/A N/A $4.16 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $4.16 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4003525 General Lab "Sulfatide Abs IgG, IgM QST" 83520 301 $417.00 $- $8.31 $- $- $333.60 $- N/A $108.42 N/A N/A $13.88 N/A N/A $250.20 N/A N/A $208.50 N/A N/A $8.31 N/A N/A $283.56 N/A N/A $204.33 N/A N/A $162.63 N/A N/A $291.90 N/A N/A $333.60 N/A N/A $229.35 N/A N/A $291.90 N/A N/A $139.70 N/A N/A $8.31 N/A N/A $250.20 N/A N/A $145.95 N/A N/A $271.05 N/A N/A $125.10 N/A N/A $250.20 N/A N/A $291.90 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A $417.00 $417.00 N/A 4003525 General Lab Sulfatide AutoAntibody QLS 83520 302 $417.00 $- $108.42 $- $- $333.60 $- N/A $108.42 N/A N/A N/A N/A N/A $250.20 N/A N/A $208.50 N/A N/A N/A N/A N/A $283.56 N/A N/A $204.33 N/A N/A $162.63 N/A N/A $291.90 N/A N/A $333.60 N/A N/A $229.35 N/A N/A $291.90 N/A N/A $139.70 N/A N/A N/A N/A N/A $250.20 N/A N/A $145.95 N/A N/A $271.05 N/A N/A $125.10 N/A N/A $250.20 N/A N/A $291.90 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A $417.00 $417.00 N/A 4003595 General Lab Celiac Disease Comprehensive Panel QLS 83516 305 $143.00 $- $37.18 $- $- $114.40 $- N/A $37.18 N/A N/A N/A N/A N/A $85.80 N/A N/A $71.50 N/A N/A N/A N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A N/A N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4003595 General Lab Celiac Disease Comprehensive Panel QLS 82784 305 $143.00 $- $4.30 $- $- $114.40 $- N/A $37.18 N/A N/A $7.18 N/A N/A $85.80 N/A N/A $71.50 N/A N/A $4.30 N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A $4.30 N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4003595 General Lab Celiac Disease Comprehensive Panel QST 82784 305 $143.00 $- $4.30 $- $- $114.40 $- N/A $37.18 N/A N/A $7.18 N/A N/A $85.80 N/A N/A $71.50 N/A N/A $4.30 N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A $4.30 N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4003610 General Lab Stone Analysis QLS 82365 301 $225.00 $- $8.28 $- $- $180.00 $- N/A $58.50 N/A N/A $13.82 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $8.28 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $8.28 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4003610 General Lab StoneRisk Diagnostic Profile QST 82365 301 $225.00 $- $8.28 $- $- $180.00 $- N/A $58.50 N/A N/A $13.82 N/A N/A $135.00 N/A N/A $112.50 N/A N/A $8.28 N/A N/A $153.00 N/A N/A $110.25 N/A N/A $87.75 N/A N/A $157.50 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $157.50 N/A N/A $75.38 N/A N/A $8.28 N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $157.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 4003652 General Lab Legionella Antigen Urine QST 87449 306 $221.00 $- $7.69 $- $- $176.80 $- N/A $57.46 N/A N/A $12.86 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $7.69 N/A N/A $150.28 N/A N/A $108.29 N/A N/A $86.19 N/A N/A $154.70 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $154.70 N/A N/A $74.04 N/A N/A $7.69 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $154.70 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 4003652 General Lab "Legionella Antigen, EIA, Urine QLS" 87449 306 $221.00 $- $7.69 $- $- $176.80 $- N/A $57.46 N/A N/A $12.86 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $7.69 N/A N/A $150.28 N/A N/A $108.29 N/A N/A $86.19 N/A N/A $154.70 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $154.70 N/A N/A $74.04 N/A N/A $7.69 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $154.70 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 4003721 General Lab Direct LDL 83721 301 $149.00 $- $6.12 $- $- $119.20 $- N/A $38.74 N/A N/A $10.22 N/A N/A $89.40 N/A N/A $74.50 N/A N/A $6.12 N/A N/A $101.32 N/A N/A $73.01 N/A N/A $58.11 N/A N/A $104.30 N/A N/A $119.20 N/A N/A $81.95 N/A N/A $104.30 N/A N/A $49.92 N/A N/A $6.12 N/A N/A $89.40 N/A N/A $52.15 N/A N/A $96.85 N/A N/A $44.70 N/A N/A $89.40 N/A N/A $104.30 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A $149.00 $149.00 N/A 4003721 General Lab LDL Direct QST 83721 301 $149.00 $- $6.12 $- $- $119.20 $- N/A $38.74 N/A N/A $10.22 N/A N/A $89.40 N/A N/A $74.50 N/A N/A $6.12 N/A N/A $101.32 N/A N/A $73.01 N/A N/A $58.11 N/A N/A $104.30 N/A N/A $119.20 N/A N/A $81.95 N/A N/A $104.30 N/A N/A $49.92 N/A N/A $6.12 N/A N/A $89.40 N/A N/A $52.15 N/A N/A $96.85 N/A N/A $44.70 N/A N/A $89.40 N/A N/A $104.30 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A $149.00 $149.00 N/A 4003724 General Lab "Carbamazepine, Total QST" 80156 301 $268.00 $- $9.35 $- $- $214.40 $- N/A $69.68 N/A N/A $15.61 N/A N/A $160.80 N/A N/A $134.00 N/A N/A $9.35 N/A N/A $182.24 N/A N/A $131.32 N/A N/A $104.52 N/A N/A $187.60 N/A N/A $214.40 N/A N/A $147.40 N/A N/A $187.60 N/A N/A $89.78 N/A N/A $9.35 N/A N/A $160.80 N/A N/A $93.80 N/A N/A $174.20 N/A N/A $80.40 N/A N/A $160.80 N/A N/A $187.60 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A $268.00 $268.00 N/A 4003724 General Lab Carbamazepine (Tegretol) QLS 80156 301 $268.00 $- $9.35 $- $- $214.40 $- N/A $69.68 N/A N/A $15.61 N/A N/A $160.80 N/A N/A $134.00 N/A N/A $9.35 N/A N/A $182.24 N/A N/A $131.32 N/A N/A $104.52 N/A N/A $187.60 N/A N/A $214.40 N/A N/A $147.40 N/A N/A $187.60 N/A N/A $89.78 N/A N/A $9.35 N/A N/A $160.80 N/A N/A $93.80 N/A N/A $174.20 N/A N/A $80.40 N/A N/A $160.80 N/A N/A $187.60 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A N/A $80.40 N/A $268.00 $268.00 N/A 4003740 General Lab Carbon Dioxide Level 82374 301 $163.00 $- $3.14 $- $- $130.40 $- N/A $42.38 N/A N/A $5.24 N/A N/A $97.80 N/A N/A $81.50 N/A N/A $3.14 N/A N/A $110.84 N/A N/A $79.87 N/A N/A $63.57 N/A N/A $114.10 N/A N/A $130.40 N/A N/A $89.65 N/A N/A $114.10 N/A N/A $54.61 N/A N/A $3.14 N/A N/A $97.80 N/A N/A $57.05 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $97.80 N/A N/A $114.10 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A $163.00 $163.00 N/A 4003823 General Lab "Catecholamines, 24 hr Urine QLS" 82384 301 $653.00 $- $16.20 $- $- $522.40 $- N/A $169.78 N/A N/A $27.07 N/A N/A $391.80 N/A N/A $326.50 N/A N/A $16.20 N/A N/A $444.04 N/A N/A $319.97 N/A N/A $254.67 N/A N/A $457.10 N/A N/A $522.40 N/A N/A $359.15 N/A N/A $457.10 N/A N/A $218.76 N/A N/A $16.20 N/A N/A $391.80 N/A N/A $228.55 N/A N/A $424.45 N/A N/A $195.90 N/A N/A $391.80 N/A N/A $457.10 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A $653.00 $653.00 N/A 4003874 General Lab Myoglobin QST 83874 301 $117.00 $- $8.29 $- $- $93.60 $- N/A $30.42 N/A N/A $13.85 N/A N/A $70.20 N/A N/A $58.50 N/A N/A $8.29 N/A N/A $79.56 N/A N/A $57.33 N/A N/A $45.63 N/A N/A $81.90 N/A N/A $93.60 N/A N/A $64.35 N/A N/A $81.90 N/A N/A $39.20 N/A N/A $8.29 N/A N/A $70.20 N/A N/A $40.95 N/A N/A $76.05 N/A N/A $35.10 N/A N/A $70.20 N/A N/A $81.90 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A $117.00 $117.00 N/A 4003874 General Lab "Myoglobin, Serum QLS" 83874 301 $117.00 $- $8.29 $- $- $93.60 $- N/A $30.42 N/A N/A $13.85 N/A N/A $70.20 N/A N/A $58.50 N/A N/A $8.29 N/A N/A $79.56 N/A N/A $57.33 N/A N/A $45.63 N/A N/A $81.90 N/A N/A $93.60 N/A N/A $64.35 N/A N/A $81.90 N/A N/A $39.20 N/A N/A $8.29 N/A N/A $70.20 N/A N/A $40.95 N/A N/A $76.05 N/A N/A $35.10 N/A N/A $70.20 N/A N/A $81.90 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A N/A $35.10 N/A $117.00 $117.00 N/A 4003921 General Lab Methylmalonic Acid QST 83921 301 $631.00 $- $10.56 $- $- $504.80 $- N/A $164.06 N/A N/A $17.64 N/A N/A $378.60 N/A N/A $315.50 N/A N/A $10.56 N/A N/A $429.08 N/A N/A $309.19 N/A N/A $246.09 N/A N/A $441.70 N/A N/A $504.80 N/A N/A $347.05 N/A N/A $441.70 N/A N/A $211.39 N/A N/A $10.56 N/A N/A $378.60 N/A N/A $220.85 N/A N/A $410.15 N/A N/A $189.30 N/A N/A $378.60 N/A N/A $441.70 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A $631.00 $631.00 N/A 4003921 General Lab Methylmalonic Acid QLS 83921 301 $631.00 $- $10.56 $- $- $504.80 $- N/A $164.06 N/A N/A $17.64 N/A N/A $378.60 N/A N/A $315.50 N/A N/A $10.56 N/A N/A $429.08 N/A N/A $309.19 N/A N/A $246.09 N/A N/A $441.70 N/A N/A $504.80 N/A N/A $347.05 N/A N/A $441.70 N/A N/A $211.39 N/A N/A $10.56 N/A N/A $378.60 N/A N/A $220.85 N/A N/A $410.15 N/A N/A $189.30 N/A N/A $378.60 N/A N/A $441.70 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A N/A $189.30 N/A $631.00 $631.00 N/A 4004033 General Lab Cryptococcal Antigen (LA) w/Rlfx Titer QLS 86403 302 $168.00 $- $6.54 $- $- $134.40 $- N/A $43.68 N/A N/A $10.93 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $6.54 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $6.54 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4004033 General Lab "Cryptococcal Ag, Ltx Scr w/Rfx Titer QST" 86403 302 $168.00 $- $6.54 $- $- $134.40 $- N/A $43.68 N/A N/A $10.93 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $6.54 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $6.54 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4004033 General Lab Cryptococcal Ag (LA) Titer QST 86043 302 $168.00 $- $43.68 $- $- $134.40 $- N/A $43.68 N/A N/A N/A N/A N/A $100.80 N/A N/A $84.00 N/A N/A N/A N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A N/A N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4004118 General Lab Pregnancy Test Urine 3 81025 307 $237.00 $- $4.07 $- $- $189.60 $- N/A $61.62 N/A N/A $6.79 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $4.07 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $4.07 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4004158 General Lab Bill Collection Fee 36415 300 $9.57 $- $2.49 $- $- $7.66 $- N/A $2.49 N/A N/A $3.35 N/A N/A $5.74 N/A N/A $4.79 N/A N/A $2.51 N/A N/A $6.51 N/A N/A $4.69 N/A N/A $3.73 N/A N/A $6.70 N/A N/A $7.66 N/A N/A $5.26 N/A N/A $6.70 N/A N/A $3.21 N/A N/A $2.51 N/A N/A $5.74 N/A N/A $3.35 N/A N/A $6.22 N/A N/A $2.87 N/A N/A $5.74 N/A N/A $6.70 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A $9.57 $9.57 N/A 4004158 General Lab Bill DRUG SCREEN COLLECTION 36415 300 $9.57 $- $2.49 $- $- $7.66 $- N/A $2.49 N/A N/A $3.35 N/A N/A $5.74 N/A N/A $4.79 N/A N/A $2.51 N/A N/A $6.51 N/A N/A $4.69 N/A N/A $3.73 N/A N/A $6.70 N/A N/A $7.66 N/A N/A $5.26 N/A N/A $6.70 N/A N/A $3.21 N/A N/A $2.51 N/A N/A $5.74 N/A N/A $3.35 N/A N/A $6.22 N/A N/A $2.87 N/A N/A $5.74 N/A N/A $6.70 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A $9.57 $9.57 N/A 4004158 General Lab COLLECTION: Venous Draw 36415 300 $9.57 $- $2.49 $- $- $7.66 $- N/A $2.49 N/A N/A $3.35 N/A N/A $5.74 N/A N/A $4.79 N/A N/A $2.51 N/A N/A $6.51 N/A N/A $4.69 N/A N/A $3.73 N/A N/A $6.70 N/A N/A $7.66 N/A N/A $5.26 N/A N/A $6.70 N/A N/A $3.21 N/A N/A $2.51 N/A N/A $5.74 N/A N/A $3.35 N/A N/A $6.22 N/A N/A $2.87 N/A N/A $5.74 N/A N/A $6.70 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A $9.57 $9.57 N/A 4004158 General Lab Venous Blood Draw 36415 300 $9.57 $- $2.49 $- $- $7.66 $- N/A $2.49 N/A N/A $3.35 N/A N/A $5.74 N/A N/A $4.79 N/A N/A $2.51 N/A N/A $6.51 N/A N/A $4.69 N/A N/A $3.73 N/A N/A $6.70 N/A N/A $7.66 N/A N/A $5.26 N/A N/A $6.70 N/A N/A $3.21 N/A N/A $2.51 N/A N/A $5.74 N/A N/A $3.35 N/A N/A $6.22 N/A N/A $2.87 N/A N/A $5.74 N/A N/A $6.70 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A N/A $2.87 N/A $9.57 $9.57 N/A 4004165 General Lab "Abnormal Protein Band 1, U24 QST" 84166 301 $68.00 $- $11.44 $- $- $54.40 $- N/A $17.68 N/A N/A $19.13 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $11.44 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $11.44 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab Creatinine 24 Hr Urine QST 82570 301 $68.00 $- $3.32 $- $- $54.40 $- N/A $17.68 N/A N/A $5.54 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $3.32 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $3.32 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab Protein 24 Hr Urine QST 84156 301 $68.00 $- $2.35 $- $- $54.40 $- N/A $17.68 N/A N/A $3.94 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $2.35 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $2.35 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab Protein Electrophoresis Random Ur QST 82570 301 $68.00 $- $3.32 $- $- $54.40 $- N/A $17.68 N/A N/A $5.54 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $3.32 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $3.32 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab "Protein Electrophoresis, Random Urine QLS" 82570 301 $68.00 $- $3.32 $- $- $54.40 $- N/A $17.68 N/A N/A $5.54 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $3.32 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $3.32 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab "Protein Electrophoresis, Random Urine QLS" 84166 301 $68.00 $- $11.44 $- $- $54.40 $- N/A $17.68 N/A N/A $19.13 N/A N/A $40.80 N/A N/A $34.00 N/A N/A $11.44 N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A $11.44 N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004165 General Lab "Protein Electrophoresis, Random Urine QLS" 841565 301 $68.00 $- $17.68 $- $- $54.40 $- N/A $17.68 N/A N/A N/A N/A N/A $40.80 N/A N/A $34.00 N/A N/A N/A N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A N/A N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 4004251 General Lab Vitamin B1 (Thiamine) QST 84425 301 $307.00 $- $13.62 $- $- $245.60 $- N/A $79.82 N/A N/A $22.76 N/A N/A $184.20 N/A N/A $153.50 N/A N/A $13.62 N/A N/A $208.76 N/A N/A $150.43 N/A N/A $119.73 N/A N/A $214.90 N/A N/A $245.60 N/A N/A $168.85 N/A N/A $214.90 N/A N/A $102.85 N/A N/A $13.62 N/A N/A $184.20 N/A N/A $107.45 N/A N/A $199.55 N/A N/A $92.10 N/A N/A $184.20 N/A N/A $214.90 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A $307.00 $307.00 N/A 4004251 General Lab Vitamin B1 (Thiamine) Plasma QLS 84425 301 $307.00 $- $13.62 $- $- $245.60 $- N/A $79.82 N/A N/A $22.76 N/A N/A $184.20 N/A N/A $153.50 N/A N/A $13.62 N/A N/A $208.76 N/A N/A $150.43 N/A N/A $119.73 N/A N/A $214.90 N/A N/A $245.60 N/A N/A $168.85 N/A N/A $214.90 N/A N/A $102.85 N/A N/A $13.62 N/A N/A $184.20 N/A N/A $107.45 N/A N/A $199.55 N/A N/A $92.10 N/A N/A $184.20 N/A N/A $214.90 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A $307.00 $307.00 N/A 4004252 General Lab Vitamin B1 (Thiamine) Blood QST 84425 301 $307.00 $- $13.62 $- $- $245.60 $- N/A $79.82 N/A N/A $22.76 N/A N/A $184.20 N/A N/A $153.50 N/A N/A $13.62 N/A N/A $208.76 N/A N/A $150.43 N/A N/A $119.73 N/A N/A $214.90 N/A N/A $245.60 N/A N/A $168.85 N/A N/A $214.90 N/A N/A $102.85 N/A N/A $13.62 N/A N/A $184.20 N/A N/A $107.45 N/A N/A $199.55 N/A N/A $92.10 N/A N/A $184.20 N/A N/A $214.90 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A $307.00 $307.00 N/A 4004252 General Lab Vitamin B1 (Thiamine) Whole Blood QLS 84425 301 $307.00 $- $13.62 $- $- $245.60 $- N/A $79.82 N/A N/A $22.76 N/A N/A $184.20 N/A N/A $153.50 N/A N/A $13.62 N/A N/A $208.76 N/A N/A $150.43 N/A N/A $119.73 N/A N/A $214.90 N/A N/A $245.60 N/A N/A $168.85 N/A N/A $214.90 N/A N/A $102.85 N/A N/A $13.62 N/A N/A $184.20 N/A N/A $107.45 N/A N/A $199.55 N/A N/A $92.10 N/A N/A $184.20 N/A N/A $214.90 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A N/A $92.10 N/A $307.00 $307.00 N/A 4004260 General Lab Serotonin QST 84260 301 $334.00 $- $19.87 $- $- $267.20 $- N/A $86.84 N/A N/A $33.22 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $19.87 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $19.87 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4004260 General Lab "Serotonin, Serum QLS" 84260 301 $334.00 $- $19.87 $- $- $267.20 $- N/A $86.84 N/A N/A $33.22 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $19.87 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $19.87 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4004306 General Lab Rheumatoid Factor 3 86431 302 $113.00 $- $3.64 $- $- $90.40 $- N/A $29.38 N/A N/A $6.08 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $3.64 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $3.64 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4004306 General Lab Rheumatoid Factor 2 86431 302 $113.00 $- $3.64 $- $- $90.40 $- N/A $29.38 N/A N/A $6.08 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $3.64 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $3.64 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4004359 General Lab Chloride Level 82435 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4004359 General Lab Chloride QLS 82435 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4004359 General Lab Chloride QST 82435 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4004399 General Lab "T4 (Thyroxine), Total QLS" 84436 301 $273.00 $- $4.41 $- $- $218.40 $- N/A $70.98 N/A N/A $7.37 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $4.41 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $4.41 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4004399 General Lab T4 Total QST 84436 301 $273.00 $- $4.41 $- $- $218.40 $- N/A $70.98 N/A N/A $7.37 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $4.41 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $4.41 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4004399 General Lab "T4, Total" 84436 301 $273.00 $- $4.41 $- $- $218.40 $- N/A $70.98 N/A N/A $7.37 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $4.41 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $4.41 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4004399 General Lab Thyroid Panel QST 84436 301 $273.00 $- $4.41 $- $- $218.40 $- N/A $70.98 N/A N/A $7.37 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $4.41 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $4.41 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4004399 General Lab Thyroid Profile 918 QLS 84436 301 $273.00 $- $4.41 $- $- $218.40 $- N/A $70.98 N/A N/A $7.37 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $4.41 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $4.41 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4004431 General Lab Hemoglobin A1c MCL 84443 301 $324.00 $- $10.79 $- $- $259.20 $- N/A $84.24 N/A N/A $18.02 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $10.79 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $10.79 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4004431 General Lab TSH QLS 84443 301 $324.00 $- $10.79 $- $- $259.20 $- N/A $84.24 N/A N/A $18.02 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $10.79 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $10.79 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4004431 General Lab "TSH, 3rd Generation QST" 84443 301 $324.00 $- $10.79 $- $- $259.20 $- N/A $84.24 N/A N/A $18.02 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $10.79 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $10.79 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4004431 General Lab Thyroid Stimulating Hormone 84443 301 $324.00 $- $10.79 $- $- $259.20 $- N/A $84.24 N/A N/A $18.02 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $10.79 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $10.79 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4004431 General Lab TSH 84443 301 $324.00 $- $10.79 $- $- $259.20 $- N/A $84.24 N/A N/A $18.02 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $10.79 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $10.79 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4004461 General Lab Vitamin E QLS 84446 301 $343.00 $- $9.09 $- $- $274.40 $- N/A $89.18 N/A N/A $15.20 N/A N/A $205.80 N/A N/A $171.50 N/A N/A $9.09 N/A N/A $233.24 N/A N/A $168.07 N/A N/A $133.77 N/A N/A $240.10 N/A N/A $274.40 N/A N/A $188.65 N/A N/A $240.10 N/A N/A $114.91 N/A N/A $9.09 N/A N/A $205.80 N/A N/A $120.05 N/A N/A $222.95 N/A N/A $102.90 N/A N/A $205.80 N/A N/A $240.10 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A $343.00 $343.00 N/A 4004461 General Lab Vitamin E (Tocopherol) Level QST 84446 301 $343.00 $- $9.09 $- $- $274.40 $- N/A $89.18 N/A N/A $15.20 N/A N/A $205.80 N/A N/A $171.50 N/A N/A $9.09 N/A N/A $233.24 N/A N/A $168.07 N/A N/A $133.77 N/A N/A $240.10 N/A N/A $274.40 N/A N/A $188.65 N/A N/A $240.10 N/A N/A $114.91 N/A N/A $9.09 N/A N/A $205.80 N/A N/A $120.05 N/A N/A $222.95 N/A N/A $102.90 N/A N/A $205.80 N/A N/A $240.10 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A N/A $102.90 N/A $343.00 $343.00 N/A 4004466 General Lab Transferrin QST 84466 301 $113.00 $- $8.19 $- $- $90.40 $- N/A $29.38 N/A N/A $13.69 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $8.19 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $8.19 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4004466 General Lab Transferrin QLS 84466 301 $113.00 $- $8.19 $- $- $90.40 $- N/A $29.38 N/A N/A $13.69 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $8.19 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $8.19 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4004484 General Lab High Sensitivity Troponin 84484 301 $435.00 $- $6.31 $- $- $348.00 $- N/A $113.10 N/A N/A $10.55 N/A N/A $261.00 N/A N/A $217.50 N/A N/A $6.31 N/A N/A $295.80 N/A N/A $213.15 N/A N/A $169.65 N/A N/A $304.50 N/A N/A $348.00 N/A N/A $239.25 N/A N/A $304.50 N/A N/A $145.73 N/A N/A $6.31 N/A N/A $261.00 N/A N/A $152.25 N/A N/A $282.75 N/A N/A $130.50 N/A N/A $261.00 N/A N/A $304.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A $435.00 $435.00 N/A 4004484 General Lab Troponin I 84484 301 $435.00 $- $6.31 $- $- $348.00 $- N/A $113.10 N/A N/A $10.55 N/A N/A $261.00 N/A N/A $217.50 N/A N/A $6.31 N/A N/A $295.80 N/A N/A $213.15 N/A N/A $169.65 N/A N/A $304.50 N/A N/A $348.00 N/A N/A $239.25 N/A N/A $304.50 N/A N/A $145.73 N/A N/A $6.31 N/A N/A $261.00 N/A N/A $152.25 N/A N/A $282.75 N/A N/A $130.50 N/A N/A $261.00 N/A N/A $304.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A $435.00 $435.00 N/A 4004506 General Lab AST 84450 301 $101.00 $- $3.32 $- $- $80.80 $- N/A $26.26 N/A N/A $5.54 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $3.32 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $3.32 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4004605 General Lab ALT (SGPT) QLS 84460 301 $102.00 $- $3.40 $- $- $81.60 $- N/A $26.52 N/A N/A $5.68 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $3.40 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $3.40 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4004605 General Lab ALT 84460 301 $102.00 $- $3.40 $- $- $81.60 $- N/A $26.52 N/A N/A $5.68 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $3.40 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $3.40 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4004605 General Lab ALT (SGPT) QLS 84460 301 $102.00 $- $3.40 $- $- $81.60 $- N/A $26.52 N/A N/A $5.68 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $3.40 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $3.40 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4004605 General Lab Alanine Aminotransferase (ALT) QST 84460 301 $102.00 $- $3.40 $- $- $81.60 $- N/A $26.52 N/A N/A $5.68 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $3.40 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $3.40 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4004656 General Lab Cholesterol (f) QLS 82465 301 $82.00 $- $2.80 $- $- $65.60 $- N/A $21.32 N/A N/A $4.67 N/A N/A $49.20 N/A N/A $41.00 N/A N/A $2.80 N/A N/A $55.76 N/A N/A $40.18 N/A N/A $31.98 N/A N/A $57.40 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $57.40 N/A N/A $27.47 N/A N/A $2.80 N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $57.40 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 4004656 General Lab Cholesterol Total 82465 301 $82.00 $- $2.80 $- $- $65.60 $- N/A $21.32 N/A N/A $4.67 N/A N/A $49.20 N/A N/A $41.00 N/A N/A $2.80 N/A N/A $55.76 N/A N/A $40.18 N/A N/A $31.98 N/A N/A $57.40 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $57.40 N/A N/A $27.47 N/A N/A $2.80 N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $57.40 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 4004702 General Lab hCG Qnt QST 84702 301 $384.00 $- $9.01 $- $- $307.20 $- N/A $99.84 N/A N/A $15.06 N/A N/A $230.40 N/A N/A $192.00 N/A N/A $9.01 N/A N/A $261.12 N/A N/A $188.16 N/A N/A $149.76 N/A N/A $268.80 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $268.80 N/A N/A $128.64 N/A N/A $9.01 N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $268.80 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 4004702 General Lab "hCG Total, Quantitative QLS" 84702 301 $384.00 $- $9.01 $- $- $307.20 $- N/A $99.84 N/A N/A $15.06 N/A N/A $230.40 N/A N/A $192.00 N/A N/A $9.01 N/A N/A $261.12 N/A N/A $188.16 N/A N/A $149.76 N/A N/A $268.80 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $268.80 N/A N/A $128.64 N/A N/A $9.01 N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $268.80 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 4004702 General Lab hCG w/Gestational Table QST 84702 301 $384.00 $- $9.01 $- $- $307.20 $- N/A $99.84 N/A N/A $15.06 N/A N/A $230.40 N/A N/A $192.00 N/A N/A $9.01 N/A N/A $261.12 N/A N/A $188.16 N/A N/A $149.76 N/A N/A $268.80 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $268.80 N/A N/A $128.64 N/A N/A $9.01 N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $268.80 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 4004787 General Lab Triglycerides 84478 301 $114.00 $- $3.69 $- $- $91.20 $- N/A $29.64 N/A N/A $6.17 N/A N/A $68.40 N/A N/A $57.00 N/A N/A $3.69 N/A N/A $77.52 N/A N/A $55.86 N/A N/A $44.46 N/A N/A $79.80 N/A N/A $91.20 N/A N/A $62.70 N/A N/A $79.80 N/A N/A $38.19 N/A N/A $3.69 N/A N/A $68.40 N/A N/A $39.90 N/A N/A $74.10 N/A N/A $34.20 N/A N/A $68.40 N/A N/A $79.80 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A $114.00 $114.00 N/A 4004803 General Lab "T3, Total QLS" 84480 301 $274.00 $- $9.09 $- $- $219.20 $- N/A $71.24 N/A N/A $15.20 N/A N/A $164.40 N/A N/A $137.00 N/A N/A $9.09 N/A N/A $186.32 N/A N/A $134.26 N/A N/A $106.86 N/A N/A $191.80 N/A N/A $219.20 N/A N/A $150.70 N/A N/A $191.80 N/A N/A $91.79 N/A N/A $9.09 N/A N/A $164.40 N/A N/A $95.90 N/A N/A $178.10 N/A N/A $82.20 N/A N/A $164.40 N/A N/A $191.80 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A $274.00 $274.00 N/A 4004803 General Lab Total T3 QST 84480 301 $274.00 $- $9.09 $- $- $219.20 $- N/A $71.24 N/A N/A $15.20 N/A N/A $164.40 N/A N/A $137.00 N/A N/A $9.09 N/A N/A $186.32 N/A N/A $134.26 N/A N/A $106.86 N/A N/A $191.80 N/A N/A $219.20 N/A N/A $150.70 N/A N/A $191.80 N/A N/A $91.79 N/A N/A $9.09 N/A N/A $164.40 N/A N/A $95.90 N/A N/A $178.10 N/A N/A $82.20 N/A N/A $164.40 N/A N/A $191.80 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A $274.00 $274.00 N/A 4004978 General Lab 5-HIAA (hydroxyindoleacetic acid) 24 HR UR Panel w/Creat QST 82570 301 $260.00 $- $67.60 $- $- $208.00 $- N/A $67.60 N/A N/A N/A N/A N/A $156.00 N/A N/A $130.00 N/A N/A N/A N/A N/A $176.80 N/A N/A $127.40 N/A N/A $101.40 N/A N/A $182.00 N/A N/A $208.00 N/A N/A $143.00 N/A N/A $182.00 N/A N/A $87.10 N/A N/A N/A N/A N/A $156.00 N/A N/A $91.00 N/A N/A $169.00 N/A N/A $78.00 N/A N/A $156.00 N/A N/A $182.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A $260.00 $260.00 N/A 4005071 General Lab HIV 2 Antibody QLS 86702 302 $205.00 $- $8.67 $- $- $164.00 $- N/A $53.30 N/A N/A $14.50 N/A N/A $123.00 N/A N/A $102.50 N/A N/A $8.67 N/A N/A $139.40 N/A N/A $100.45 N/A N/A $79.95 N/A N/A $143.50 N/A N/A $164.00 N/A N/A $112.75 N/A N/A $143.50 N/A N/A $68.68 N/A N/A $8.67 N/A N/A $123.00 N/A N/A $71.75 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $123.00 N/A N/A $143.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A $205.00 $205.00 N/A 4005200 General Lab "Gliadin (Deaminated Peptide) Ab (IgG, IgA) QLS" 83516 301 $143.00 $- $37.18 $- $- $114.40 $- N/A $37.18 N/A N/A N/A N/A N/A $85.80 N/A N/A $71.50 N/A N/A N/A N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A N/A N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4005200 General Lab "Gliadin IgG, IgA Ab QST" 83516 301 $143.00 $- $7.40 $- $- $114.40 $- N/A $37.18 N/A N/A $12.37 N/A N/A $85.80 N/A N/A $71.50 N/A N/A $7.40 N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A $7.40 N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4005206 General Lab BUN 84520 301 $78.00 $- $2.54 $- $- $62.40 $- N/A $20.28 N/A N/A $4.24 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.54 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.54 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4005206 General Lab Blood Urea Nitrogen 84520 301 $78.00 $- $2.54 $- $- $62.40 $- N/A $20.28 N/A N/A $4.24 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.54 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.54 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4005215 General Lab Hereditary Hemochromatosis DNA Mutation QLS 81256 300 "$1,247.00 " $- $79.79 $- $- $997.60 $- N/A $324.22 N/A N/A $79.79 N/A N/A $748.20 N/A N/A $623.50 N/A N/A N/A N/A N/A $847.96 N/A N/A $611.03 N/A N/A $486.33 N/A N/A $872.90 N/A N/A $997.60 N/A N/A $685.85 N/A N/A $872.90 N/A N/A $417.75 N/A N/A N/A N/A N/A $748.20 N/A N/A $436.45 N/A N/A $810.55 N/A N/A $374.10 N/A N/A $748.20 N/A N/A $872.90 N/A N/A $374.10 N/A N/A $374.10 N/A N/A $374.10 N/A N/A $374.10 N/A N/A $374.10 N/A N/A $374.10 N/A "$1,247.00 " "$1,247.00 " N/A 4005256 General Lab Insulin QST 83525 301 $247.00 $- $7.34 $- $- $197.60 $- N/A $64.22 N/A N/A $12.25 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $7.34 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $7.34 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4005256 General Lab "Insulin, Total QST" 83525 301 $247.00 $- $7.34 $- $- $197.60 $- N/A $64.22 N/A N/A $12.25 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $7.34 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $7.34 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4005256 General Lab "Insulin, Fasting QLS" 83525 301 $247.00 $- $7.34 $- $- $197.60 $- N/A $64.22 N/A N/A $12.25 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $7.34 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $7.34 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4005257 General Lab Copper Level QST 82525 301 $473.00 $- $7.97 $- $- $378.40 $- N/A $122.98 N/A N/A $13.31 N/A N/A $283.80 N/A N/A $236.50 N/A N/A $7.97 N/A N/A $321.64 N/A N/A $231.77 N/A N/A $184.47 N/A N/A $331.10 N/A N/A $378.40 N/A N/A $260.15 N/A N/A $331.10 N/A N/A $158.46 N/A N/A $7.97 N/A N/A $283.80 N/A N/A $165.55 N/A N/A $307.45 N/A N/A $141.90 N/A N/A $283.80 N/A N/A $331.10 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A $473.00 $473.00 N/A 4005257 General Lab Copper QLS 82525 301 $473.00 $- $7.97 $- $- $378.40 $- N/A $122.98 N/A N/A $13.31 N/A N/A $283.80 N/A N/A $236.50 N/A N/A $7.97 N/A N/A $321.64 N/A N/A $231.77 N/A N/A $184.47 N/A N/A $331.10 N/A N/A $378.40 N/A N/A $260.15 N/A N/A $331.10 N/A N/A $158.46 N/A N/A $7.97 N/A N/A $283.80 N/A N/A $165.55 N/A N/A $307.45 N/A N/A $141.90 N/A N/A $283.80 N/A N/A $331.10 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A $473.00 $473.00 N/A 4005310 General Lab Tryptase QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4005331 General Lab Cortisol AM QST 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4005331 General Lab Cortisol PM QST 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4005331 General Lab Cortisol QLS 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4005331 General Lab "Cortisol, A.M. QLS" 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4005331 General Lab "Cortisol, P.M. QLS" 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 4005405 General Lab Iron QLS 83540 301 $246.00 $- $3.66 $- $- $196.80 $- N/A $63.96 N/A N/A $6.11 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $3.66 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $3.66 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4005405 General Lab Iron Total QST 83540 301 $246.00 $- $3.66 $- $- $196.80 $- N/A $63.96 N/A N/A $6.11 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $3.66 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $3.66 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4005503 General Lab Uric Acid 84550 301 $91.00 $- $2.90 $- $- $72.80 $- N/A $23.66 N/A N/A $4.85 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $2.90 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $2.90 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4005503 General Lab Uric Acid QLS 84550 301 $91.00 $- $2.90 $- $- $72.80 $- N/A $23.66 N/A N/A $4.85 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $2.90 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $2.90 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4005504 General Lab Iron Binding Capacity Iron Total QST 83540 301 $139.00 $- $3.66 $- $- $111.20 $- N/A $36.14 N/A N/A $6.11 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $3.66 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $3.66 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4005504 General Lab Iron and TIBC QLS 83550 301 $139.00 $- $4.50 $- $- $111.20 $- N/A $36.14 N/A N/A $7.50 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $4.50 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $4.50 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4005504 General Lab Iron and TIBC QLS 83540 301 $139.00 $- $3.66 $- $- $111.20 $- N/A $36.14 N/A N/A $6.11 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $3.66 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $3.66 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4005515 General Lab CPK (Creatine Kinase) QLS 82550 301 $123.00 $- $4.18 $- $- $98.40 $- N/A $31.98 N/A N/A $6.98 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.18 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.18 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4005515 General Lab CPK MB Fraction QST 82550 301 $123.00 $- $4.18 $- $- $98.40 $- N/A $31.98 N/A N/A $6.98 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.18 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.18 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4005515 General Lab Creatine Kinase 82550 301 $123.00 $- $4.18 $- $- $98.40 $- N/A $31.98 N/A N/A $6.98 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.18 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.18 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4005515 General Lab "Creatine Kinase, Total QST" 82550 301 $123.00 $- $4.18 $- $- $98.40 $- N/A $31.98 N/A N/A $6.98 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.18 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.18 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4005515 General Lab "Creatinine Kinase, Total QST" 82550 301 $123.00 $- $4.18 $- $- $98.40 $- N/A $31.98 N/A N/A $6.98 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.18 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.18 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4005651 General Lab Creatinine Level Urine 82570 301 $90.00 $- $3.32 $- $- $72.00 $- N/A $23.40 N/A N/A $5.54 N/A N/A $54.00 N/A N/A $45.00 N/A N/A $3.32 N/A N/A $61.20 N/A N/A $44.10 N/A N/A $35.10 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A $3.32 N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $54.00 N/A N/A $63.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A $90.00 $90.00 N/A 4005653 General Lab BUN/Creat Ratio QST 82565 301 $168.00 $- $3.29 $- $- $134.40 $- N/A $43.68 N/A N/A $5.50 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $3.29 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $3.29 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4005653 General Lab Creatinine 82565 301 $168.00 $- $3.29 $- $- $134.40 $- N/A $43.68 N/A N/A $5.50 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $3.29 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $3.29 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4005653 General Lab Creatinine Level 82565 301 $168.00 $- $3.29 $- $- $134.40 $- N/A $43.68 N/A N/A $5.50 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $3.29 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $3.29 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4005701 General Lab HIV 1 Antibody QLS 86701 302 $205.00 $- $5.70 $- $- $164.00 $- N/A $53.30 N/A N/A $9.53 N/A N/A $123.00 N/A N/A $102.50 N/A N/A $5.70 N/A N/A $139.40 N/A N/A $100.45 N/A N/A $79.95 N/A N/A $143.50 N/A N/A $164.00 N/A N/A $112.75 N/A N/A $143.50 N/A N/A $68.68 N/A N/A $5.70 N/A N/A $123.00 N/A N/A $71.75 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $123.00 N/A N/A $143.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A $205.00 $205.00 N/A 4005752 General Lab Creat Clearance w/eGFR QLS 82575 301 $179.00 $- $6.07 $- $- $143.20 $- N/A $46.54 N/A N/A $10.13 N/A N/A $107.40 N/A N/A $89.50 N/A N/A $6.07 N/A N/A $121.72 N/A N/A $87.71 N/A N/A $69.81 N/A N/A $125.30 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $125.30 N/A N/A $59.97 N/A N/A $6.07 N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $125.30 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 4005752 General Lab zzCreatinine Clearance w/eGFR QST 82575 301 $179.00 $- $6.07 $- $- $143.20 $- N/A $46.54 N/A N/A $10.13 N/A N/A $107.40 N/A N/A $89.50 N/A N/A $6.07 N/A N/A $121.72 N/A N/A $87.71 N/A N/A $69.81 N/A N/A $125.30 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $125.30 N/A N/A $59.97 N/A N/A $6.07 N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $125.30 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 4005809 General Lab Platelet Count 85049 305 $90.00 $- $2.88 $- $- $72.00 $- N/A $23.40 N/A N/A $4.80 N/A N/A $54.00 N/A N/A $45.00 N/A N/A $2.88 N/A N/A $61.20 N/A N/A $44.10 N/A N/A $35.10 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A $2.88 N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $54.00 N/A N/A $63.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A $90.00 $90.00 N/A 4005901 General Lab Vitamin A QLS 84590 301 $416.00 $- $7.45 $- $- $332.80 $- N/A $108.16 N/A N/A $12.44 N/A N/A $249.60 N/A N/A $208.00 N/A N/A $7.45 N/A N/A $282.88 N/A N/A $203.84 N/A N/A $162.24 N/A N/A $291.20 N/A N/A $332.80 N/A N/A $228.80 N/A N/A $291.20 N/A N/A $139.36 N/A N/A $7.45 N/A N/A $249.60 N/A N/A $145.60 N/A N/A $270.40 N/A N/A $124.80 N/A N/A $249.60 N/A N/A $291.20 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A $416.00 $416.00 N/A 4005901 General Lab Vitamin A QST 84590 301 $416.00 $- $7.45 $- $- $332.80 $- N/A $108.16 N/A N/A $12.44 N/A N/A $249.60 N/A N/A $208.00 N/A N/A $7.45 N/A N/A $282.88 N/A N/A $203.84 N/A N/A $162.24 N/A N/A $291.20 N/A N/A $332.80 N/A N/A $228.80 N/A N/A $291.20 N/A N/A $139.36 N/A N/A $7.45 N/A N/A $249.60 N/A N/A $145.60 N/A N/A $270.40 N/A N/A $124.80 N/A N/A $249.60 N/A N/A $291.20 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A N/A $124.80 N/A $416.00 $416.00 N/A 4005950 General Lab Cryoglobulin QST 82595 301 $145.00 $- $4.16 $- $- $116.00 $- N/A $37.70 N/A N/A $6.94 N/A N/A $87.00 N/A N/A $72.50 N/A N/A $4.16 N/A N/A $98.60 N/A N/A $71.05 N/A N/A $56.55 N/A N/A $101.50 N/A N/A $116.00 N/A N/A $79.75 N/A N/A $101.50 N/A N/A $48.58 N/A N/A $4.16 N/A N/A $87.00 N/A N/A $50.75 N/A N/A $94.25 N/A N/A $43.50 N/A N/A $87.00 N/A N/A $101.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A $145.00 $145.00 N/A 4005950 General Lab "Cryoglobulin,Qualitative Analysis QLS" 82595 301 $145.00 $- $4.16 $- $- $116.00 $- N/A $37.70 N/A N/A $6.94 N/A N/A $87.00 N/A N/A $72.50 N/A N/A $4.16 N/A N/A $98.60 N/A N/A $71.05 N/A N/A $56.55 N/A N/A $101.50 N/A N/A $116.00 N/A N/A $79.75 N/A N/A $101.50 N/A N/A $48.58 N/A N/A $4.16 N/A N/A $87.00 N/A N/A $50.75 N/A N/A $94.25 N/A N/A $43.50 N/A N/A $87.00 N/A N/A $101.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A N/A $43.50 N/A $145.00 $145.00 N/A 4006056 General Lab Lactic Acid 83605 301 $389.00 $- $6.86 $- $- $311.20 $- N/A $101.14 N/A N/A $11.45 N/A N/A $233.40 N/A N/A $194.50 N/A N/A $6.86 N/A N/A $264.52 N/A N/A $190.61 N/A N/A $151.71 N/A N/A $272.30 N/A N/A $311.20 N/A N/A $213.95 N/A N/A $272.30 N/A N/A $130.32 N/A N/A $6.86 N/A N/A $233.40 N/A N/A $136.15 N/A N/A $252.85 N/A N/A $116.70 N/A N/A $233.40 N/A N/A $272.30 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A $389.00 $389.00 N/A 4006056 General Lab Lactic Acid 3 83605 301 $389.00 $- $6.86 $- $- $311.20 $- N/A $101.14 N/A N/A $11.45 N/A N/A $233.40 N/A N/A $194.50 N/A N/A $6.86 N/A N/A $264.52 N/A N/A $190.61 N/A N/A $151.71 N/A N/A $272.30 N/A N/A $311.20 N/A N/A $213.95 N/A N/A $272.30 N/A N/A $130.32 N/A N/A $6.86 N/A N/A $233.40 N/A N/A $136.15 N/A N/A $252.85 N/A N/A $116.70 N/A N/A $233.40 N/A N/A $272.30 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A $389.00 $389.00 N/A 4006065 General Lab Vitamin B12 Level 82607 301 $289.00 $- $9.67 $- $- $231.20 $- N/A $75.14 N/A N/A $16.16 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $9.67 N/A N/A $196.52 N/A N/A $141.61 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $9.67 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 4006065 General Lab Vitamin B12 Level QST 82607 301 $289.00 $- $9.67 $- $- $231.20 $- N/A $75.14 N/A N/A $16.16 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $9.67 N/A N/A $196.52 N/A N/A $141.61 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $9.67 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 4006065 General Lab Vitamin B12 QLS 82607 301 $289.00 $- $9.67 $- $- $231.20 $- N/A $75.14 N/A N/A $16.16 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $9.67 N/A N/A $196.52 N/A N/A $141.61 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $9.67 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 4006104 General Lab PT/INR and PTT QST 85610 305 $120.00 $- $2.53 $- $- $96.00 $- N/A $31.20 N/A N/A $4.21 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $2.53 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $2.53 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4006104 General Lab PT/INR 85610 305 $120.00 $- $2.53 $- $- $96.00 $- N/A $31.20 N/A N/A $4.21 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $2.53 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $2.53 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4006104 General Lab Prothrombin with INR 85610 305 $120.00 $- $2.53 $- $- $96.00 $- N/A $31.20 N/A N/A $4.21 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $2.53 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $2.53 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4006141 General Lab Cardio CRP (R) QST 86141 302 $238.00 $- $8.31 $- $- $190.40 $- N/A $61.88 N/A N/A $13.88 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $8.31 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $8.31 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4006141 General Lab HS CRP QLS 86141 302 $238.00 $- $8.31 $- $- $190.40 $- N/A $61.88 N/A N/A $13.88 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $8.31 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $8.31 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4006155 General Lab Lactate Dehydrogenase 83615 301 $121.00 $- $3.88 $- $- $96.80 $- N/A $31.46 N/A N/A $6.48 N/A N/A $72.60 N/A N/A $60.50 N/A N/A $3.88 N/A N/A $82.28 N/A N/A $59.29 N/A N/A $47.19 N/A N/A $84.70 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $84.70 N/A N/A $40.54 N/A N/A $3.88 N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $84.70 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 4006234 General Lab Sjogren's Ab (SS-A) QLS 86235 302 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $17.95 N/A N/A $14.40 N/A N/A $12.00 N/A N/A $10.74 N/A N/A $16.32 N/A N/A $11.76 N/A N/A $9.36 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A $10.74 N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $16.80 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 4006234 General Lab Sjogren's Ab (SS-B) QST 86235 302 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $17.95 N/A N/A $14.40 N/A N/A $12.00 N/A N/A $10.74 N/A N/A $16.32 N/A N/A $11.76 N/A N/A $9.36 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A $10.74 N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $16.80 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 4006235 General Lab Cyclic Citrullinated Peptide Ab IgG (CCP) QST 86200 302 $260.00 $- $8.31 $- $- $208.00 $- N/A $67.60 N/A N/A $13.88 N/A N/A $156.00 N/A N/A $130.00 N/A N/A $8.31 N/A N/A $176.80 N/A N/A $127.40 N/A N/A $101.40 N/A N/A $182.00 N/A N/A $208.00 N/A N/A $143.00 N/A N/A $182.00 N/A N/A $87.10 N/A N/A $8.31 N/A N/A $156.00 N/A N/A $91.00 N/A N/A $169.00 N/A N/A $78.00 N/A N/A $156.00 N/A N/A $182.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A $260.00 $260.00 N/A 4006235 General Lab Cyclic Citrullinated Peptide (CCP) Ab (IgG) QLS 86200 302 $260.00 $- $8.31 $- $- $208.00 $- N/A $67.60 N/A N/A $13.88 N/A N/A $156.00 N/A N/A $130.00 N/A N/A $8.31 N/A N/A $176.80 N/A N/A $127.40 N/A N/A $101.40 N/A N/A $182.00 N/A N/A $208.00 N/A N/A $143.00 N/A N/A $182.00 N/A N/A $87.10 N/A N/A $8.31 N/A N/A $156.00 N/A N/A $91.00 N/A N/A $169.00 N/A N/A $78.00 N/A N/A $156.00 N/A N/A $182.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A $260.00 $260.00 N/A 4006236 General Lab RNP Ab QLS 86235 302 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $17.95 N/A N/A $21.60 N/A N/A $18.00 N/A N/A $10.74 N/A N/A $24.48 N/A N/A $17.64 N/A N/A $14.04 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A $10.74 N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $25.20 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 4006236 General Lab RNP Antibody QST 86235 302 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $17.95 N/A N/A $21.60 N/A N/A $18.00 N/A N/A $10.74 N/A N/A $24.48 N/A N/A $17.64 N/A N/A $14.04 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A $10.74 N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $25.20 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 4006263 General Lab DHEA QST 82626 301 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $27.10 N/A N/A $30.00 N/A N/A $25.00 N/A N/A $16.21 N/A N/A $34.00 N/A N/A $24.50 N/A N/A $19.50 N/A N/A $35.00 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $35.00 N/A N/A $16.75 N/A N/A $16.21 N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $35.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 4006263 General Lab "Dhea, Unconjugated QLS" 82626 301 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $27.10 N/A N/A $30.00 N/A N/A $25.00 N/A N/A $16.21 N/A N/A $34.00 N/A N/A $24.50 N/A N/A $19.50 N/A N/A $35.00 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $35.00 N/A N/A $16.75 N/A N/A $16.21 N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $35.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 4006270 General Lab DHEA Sulfate QST 82627 301 $234.00 $- $14.26 $- $- $187.20 $- N/A $60.84 N/A N/A $23.83 N/A N/A $140.40 N/A N/A $117.00 N/A N/A $14.26 N/A N/A $159.12 N/A N/A $114.66 N/A N/A $91.26 N/A N/A $163.80 N/A N/A $187.20 N/A N/A $128.70 N/A N/A $163.80 N/A N/A $78.39 N/A N/A $14.26 N/A N/A $140.40 N/A N/A $81.90 N/A N/A $152.10 N/A N/A $70.20 N/A N/A $140.40 N/A N/A $163.80 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A $234.00 $234.00 N/A 4006270 General Lab Dhea Sulfate QLS 82627 301 $234.00 $- $14.26 $- $- $187.20 $- N/A $60.84 N/A N/A $23.83 N/A N/A $140.40 N/A N/A $117.00 N/A N/A $14.26 N/A N/A $159.12 N/A N/A $114.66 N/A N/A $91.26 N/A N/A $163.80 N/A N/A $187.20 N/A N/A $128.70 N/A N/A $163.80 N/A N/A $78.39 N/A N/A $14.26 N/A N/A $140.40 N/A N/A $81.90 N/A N/A $152.10 N/A N/A $70.20 N/A N/A $140.40 N/A N/A $163.80 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A N/A $70.20 N/A $234.00 $234.00 N/A 4006438 General Lab Digoxin Level 80162 301 $466.00 $- $8.52 $- $- $372.80 $- N/A $121.16 N/A N/A $14.23 N/A N/A $279.60 N/A N/A $233.00 N/A N/A $8.52 N/A N/A $316.88 N/A N/A $228.34 N/A N/A $181.74 N/A N/A $326.20 N/A N/A $372.80 N/A N/A $256.30 N/A N/A $326.20 N/A N/A $156.11 N/A N/A $8.52 N/A N/A $279.60 N/A N/A $163.10 N/A N/A $302.90 N/A N/A $139.80 N/A N/A $279.60 N/A N/A $326.20 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A $466.00 $466.00 N/A 4006500 General Lab Sedimentation Rate 85652 305 $55.00 $- $1.74 $- $- $44.00 $- N/A $14.30 N/A N/A $2.89 N/A N/A $33.00 N/A N/A $27.50 N/A N/A $1.74 N/A N/A $37.40 N/A N/A $26.95 N/A N/A $21.45 N/A N/A $38.50 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $38.50 N/A N/A $18.43 N/A N/A $1.74 N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $38.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 4006505 General Lab Rheumatoid Factor QST 86431 302 $106.00 $- $3.64 $- $- $84.80 $- N/A $27.56 N/A N/A $6.08 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $3.64 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $3.64 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4006505 General Lab "Rheumatoid Factor, (RA) Quant. QLS" 86431 302 $106.00 $- $3.64 $- $- $84.80 $- N/A $27.56 N/A N/A $6.08 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $3.64 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $3.64 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4006555 General Lab "CK, CKMB with Index" 82553 301 $478.00 $- $7.41 $- $- $382.40 $- N/A $124.28 N/A N/A $12.38 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $7.41 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $7.41 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 4006555 General Lab CK with Reflex 82553 301 $478.00 $- $7.41 $- $- $382.40 $- N/A $124.28 N/A N/A $12.38 N/A N/A $286.80 N/A N/A $239.00 N/A N/A $7.41 N/A N/A $325.04 N/A N/A $234.22 N/A N/A $186.42 N/A N/A $334.60 N/A N/A $382.40 N/A N/A $262.90 N/A N/A $334.60 N/A N/A $160.13 N/A N/A $7.41 N/A N/A $286.80 N/A N/A $167.30 N/A N/A $310.70 N/A N/A $143.40 N/A N/A $286.80 N/A N/A $334.60 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A N/A $143.40 N/A $478.00 $478.00 N/A 4006602 General Lab "Drug Abuse Panel 9, with Confirmation, Serum QST" 80307 301 $601.00 $- $37.52 $- $- $480.80 $- N/A $156.26 N/A N/A $62.26 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $37.52 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $37.52 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4006602 General Lab "Drug Monitoring, Panel 8 with Confirmation, Urine QST" 80307 301 $601.00 $- $37.52 $- $- $480.80 $- N/A $156.26 N/A N/A $62.26 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $37.52 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $37.52 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4006602 General Lab Urine Drug Screen 14 80307 301 $601.00 $- $37.52 $- $- $480.80 $- N/A $156.26 N/A N/A $62.26 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $37.52 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $37.52 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4006630 General Lab Immunofixation Serum QST 86334 301 $455.00 $- $14.33 $- $- $364.00 $- N/A $118.30 N/A N/A $23.95 N/A N/A $273.00 N/A N/A $227.50 N/A N/A $14.33 N/A N/A $309.40 N/A N/A $222.95 N/A N/A $177.45 N/A N/A $318.50 N/A N/A $364.00 N/A N/A $250.25 N/A N/A $318.50 N/A N/A $152.43 N/A N/A $14.33 N/A N/A $273.00 N/A N/A $159.25 N/A N/A $295.75 N/A N/A $136.50 N/A N/A $273.00 N/A N/A $318.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A $455.00 $455.00 N/A 4006630 General Lab "Immunofixation IgA, IgG, IgM Qt QST" 86334 301 $455.00 $- $14.33 $- $- $364.00 $- N/A $118.30 N/A N/A $23.95 N/A N/A $273.00 N/A N/A $227.50 N/A N/A $14.33 N/A N/A $309.40 N/A N/A $222.95 N/A N/A $177.45 N/A N/A $318.50 N/A N/A $364.00 N/A N/A $250.25 N/A N/A $318.50 N/A N/A $152.43 N/A N/A $14.33 N/A N/A $273.00 N/A N/A $159.25 N/A N/A $295.75 N/A N/A $136.50 N/A N/A $273.00 N/A N/A $318.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A $455.00 $455.00 N/A 4006630 General Lab "Immunofixation, Serum QLS" 86334 301 $455.00 $- $14.33 $- $- $364.00 $- N/A $118.30 N/A N/A $23.95 N/A N/A $273.00 N/A N/A $227.50 N/A N/A $14.33 N/A N/A $309.40 N/A N/A $222.95 N/A N/A $177.45 N/A N/A $318.50 N/A N/A $364.00 N/A N/A $250.25 N/A N/A $318.50 N/A N/A $152.43 N/A N/A $14.33 N/A N/A $273.00 N/A N/A $159.25 N/A N/A $295.75 N/A N/A $136.50 N/A N/A $273.00 N/A N/A $318.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A N/A $136.50 N/A $455.00 $455.00 N/A 4006681 General Lab Erythropoietin (EPO) QST 82668 301 $352.00 $- $12.07 $- $- $281.60 $- N/A $91.52 N/A N/A $20.16 N/A N/A $211.20 N/A N/A $176.00 N/A N/A $12.07 N/A N/A $239.36 N/A N/A $172.48 N/A N/A $137.28 N/A N/A $246.40 N/A N/A $281.60 N/A N/A $193.60 N/A N/A $246.40 N/A N/A $117.92 N/A N/A $12.07 N/A N/A $211.20 N/A N/A $123.20 N/A N/A $228.80 N/A N/A $105.60 N/A N/A $211.20 N/A N/A $246.40 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A $352.00 $352.00 N/A 4006681 General Lab Erythropoietin QLS 82668 301 $352.00 $- $12.07 $- $- $281.60 $- N/A $91.52 N/A N/A $20.16 N/A N/A $211.20 N/A N/A $176.00 N/A N/A $12.07 N/A N/A $239.36 N/A N/A $172.48 N/A N/A $137.28 N/A N/A $246.40 N/A N/A $281.60 N/A N/A $193.60 N/A N/A $246.40 N/A N/A $117.92 N/A N/A $12.07 N/A N/A $211.20 N/A N/A $123.20 N/A N/A $228.80 N/A N/A $105.60 N/A N/A $211.20 N/A N/A $246.40 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A N/A $105.60 N/A $352.00 $352.00 N/A 4006701 General Lab Estradiol QLS 82670 301 $423.00 $- $17.92 $- $- $338.40 $- N/A $109.98 N/A N/A $29.96 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $17.92 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $17.92 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4006701 General Lab Estradiol QST 82670 301 $423.00 $- $17.92 $- $- $338.40 $- N/A $109.98 N/A N/A $29.96 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $17.92 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $17.92 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4006704 General Lab Hepatitis B Core Ab Total QST 86704 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4006704 General Lab Hepatitis B Core Antibody QLS 86704 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4006704 General Lab Hepatitis B Core Ab Total (Refl) QST 86704 302 $337.00 $- $7.73 $- $- $269.60 $- N/A $87.62 N/A N/A $12.92 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.73 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.73 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4006708 General Lab Prothrombin (Factor II) Mutation Analysis QST 81240 300 $107.00 $- $27.82 $- $- $85.60 $- N/A $27.82 N/A N/A $60.70 N/A N/A $64.20 N/A N/A $53.50 N/A N/A N/A N/A N/A $72.76 N/A N/A $52.43 N/A N/A $41.73 N/A N/A $74.90 N/A N/A $85.60 N/A N/A $58.85 N/A N/A $74.90 N/A N/A $35.85 N/A N/A N/A N/A N/A $64.20 N/A N/A $37.45 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $64.20 N/A N/A $74.90 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A $107.00 $107.00 N/A 4006727 General Lab Estrogen Level QST 82672 301 $561.00 $- $13.92 $- $- $448.80 $- N/A $145.86 N/A N/A $23.26 N/A N/A $336.60 N/A N/A $280.50 N/A N/A $13.92 N/A N/A $381.48 N/A N/A $274.89 N/A N/A $218.79 N/A N/A $392.70 N/A N/A $448.80 N/A N/A $308.55 N/A N/A $392.70 N/A N/A $187.94 N/A N/A $13.92 N/A N/A $336.60 N/A N/A $196.35 N/A N/A $364.65 N/A N/A $168.30 N/A N/A $336.60 N/A N/A $392.70 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A $561.00 $561.00 N/A 4006727 General Lab "Estrogen, Total, Serum QLS" 82672 301 $561.00 $- $13.92 $- $- $448.80 $- N/A $145.86 N/A N/A $23.26 N/A N/A $336.60 N/A N/A $280.50 N/A N/A $13.92 N/A N/A $381.48 N/A N/A $274.89 N/A N/A $218.79 N/A N/A $392.70 N/A N/A $448.80 N/A N/A $308.55 N/A N/A $392.70 N/A N/A $187.94 N/A N/A $13.92 N/A N/A $336.60 N/A N/A $196.35 N/A N/A $364.65 N/A N/A $168.30 N/A N/A $336.60 N/A N/A $392.70 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A $561.00 $561.00 N/A 4006908 General Lab Lipase Level 83690 301 $321.00 $- $4.42 $- $- $256.80 $- N/A $83.46 N/A N/A $7.39 N/A N/A $192.60 N/A N/A $160.50 N/A N/A $4.42 N/A N/A $218.28 N/A N/A $157.29 N/A N/A $125.19 N/A N/A $224.70 N/A N/A $256.80 N/A N/A $176.55 N/A N/A $224.70 N/A N/A $107.54 N/A N/A $4.42 N/A N/A $192.60 N/A N/A $112.35 N/A N/A $208.65 N/A N/A $96.30 N/A N/A $192.60 N/A N/A $224.70 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A $321.00 $321.00 N/A 4006956 General Lab Gentamicin QLS 80170 301 $318.00 $- $10.51 $- $- $254.40 $- N/A $82.68 N/A N/A $17.57 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $10.51 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $10.51 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4007038 General Lab DESC-Serum Pregnancy Test 84703 301 $318.00 $- $4.83 $- $- $254.40 $- N/A $82.68 N/A N/A $8.05 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $4.83 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $4.83 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4007038 General Lab Pregnancy Test Serum 1 84703 301 $318.00 $- $4.83 $- $- $254.40 $- N/A $82.68 N/A N/A $8.05 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $4.83 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $4.83 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4007038 General Lab "Pregnancy, Qualitative QLS" 84703 301 $318.00 $- $4.83 $- $- $254.40 $- N/A $82.68 N/A N/A $8.05 N/A N/A $190.80 N/A N/A $159.00 N/A N/A $4.83 N/A N/A $216.24 N/A N/A $155.82 N/A N/A $124.02 N/A N/A $222.60 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $222.60 N/A N/A $106.53 N/A N/A $4.83 N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $222.60 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 4007105 General Lab Fecal Fat Screen QLS 82705 301 $100.00 $- $3.27 $- $- $80.00 $- N/A $26.00 N/A N/A $5.45 N/A N/A $60.00 N/A N/A $50.00 N/A N/A $3.27 N/A N/A $68.00 N/A N/A $49.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A $3.27 N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4007105 General Lab "Fecal Fat, Qual QST" 82705 301 $100.00 $- $3.27 $- $- $80.00 $- N/A $26.00 N/A N/A $5.45 N/A N/A $60.00 N/A N/A $50.00 N/A N/A $3.27 N/A N/A $68.00 N/A N/A $49.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A $3.27 N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4007252 General Lab Lithium Level QST 80178 301 $123.00 $- $4.24 $- $- $98.40 $- N/A $31.98 N/A N/A $7.09 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.24 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.24 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4007252 General Lab Lithium QLS 80178 301 $123.00 $- $4.24 $- $- $98.40 $- N/A $31.98 N/A N/A $7.09 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.24 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.24 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4007275 General Lab Antiphospholipid Antibody Panel QST 86146 302 $371.00 $- $16.32 $- $- $296.80 $- N/A $96.46 N/A N/A $27.28 N/A N/A $222.60 N/A N/A $185.50 N/A N/A $16.32 N/A N/A $252.28 N/A N/A $181.79 N/A N/A $144.69 N/A N/A $259.70 N/A N/A $296.80 N/A N/A $204.05 N/A N/A $259.70 N/A N/A $124.29 N/A N/A $16.32 N/A N/A $222.60 N/A N/A $129.85 N/A N/A $241.15 N/A N/A $111.30 N/A N/A $222.60 N/A N/A $259.70 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A $371.00 $371.00 N/A 4007275 General Lab Antiphospholipid Antibody Panel QST 86147 302 $371.00 $- $16.32 $- $- $296.80 $- N/A $96.46 N/A N/A $27.28 N/A N/A $222.60 N/A N/A $185.50 N/A N/A $16.32 N/A N/A $252.28 N/A N/A $181.79 N/A N/A $144.69 N/A N/A $259.70 N/A N/A $296.80 N/A N/A $204.05 N/A N/A $259.70 N/A N/A $124.29 N/A N/A $16.32 N/A N/A $222.60 N/A N/A $129.85 N/A N/A $241.15 N/A N/A $111.30 N/A N/A $222.60 N/A N/A $259.70 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A $371.00 $371.00 N/A 4007275 General Lab Antiphospholipid Antibody Panel QST 86148 302 $371.00 $- $10.31 $- $- $296.80 $- N/A $96.46 N/A N/A $17.22 N/A N/A $222.60 N/A N/A $185.50 N/A N/A $10.31 N/A N/A $252.28 N/A N/A $181.79 N/A N/A $144.69 N/A N/A $259.70 N/A N/A $296.80 N/A N/A $204.05 N/A N/A $259.70 N/A N/A $124.29 N/A N/A $10.31 N/A N/A $222.60 N/A N/A $129.85 N/A N/A $241.15 N/A N/A $111.30 N/A N/A $222.60 N/A N/A $259.70 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A N/A $111.30 N/A $371.00 $371.00 N/A 4007287 General Lab Ferritin Level 82728 301 $251.00 $- $8.75 $- $- $200.80 $- N/A $65.26 N/A N/A $14.60 N/A N/A $150.60 N/A N/A $125.50 N/A N/A $8.75 N/A N/A $170.68 N/A N/A $122.99 N/A N/A $97.89 N/A N/A $175.70 N/A N/A $200.80 N/A N/A $138.05 N/A N/A $175.70 N/A N/A $84.09 N/A N/A $8.75 N/A N/A $150.60 N/A N/A $87.85 N/A N/A $163.15 N/A N/A $75.30 N/A N/A $150.60 N/A N/A $175.70 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A $251.00 $251.00 N/A 4007287 General Lab Ferritin QLS 82728 301 $251.00 $- $8.75 $- $- $200.80 $- N/A $65.26 N/A N/A $14.60 N/A N/A $150.60 N/A N/A $125.50 N/A N/A $8.75 N/A N/A $170.68 N/A N/A $122.99 N/A N/A $97.89 N/A N/A $175.70 N/A N/A $200.80 N/A N/A $138.05 N/A N/A $175.70 N/A N/A $84.09 N/A N/A $8.75 N/A N/A $150.60 N/A N/A $87.85 N/A N/A $163.15 N/A N/A $75.30 N/A N/A $150.60 N/A N/A $175.70 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A $251.00 $251.00 N/A 4007300 General Lab PTT 85730 305 $120.00 $- $3.86 $- $- $96.00 $- N/A $31.20 N/A N/A $6.43 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $3.86 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $3.86 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4007303 General Lab "Fibrinogen Activity, Clauss QLS" 85384 301 $148.00 $- $5.45 $- $- $118.40 $- N/A $38.48 N/A N/A $9.11 N/A N/A $88.80 N/A N/A $74.00 N/A N/A $5.45 N/A N/A $100.64 N/A N/A $72.52 N/A N/A $57.72 N/A N/A $103.60 N/A N/A $118.40 N/A N/A $81.40 N/A N/A $103.60 N/A N/A $49.58 N/A N/A $5.45 N/A N/A $88.80 N/A N/A $51.80 N/A N/A $96.20 N/A N/A $44.40 N/A N/A $88.80 N/A N/A $103.60 N/A N/A $44.40 N/A N/A $44.40 N/A N/A $44.40 N/A N/A $44.40 N/A N/A $44.40 N/A N/A $44.40 N/A $148.00 $148.00 N/A 4007328 General Lab "Giardia Antigen, EIA, Stool QST" 87329 306 $270.00 $- $7.69 $- $- $216.00 $- N/A $70.20 N/A N/A $12.86 N/A N/A $162.00 N/A N/A $135.00 N/A N/A $7.69 N/A N/A $183.60 N/A N/A $132.30 N/A N/A $105.30 N/A N/A $189.00 N/A N/A $216.00 N/A N/A $148.50 N/A N/A $189.00 N/A N/A $90.45 N/A N/A $7.69 N/A N/A $162.00 N/A N/A $94.50 N/A N/A $175.50 N/A N/A $81.00 N/A N/A $162.00 N/A N/A $189.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A $270.00 $270.00 N/A 4007351 General Lab Magnesium Level 83735 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.19 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4007400 General Lab B-Natriuretic Peptide QLS 83880 301 $439.00 $- $21.78 $- $- $351.20 $- N/A $114.14 N/A N/A $36.40 N/A N/A $263.40 N/A N/A $219.50 N/A N/A $21.78 N/A N/A $298.52 N/A N/A $215.11 N/A N/A $171.21 N/A N/A $307.30 N/A N/A $351.20 N/A N/A $241.45 N/A N/A $307.30 N/A N/A $147.07 N/A N/A $21.78 N/A N/A $263.40 N/A N/A $153.65 N/A N/A $285.35 N/A N/A $131.70 N/A N/A $263.40 N/A N/A $307.30 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A $439.00 $439.00 N/A 4007400 General Lab Brain Natriuretic Peptide 83880 301 $439.00 $- $21.78 $- $- $351.20 $- N/A $114.14 N/A N/A $36.40 N/A N/A $263.40 N/A N/A $219.50 N/A N/A $21.78 N/A N/A $298.52 N/A N/A $215.11 N/A N/A $171.21 N/A N/A $307.30 N/A N/A $351.20 N/A N/A $241.45 N/A N/A $307.30 N/A N/A $147.07 N/A N/A $21.78 N/A N/A $263.40 N/A N/A $153.65 N/A N/A $285.35 N/A N/A $131.70 N/A N/A $263.40 N/A N/A $307.30 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A N/A $131.70 N/A $439.00 $439.00 N/A 4007454 General Lab "Testosterone Level Total, M QST" 84403 301 $362.00 $- $16.56 $- $- $289.60 $- N/A $94.12 N/A N/A $27.68 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $16.56 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $16.56 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4007454 General Lab Testosterone Level Total QST 84403 301 $362.00 $- $16.56 $- $- $289.60 $- N/A $94.12 N/A N/A $27.68 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $16.56 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $16.56 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4007454 General Lab "Testosterone, Total QLS" 84403 301 $362.00 $- $16.56 $- $- $289.60 $- N/A $94.12 N/A N/A $27.68 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $16.56 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $16.56 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4007454 General Lab "Testosterone, Total (Males), Immunoassay QLS" 84403 301 $362.00 $- $16.56 $- $- $289.60 $- N/A $94.12 N/A N/A $27.68 N/A N/A $217.20 N/A N/A $181.00 N/A N/A $16.56 N/A N/A $246.16 N/A N/A $177.38 N/A N/A $141.18 N/A N/A $253.40 N/A N/A $289.60 N/A N/A $199.10 N/A N/A $253.40 N/A N/A $121.27 N/A N/A $16.56 N/A N/A $217.20 N/A N/A $126.70 N/A N/A $235.30 N/A N/A $108.60 N/A N/A $217.20 N/A N/A $253.40 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A N/A $108.60 N/A $362.00 $362.00 N/A 4007457 General Lab PSA Diagnostic 84152 301 $355.00 $- $11.80 $- $- $284.00 $- N/A $92.30 N/A N/A $19.73 N/A N/A $213.00 N/A N/A $177.50 N/A N/A $11.80 N/A N/A $241.40 N/A N/A $173.95 N/A N/A $138.45 N/A N/A $248.50 N/A N/A $284.00 N/A N/A $195.25 N/A N/A $248.50 N/A N/A $118.93 N/A N/A $11.80 N/A N/A $213.00 N/A N/A $124.25 N/A N/A $230.75 N/A N/A $106.50 N/A N/A $213.00 N/A N/A $248.50 N/A N/A $106.50 N/A N/A $106.50 N/A N/A $106.50 N/A N/A $106.50 N/A N/A $106.50 N/A N/A $106.50 N/A $355.00 $355.00 N/A 4007469 General Lab Folate Level 82746 301 $468.00 $- $9.43 $- $- $374.40 $- N/A $121.68 N/A N/A $15.77 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.43 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.43 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4007469 General Lab Folate 82746 301 $468.00 $- $9.43 $- $- $374.40 $- N/A $121.68 N/A N/A $15.77 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.43 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.43 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4007469 General Lab Folate QLS 82746 301 $468.00 $- $9.43 $- $- $374.40 $- N/A $121.68 N/A N/A $15.77 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.43 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.43 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4007469 General Lab Folate QST 82746 301 $468.00 $- $9.43 $- $- $374.40 $- N/A $121.68 N/A N/A $15.77 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.43 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.43 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4007473 General Lab "HCV RNA, Qn, PCR w/Rfl Genotype QLS" 87522 306 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4007871 General Lab Varicella Zoster Virus Abs QST 86787 302 $167.00 $- $8.27 $- $- $133.60 $- N/A $43.42 N/A N/A $13.81 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $8.27 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $8.27 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4007871 General Lab Varicella Zoster IgG Ab QST 86787 300 $167.00 $- $8.27 $- $- $133.60 $- N/A $43.42 N/A N/A $13.81 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $8.27 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $8.27 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4007871 General Lab Varicella-Zoster Virus Antibody (IgG) QLS 86787 302 $167.00 $- $8.27 $- $- $133.60 $- N/A $43.42 N/A N/A $13.81 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $8.27 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $8.27 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4007903 General Lab "HCV RNA, Quant Real Time PCR QST" 87522 306 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4007903 General Lab Hepatitis C RNA PCR Qt QST 87522 306 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4007903 General Lab Hepatitis C Virus RNA Quant w/ Reflex to Genotype QST 87522 306 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4007903 General Lab "Hepatitis C Viral RNA, PCR QuAntitative QLS" 87522 306 $477.00 $- $27.47 $- $- $381.60 $- N/A $124.02 N/A N/A $45.92 N/A N/A $286.20 N/A N/A $238.50 N/A N/A $27.47 N/A N/A $324.36 N/A N/A $233.73 N/A N/A $186.03 N/A N/A $333.90 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $333.90 N/A N/A $159.80 N/A N/A $27.47 N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $333.90 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 4008000 General Lab Thyroglobulin Antibody QST 86800 301 $227.00 $- $10.20 $- $- $181.60 $- N/A $59.02 N/A N/A $17.05 N/A N/A $136.20 N/A N/A $113.50 N/A N/A $10.20 N/A N/A $154.36 N/A N/A $111.23 N/A N/A $88.53 N/A N/A $158.90 N/A N/A $181.60 N/A N/A $124.85 N/A N/A $158.90 N/A N/A $76.05 N/A N/A $10.20 N/A N/A $136.20 N/A N/A $79.45 N/A N/A $147.55 N/A N/A $68.10 N/A N/A $136.20 N/A N/A $158.90 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A $227.00 $227.00 N/A 4008000 General Lab Thyroglobulin Antibodies QLS 86800 301 $227.00 $- $10.20 $- $- $181.60 $- N/A $59.02 N/A N/A $17.05 N/A N/A $136.20 N/A N/A $113.50 N/A N/A $10.20 N/A N/A $154.36 N/A N/A $111.23 N/A N/A $88.53 N/A N/A $158.90 N/A N/A $181.60 N/A N/A $124.85 N/A N/A $158.90 N/A N/A $76.05 N/A N/A $10.20 N/A N/A $136.20 N/A N/A $79.45 N/A N/A $147.55 N/A N/A $68.10 N/A N/A $136.20 N/A N/A $158.90 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A $227.00 $227.00 N/A 4008012 General Lab Antithrombin III QLS 85300 305 $393.00 $- $7.61 $- $- $314.40 $- N/A $102.18 N/A N/A $12.71 N/A N/A $235.80 N/A N/A $196.50 N/A N/A $7.61 N/A N/A $267.24 N/A N/A $192.57 N/A N/A $153.27 N/A N/A $275.10 N/A N/A $314.40 N/A N/A $216.15 N/A N/A $275.10 N/A N/A $131.66 N/A N/A $7.61 N/A N/A $235.80 N/A N/A $137.55 N/A N/A $255.45 N/A N/A $117.90 N/A N/A $235.80 N/A N/A $275.10 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A $393.00 $393.00 N/A 4008012 General Lab Antithrombin III Ag QST 85300 305 $393.00 $- $7.61 $- $- $314.40 $- N/A $102.18 N/A N/A $12.71 N/A N/A $235.80 N/A N/A $196.50 N/A N/A $7.61 N/A N/A $267.24 N/A N/A $192.57 N/A N/A $153.27 N/A N/A $275.10 N/A N/A $314.40 N/A N/A $216.15 N/A N/A $275.10 N/A N/A $131.66 N/A N/A $7.61 N/A N/A $235.80 N/A N/A $137.55 N/A N/A $255.45 N/A N/A $117.90 N/A N/A $235.80 N/A N/A $275.10 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A N/A $117.90 N/A $393.00 $393.00 N/A 4008129 General Lab C-Peptide QLS 84681 301 $457.00 $- $13.35 $- $- $365.60 $- N/A $118.82 N/A N/A $22.32 N/A N/A $274.20 N/A N/A $228.50 N/A N/A $13.35 N/A N/A $310.76 N/A N/A $223.93 N/A N/A $178.23 N/A N/A $319.90 N/A N/A $365.60 N/A N/A $251.35 N/A N/A $319.90 N/A N/A $153.10 N/A N/A $13.35 N/A N/A $274.20 N/A N/A $159.95 N/A N/A $297.05 N/A N/A $137.10 N/A N/A $274.20 N/A N/A $319.90 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A $457.00 $457.00 N/A 4008129 General Lab C-Peptide QST 84681 301 $457.00 $- $13.35 $- $- $365.60 $- N/A $118.82 N/A N/A $22.32 N/A N/A $274.20 N/A N/A $228.50 N/A N/A $13.35 N/A N/A $310.76 N/A N/A $223.93 N/A N/A $178.23 N/A N/A $319.90 N/A N/A $365.60 N/A N/A $251.35 N/A N/A $319.90 N/A N/A $153.10 N/A N/A $13.35 N/A N/A $274.20 N/A N/A $159.95 N/A N/A $297.05 N/A N/A $137.10 N/A N/A $274.20 N/A N/A $319.90 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A $457.00 $457.00 N/A 4008137 General Lab CA 19-9 QLS 86301 302 $423.00 $- $13.35 $- $- $338.40 $- N/A $109.98 N/A N/A $22.32 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $13.35 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $13.35 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4008137 General Lab CA 19-9 QST 86301 302 $423.00 $- $13.35 $- $- $338.40 $- N/A $109.98 N/A N/A $22.32 N/A N/A $253.80 N/A N/A $211.50 N/A N/A $13.35 N/A N/A $287.64 N/A N/A $207.27 N/A N/A $164.97 N/A N/A $296.10 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $296.10 N/A N/A $141.71 N/A N/A $13.35 N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $296.10 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 4008145 General Lab CA 125 QLS 86304 302 $457.00 $- $13.35 $- $- $365.60 $- N/A $118.82 N/A N/A $22.32 N/A N/A $274.20 N/A N/A $228.50 N/A N/A $13.35 N/A N/A $310.76 N/A N/A $223.93 N/A N/A $178.23 N/A N/A $319.90 N/A N/A $365.60 N/A N/A $251.35 N/A N/A $319.90 N/A N/A $153.10 N/A N/A $13.35 N/A N/A $274.20 N/A N/A $159.95 N/A N/A $297.05 N/A N/A $137.10 N/A N/A $274.20 N/A N/A $319.90 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A $457.00 $457.00 N/A 4008145 General Lab CA 125 QST 86304 302 $457.00 $- $13.35 $- $- $365.60 $- N/A $118.82 N/A N/A $22.32 N/A N/A $274.20 N/A N/A $228.50 N/A N/A $13.35 N/A N/A $310.76 N/A N/A $223.93 N/A N/A $178.23 N/A N/A $319.90 N/A N/A $365.60 N/A N/A $251.35 N/A N/A $319.90 N/A N/A $153.10 N/A N/A $13.35 N/A N/A $274.20 N/A N/A $159.95 N/A N/A $297.05 N/A N/A $137.10 N/A N/A $274.20 N/A N/A $319.90 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A $457.00 $457.00 N/A 4008186 General Lab Hemogram 5 85027 305 $101.00 $- $4.16 $- $- $80.80 $- N/A $26.26 N/A N/A $6.94 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $4.16 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $4.16 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4008186 General Lab Hemogram1 85027 305 $101.00 $- $4.16 $- $- $80.80 $- N/A $26.26 N/A N/A $6.94 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $4.16 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $4.16 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4008243 General Lab Arginine Vasopressin QST 84588 301 $617.00 $- $21.78 $- $- $493.60 $- N/A $160.42 N/A N/A $36.40 N/A N/A $370.20 N/A N/A $308.50 N/A N/A $21.78 N/A N/A $419.56 N/A N/A $302.33 N/A N/A $240.63 N/A N/A $431.90 N/A N/A $493.60 N/A N/A $339.35 N/A N/A $431.90 N/A N/A $206.70 N/A N/A $21.78 N/A N/A $370.20 N/A N/A $215.95 N/A N/A $401.05 N/A N/A $185.10 N/A N/A $370.20 N/A N/A $431.90 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A $617.00 $617.00 N/A 4008243 General Lab Arginine Vasopressin (ADH) QLS 84588 301 $617.00 $- $21.78 $- $- $493.60 $- N/A $160.42 N/A N/A $36.40 N/A N/A $370.20 N/A N/A $308.50 N/A N/A $21.78 N/A N/A $419.56 N/A N/A $302.33 N/A N/A $240.63 N/A N/A $431.90 N/A N/A $493.60 N/A N/A $339.35 N/A N/A $431.90 N/A N/A $206.70 N/A N/A $21.78 N/A N/A $370.20 N/A N/A $215.95 N/A N/A $401.05 N/A N/A $185.10 N/A N/A $370.20 N/A N/A $431.90 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A $617.00 $617.00 N/A 4008278 General Lab "C. Trachomatis, N. Gonorrhoeae RNA, TMA QLS" 87491 306 $175.00 $- $22.51 $- $- $140.00 $- N/A $45.50 N/A N/A $37.63 N/A N/A $105.00 N/A N/A $87.50 N/A N/A $22.51 N/A N/A $119.00 N/A N/A $85.75 N/A N/A $68.25 N/A N/A $122.50 N/A N/A $140.00 N/A N/A $96.25 N/A N/A $122.50 N/A N/A $58.63 N/A N/A $22.51 N/A N/A $105.00 N/A N/A $61.25 N/A N/A $113.75 N/A N/A $52.50 N/A N/A $105.00 N/A N/A $122.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A $175.00 $175.00 N/A 4008278 General Lab Chlamydia Trachomatis/ N. gonorrheae DNA Probe QST 87591 306 $175.00 $- $22.51 $- $- $140.00 $- N/A $45.50 N/A N/A $37.63 N/A N/A $105.00 N/A N/A $87.50 N/A N/A $22.51 N/A N/A $119.00 N/A N/A $85.75 N/A N/A $68.25 N/A N/A $122.50 N/A N/A $140.00 N/A N/A $96.25 N/A N/A $122.50 N/A N/A $58.63 N/A N/A $22.51 N/A N/A $105.00 N/A N/A $61.25 N/A N/A $113.75 N/A N/A $52.50 N/A N/A $105.00 N/A N/A $122.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A $175.00 $175.00 N/A 4008293 General Lab Complement C4 QLS 86160 302 $337.00 $- $7.70 $- $- $269.60 $- N/A $87.62 N/A N/A $12.88 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.70 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.70 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4008293 General Lab Complement Component C4 QST 86160 302 $337.00 $- $7.70 $- $- $269.60 $- N/A $87.62 N/A N/A $12.88 N/A N/A $202.20 N/A N/A $168.50 N/A N/A $7.70 N/A N/A $229.16 N/A N/A $165.13 N/A N/A $131.43 N/A N/A $235.90 N/A N/A $269.60 N/A N/A $185.35 N/A N/A $235.90 N/A N/A $112.90 N/A N/A $7.70 N/A N/A $202.20 N/A N/A $117.95 N/A N/A $219.05 N/A N/A $101.10 N/A N/A $202.20 N/A N/A $235.90 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A N/A $101.10 N/A $337.00 $337.00 N/A 4008312 General Lab Bill GNSS-PN Stain 88312 310 $246.00 $- $46.42 $- $- $196.80 $- N/A $63.96 N/A N/A $79.85 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $46.42 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $46.42 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4008342 General Lab Bill B Cell Stain 88342 310 $317.00 $- $52.52 $- $- $253.60 $- N/A $82.42 N/A N/A $94.06 N/A N/A $190.20 N/A N/A $158.50 N/A N/A $52.52 N/A N/A $215.56 N/A N/A $155.33 N/A N/A $123.63 N/A N/A $221.90 N/A N/A $253.60 N/A N/A $174.35 N/A N/A $221.90 N/A N/A $106.20 N/A N/A $52.52 N/A N/A $190.20 N/A N/A $110.95 N/A N/A $206.05 N/A N/A $95.10 N/A N/A $190.20 N/A N/A $221.90 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A N/A $95.10 N/A $317.00 $317.00 N/A 4008359 General Lab "Metanephrines, Fractionated, 24hr Urine QLS" 83835 301 $557.00 $- $10.87 $- $- $445.60 $- N/A $144.82 N/A N/A $18.17 N/A N/A $334.20 N/A N/A $278.50 N/A N/A $10.87 N/A N/A $378.76 N/A N/A $272.93 N/A N/A $217.23 N/A N/A $389.90 N/A N/A $445.60 N/A N/A $306.35 N/A N/A $389.90 N/A N/A $186.60 N/A N/A $10.87 N/A N/A $334.20 N/A N/A $194.95 N/A N/A $362.05 N/A N/A $167.10 N/A N/A $334.20 N/A N/A $389.90 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A $557.00 $557.00 N/A 4008496 General Lab Ganglioside Asialo-GM-1 Ab (IgG) QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4008496 General Lab Glomerular Basement Membrane Ab IgG QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4008496 General Lab Glomerular Basement Membrane Ab (IgG) QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4008541 General Lab Cholesterol HDL 83718 301 $162.00 $- $5.26 $- $- $129.60 $- N/A $42.12 N/A N/A $8.78 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $5.26 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $5.26 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4008541 General Lab HDL Cholesterol QST 83718 301 $162.00 $- $5.26 $- $- $129.60 $- N/A $42.12 N/A N/A $8.78 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $5.26 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $5.26 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4008632 General Lab "IgA, Serum QLS" 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008632 General Lab Immunoglobulin A QST 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008632 General Lab IgA Serum QLS 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008657 General Lab "IgG,serum QLS" 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008657 General Lab Immunoglobulin G QST 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008657 General Lab IgG Serum QLS 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008665 General Lab "IgM, Serum QLS" 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008665 General Lab Immunoglobulin M QST 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008665 General Lab IgM Serum QLS 82784 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.18 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4008681 General Lab Immunoglobulins Panel QLS 82784 301 $334.00 $- $4.30 $- $- $267.20 $- N/A $86.84 N/A N/A $7.18 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $4.30 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $4.30 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4008723 General Lab Lead Level QST 83655 301 $150.00 $- $7.77 $- $- $120.00 $- N/A $39.00 N/A N/A $12.98 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $7.77 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $7.77 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4008731 General Lab 86713 302 $658.00 $- $9.82 $- $- $526.40 $- N/A $171.08 N/A N/A $16.42 N/A N/A $394.80 N/A N/A $329.00 N/A N/A $9.82 N/A N/A $447.44 N/A N/A $322.42 N/A N/A $256.62 N/A N/A $460.60 N/A N/A $526.40 N/A N/A $361.90 N/A N/A $460.60 N/A N/A $220.43 N/A N/A $9.82 N/A N/A $394.80 N/A N/A $230.30 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $394.80 N/A N/A $460.60 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A $658.00 $658.00 N/A 4008764 General Lab Phenobarbital QLS 80184 301 $223.00 $- $7.35 $- $- $178.40 $- N/A $57.98 N/A N/A $11.94 N/A N/A $133.80 N/A N/A $111.50 N/A N/A $7.35 N/A N/A $151.64 N/A N/A $109.27 N/A N/A $86.97 N/A N/A $156.10 N/A N/A $178.40 N/A N/A $122.65 N/A N/A $156.10 N/A N/A $74.71 N/A N/A $7.35 N/A N/A $133.80 N/A N/A $78.05 N/A N/A $144.95 N/A N/A $66.90 N/A N/A $133.80 N/A N/A $156.10 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A $223.00 $223.00 N/A 4008764 General Lab Phenobarbital Level QST 80184 301 $223.00 $- $7.35 $- $- $178.40 $- N/A $57.98 N/A N/A $11.94 N/A N/A $133.80 N/A N/A $111.50 N/A N/A $7.35 N/A N/A $151.64 N/A N/A $109.27 N/A N/A $86.97 N/A N/A $156.10 N/A N/A $178.40 N/A N/A $122.65 N/A N/A $156.10 N/A N/A $74.71 N/A N/A $7.35 N/A N/A $133.80 N/A N/A $78.05 N/A N/A $144.95 N/A N/A $66.90 N/A N/A $133.80 N/A N/A $156.10 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A $223.00 $223.00 N/A 4008800 General Lab "Liver Fibrosis, Fibro Test-Actitest Panel QST" 82977 301 $74.00 $- $4.62 $- $- $59.20 $- N/A $19.24 N/A N/A $7.73 N/A N/A $44.40 N/A N/A $37.00 N/A N/A $4.62 N/A N/A $50.32 N/A N/A $36.26 N/A N/A $28.86 N/A N/A $51.80 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $51.80 N/A N/A $24.79 N/A N/A $4.62 N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $51.80 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 4008801 General Lab Hepatitis C Genotype QST 87902 306 $444.00 $- $115.44 $- $- $355.20 $- N/A $115.44 N/A N/A $276.02 N/A N/A $266.40 N/A N/A $222.00 N/A N/A $165.08 N/A N/A $301.92 N/A N/A $217.56 N/A N/A $173.16 N/A N/A $310.80 N/A N/A $355.20 N/A N/A $244.20 N/A N/A $310.80 N/A N/A $148.74 N/A N/A $165.08 N/A N/A $266.40 N/A N/A $155.40 N/A N/A $288.60 N/A N/A $133.20 N/A N/A $266.40 N/A N/A $310.80 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A $444.00 $444.00 N/A 4008801 General Lab Hepatitis C Viral RNA NS3 Genotype QST 87902 306 $444.00 $- $115.44 $- $- $355.20 $- N/A $115.44 N/A N/A $276.02 N/A N/A $266.40 N/A N/A $222.00 N/A N/A $165.08 N/A N/A $301.92 N/A N/A $217.56 N/A N/A $173.16 N/A N/A $310.80 N/A N/A $355.20 N/A N/A $244.20 N/A N/A $310.80 N/A N/A $148.74 N/A N/A $165.08 N/A N/A $266.40 N/A N/A $155.40 N/A N/A $288.60 N/A N/A $133.20 N/A N/A $266.40 N/A N/A $310.80 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A $444.00 $444.00 N/A 4008801 General Lab Hepatitis C Viral RNA NS3 Drug Resistance QLS 87902 306 $444.00 $- $115.44 $- $- $355.20 $- N/A $115.44 N/A N/A $276.02 N/A N/A $266.40 N/A N/A $222.00 N/A N/A $165.08 N/A N/A $301.92 N/A N/A $217.56 N/A N/A $173.16 N/A N/A $310.80 N/A N/A $355.20 N/A N/A $244.20 N/A N/A $310.80 N/A N/A $148.74 N/A N/A $165.08 N/A N/A $266.40 N/A N/A $155.40 N/A N/A $288.60 N/A N/A $133.20 N/A N/A $266.40 N/A N/A $310.80 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A N/A $133.20 N/A $444.00 $444.00 N/A 4008913 General Lab "Microalbumin, Random Urine w/ Creat QST" 82043 301 $202.00 $- $52.52 $- $- $161.60 $- N/A $52.52 N/A N/A N/A N/A N/A $121.20 N/A N/A $101.00 N/A N/A N/A N/A N/A $137.36 N/A N/A $98.98 N/A N/A $78.78 N/A N/A $141.40 N/A N/A $161.60 N/A N/A $111.10 N/A N/A $141.40 N/A N/A $67.67 N/A N/A N/A N/A N/A $121.20 N/A N/A $70.70 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $121.20 N/A N/A $141.40 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A $202.00 $202.00 N/A 4008913 General Lab "Microalbumin, Random Urine w/ Creat QST" 82570 301 $202.00 $- $3.32 $- $- $161.60 $- N/A $52.52 N/A N/A $5.54 N/A N/A $121.20 N/A N/A $101.00 N/A N/A $3.32 N/A N/A $137.36 N/A N/A $98.98 N/A N/A $78.78 N/A N/A $141.40 N/A N/A $161.60 N/A N/A $111.10 N/A N/A $141.40 N/A N/A $67.67 N/A N/A $3.32 N/A N/A $121.20 N/A N/A $70.70 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $121.20 N/A N/A $141.40 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A $202.00 $202.00 N/A 4008913 General Lab "Microalbumin, Random Ur (w/Creat) QLS" 82043 301 $202.00 $- $3.72 $- $- $161.60 $- N/A $52.52 N/A N/A $6.20 N/A N/A $121.20 N/A N/A $101.00 N/A N/A $3.72 N/A N/A $137.36 N/A N/A $98.98 N/A N/A $78.78 N/A N/A $141.40 N/A N/A $161.60 N/A N/A $111.10 N/A N/A $141.40 N/A N/A $67.67 N/A N/A $3.72 N/A N/A $121.20 N/A N/A $70.70 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $121.20 N/A N/A $141.40 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A $202.00 $202.00 N/A 4008915 General Lab "Microalbumin, 24hr Ur(w/Creat) QLS" 301 $203.00 $- $52.78 $- $- $162.40 $- N/A $52.78 N/A N/A N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4008915 General Lab "Microalbumin, 24 Hr Ur w/Creat" 82043 301 $203.00 $- $3.72 $- $- $162.40 $- N/A $52.78 N/A N/A $6.20 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $3.72 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $3.72 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4009011 General Lab Rh Grouping 86901 302 $144.00 $- $1.92 $- $- $115.20 $- N/A $37.44 N/A N/A $3.20 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $1.92 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $1.92 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4009135 General Lab RSV Antigen QLS 87807 302 $330.00 $- $7.69 $- $- $264.00 $- N/A $85.80 N/A N/A $12.86 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $7.69 N/A N/A $224.40 N/A N/A $161.70 N/A N/A $128.70 N/A N/A $231.00 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $231.00 N/A N/A $110.55 N/A N/A $7.69 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $231.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 4009135 General Lab RSV Immunoassay QST 87807 302 $330.00 $- $7.69 $- $- $264.00 $- N/A $85.80 N/A N/A $12.86 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $7.69 N/A N/A $224.40 N/A N/A $161.70 N/A N/A $128.70 N/A N/A $231.00 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $231.00 N/A N/A $110.55 N/A N/A $7.69 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $231.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 4009168 General Lab Rotavirus Ag Detection QLS 87425 306 $175.00 $- $7.69 $- $- $140.00 $- N/A $45.50 N/A N/A $12.86 N/A N/A $105.00 N/A N/A $87.50 N/A N/A $7.69 N/A N/A $119.00 N/A N/A $85.75 N/A N/A $68.25 N/A N/A $122.50 N/A N/A $140.00 N/A N/A $96.25 N/A N/A $122.50 N/A N/A $58.63 N/A N/A $7.69 N/A N/A $105.00 N/A N/A $61.25 N/A N/A $113.75 N/A N/A $52.50 N/A N/A $105.00 N/A N/A $122.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A N/A $52.50 N/A $175.00 $175.00 N/A 4009184 General Lab Sickle Cell Screen QLS 85660 305 $107.00 $- $3.55 $- $- $85.60 $- N/A $27.82 N/A N/A $5.92 N/A N/A $64.20 N/A N/A $53.50 N/A N/A $3.55 N/A N/A $72.76 N/A N/A $52.43 N/A N/A $41.73 N/A N/A $74.90 N/A N/A $85.60 N/A N/A $58.85 N/A N/A $74.90 N/A N/A $35.85 N/A N/A $3.55 N/A N/A $64.20 N/A N/A $37.45 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $64.20 N/A N/A $74.90 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A $107.00 $107.00 N/A 4009259 General Lab Thyroglobulin Quant QST 84432 301 $453.00 $- $10.31 $- $- $362.40 $- N/A $117.78 N/A N/A $17.22 N/A N/A $271.80 N/A N/A $226.50 N/A N/A $10.31 N/A N/A $308.04 N/A N/A $221.97 N/A N/A $176.67 N/A N/A $317.10 N/A N/A $362.40 N/A N/A $249.15 N/A N/A $317.10 N/A N/A $151.76 N/A N/A $10.31 N/A N/A $271.80 N/A N/A $158.55 N/A N/A $294.45 N/A N/A $135.90 N/A N/A $271.80 N/A N/A $317.10 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A $453.00 $453.00 N/A 4009259 General Lab Thyroglobulin QLS 84432 301 $453.00 $- $10.31 $- $- $362.40 $- N/A $117.78 N/A N/A $17.22 N/A N/A $271.80 N/A N/A $226.50 N/A N/A $10.31 N/A N/A $308.04 N/A N/A $221.97 N/A N/A $176.67 N/A N/A $317.10 N/A N/A $362.40 N/A N/A $249.15 N/A N/A $317.10 N/A N/A $151.76 N/A N/A $10.31 N/A N/A $271.80 N/A N/A $158.55 N/A N/A $294.45 N/A N/A $135.90 N/A N/A $271.80 N/A N/A $317.10 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A $453.00 $453.00 N/A 4009301 General Lab Osmolality Urine QST 83935 301 $203.00 $- $4.38 $- $- $162.40 $- N/A $52.78 N/A N/A $7.31 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $4.38 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $4.38 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4009301 General Lab "Osmolality, Urine Random QLS" 83935 301 $203.00 $- $4.38 $- $- $162.40 $- N/A $52.78 N/A N/A $7.31 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $4.38 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $4.38 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4009308 General Lab Osmolality QST 83930 301 $123.00 $- $4.24 $- $- $98.40 $- N/A $31.98 N/A N/A $7.09 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.24 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.24 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4009308 General Lab "Osmolality, Serum QLS" 83930 301 $123.00 $- $4.24 $- $- $98.40 $- N/A $31.98 N/A N/A $7.09 N/A N/A $73.80 N/A N/A $61.50 N/A N/A $4.24 N/A N/A $83.64 N/A N/A $60.27 N/A N/A $47.97 N/A N/A $86.10 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $86.10 N/A N/A $41.21 N/A N/A $4.24 N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $86.10 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 4009358 General Lab Vancomycin Random 84630 301 $350.00 $- $7.31 $- $- $280.00 $- N/A $91.00 N/A N/A $12.20 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $7.31 N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A $7.31 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4009370 General Lab HLA-B27 Ag QST 86812 302 $470.00 $- $16.56 $- $- $376.00 $- N/A $122.20 N/A N/A $27.67 N/A N/A $282.00 N/A N/A $235.00 N/A N/A $16.56 N/A N/A $319.60 N/A N/A $230.30 N/A N/A $183.30 N/A N/A $329.00 N/A N/A $376.00 N/A N/A $258.50 N/A N/A $329.00 N/A N/A $157.45 N/A N/A $16.56 N/A N/A $282.00 N/A N/A $164.50 N/A N/A $305.50 N/A N/A $141.00 N/A N/A $282.00 N/A N/A $329.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A $470.00 $470.00 N/A 4009370 General Lab HLA-B27 Antigen QLS 86812 302 $470.00 $- $16.56 $- $- $376.00 $- N/A $122.20 N/A N/A $27.67 N/A N/A $282.00 N/A N/A $235.00 N/A N/A $16.56 N/A N/A $319.60 N/A N/A $230.30 N/A N/A $183.30 N/A N/A $329.00 N/A N/A $376.00 N/A N/A $258.50 N/A N/A $329.00 N/A N/A $157.45 N/A N/A $16.56 N/A N/A $282.00 N/A N/A $164.50 N/A N/A $305.50 N/A N/A $141.00 N/A N/A $282.00 N/A N/A $329.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A N/A $141.00 N/A $470.00 $470.00 N/A 4009416 General Lab Gastrin QLS 82941 301 $324.00 $- $11.31 $- $- $259.20 $- N/A $84.24 N/A N/A $18.91 N/A N/A $194.40 N/A N/A $162.00 N/A N/A $11.31 N/A N/A $220.32 N/A N/A $158.76 N/A N/A $126.36 N/A N/A $226.80 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $226.80 N/A N/A $108.54 N/A N/A $11.31 N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $226.80 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 4009420 General Lab Clozapine (Clozaril) QST 80159 301 $320.00 $- $11.87 $- $- $256.00 $- N/A $83.20 N/A N/A $19.68 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $11.87 N/A N/A $217.60 N/A N/A $156.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $11.87 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4009420 General Lab Clozapine QLS 80159 301 $320.00 $- $11.87 $- $- $256.00 $- N/A $83.20 N/A N/A $19.68 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $11.87 N/A N/A $217.60 N/A N/A $156.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $11.87 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4009471 General Lab CSF Glucose 82947 301 $78.00 $- $2.52 $- $- $62.40 $- N/A $20.28 N/A N/A $4.20 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.52 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.52 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4009473 General Lab .Gestational GTT 1-Hr 82947 301 $78.00 $- $2.52 $- $- $62.40 $- N/A $20.28 N/A N/A $4.20 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.52 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.52 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4009473 General Lab .Gestational GTT 1-Hr 82947 301 $78.00 $- $2.52 $- $- $62.40 $- N/A $20.28 N/A N/A $4.20 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.52 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.52 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4009473 General Lab Glucose Level 82947 301 $78.00 $- $2.52 $- $- $62.40 $- N/A $20.28 N/A N/A $4.20 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.52 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.52 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4009500 General Lab MRSA Culture Screen QST 87081 306 $608.00 $- $4.26 $- $- $486.40 $- N/A $158.08 N/A N/A $7.12 N/A N/A $364.80 N/A N/A $304.00 N/A N/A $4.26 N/A N/A $413.44 N/A N/A $297.92 N/A N/A $237.12 N/A N/A $425.60 N/A N/A $486.40 N/A N/A $334.40 N/A N/A $425.60 N/A N/A $203.68 N/A N/A $4.26 N/A N/A $364.80 N/A N/A $212.80 N/A N/A $395.20 N/A N/A $182.40 N/A N/A $364.80 N/A N/A $425.60 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A $608.00 $608.00 N/A 4009500 General Lab MRSA Screen QLS 87081 306 $608.00 $- $4.26 $- $- $486.40 $- N/A $158.08 N/A N/A $7.12 N/A N/A $364.80 N/A N/A $304.00 N/A N/A $4.26 N/A N/A $413.44 N/A N/A $297.92 N/A N/A $237.12 N/A N/A $425.60 N/A N/A $486.40 N/A N/A $334.40 N/A N/A $425.60 N/A N/A $203.68 N/A N/A $4.26 N/A N/A $364.80 N/A N/A $212.80 N/A N/A $395.20 N/A N/A $182.40 N/A N/A $364.80 N/A N/A $425.60 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A N/A $182.40 N/A $608.00 $608.00 N/A 4009507 General Lab GTT 3-Hr 82951 301 $246.00 $- $6.69 $- $- $196.80 $- N/A $63.96 N/A N/A $11.17 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $6.69 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $6.69 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4009515 General Lab GTT 4-Hr 82952 301 $205.00 $- $2.52 $- $- $164.00 $- N/A $53.30 N/A N/A $4.20 N/A N/A $123.00 N/A N/A $102.50 N/A N/A $2.52 N/A N/A $139.40 N/A N/A $100.45 N/A N/A $79.95 N/A N/A $143.50 N/A N/A $164.00 N/A N/A $112.75 N/A N/A $143.50 N/A N/A $68.68 N/A N/A $2.52 N/A N/A $123.00 N/A N/A $71.75 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $123.00 N/A N/A $143.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A $205.00 $205.00 N/A 4009770 General Lab GGTP (f) QLS 82977 301 $142.00 $- $4.62 $- $- $113.60 $- N/A $36.92 N/A N/A $7.73 N/A N/A $85.20 N/A N/A $71.00 N/A N/A $4.62 N/A N/A $96.56 N/A N/A $69.58 N/A N/A $55.38 N/A N/A $99.40 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $99.40 N/A N/A $47.57 N/A N/A $4.62 N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $99.40 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 4009770 General Lab Gamma Glutamyl Transferase (GGT) QST 82977 301 $142.00 $- $4.62 $- $- $113.60 $- N/A $36.92 N/A N/A $7.73 N/A N/A $85.20 N/A N/A $71.00 N/A N/A $4.62 N/A N/A $96.56 N/A N/A $69.58 N/A N/A $55.38 N/A N/A $99.40 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $99.40 N/A N/A $47.57 N/A N/A $4.62 N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $99.40 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 4009851 General Lab Fructosamine QLS 82985 301 $273.00 $- $9.67 $- $- $218.40 $- N/A $70.98 N/A N/A $16.16 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $9.67 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $9.67 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4009851 General Lab Fructosamine QST 82985 301 $273.00 $- $9.67 $- $- $218.40 $- N/A $70.98 N/A N/A $16.16 N/A N/A $163.80 N/A N/A $136.50 N/A N/A $9.67 N/A N/A $185.64 N/A N/A $133.77 N/A N/A $106.47 N/A N/A $191.10 N/A N/A $218.40 N/A N/A $150.15 N/A N/A $191.10 N/A N/A $91.46 N/A N/A $9.67 N/A N/A $163.80 N/A N/A $95.55 N/A N/A $177.45 N/A N/A $81.90 N/A N/A $163.80 N/A N/A $191.10 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A N/A $81.90 N/A $273.00 $273.00 N/A 4009899 General Lab ADmark ApoE Genotype QLS 81401 300 $764.00 $- $78.00 $- $- $611.20 $- N/A $198.64 N/A N/A $78.00 N/A N/A $458.40 N/A N/A $382.00 N/A N/A N/A N/A N/A $519.52 N/A N/A $374.36 N/A N/A $297.96 N/A N/A $534.80 N/A N/A $611.20 N/A N/A $420.20 N/A N/A $534.80 N/A N/A $255.94 N/A N/A N/A N/A N/A $458.40 N/A N/A $267.40 N/A N/A $496.60 N/A N/A $229.20 N/A N/A $458.40 N/A N/A $534.80 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A N/A $229.20 N/A $764.00 $764.00 N/A 4009980 General Lab "PTH, Intact and Calcium QLS" 83970 301 $658.00 $- $171.08 $- $- $526.40 $- N/A $171.08 N/A N/A N/A N/A N/A $394.80 N/A N/A $329.00 N/A N/A N/A N/A N/A $447.44 N/A N/A $322.42 N/A N/A $256.62 N/A N/A $460.60 N/A N/A $526.40 N/A N/A $361.90 N/A N/A $460.60 N/A N/A $220.43 N/A N/A N/A N/A N/A $394.80 N/A N/A $230.30 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $394.80 N/A N/A $460.60 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A $658.00 $658.00 N/A 4009980 General Lab "PTH, Intact and Calcium QLS" 82310 301 $658.00 $- $3.31 $- $- $526.40 $- N/A $171.08 N/A N/A $5.53 N/A N/A $394.80 N/A N/A $329.00 N/A N/A $3.31 N/A N/A $447.44 N/A N/A $322.42 N/A N/A $256.62 N/A N/A $460.60 N/A N/A $526.40 N/A N/A $361.90 N/A N/A $460.60 N/A N/A $220.43 N/A N/A $3.31 N/A N/A $394.80 N/A N/A $230.30 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $394.80 N/A N/A $460.60 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A $658.00 $658.00 N/A 4009980 General Lab Parathyroid Hormone (PTH) QST 83970 301 $658.00 $- $26.48 $- $- $526.40 $- N/A $171.08 N/A N/A $44.26 N/A N/A $394.80 N/A N/A $329.00 N/A N/A $26.48 N/A N/A $447.44 N/A N/A $322.42 N/A N/A $256.62 N/A N/A $460.60 N/A N/A $526.40 N/A N/A $361.90 N/A N/A $460.60 N/A N/A $220.43 N/A N/A $26.48 N/A N/A $394.80 N/A N/A $230.30 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $394.80 N/A N/A $460.60 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A $658.00 $658.00 N/A 4009987 General Lab Vitamin B12 Binding Capacity (Unsaturated) QLS 82608 301 $264.00 $- $9.19 $- $- $211.20 $- N/A $68.64 N/A N/A $15.35 N/A N/A $158.40 N/A N/A $132.00 N/A N/A $9.19 N/A N/A $179.52 N/A N/A $129.36 N/A N/A $102.96 N/A N/A $184.80 N/A N/A $211.20 N/A N/A $145.20 N/A N/A $184.80 N/A N/A $88.44 N/A N/A $9.19 N/A N/A $158.40 N/A N/A $92.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $158.40 N/A N/A $184.80 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A $264.00 $264.00 N/A 4009992 General Lab Ganglioside Asialo-GM-1 Antibody(IgM) QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4009992 General Lab "MAG Ab (IgM), EIA QST" 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4009992 General Lab Myelin-Associated GlycoProtein (MaG) ab (IgM) QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4009994 General Lab Troponin I QLS 84484 301 $435.00 $- $6.31 $- $- $348.00 $- N/A $113.10 N/A N/A $10.55 N/A N/A $261.00 N/A N/A $217.50 N/A N/A $6.31 N/A N/A $295.80 N/A N/A $213.15 N/A N/A $169.65 N/A N/A $304.50 N/A N/A $348.00 N/A N/A $239.25 N/A N/A $304.50 N/A N/A $145.73 N/A N/A $6.31 N/A N/A $261.00 N/A N/A $152.25 N/A N/A $282.75 N/A N/A $130.50 N/A N/A $261.00 N/A N/A $304.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A $435.00 $435.00 N/A 4009995 General Lab Influenza A B RNA RT-PCR w/rflx to Influenza A H1N1 Real T 87502 306 $463.00 $- $120.38 $- $- $370.40 $- N/A $120.38 N/A N/A N/A N/A N/A $277.80 N/A N/A $231.50 N/A N/A N/A N/A N/A $314.84 N/A N/A $226.87 N/A N/A $180.57 N/A N/A $324.10 N/A N/A $370.40 N/A N/A $254.65 N/A N/A $324.10 N/A N/A $155.11 N/A N/A N/A N/A N/A $277.80 N/A N/A $162.05 N/A N/A $300.95 N/A N/A $138.90 N/A N/A $277.80 N/A N/A $324.10 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A $463.00 $463.00 N/A 4009995 General Lab "Testosterone, Free and Total QST" 84403 301 $463.00 $- $16.56 $- $- $370.40 $- N/A $120.38 N/A N/A $27.68 N/A N/A $277.80 N/A N/A $231.50 N/A N/A $16.56 N/A N/A $314.84 N/A N/A $226.87 N/A N/A $180.57 N/A N/A $324.10 N/A N/A $370.40 N/A N/A $254.65 N/A N/A $324.10 N/A N/A $155.11 N/A N/A $16.56 N/A N/A $277.80 N/A N/A $162.05 N/A N/A $300.95 N/A N/A $138.90 N/A N/A $277.80 N/A N/A $324.10 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A $463.00 $463.00 N/A 4009996 General Lab "Parainfluenza Virus (Types 1-4) RNA, Qual QLS" 87502 306 $260.00 $- $54.57 $- $- $208.00 $- N/A $67.60 N/A N/A $91.22 N/A N/A $156.00 N/A N/A $130.00 N/A N/A $54.57 N/A N/A $176.80 N/A N/A $127.40 N/A N/A $101.40 N/A N/A $182.00 N/A N/A $208.00 N/A N/A $143.00 N/A N/A $182.00 N/A N/A $87.10 N/A N/A $54.57 N/A N/A $156.00 N/A N/A $91.00 N/A N/A $169.00 N/A N/A $78.00 N/A N/A $156.00 N/A N/A $182.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A N/A $78.00 N/A $260.00 $260.00 N/A 4009997 General Lab QNatal Advanced QLS 81420 300 "$5,616.00 " $- $600.00 $- $- "$4,492.80 " $- N/A "$1,460.16 " N/A N/A $600.00 N/A N/A "$3,369.60 " N/A N/A "$2,808.00 " N/A N/A N/A N/A N/A "$3,818.88 " N/A N/A "$2,751.84 " N/A N/A "$2,190.24 " N/A N/A "$3,931.20 " N/A N/A "$4,492.80 " N/A N/A "$3,088.80 " N/A N/A "$3,931.20 " N/A N/A "$1,881.36 " N/A N/A N/A N/A N/A "$3,369.60 " N/A N/A "$1,965.60 " N/A N/A "$3,650.40 " N/A N/A "$1,684.80 " N/A N/A "$3,369.60 " N/A N/A "$3,931.20 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A "$5,616.00 " "$5,616.00 " N/A 4009997 General Lab Qnatal(TM) Advanced QST 81420 300 "$5,616.00 " $- $600.00 $- $- "$4,492.80 " $- N/A "$1,460.16 " N/A N/A $600.00 N/A N/A "$3,369.60 " N/A N/A "$2,808.00 " N/A N/A N/A N/A N/A "$3,818.88 " N/A N/A "$2,751.84 " N/A N/A "$2,190.24 " N/A N/A "$3,931.20 " N/A N/A "$4,492.80 " N/A N/A "$3,088.80 " N/A N/A "$3,931.20 " N/A N/A "$1,881.36 " N/A N/A N/A N/A N/A "$3,369.60 " N/A N/A "$1,965.60 " N/A N/A "$3,650.40 " N/A N/A "$1,684.80 " N/A N/A "$3,369.60 " N/A N/A "$3,931.20 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A N/A "$1,684.80 " N/A "$5,616.00 " "$5,616.00 " N/A 4009998 General Lab Influenza A H1N1 (2009) Oseltamivir Resistance QLS 87999 306 $150.00 $- $39.00 $- $- $120.00 $- N/A $39.00 N/A N/A N/A N/A N/A $90.00 N/A N/A $75.00 N/A N/A N/A N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A N/A N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4009999 General Lab Herpes Simplex Virus Culture QLS 86696 302 $502.00 $- $12.41 $- $- $401.60 $- N/A $130.52 N/A N/A $20.75 N/A N/A $301.20 N/A N/A $251.00 N/A N/A $12.41 N/A N/A $341.36 N/A N/A $245.98 N/A N/A $195.78 N/A N/A $351.40 N/A N/A $401.60 N/A N/A $276.10 N/A N/A $351.40 N/A N/A $168.17 N/A N/A $12.41 N/A N/A $301.20 N/A N/A $175.70 N/A N/A $326.30 N/A N/A $150.60 N/A N/A $301.20 N/A N/A $351.40 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A N/A $150.60 N/A $502.00 $502.00 N/A 4010001 General Lab "Uric Acid, Random Urine w/Creatinine QLS" 82570 301 $78.00 $- $3.32 $- $- $62.40 $- N/A $20.28 N/A N/A $5.54 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $3.32 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $3.32 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4010001 General Lab "Uric Acid, Urine w/ Creat QST" 82570 301 $78.00 $- $3.32 $- $- $62.40 $- N/A $20.28 N/A N/A $5.54 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $3.32 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $3.32 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4010003 General Lab Western Blot Test 84181 300 $130.00 $- $10.93 $- $- $104.00 $- N/A $33.80 N/A N/A $18.26 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $10.93 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $10.93 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4010003 General Lab Sensory-Motor Complete Ab Panel QST 84181 300 $130.00 $- $10.93 $- $- $104.00 $- N/A $33.80 N/A N/A $18.26 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $10.93 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $10.93 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4010004 General Lab Immunofixation Urine QST 86335 302 $218.00 $- $18.82 $- $- $174.40 $- N/A $56.68 N/A N/A $31.46 N/A N/A $130.80 N/A N/A $109.00 N/A N/A $18.82 N/A N/A $148.24 N/A N/A $106.82 N/A N/A $85.02 N/A N/A $152.60 N/A N/A $174.40 N/A N/A $119.90 N/A N/A $152.60 N/A N/A $73.03 N/A N/A $18.82 N/A N/A $130.80 N/A N/A $76.30 N/A N/A $141.70 N/A N/A $65.40 N/A N/A $130.80 N/A N/A $152.60 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A $218.00 $218.00 N/A 4010004 General Lab "Immunofixation (IFE), Urine QLS" 86335 302 $218.00 $- $18.82 $- $- $174.40 $- N/A $56.68 N/A N/A $31.46 N/A N/A $130.80 N/A N/A $109.00 N/A N/A $18.82 N/A N/A $148.24 N/A N/A $106.82 N/A N/A $85.02 N/A N/A $152.60 N/A N/A $174.40 N/A N/A $119.90 N/A N/A $152.60 N/A N/A $73.03 N/A N/A $18.82 N/A N/A $130.80 N/A N/A $76.30 N/A N/A $141.70 N/A N/A $65.40 N/A N/A $130.80 N/A N/A $152.60 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A $218.00 $218.00 N/A 4010005 General Lab VGCC Ab QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010005 General Lab Voltage Gated Calcium Channel Antibody Assay QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010006 General Lab Bill Only Molecular Red Cell Phenotype (HEA) 81403 300 $723.00 $- $120.00 $- $- $578.40 $- N/A $187.98 N/A N/A $120.00 N/A N/A $433.80 N/A N/A $361.50 N/A N/A N/A N/A N/A $491.64 N/A N/A $354.27 N/A N/A $281.97 N/A N/A $506.10 N/A N/A $578.40 N/A N/A $397.65 N/A N/A $506.10 N/A N/A $242.21 N/A N/A N/A N/A N/A $433.80 N/A N/A $253.05 N/A N/A $469.95 N/A N/A $216.90 N/A N/A $433.80 N/A N/A $506.10 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A N/A $216.90 N/A $723.00 $723.00 N/A 4010007 General Lab "Cholesterol, Pleural Fluid QLS" 84311 301 $126.00 $- $4.49 $- $- $100.80 $- N/A $32.76 N/A N/A $7.50 N/A N/A $75.60 N/A N/A $63.00 N/A N/A $4.49 N/A N/A $85.68 N/A N/A $61.74 N/A N/A $49.14 N/A N/A $88.20 N/A N/A $100.80 N/A N/A $69.30 N/A N/A $88.20 N/A N/A $42.21 N/A N/A $4.49 N/A N/A $75.60 N/A N/A $44.10 N/A N/A $81.90 N/A N/A $37.80 N/A N/A $75.60 N/A N/A $88.20 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A $126.00 $126.00 N/A 4010007 General Lab "Cholesterol, Pleural Fld QST" 84311 301 $126.00 $- $4.49 $- $- $100.80 $- N/A $32.76 N/A N/A $7.50 N/A N/A $75.60 N/A N/A $63.00 N/A N/A $4.49 N/A N/A $85.68 N/A N/A $61.74 N/A N/A $49.14 N/A N/A $88.20 N/A N/A $100.80 N/A N/A $69.30 N/A N/A $88.20 N/A N/A $42.21 N/A N/A $4.49 N/A N/A $75.60 N/A N/A $44.10 N/A N/A $81.90 N/A N/A $37.80 N/A N/A $75.60 N/A N/A $88.20 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A N/A $37.80 N/A $126.00 $126.00 N/A 4010008 General Lab "Amylase, Pleural Fluid QLS" 82150 301 $139.00 $- $4.16 $- $- $111.20 $- N/A $36.14 N/A N/A $6.95 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $4.16 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $4.16 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4010008 General Lab "Amylase, Pleural Fluid QST" 82150 301 $139.00 $- $4.16 $- $- $111.20 $- N/A $36.14 N/A N/A $6.95 N/A N/A $83.40 N/A N/A $69.50 N/A N/A $4.16 N/A N/A $94.52 N/A N/A $68.11 N/A N/A $54.21 N/A N/A $97.30 N/A N/A $111.20 N/A N/A $76.45 N/A N/A $97.30 N/A N/A $46.57 N/A N/A $4.16 N/A N/A $83.40 N/A N/A $48.65 N/A N/A $90.35 N/A N/A $41.70 N/A N/A $83.40 N/A N/A $97.30 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A N/A $41.70 N/A $139.00 $139.00 N/A 4010009 General Lab "LD, Pleural Fluid QST" 83615 301 $92.00 $- $3.88 $- $- $73.60 $- N/A $23.92 N/A N/A $6.48 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.88 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.88 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4010009 General Lab "LDH, Pleural Fluid QLS" 83615 301 $92.00 $- $3.88 $- $- $73.60 $- N/A $23.92 N/A N/A $6.48 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $3.88 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $3.88 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4010010 General Lab 88342 310 $311.00 $- $52.52 $- $- $248.80 $- N/A $80.86 N/A N/A $94.06 N/A N/A $186.60 N/A N/A $155.50 N/A N/A $52.52 N/A N/A $211.48 N/A N/A $152.39 N/A N/A $121.29 N/A N/A $217.70 N/A N/A $248.80 N/A N/A $171.05 N/A N/A $217.70 N/A N/A $104.19 N/A N/A $52.52 N/A N/A $186.60 N/A N/A $108.85 N/A N/A $202.15 N/A N/A $93.30 N/A N/A $186.60 N/A N/A $217.70 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A N/A $93.30 N/A $311.00 $311.00 N/A 4010012 General Lab "CARDIOLIPIN ANTIBODIES (IGG, IGM) QST" 86147 302 $- $- $- $- $- $27.28 $- N/A $- N/A N/A $27.28 N/A N/A $- N/A N/A $- N/A N/A $16.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $16.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4010012 General Lab "Cardiolipin Antibodies (IgG, IgM) QLS" 86147 302 $- $- $- $- $- $27.28 $- N/A $- N/A N/A $27.28 N/A N/A $- N/A N/A $- N/A N/A $16.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $16.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4010013 General Lab CBC (Includes Diff/Plt) QST 85025 305 $238.00 $- $5.00 $- $- $190.40 $- N/A $61.88 N/A N/A $8.34 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $5.00 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $5.00 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4010013 General Lab CBC (Includes Diff/Platelets) QLS 85025 305 $238.00 $- $5.00 $- $- $190.40 $- N/A $61.88 N/A N/A $8.34 N/A N/A $142.80 N/A N/A $119.00 N/A N/A $5.00 N/A N/A $161.84 N/A N/A $116.62 N/A N/A $92.82 N/A N/A $166.60 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $166.60 N/A N/A $79.73 N/A N/A $5.00 N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $166.60 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 4010014 General Lab Comprehensive Metabolic Panel QLS 80053 301 $790.00 $- $6.78 $- $- $632.00 $- N/A $205.40 N/A N/A $11.33 N/A N/A $474.00 N/A N/A $395.00 N/A N/A $6.78 N/A N/A $537.20 N/A N/A $387.10 N/A N/A $308.10 N/A N/A $553.00 N/A N/A $632.00 N/A N/A $434.50 N/A N/A $553.00 N/A N/A $264.65 N/A N/A $6.78 N/A N/A $474.00 N/A N/A $276.50 N/A N/A $513.50 N/A N/A $237.00 N/A N/A $474.00 N/A N/A $553.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A $790.00 $790.00 N/A 4010014 General Lab Comprehensive Metabolic Panel QST 80053 301 $790.00 $- $6.78 $- $- $632.00 $- N/A $205.40 N/A N/A $11.33 N/A N/A $474.00 N/A N/A $395.00 N/A N/A $6.78 N/A N/A $537.20 N/A N/A $387.10 N/A N/A $308.10 N/A N/A $553.00 N/A N/A $632.00 N/A N/A $434.50 N/A N/A $553.00 N/A N/A $264.65 N/A N/A $6.78 N/A N/A $474.00 N/A N/A $276.50 N/A N/A $513.50 N/A N/A $237.00 N/A N/A $474.00 N/A N/A $553.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A N/A $237.00 N/A $790.00 $790.00 N/A 4010017 General Lab Asialo-GM-1 Ab (IgG) QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010018 General Lab "Asialo GM1 Antibodies, Elisa serum QLS" 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010018 General Lab Asialo-GM-1 Ab (IgM) QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010018 General Lab Bullous Pemphigoid BP230 Antibody QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010018 General Lab Bullous Pemphigoid BP180 Antibody QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010020 General Lab "Estrogens, Fractionated QLS" 82671 301 $193.00 $- $20.72 $- $- $154.40 $- N/A $50.18 N/A N/A $34.63 N/A N/A $115.80 N/A N/A $96.50 N/A N/A $20.72 N/A N/A $131.24 N/A N/A $94.57 N/A N/A $75.27 N/A N/A $135.10 N/A N/A $154.40 N/A N/A $106.15 N/A N/A $135.10 N/A N/A $64.66 N/A N/A $20.72 N/A N/A $115.80 N/A N/A $67.55 N/A N/A $125.45 N/A N/A $57.90 N/A N/A $115.80 N/A N/A $135.10 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A $193.00 $193.00 N/A 4010022 General Lab Allergy-Shellfish Panel QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Bermuda Grass (G2) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Clam (F207) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Coconut (f36) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Cottonwood (T14) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab False Ragweed (w4) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab False Ragweed (w4) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Food Allergy Profile QLS 82785 302 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $17.66 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $10.57 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $10.57 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Johnson Grass (g10) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Maize/Corn (F8) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Mesquite Tree (t20) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Mugwort (w6) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Oak (T7) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Olive Tree (t9) IgE 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Perennial Rye Grass (g5) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Rough Pigweed (W14) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Sesame Seed (f10) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Sycamore (T11) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Timothy Grass (G6) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Tree Nut Allergy Panel QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Western Ragweed (w2) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab White Mulberry (t70) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010022 General Lab Food Allergy Profile QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010023 General Lab "Glucose, Synovial Fluid QLS" 82945 302 $230.00 $- $2.52 $- $- $184.00 $- N/A $59.80 N/A N/A $4.20 N/A N/A $138.00 N/A N/A $115.00 N/A N/A $2.52 N/A N/A $156.40 N/A N/A $112.70 N/A N/A $89.70 N/A N/A $161.00 N/A N/A $184.00 N/A N/A $126.50 N/A N/A $161.00 N/A N/A $77.05 N/A N/A $2.52 N/A N/A $138.00 N/A N/A $80.50 N/A N/A $149.50 N/A N/A $69.00 N/A N/A $138.00 N/A N/A $161.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A $230.00 $230.00 N/A 4010023 General Lab "Glucose, Synovial Fluid QST" 82945 302 $230.00 $- $2.52 $- $- $184.00 $- N/A $59.80 N/A N/A $4.20 N/A N/A $138.00 N/A N/A $115.00 N/A N/A $2.52 N/A N/A $156.40 N/A N/A $112.70 N/A N/A $89.70 N/A N/A $161.00 N/A N/A $184.00 N/A N/A $126.50 N/A N/A $161.00 N/A N/A $77.05 N/A N/A $2.52 N/A N/A $138.00 N/A N/A $80.50 N/A N/A $149.50 N/A N/A $69.00 N/A N/A $138.00 N/A N/A $161.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A N/A $69.00 N/A $230.00 $230.00 N/A 4010024 General Lab Hemoglobin and Hematocrit QLS 85014 305 $87.00 $- $1.53 $- $- $69.60 $- N/A $22.62 N/A N/A $2.54 N/A N/A $52.20 N/A N/A $43.50 N/A N/A $1.53 N/A N/A $59.16 N/A N/A $42.63 N/A N/A $33.93 N/A N/A $60.90 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $60.90 N/A N/A $29.15 N/A N/A $1.53 N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $60.90 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 4010024 General Lab Hemoglobin and Hematocrit QLS 85018 305 $87.00 $- $1.53 $- $- $69.60 $- N/A $22.62 N/A N/A $2.54 N/A N/A $52.20 N/A N/A $43.50 N/A N/A $1.53 N/A N/A $59.16 N/A N/A $42.63 N/A N/A $33.93 N/A N/A $60.90 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $60.90 N/A N/A $29.15 N/A N/A $1.53 N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $60.90 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 4010025 General Lab "Herpes Simplex Virus, Type 1,2 DNA, Quant QLS" 87530 302 $606.00 $- $27.47 $- $- $484.80 $- N/A $157.56 N/A N/A $45.92 N/A N/A $363.60 N/A N/A $303.00 N/A N/A $27.47 N/A N/A $412.08 N/A N/A $296.94 N/A N/A $236.34 N/A N/A $424.20 N/A N/A $484.80 N/A N/A $333.30 N/A N/A $424.20 N/A N/A $203.01 N/A N/A $27.47 N/A N/A $363.60 N/A N/A $212.10 N/A N/A $393.90 N/A N/A $181.80 N/A N/A $363.60 N/A N/A $424.20 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A $606.00 $606.00 N/A 4010027 General Lab HSV/VZV Rapid Culture QST 87254 302 $313.00 $- $12.54 $- $- $250.40 $- N/A $81.38 N/A N/A $20.96 N/A N/A $187.80 N/A N/A $156.50 N/A N/A $12.54 N/A N/A $212.84 N/A N/A $153.37 N/A N/A $122.07 N/A N/A $219.10 N/A N/A $250.40 N/A N/A $172.15 N/A N/A $219.10 N/A N/A $104.86 N/A N/A $12.54 N/A N/A $187.80 N/A N/A $109.55 N/A N/A $203.45 N/A N/A $93.90 N/A N/A $187.80 N/A N/A $219.10 N/A N/A $93.90 N/A N/A $93.90 N/A N/A $93.90 N/A N/A $93.90 N/A N/A $93.90 N/A N/A $93.90 N/A $313.00 $313.00 N/A 4010028 General Lab FSH QLS 83001 301 $290.00 $- $11.92 $- $- $232.00 $- N/A $75.40 N/A N/A $19.92 N/A N/A $174.00 N/A N/A $145.00 N/A N/A $11.92 N/A N/A $197.20 N/A N/A $142.10 N/A N/A $113.10 N/A N/A $203.00 N/A N/A $232.00 N/A N/A $159.50 N/A N/A $203.00 N/A N/A $97.15 N/A N/A $11.92 N/A N/A $174.00 N/A N/A $101.50 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $174.00 N/A N/A $203.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A $290.00 $290.00 N/A 4010028 General Lab FSH and LH QST 83001 301 $290.00 $- $11.92 $- $- $232.00 $- N/A $75.40 N/A N/A $19.92 N/A N/A $174.00 N/A N/A $145.00 N/A N/A $11.92 N/A N/A $197.20 N/A N/A $142.10 N/A N/A $113.10 N/A N/A $203.00 N/A N/A $232.00 N/A N/A $159.50 N/A N/A $203.00 N/A N/A $97.15 N/A N/A $11.92 N/A N/A $174.00 N/A N/A $101.50 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $174.00 N/A N/A $203.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A $290.00 $290.00 N/A 4010028 General Lab LH QLS 83002 301 $290.00 $- $11.88 $- $- $232.00 $- N/A $75.40 N/A N/A $19.86 N/A N/A $174.00 N/A N/A $145.00 N/A N/A $11.88 N/A N/A $197.20 N/A N/A $142.10 N/A N/A $113.10 N/A N/A $203.00 N/A N/A $232.00 N/A N/A $159.50 N/A N/A $203.00 N/A N/A $97.15 N/A N/A $11.88 N/A N/A $174.00 N/A N/A $101.50 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $174.00 N/A N/A $203.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A $290.00 $290.00 N/A 4010030 General Lab Mycobacteria Culture w/ Fluorochrome Smear QLS 87116 301 $- $- $- $- $- $11.58 $- N/A $- N/A N/A $11.58 N/A N/A $- N/A N/A $- N/A N/A $6.93 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $6.93 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4010030 General Lab Mycobacteria Culture w/ Fluorochrome Smear QLS 87015 301 $- $- $- $- $- $7.16 $- N/A $- N/A N/A $7.16 N/A N/A $- N/A N/A $- N/A N/A $4.29 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $4.29 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4010030 General Lab Mycobacteria Culture w/ Fluorochrome Smear QLS 87206 301 $- $- $- $- $- $5.76 $- N/A $- N/A N/A $5.76 N/A N/A $- N/A N/A $- N/A N/A $3.45 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $3.45 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4010031 General Lab Pathology Examination of Blood Smear QLS 85060 305 $100.00 $- $11.88 $- $- $80.00 $- N/A $26.00 N/A N/A $19.38 N/A N/A $60.00 N/A N/A $50.00 N/A N/A $11.88 N/A N/A $68.00 N/A N/A $49.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A $11.88 N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4010032 General Lab "Herpes Simplex Virus Type 1 and 2 DNA, Rt PCR QLS" 87350 302 $623.00 $- $7.40 $- $- $498.40 $- N/A $161.98 N/A N/A $12.36 N/A N/A $373.80 N/A N/A $311.50 N/A N/A $7.40 N/A N/A $423.64 N/A N/A $305.27 N/A N/A $242.97 N/A N/A $436.10 N/A N/A $498.40 N/A N/A $342.65 N/A N/A $436.10 N/A N/A $208.71 N/A N/A $7.40 N/A N/A $373.80 N/A N/A $218.05 N/A N/A $404.95 N/A N/A $186.90 N/A N/A $373.80 N/A N/A $436.10 N/A N/A $186.90 N/A N/A $186.90 N/A N/A $186.90 N/A N/A $186.90 N/A N/A $186.90 N/A N/A $186.90 N/A $623.00 $623.00 N/A 4010034 General Lab "Profile 821 Ur Drugs-Extended w/Alcohol,w/Confirm QLS" 80101 301 $654.00 $- $170.04 $- $- $523.20 $- N/A $170.04 N/A N/A N/A N/A N/A $392.40 N/A N/A $327.00 N/A N/A N/A N/A N/A $444.72 N/A N/A $320.46 N/A N/A $255.06 N/A N/A $457.80 N/A N/A $523.20 N/A N/A $359.70 N/A N/A $457.80 N/A N/A $219.09 N/A N/A N/A N/A N/A $392.40 N/A N/A $228.90 N/A N/A $425.10 N/A N/A $196.20 N/A N/A $392.40 N/A N/A $457.80 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A $654.00 $654.00 N/A 4010034 General Lab "Profile 821 Ur Drugs-Extended w/Alcohol,w/Confirm QLS" 82570 301 $654.00 $- $3.32 $- $- $523.20 $- N/A $170.04 N/A N/A $5.54 N/A N/A $392.40 N/A N/A $327.00 N/A N/A $3.32 N/A N/A $444.72 N/A N/A $320.46 N/A N/A $255.06 N/A N/A $457.80 N/A N/A $523.20 N/A N/A $359.70 N/A N/A $457.80 N/A N/A $219.09 N/A N/A $3.32 N/A N/A $392.40 N/A N/A $228.90 N/A N/A $425.10 N/A N/A $196.20 N/A N/A $392.40 N/A N/A $457.80 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A N/A $196.20 N/A $654.00 $654.00 N/A 4010035 General Lab RPR w/Reflex Titer QST 86592 302 $153.00 $- $2.74 $- $- $122.40 $- N/A $39.78 N/A N/A $4.58 N/A N/A $91.80 N/A N/A $76.50 N/A N/A $2.74 N/A N/A $104.04 N/A N/A $74.97 N/A N/A $59.67 N/A N/A $107.10 N/A N/A $122.40 N/A N/A $84.15 N/A N/A $107.10 N/A N/A $51.26 N/A N/A $2.74 N/A N/A $91.80 N/A N/A $53.55 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $91.80 N/A N/A $107.10 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A $153.00 $153.00 N/A 4010035 General Lab RPR w/Reflex FTA Conf QLS 86592 302 $153.00 $- $2.74 $- $- $122.40 $- N/A $39.78 N/A N/A $4.58 N/A N/A $91.80 N/A N/A $76.50 N/A N/A $2.74 N/A N/A $104.04 N/A N/A $74.97 N/A N/A $59.67 N/A N/A $107.10 N/A N/A $122.40 N/A N/A $84.15 N/A N/A $107.10 N/A N/A $51.26 N/A N/A $2.74 N/A N/A $91.80 N/A N/A $53.55 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $91.80 N/A N/A $107.10 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A $153.00 $153.00 N/A 4010036 General Lab RPR Titer QLS 86593 302 $74.00 $- $2.82 $- $- $59.20 $- N/A $19.24 N/A N/A $4.72 N/A N/A $44.40 N/A N/A $37.00 N/A N/A $2.82 N/A N/A $50.32 N/A N/A $36.26 N/A N/A $28.86 N/A N/A $51.80 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $51.80 N/A N/A $24.79 N/A N/A $2.82 N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $51.80 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 4010036 General Lab RPR Titer QST 86593 302 $74.00 $- $2.82 $- $- $59.20 $- N/A $19.24 N/A N/A $4.72 N/A N/A $44.40 N/A N/A $37.00 N/A N/A $2.82 N/A N/A $50.32 N/A N/A $36.26 N/A N/A $28.86 N/A N/A $51.80 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $51.80 N/A N/A $24.79 N/A N/A $2.82 N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $51.80 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 4010037 General Lab RPR (Diagnosis) w/RFL Titer and Confirmation QLS 86592 302 $153.00 $- $2.74 $- $- $122.40 $- N/A $39.78 N/A N/A $4.58 N/A N/A $91.80 N/A N/A $76.50 N/A N/A $2.74 N/A N/A $104.04 N/A N/A $74.97 N/A N/A $59.67 N/A N/A $107.10 N/A N/A $122.40 N/A N/A $84.15 N/A N/A $107.10 N/A N/A $51.26 N/A N/A $2.74 N/A N/A $91.80 N/A N/A $53.55 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $91.80 N/A N/A $107.10 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A $153.00 $153.00 N/A 4010037 General Lab RPR w/ Reflex and Confirm QST 86592 302 $153.00 $- $2.74 $- $- $122.40 $- N/A $39.78 N/A N/A $4.58 N/A N/A $91.80 N/A N/A $76.50 N/A N/A $2.74 N/A N/A $104.04 N/A N/A $74.97 N/A N/A $59.67 N/A N/A $107.10 N/A N/A $122.40 N/A N/A $84.15 N/A N/A $107.10 N/A N/A $51.26 N/A N/A $2.74 N/A N/A $91.80 N/A N/A $53.55 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $91.80 N/A N/A $107.10 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A $153.00 $153.00 N/A 4010041 General Lab HIV 1/2 Ag/Ab QST 87389 302 $733.00 $- $15.45 $- $- $586.40 $- N/A $190.58 N/A N/A $25.82 N/A N/A $439.80 N/A N/A $366.50 N/A N/A $15.45 N/A N/A $498.44 N/A N/A $359.17 N/A N/A $285.87 N/A N/A $513.10 N/A N/A $586.40 N/A N/A $403.15 N/A N/A $513.10 N/A N/A $245.56 N/A N/A $15.45 N/A N/A $439.80 N/A N/A $256.55 N/A N/A $476.45 N/A N/A $219.90 N/A N/A $439.80 N/A N/A $513.10 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A $733.00 $733.00 N/A 4010041 General Lab HIV Ab Differentiation QST 87389 302 $733.00 $- $15.45 $- $- $586.40 $- N/A $190.58 N/A N/A $25.82 N/A N/A $439.80 N/A N/A $366.50 N/A N/A $15.45 N/A N/A $498.44 N/A N/A $359.17 N/A N/A $285.87 N/A N/A $513.10 N/A N/A $586.40 N/A N/A $403.15 N/A N/A $513.10 N/A N/A $245.56 N/A N/A $15.45 N/A N/A $439.80 N/A N/A $256.55 N/A N/A $476.45 N/A N/A $219.90 N/A N/A $439.80 N/A N/A $513.10 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A $733.00 $733.00 N/A 4010041 General Lab "HIV Antibodies, HIV 1/2, EIA w/Rlf QLS" 87389 302 $733.00 $- $15.45 $- $- $586.40 $- N/A $190.58 N/A N/A $25.82 N/A N/A $439.80 N/A N/A $366.50 N/A N/A $15.45 N/A N/A $498.44 N/A N/A $359.17 N/A N/A $285.87 N/A N/A $513.10 N/A N/A $586.40 N/A N/A $403.15 N/A N/A $513.10 N/A N/A $245.56 N/A N/A $15.45 N/A N/A $439.80 N/A N/A $256.55 N/A N/A $476.45 N/A N/A $219.90 N/A N/A $439.80 N/A N/A $513.10 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A N/A $219.90 N/A $733.00 $733.00 N/A 4010042 General Lab "Albumin, Peritoneal Fluid QLS" 82042 301 $80.00 $- $3.32 $- $- $64.00 $- N/A $20.80 N/A N/A $5.54 N/A N/A $48.00 N/A N/A $40.00 N/A N/A $3.32 N/A N/A $54.40 N/A N/A $39.20 N/A N/A $31.20 N/A N/A $56.00 N/A N/A $64.00 N/A N/A $44.00 N/A N/A $56.00 N/A N/A $26.80 N/A N/A $3.32 N/A N/A $48.00 N/A N/A $28.00 N/A N/A $52.00 N/A N/A $24.00 N/A N/A $48.00 N/A N/A $56.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A $80.00 $80.00 N/A 4010043 General Lab "Anti-HBS Ab, Quant QLS" 86317 302 $91.00 $- $9.62 $- $- $72.80 $- N/A $23.66 N/A N/A $16.08 N/A N/A $54.60 N/A N/A $45.50 N/A N/A $9.62 N/A N/A $61.88 N/A N/A $44.59 N/A N/A $35.49 N/A N/A $63.70 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $63.70 N/A N/A $30.49 N/A N/A $9.62 N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $63.70 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 4010044 General Lab Thyroid Cascading Reflex QLS 84443 301 $954.00 $- $10.79 $- $- $763.20 $- N/A $248.04 N/A N/A $18.02 N/A N/A $572.40 N/A N/A $477.00 N/A N/A $10.79 N/A N/A $648.72 N/A N/A $467.46 N/A N/A $372.06 N/A N/A $667.80 N/A N/A $763.20 N/A N/A $524.70 N/A N/A $667.80 N/A N/A $319.59 N/A N/A $10.79 N/A N/A $572.40 N/A N/A $333.90 N/A N/A $620.10 N/A N/A $286.20 N/A N/A $572.40 N/A N/A $667.80 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A $954.00 $954.00 N/A 4010044 General Lab Thyroid Cascading Relex QST 84443 301 $954.00 $- $10.79 $- $- $763.20 $- N/A $248.04 N/A N/A $18.02 N/A N/A $572.40 N/A N/A $477.00 N/A N/A $10.79 N/A N/A $648.72 N/A N/A $467.46 N/A N/A $372.06 N/A N/A $667.80 N/A N/A $763.20 N/A N/A $524.70 N/A N/A $667.80 N/A N/A $319.59 N/A N/A $10.79 N/A N/A $572.40 N/A N/A $333.90 N/A N/A $620.10 N/A N/A $286.20 N/A N/A $572.40 N/A N/A $667.80 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A N/A $286.20 N/A $954.00 $954.00 N/A 4010045 General Lab A. Alternata (M6) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab A. fumigatus (M3) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Beef (F27) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Bermuda grass (G2) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Box maple elder(T1) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab C. Herbarum (M2) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Cat Dander (E1) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Chicken meat (F83) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Class QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Cockroach (I6) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Coffee (F221) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Common pigweed (W14) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Common ragweed(W1) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Cottonwood (T14) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab D. Farinae (D2) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab D. Pteronyssinus (D1) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Dog Dander (E5) IGE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Elm (T8) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab IgE QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Interpretation QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Mountain juniper(T6) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Mugwort (W6) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Mulberry tree (T70) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Oak (T7) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Oats (F7) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Olive tree (T9) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Orange (food) (F33) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab P. notatum (M1) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Pineapple (F210) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Potato (F35) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab "Respiratory Allergy Profile, Region XV QLS" 82785 302 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $17.66 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $10.57 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $10.57 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Respiratory Allergy Profile Region XV QST 82785 302 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $17.66 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $10.57 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $10.57 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Rice (F9) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Russian thistle (W11) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Rye (F5) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Strawberry (F44) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Timothy grass (G6) QLS 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010045 General Lab Tomato (F25) QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010046 General Lab Rituxan Sensitivity QLS 86356 301 $167.00 $- $11.61 $- $- $133.60 $- N/A $43.42 N/A N/A $19.40 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $11.61 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $11.61 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4010047 General Lab "S. Pneumoniae IgG Ab Panel (14 serotypes), Maid QLS" 86317 301 "$1,223.00 " $- $9.62 $- $- $978.40 $- N/A $317.98 N/A N/A $16.08 N/A N/A $733.80 N/A N/A $611.50 N/A N/A $9.62 N/A N/A $831.64 N/A N/A $599.27 N/A N/A $476.97 N/A N/A $856.10 N/A N/A $978.40 N/A N/A $672.65 N/A N/A $856.10 N/A N/A $409.71 N/A N/A $9.62 N/A N/A $733.80 N/A N/A $428.05 N/A N/A $794.95 N/A N/A $366.90 N/A N/A $733.80 N/A N/A $856.10 N/A N/A $366.90 N/A N/A $366.90 N/A N/A $366.90 N/A N/A $366.90 N/A N/A $366.90 N/A N/A $366.90 N/A "$1,223.00 " "$1,223.00 " N/A 4010048 General Lab Shiga Toxins to E. Coli 0157 Culture QST 87427 306 $93.00 $- $7.69 $- $- $74.40 $- N/A $24.18 N/A N/A $12.86 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.69 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.69 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4010048 General Lab "Shiga Toxins, EIA w/Rlx to e. Coli 0157 Culture QLS" 87427 306 $93.00 $- $7.69 $- $- $74.40 $- N/A $24.18 N/A N/A $12.86 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $7.69 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $7.69 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4010050 General Lab Vitamin B12 and Folate QLS 82607 301 $468.00 $- $9.67 $- $- $374.40 $- N/A $121.68 N/A N/A $16.16 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.67 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.67 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4010050 General Lab Vitamin B12/Folate Panel QST 82607 301 $468.00 $- $9.67 $- $- $374.40 $- N/A $121.68 N/A N/A $16.16 N/A N/A $280.80 N/A N/A $234.00 N/A N/A $9.67 N/A N/A $318.24 N/A N/A $229.32 N/A N/A $182.52 N/A N/A $327.60 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $327.60 N/A N/A $156.78 N/A N/A $9.67 N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $327.60 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 4010051 General Lab BRCAvantage Comprehensive QLS 81162 310 "$3,844.00 " $- $999.44 $- $- "$3,075.20 " $- N/A $999.44 N/A N/A "$1,938.97 " N/A N/A "$2,306.40 " N/A N/A "$1,922.00 " N/A N/A N/A N/A N/A "$2,613.92 " N/A N/A "$1,883.56 " N/A N/A "$1,499.16 " N/A N/A "$2,690.80 " N/A N/A "$3,075.20 " N/A N/A "$2,114.20 " N/A N/A "$2,690.80 " N/A N/A "$1,287.74 " N/A N/A N/A N/A N/A "$2,306.40 " N/A N/A "$1,345.40 " N/A N/A "$2,498.60 " N/A N/A "$1,153.20 " N/A N/A "$2,306.40 " N/A N/A "$2,690.80 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A "$3,844.00 " "$3,844.00 " N/A 4010051 General Lab "BRCAvantage(Tm), Comprehensive QST" 81162 310 "$3,844.00 " $- $999.44 $- $- "$3,075.20 " $- N/A $999.44 N/A N/A "$1,938.97 " N/A N/A "$2,306.40 " N/A N/A "$1,922.00 " N/A N/A N/A N/A N/A "$2,613.92 " N/A N/A "$1,883.56 " N/A N/A "$1,499.16 " N/A N/A "$2,690.80 " N/A N/A "$3,075.20 " N/A N/A "$2,114.20 " N/A N/A "$2,690.80 " N/A N/A "$1,287.74 " N/A N/A N/A N/A N/A "$2,306.40 " N/A N/A "$1,345.40 " N/A N/A "$2,498.60 " N/A N/A "$1,153.20 " N/A N/A "$2,306.40 " N/A N/A "$2,690.80 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A "$3,844.00 " "$3,844.00 " N/A 4010053 General Lab BRCAvantage w/ Reflex to Breast Plus Panel QLS 81162 310 "$3,844.00 " $- $999.44 $- $- "$3,075.20 " $- N/A $999.44 N/A N/A "$1,938.97 " N/A N/A "$2,306.40 " N/A N/A "$1,922.00 " N/A N/A N/A N/A N/A "$2,613.92 " N/A N/A "$1,883.56 " N/A N/A "$1,499.16 " N/A N/A "$2,690.80 " N/A N/A "$3,075.20 " N/A N/A "$2,114.20 " N/A N/A "$2,690.80 " N/A N/A "$1,287.74 " N/A N/A N/A N/A N/A "$2,306.40 " N/A N/A "$1,345.40 " N/A N/A "$2,498.60 " N/A N/A "$1,153.20 " N/A N/A "$2,306.40 " N/A N/A "$2,690.80 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A N/A "$1,153.20 " N/A "$3,844.00 " "$3,844.00 " N/A 4010054 General Lab IGF I QST 84305 301 $334.00 $- $13.63 $- $- $267.20 $- N/A $86.84 N/A N/A $22.79 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $13.63 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $13.63 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4010054 General Lab "IGF-1, LC/MS" 84305 301 $334.00 $- $13.63 $- $- $267.20 $- N/A $86.84 N/A N/A $22.79 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $13.63 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $13.63 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4010054 General Lab "IGF-1, LC/MS QLS" 84305 301 $334.00 $- $13.63 $- $- $267.20 $- N/A $86.84 N/A N/A $22.79 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $13.63 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $13.63 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 4010056 General Lab Hypersensitivity Pneumonitis Eval QST 86606 302 $606.00 $- $9.66 $- $- $484.80 $- N/A $157.56 N/A N/A $16.15 N/A N/A $363.60 N/A N/A $303.00 N/A N/A $9.66 N/A N/A $412.08 N/A N/A $296.94 N/A N/A $236.34 N/A N/A $424.20 N/A N/A $484.80 N/A N/A $333.30 N/A N/A $424.20 N/A N/A $203.01 N/A N/A $9.66 N/A N/A $363.60 N/A N/A $212.10 N/A N/A $393.90 N/A N/A $181.80 N/A N/A $363.60 N/A N/A $424.20 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A $606.00 $606.00 N/A 4010056 General Lab Hypersensitivity Pneumonitis Evaluation QST 86606 302 $606.00 $- $9.66 $- $- $484.80 $- N/A $157.56 N/A N/A $16.15 N/A N/A $363.60 N/A N/A $303.00 N/A N/A $9.66 N/A N/A $412.08 N/A N/A $296.94 N/A N/A $236.34 N/A N/A $424.20 N/A N/A $484.80 N/A N/A $333.30 N/A N/A $424.20 N/A N/A $203.01 N/A N/A $9.66 N/A N/A $363.60 N/A N/A $212.10 N/A N/A $393.90 N/A N/A $181.80 N/A N/A $363.60 N/A N/A $424.20 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A N/A $181.80 N/A $606.00 $606.00 N/A 4010057 General Lab Allergen Specific IgE 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 4010058 General Lab Anti-Streptolysin O Antibody (ASO) QLS 86060 302 $99.00 $- $4.69 $- $- $79.20 $- N/A $25.74 N/A N/A $7.82 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $4.69 N/A N/A $67.32 N/A N/A $48.51 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $69.30 N/A N/A $33.17 N/A N/A $4.69 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4010058 General Lab Antistreptolysin O QST 86060 302 $99.00 $- $4.69 $- $- $79.20 $- N/A $25.74 N/A N/A $7.82 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $4.69 N/A N/A $67.32 N/A N/A $48.51 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $69.30 N/A N/A $33.17 N/A N/A $4.69 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4010060 General Lab Sex Hormone Binding Globulin QST 84270 301 $140.00 $- $13.95 $- $- $112.00 $- N/A $36.40 N/A N/A $23.30 N/A N/A $84.00 N/A N/A $70.00 N/A N/A $13.95 N/A N/A $95.20 N/A N/A $68.60 N/A N/A $54.60 N/A N/A $98.00 N/A N/A $112.00 N/A N/A $77.00 N/A N/A $98.00 N/A N/A $46.90 N/A N/A $13.95 N/A N/A $84.00 N/A N/A $49.00 N/A N/A $91.00 N/A N/A $42.00 N/A N/A $84.00 N/A N/A $98.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A $140.00 $140.00 N/A 4010060 General Lab Sex Hormone Binding Globulin QLS 84270 301 $140.00 $- $13.95 $- $- $112.00 $- N/A $36.40 N/A N/A $23.30 N/A N/A $84.00 N/A N/A $70.00 N/A N/A $13.95 N/A N/A $95.20 N/A N/A $68.60 N/A N/A $54.60 N/A N/A $98.00 N/A N/A $112.00 N/A N/A $77.00 N/A N/A $98.00 N/A N/A $46.90 N/A N/A $13.95 N/A N/A $84.00 N/A N/A $49.00 N/A N/A $91.00 N/A N/A $42.00 N/A N/A $84.00 N/A N/A $98.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A N/A $42.00 N/A $140.00 $140.00 N/A 4010061 General Lab "Bill Immunocyto 7 AB, TC" 88342 310 $102.00 $- $26.52 $- $- $94.06 $- N/A $26.52 N/A N/A $94.06 N/A N/A $61.20 N/A N/A $51.00 N/A N/A $52.52 N/A N/A $69.36 N/A N/A $49.98 N/A N/A $39.78 N/A N/A $71.40 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $71.40 N/A N/A $34.17 N/A N/A $52.52 N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $71.40 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 4010062 General Lab "T3 Reverse, LC/MS/MS QLS" 84482 301 $160.00 $- $10.11 $- $- $128.00 $- N/A $41.60 N/A N/A $16.91 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $10.11 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $10.11 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4010062 General Lab "T3 Reverse, LC/MS/MS QST" 84482 301 $160.00 $- $10.11 $- $- $128.00 $- N/A $41.60 N/A N/A $16.91 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $10.11 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $10.11 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4010063 General Lab Fetal Fibronectin QLS 82731 301 $712.00 $- $23.83 $- $- $569.60 $- N/A $185.12 N/A N/A $39.84 N/A N/A $427.20 N/A N/A $356.00 N/A N/A $23.83 N/A N/A $484.16 N/A N/A $348.88 N/A N/A $277.68 N/A N/A $498.40 N/A N/A $569.60 N/A N/A $391.60 N/A N/A $498.40 N/A N/A $238.52 N/A N/A $23.83 N/A N/A $427.20 N/A N/A $249.20 N/A N/A $462.80 N/A N/A $213.60 N/A N/A $427.20 N/A N/A $498.40 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A $712.00 $712.00 N/A 4010063 General Lab Fetal Fibronectin QST 82731 301 $712.00 $- $23.83 $- $- $569.60 $- N/A $185.12 N/A N/A $39.84 N/A N/A $427.20 N/A N/A $356.00 N/A N/A $23.83 N/A N/A $484.16 N/A N/A $348.88 N/A N/A $277.68 N/A N/A $498.40 N/A N/A $569.60 N/A N/A $391.60 N/A N/A $498.40 N/A N/A $238.52 N/A N/A $23.83 N/A N/A $427.20 N/A N/A $249.20 N/A N/A $462.80 N/A N/A $213.60 N/A N/A $427.20 N/A N/A $498.40 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A N/A $213.60 N/A $712.00 $712.00 N/A 4010064 General Lab "Zika Virus RNA, Qual Real-Time RT PCR Panel, Serum QLS" 87798 306 $890.00 $- $22.51 $- $- $712.00 $- N/A $231.40 N/A N/A $37.63 N/A N/A $534.00 N/A N/A $445.00 N/A N/A $22.51 N/A N/A $605.20 N/A N/A $436.10 N/A N/A $347.10 N/A N/A $623.00 N/A N/A $712.00 N/A N/A $489.50 N/A N/A $623.00 N/A N/A $298.15 N/A N/A $22.51 N/A N/A $534.00 N/A N/A $311.50 N/A N/A $578.50 N/A N/A $267.00 N/A N/A $534.00 N/A N/A $623.00 N/A N/A $267.00 N/A N/A $267.00 N/A N/A $267.00 N/A N/A $267.00 N/A N/A $267.00 N/A N/A $267.00 N/A $890.00 $890.00 N/A 4010065 General Lab Mumps Antibody IgG/IgM QST 86735 302 $106.00 $- $8.37 $- $- $84.80 $- N/A $27.56 N/A N/A $13.99 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.37 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.37 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010065 General Lab Mumps Virus IgG QLS 86735 302 $106.00 $- $8.37 $- $- $84.80 $- N/A $27.56 N/A N/A $13.99 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.37 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.37 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010066 General Lab Measles Antibodies IgG QLS 86765 302 $106.00 $- $8.27 $- $- $84.80 $- N/A $27.56 N/A N/A $13.81 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.27 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.27 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010066 General Lab "Measles Antibodies (IgG,IgM) QST" 86765 302 $106.00 $- $8.27 $- $- $84.80 $- N/A $27.56 N/A N/A $13.81 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.27 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.27 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010067 General Lab Hepatitis B Surface Ab Quant QST 86317 302 $93.00 $- $9.62 $- $- $74.40 $- N/A $24.18 N/A N/A $16.08 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $9.62 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $9.62 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4010069 General Lab ".Clostridium Difficile Toxin B, QL Real Time PCR QST" 87081 306 $59.00 $- $4.26 $- $- $47.20 $- N/A $15.34 N/A N/A $7.12 N/A N/A $35.40 N/A N/A $29.50 N/A N/A $4.26 N/A N/A $40.12 N/A N/A $28.91 N/A N/A $23.01 N/A N/A $41.30 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $41.30 N/A N/A $19.77 N/A N/A $4.26 N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $41.30 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 4010069 General Lab Streptococcus Group B Culture QLS 87081 306 $59.00 $- $4.26 $- $- $47.20 $- N/A $15.34 N/A N/A $7.12 N/A N/A $35.40 N/A N/A $29.50 N/A N/A $4.26 N/A N/A $40.12 N/A N/A $28.91 N/A N/A $23.01 N/A N/A $41.30 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $41.30 N/A N/A $19.77 N/A N/A $4.26 N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $41.30 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 4010070 General Lab CULTURE TYPING GLC/HPLC 87143 306 $106.00 $- $8.04 $- $- $84.80 $- N/A $27.56 N/A N/A $13.43 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.04 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.04 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010072 General Lab MICROBE SUSCEPTIBLE DISK 87184 306 $114.00 $- $4.43 $- $- $91.20 $- N/A $29.64 N/A N/A $7.40 N/A N/A $68.40 N/A N/A $57.00 N/A N/A $4.43 N/A N/A $77.52 N/A N/A $55.86 N/A N/A $44.46 N/A N/A $79.80 N/A N/A $91.20 N/A N/A $62.70 N/A N/A $79.80 N/A N/A $38.19 N/A N/A $4.43 N/A N/A $68.40 N/A N/A $39.90 N/A N/A $74.10 N/A N/A $34.20 N/A N/A $68.40 N/A N/A $79.80 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A $114.00 $114.00 N/A 4010073 General Lab MICROBE SUSCEPTIBLE ENZYME 87185 306 $63.00 $- $1.09 $- $- $50.40 $- N/A $16.38 N/A N/A $1.80 N/A N/A $37.80 N/A N/A $31.50 N/A N/A $1.09 N/A N/A $42.84 N/A N/A $30.87 N/A N/A $24.57 N/A N/A $44.10 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $44.10 N/A N/A $21.11 N/A N/A $1.09 N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $44.10 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 4010074 General Lab Bill Culture Type Immunofluoresc 87140 306 $72.00 $- $3.59 $- $- $57.60 $- N/A $18.72 N/A N/A $5.99 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $3.59 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $3.59 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4010075 General Lab CULTURE AEROBIC IDENTIFY 87077 306 $106.00 $- $5.19 $- $- $84.80 $- N/A $27.56 N/A N/A $8.66 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $5.19 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $5.19 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010076 General Lab Acetylcholine Receptor Blocking Ab QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010076 General Lab Acetylcholine Receptor Blocking Ab QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010077 General Lab MuSK Antibody 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010078 General Lab Acetylcholine Receptor Modulating Ab QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010078 General Lab Acetylcholine Receptor Modulating Ab QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010079 General Lab Acetylcholine Receptor Binding Ab QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010079 General Lab Acetylcholine Receptor Binding Ab QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010079 General Lab Thyrotropin-Binding Inhibitory Immunoglobulin QLS 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010081 General Lab UA Microscopic 81015 307 $49.00 $- $1.96 $- $- $39.20 $- N/A $12.74 N/A N/A $3.26 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $1.96 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $1.96 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4010083 General Lab "Insulin, B Chain, LC/MS/MS QLS" 83525 301 $128.00 $- $7.34 $- $- $102.40 $- N/A $33.28 N/A N/A $12.25 N/A N/A $76.80 N/A N/A $64.00 N/A N/A $7.34 N/A N/A $87.04 N/A N/A $62.72 N/A N/A $49.92 N/A N/A $89.60 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $89.60 N/A N/A $42.88 N/A N/A $7.34 N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $89.60 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 4010084 General Lab Bartonella Hensalae Ab (IgG/IgM) w/Rfx to Titer QLS 86611 302 $90.00 $- $6.54 $- $- $72.00 $- N/A $23.40 N/A N/A $10.91 N/A N/A $54.00 N/A N/A $45.00 N/A N/A $6.54 N/A N/A $61.20 N/A N/A $44.10 N/A N/A $35.10 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A $6.54 N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $54.00 N/A N/A $63.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A $90.00 $90.00 N/A 4010084 General Lab "Bartonella henselae Ab (IgG, IgM) with Reflex to Titer QST" 86611 302 $90.00 $- $6.54 $- $- $72.00 $- N/A $23.40 N/A N/A $10.91 N/A N/A $54.00 N/A N/A $45.00 N/A N/A $6.54 N/A N/A $61.20 N/A N/A $44.10 N/A N/A $35.10 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A $6.54 N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $54.00 N/A N/A $63.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A $90.00 $90.00 N/A 4010085 General Lab Alkaline Phosphatase Iso QST 84080 301 $122.00 $- $9.49 $- $- $97.60 $- N/A $31.72 N/A N/A $15.85 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $9.49 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $9.49 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 4010085 General Lab Alkaline Phosphatase Isoenzymes QLS 84080 301 $122.00 $- $9.49 $- $- $97.60 $- N/A $31.72 N/A N/A $15.85 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $9.49 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $9.49 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 4010086 General Lab Toxoplasma Antibody IgG QLS 86777 302 $146.00 $- $9.24 $- $- $116.80 $- N/A $37.96 N/A N/A $15.43 N/A N/A $87.60 N/A N/A $73.00 N/A N/A $9.24 N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A $9.24 N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4010087 General Lab FTA-ABS QLS 86780 302 $113.00 $- $8.49 $- $- $90.40 $- N/A $29.38 N/A N/A $14.20 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $8.49 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $8.49 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4010087 General Lab FTA-ABS QST 86780 302 $113.00 $- $8.49 $- $- $90.40 $- N/A $29.38 N/A N/A $14.20 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $8.49 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $8.49 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4010088 General Lab VDRL QLS 86592 302 $84.00 $- $2.74 $- $- $67.20 $- N/A $21.84 N/A N/A $4.58 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $2.74 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $2.74 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4010088 General Lab VDRL QST 86592 302 $84.00 $- $2.74 $- $- $67.20 $- N/A $21.84 N/A N/A $4.58 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $2.74 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $2.74 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4010089 General Lab Lysozyme (Muramidase) QLS 85549 305 $167.00 $- $12.04 $- $- $133.60 $- N/A $43.42 N/A N/A $20.11 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $12.04 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $12.04 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4010089 General Lab Lysozyme QST 85549 305 $167.00 $- $12.04 $- $- $133.60 $- N/A $43.42 N/A N/A $20.11 N/A N/A $100.20 N/A N/A $83.50 N/A N/A $12.04 N/A N/A $113.56 N/A N/A $81.83 N/A N/A $65.13 N/A N/A $116.90 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $116.90 N/A N/A $55.95 N/A N/A $12.04 N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $116.90 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 4010090 General Lab Angiotensin Converting Enzyme (ACE) QLS 82164 301 $162.00 $- $9.37 $- $- $129.60 $- N/A $42.12 N/A N/A $15.66 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $9.37 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $9.37 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4010090 General Lab Angiotensin-Converting Enzyme QST 82164 301 $162.00 $- $9.37 $- $- $129.60 $- N/A $42.12 N/A N/A $15.66 N/A N/A $97.20 N/A N/A $81.00 N/A N/A $9.37 N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A $9.37 N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4010091 General Lab Insulin Autoantibody QST 86337 302 $294.00 $- $13.74 $- $- $235.20 $- N/A $76.44 N/A N/A $22.96 N/A N/A $176.40 N/A N/A $147.00 N/A N/A $13.74 N/A N/A $199.92 N/A N/A $144.06 N/A N/A $114.66 N/A N/A $205.80 N/A N/A $235.20 N/A N/A $161.70 N/A N/A $205.80 N/A N/A $98.49 N/A N/A $13.74 N/A N/A $176.40 N/A N/A $102.90 N/A N/A $191.10 N/A N/A $88.20 N/A N/A $176.40 N/A N/A $205.80 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A $294.00 $294.00 N/A 4010091 General Lab Insulin Autoantibody QLS 86337 302 $294.00 $- $13.74 $- $- $235.20 $- N/A $76.44 N/A N/A $22.96 N/A N/A $176.40 N/A N/A $147.00 N/A N/A $13.74 N/A N/A $199.92 N/A N/A $144.06 N/A N/A $114.66 N/A N/A $205.80 N/A N/A $235.20 N/A N/A $161.70 N/A N/A $205.80 N/A N/A $98.49 N/A N/A $13.74 N/A N/A $176.40 N/A N/A $102.90 N/A N/A $191.10 N/A N/A $88.20 N/A N/A $176.40 N/A N/A $205.80 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A $294.00 $294.00 N/A 4010092 General Lab Alpha-Fetoprotein (AFP) and AFP-L3 QLS 82107 301 $294.00 $- $23.83 $- $- $235.20 $- N/A $76.44 N/A N/A $39.84 N/A N/A $176.40 N/A N/A $147.00 N/A N/A $23.83 N/A N/A $199.92 N/A N/A $144.06 N/A N/A $114.66 N/A N/A $205.80 N/A N/A $235.20 N/A N/A $161.70 N/A N/A $205.80 N/A N/A $98.49 N/A N/A $23.83 N/A N/A $176.40 N/A N/A $102.90 N/A N/A $191.10 N/A N/A $88.20 N/A N/A $176.40 N/A N/A $205.80 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A $294.00 $294.00 N/A 4010092 General Lab Alpha-Fetoprotein (AFP) And AFP-L3 QST 82107 301 $294.00 $- $23.83 $- $- $235.20 $- N/A $76.44 N/A N/A $39.84 N/A N/A $176.40 N/A N/A $147.00 N/A N/A $23.83 N/A N/A $199.92 N/A N/A $144.06 N/A N/A $114.66 N/A N/A $205.80 N/A N/A $235.20 N/A N/A $161.70 N/A N/A $205.80 N/A N/A $98.49 N/A N/A $23.83 N/A N/A $176.40 N/A N/A $102.90 N/A N/A $191.10 N/A N/A $88.20 N/A N/A $176.40 N/A N/A $205.80 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A N/A $88.20 N/A $294.00 $294.00 N/A 4010093 General Lab Hemosure iFOB Screen 82274 301 $100.00 $- $10.20 $- $- $80.00 $- N/A $26.00 N/A N/A $17.05 N/A N/A $60.00 N/A N/A $50.00 N/A N/A $10.20 N/A N/A $68.00 N/A N/A $49.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A $10.20 N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4010094 General Lab Nicotine And Cotinine QST 80323 G0480 301 $350.00 $- $0.01 $- $- $280.00 $- N/A $91.00 N/A N/A $0.01 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4010094 General Lab "Nicotine and Cotinine, LC/MS/MS QLS" 80323 G0480 301 $350.00 $- $0.01 $- $- $280.00 $- N/A $91.00 N/A N/A $0.01 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4010095 General Lab Cystic Fibrosis Screen QLS 81220 300 $610.00 $- $158.60 $- $- $979.75 $- N/A $158.60 N/A N/A $979.75 N/A N/A $366.00 N/A N/A $305.00 N/A N/A N/A N/A N/A $414.80 N/A N/A $298.90 N/A N/A $237.90 N/A N/A $427.00 N/A N/A $488.00 N/A N/A $335.50 N/A N/A $427.00 N/A N/A $204.35 N/A N/A N/A N/A N/A $366.00 N/A N/A $213.50 N/A N/A $396.50 N/A N/A $183.00 N/A N/A $366.00 N/A N/A $427.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A $610.00 $610.00 N/A 4010095 General Lab Cystic Fibrosis Screen QST 81220 300 $610.00 $- $158.60 $- $- $979.75 $- N/A $158.60 N/A N/A $979.75 N/A N/A $366.00 N/A N/A $305.00 N/A N/A N/A N/A N/A $414.80 N/A N/A $298.90 N/A N/A $237.90 N/A N/A $427.00 N/A N/A $488.00 N/A N/A $335.50 N/A N/A $427.00 N/A N/A $204.35 N/A N/A N/A N/A N/A $366.00 N/A N/A $213.50 N/A N/A $396.50 N/A N/A $183.00 N/A N/A $366.00 N/A N/A $427.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A N/A $183.00 N/A $610.00 $610.00 N/A 4010096 General Lab "Fungal Panel 2, ID and CF QST" 86612 302 $58.00 $- $13.84 $- $- $46.40 $- N/A $15.08 N/A N/A $13.84 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010096 General Lab "Fungal Panel 2, ID and CF QST" 86635 302 $58.00 $- $12.30 $- $- $46.40 $- N/A $15.08 N/A N/A $12.30 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010096 General Lab "Fungal Panel 2, ID and CF QST" 86698 302 $58.00 $- $13.40 $- $- $46.40 $- N/A $15.08 N/A N/A $13.40 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010096 General Lab "Fungal Panel 2, ID and CF QST" 86606 302 $58.00 $- $15.08 $- $- $46.40 $- N/A $15.08 N/A N/A $16.15 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010097 General Lab "Coccidioides Ab, CF QST" 86635 302 $146.00 $- $12.30 $- $- $116.80 $- N/A $37.96 N/A N/A $12.30 N/A N/A $87.60 N/A N/A $73.00 N/A N/A N/A N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A N/A N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4010097 General Lab "Coccidioides Ab,ID,CSF QST" 86635 302 $146.00 $- $7.37 $- $- $116.80 $- N/A $37.96 N/A N/A $12.30 N/A N/A $87.60 N/A N/A $73.00 N/A N/A $7.37 N/A N/A $99.28 N/A N/A $71.54 N/A N/A $56.94 N/A N/A $102.20 N/A N/A $116.80 N/A N/A $80.30 N/A N/A $102.20 N/A N/A $48.91 N/A N/A $7.37 N/A N/A $87.60 N/A N/A $51.10 N/A N/A $94.90 N/A N/A $43.80 N/A N/A $87.60 N/A N/A $102.20 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A N/A $43.80 N/A $146.00 $146.00 N/A 4010099 General Lab U medMATCH Benzodiazepines QST 80346 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010100 General Lab U medMATCH Opiates QST 80361 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010101 General Lab U Amphetamine QST 80324 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010101 General Lab U Amphetamine QST 80324 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010102 General Lab U Barbiturates QST 80345 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010103 General Lab U Marijuana Metabolite QST 80349 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010104 General Lab U medMATCH Cocaine Metab QST 80353 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010105 General Lab U medMATCH Methadone Metab QST 80358 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010105 General Lab U medMATCH Methadone QST 80358 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010106 General Lab U medMATCH Oxycodone QST 80365 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010107 General Lab U medMATCH Phencyclidine QST 83992 G0480 301 $203.00 $- $0.01 $- $- $162.40 $- N/A $52.78 N/A N/A $0.01 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $8.18 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $8.18 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4010108 General Lab Glutathione QLS 82978 301 $132.00 $- $9.15 $- $- $105.60 $- N/A $34.32 N/A N/A $15.29 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $9.15 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $9.15 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4010108 General Lab Glutathione QST 82978 301 $132.00 $- $9.15 $- $- $105.60 $- N/A $34.32 N/A N/A $15.29 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $9.15 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $9.15 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4010111 General Lab PAI-1 4G/5G QST 81400 310 $298.00 $- $77.48 $- $- $238.40 $- N/A $77.48 N/A N/A $82.22 N/A N/A $178.80 N/A N/A $149.00 N/A N/A N/A N/A N/A $202.64 N/A N/A $146.02 N/A N/A $116.22 N/A N/A $208.60 N/A N/A $238.40 N/A N/A $163.90 N/A N/A $208.60 N/A N/A $99.83 N/A N/A N/A N/A N/A $178.80 N/A N/A $104.30 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $178.80 N/A N/A $208.60 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A $298.00 $298.00 N/A 4010111 General Lab Plasminogen Activator Inhibitor-1 (PAI-1) 4G/5G QLS 81400 310 $298.00 $- $77.48 $- $- $238.40 $- N/A $77.48 N/A N/A $82.22 N/A N/A $178.80 N/A N/A $149.00 N/A N/A N/A N/A N/A $202.64 N/A N/A $146.02 N/A N/A $116.22 N/A N/A $208.60 N/A N/A $238.40 N/A N/A $163.90 N/A N/A $208.60 N/A N/A $99.83 N/A N/A N/A N/A N/A $178.80 N/A N/A $104.30 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $178.80 N/A N/A $208.60 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A $298.00 $298.00 N/A 4010113 General Lab "Factor VIII Activity, Chromogenic QLS" 85240 305 $132.00 $- $11.49 $- $- $105.60 $- N/A $34.32 N/A N/A $19.20 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $11.49 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $11.49 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4010113 General Lab "Factor VIII Activity, Chrom QST" 85240 305 $132.00 $- $11.49 $- $- $105.60 $- N/A $34.32 N/A N/A $19.20 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $11.49 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $11.49 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4010114 General Lab ANA Titer and Pattern Rflx 86039 302 $64.00 $- $7.17 $- $- $51.20 $- N/A $16.64 N/A N/A $11.98 N/A N/A $38.40 N/A N/A $32.00 N/A N/A $7.17 N/A N/A $43.52 N/A N/A $31.36 N/A N/A $24.96 N/A N/A $44.80 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $44.80 N/A N/A $21.44 N/A N/A $7.17 N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $44.80 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 4010114 General Lab ".Antinuclear Antibodies, Titer/Pattern QST" 86039 302 $64.00 $- $7.17 $- $- $51.20 $- N/A $16.64 N/A N/A $11.98 N/A N/A $38.40 N/A N/A $32.00 N/A N/A $7.17 N/A N/A $43.52 N/A N/A $31.36 N/A N/A $24.96 N/A N/A $44.80 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $44.80 N/A N/A $21.44 N/A N/A $7.17 N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $44.80 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 4010115 General Lab "Cardio IQ ProBNP, N-Termal QLS" 83880 301 $316.00 $- $21.78 $- $- $252.80 $- N/A $82.16 N/A N/A $36.40 N/A N/A $189.60 N/A N/A $158.00 N/A N/A $21.78 N/A N/A $214.88 N/A N/A $154.84 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $21.78 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $205.40 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 4010115 General Lab Cardio IQ(R) NT-PRO BNP QST 83880 301 $316.00 $- $21.78 $- $- $252.80 $- N/A $82.16 N/A N/A $36.40 N/A N/A $189.60 N/A N/A $158.00 N/A N/A $21.78 N/A N/A $214.88 N/A N/A $154.84 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $21.78 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $205.40 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 4010115 General Lab NT-PRO BNP QST 83880 301 $316.00 $- $21.78 $- $- $252.80 $- N/A $82.16 N/A N/A $36.40 N/A N/A $189.60 N/A N/A $158.00 N/A N/A $21.78 N/A N/A $214.88 N/A N/A $154.84 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $21.78 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $205.40 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 4010116 General Lab Histone Antibodies QST 83516 302 $135.00 $- $7.40 $- $- $108.00 $- N/A $35.10 N/A N/A $12.37 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $7.40 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $7.40 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 4010116 General Lab Histone Antibodies QLS 83516 302 $135.00 $- $7.40 $- $- $108.00 $- N/A $35.10 N/A N/A $12.37 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $7.40 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $7.40 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 4010117 General Lab "Cortisol, Saliva QST" 82530 301 $158.00 $- $10.72 $- $- $126.40 $- N/A $41.08 N/A N/A $17.92 N/A N/A $94.80 N/A N/A $79.00 N/A N/A $10.72 N/A N/A $107.44 N/A N/A $77.42 N/A N/A $61.62 N/A N/A $110.60 N/A N/A $126.40 N/A N/A $86.90 N/A N/A $110.60 N/A N/A $52.93 N/A N/A $10.72 N/A N/A $94.80 N/A N/A $55.30 N/A N/A $102.70 N/A N/A $47.40 N/A N/A $94.80 N/A N/A $110.60 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A $158.00 $158.00 N/A 4010117 General Lab "Cortisol, Saliva, LC/MS/MS QLS" 82530 301 $158.00 $- $10.72 $- $- $126.40 $- N/A $41.08 N/A N/A $17.92 N/A N/A $94.80 N/A N/A $79.00 N/A N/A $10.72 N/A N/A $107.44 N/A N/A $77.42 N/A N/A $61.62 N/A N/A $110.60 N/A N/A $126.40 N/A N/A $86.90 N/A N/A $110.60 N/A N/A $52.93 N/A N/A $10.72 N/A N/A $94.80 N/A N/A $55.30 N/A N/A $102.70 N/A N/A $47.40 N/A N/A $94.80 N/A N/A $110.60 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A $158.00 $158.00 N/A 4010118 General Lab Glutamic Acid Decarboxylase 65 Ab QST 86341 302 $261.00 $- $12.69 $- $- $208.80 $- N/A $67.86 N/A N/A $21.22 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $12.69 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $12.69 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4010118 General Lab Glutamic Acid Decarboxylase-65 Antibody QLS 86341 302 $261.00 $- $12.69 $- $- $208.80 $- N/A $67.86 N/A N/A $21.22 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $12.69 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $12.69 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4010119 General Lab "Electrolytes, Feces QST" 84311 301 $122.00 $- $4.49 $- $- $97.60 $- N/A $31.72 N/A N/A $7.50 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $4.49 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $4.49 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 4010119 General Lab "Sodium, Feces QST" 84302 301 $122.00 $- $3.13 $- $- $97.60 $- N/A $31.72 N/A N/A $5.22 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $3.13 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $3.13 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 4010120 General Lab Systemic Lupus Erythematosus (SLE) QST 86038 302 "$1,532.00 " $- $7.76 $- $- "$1,225.60 " $- N/A $398.32 N/A N/A $12.96 N/A N/A $919.20 N/A N/A $766.00 N/A N/A $7.76 N/A N/A "$1,041.76 " N/A N/A $750.68 N/A N/A $597.48 N/A N/A "$1,072.40 " N/A N/A "$1,225.60 " N/A N/A $842.60 N/A N/A "$1,072.40 " N/A N/A $513.22 N/A N/A $7.76 N/A N/A $919.20 N/A N/A $536.20 N/A N/A $995.80 N/A N/A $459.60 N/A N/A $919.20 N/A N/A "$1,072.40 " N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A "$1,532.00 " "$1,532.00 " N/A 4010120 General Lab Systemic Lupus Erythematosus (SLE) QST 86225 302 "$1,532.00 " $- $8.81 $- $- "$1,225.60 " $- N/A $398.32 N/A N/A $14.72 N/A N/A $919.20 N/A N/A $766.00 N/A N/A $8.81 N/A N/A "$1,041.76 " N/A N/A $750.68 N/A N/A $597.48 N/A N/A "$1,072.40 " N/A N/A "$1,225.60 " N/A N/A $842.60 N/A N/A "$1,072.40 " N/A N/A $513.22 N/A N/A $8.81 N/A N/A $919.20 N/A N/A $536.20 N/A N/A $995.80 N/A N/A $459.60 N/A N/A $919.20 N/A N/A "$1,072.40 " N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A "$1,532.00 " "$1,532.00 " N/A 4010120 General Lab Systemic Lupus Erythematosus (SLE) QST 86235 302 "$1,532.00 " $- $10.74 $- $- "$1,225.60 " $- N/A $398.32 N/A N/A $17.95 N/A N/A $919.20 N/A N/A $766.00 N/A N/A $10.74 N/A N/A "$1,041.76 " N/A N/A $750.68 N/A N/A $597.48 N/A N/A "$1,072.40 " N/A N/A "$1,225.60 " N/A N/A $842.60 N/A N/A "$1,072.40 " N/A N/A $513.22 N/A N/A $10.74 N/A N/A $919.20 N/A N/A $536.20 N/A N/A $995.80 N/A N/A $459.60 N/A N/A $919.20 N/A N/A "$1,072.40 " N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A "$1,532.00 " "$1,532.00 " N/A 4010120 General Lab Systemic Lupus Erythematosus (SLE) QST 86160 302 "$1,532.00 " $- $7.70 $- $- "$1,225.60 " $- N/A $398.32 N/A N/A $12.88 N/A N/A $919.20 N/A N/A $766.00 N/A N/A $7.70 N/A N/A "$1,041.76 " N/A N/A $750.68 N/A N/A $597.48 N/A N/A "$1,072.40 " N/A N/A "$1,225.60 " N/A N/A $842.60 N/A N/A "$1,072.40 " N/A N/A $513.22 N/A N/A $7.70 N/A N/A $919.20 N/A N/A $536.20 N/A N/A $995.80 N/A N/A $459.60 N/A N/A $919.20 N/A N/A "$1,072.40 " N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A "$1,532.00 " "$1,532.00 " N/A 4010120 General Lab Systemic Lupus Erythematosus (SLE) QST 86162 302 "$1,532.00 " $- $13.03 $- $- "$1,225.60 " $- N/A $398.32 N/A N/A $21.78 N/A N/A $919.20 N/A N/A $766.00 N/A N/A $13.03 N/A N/A "$1,041.76 " N/A N/A $750.68 N/A N/A $597.48 N/A N/A "$1,072.40 " N/A N/A "$1,225.60 " N/A N/A $842.60 N/A N/A "$1,072.40 " N/A N/A $513.22 N/A N/A $13.03 N/A N/A $919.20 N/A N/A $536.20 N/A N/A $995.80 N/A N/A $459.60 N/A N/A $919.20 N/A N/A "$1,072.40 " N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A N/A $459.60 N/A "$1,532.00 " "$1,532.00 " N/A 4010121 General Lab Calprotectin QST 83993 301 $320.00 $- $12.59 $- $- $256.00 $- N/A $83.20 N/A N/A $21.05 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $12.59 N/A N/A $217.60 N/A N/A $156.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $12.59 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4010121 General Lab "Calprotectin, Stool QLS" 83993 301 $320.00 $- $12.59 $- $- $256.00 $- N/A $83.20 N/A N/A $21.05 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $12.59 N/A N/A $217.60 N/A N/A $156.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $12.59 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4010123 General Lab Cryptococcus Antibody QLS 86403 302 $168.00 $- $6.54 $- $- $134.40 $- N/A $43.68 N/A N/A $10.93 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $6.54 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $6.54 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4010123 General Lab Cryptococcus Ab QST 86403 302 $168.00 $- $6.54 $- $- $134.40 $- N/A $43.68 N/A N/A $10.93 N/A N/A $100.80 N/A N/A $84.00 N/A N/A $6.54 N/A N/A $114.24 N/A N/A $82.32 N/A N/A $65.52 N/A N/A $117.60 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $117.60 N/A N/A $56.28 N/A N/A $6.54 N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $117.60 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 4010125 General Lab "Opiates Clinical Screen, with Confirmation, Urine QLS" 80307 301 $601.00 $- $37.52 $- $- $480.80 $- N/A $156.26 N/A N/A $62.26 N/A N/A $360.60 N/A N/A $300.50 N/A N/A $37.52 N/A N/A $408.68 N/A N/A $294.49 N/A N/A $234.39 N/A N/A $420.70 N/A N/A $480.80 N/A N/A $330.55 N/A N/A $420.70 N/A N/A $201.34 N/A N/A $37.52 N/A N/A $360.60 N/A N/A $210.35 N/A N/A $390.65 N/A N/A $180.30 N/A N/A $360.60 N/A N/A $420.70 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A N/A $180.30 N/A $601.00 $601.00 N/A 4010127 General Lab Pro B-Type Natriuretic Peptide N-Terminal QLS 83880 301 $316.00 $- $21.78 $- $- $252.80 $- N/A $82.16 N/A N/A $36.40 N/A N/A $189.60 N/A N/A $158.00 N/A N/A $21.78 N/A N/A $214.88 N/A N/A $154.84 N/A N/A $123.24 N/A N/A $221.20 N/A N/A $252.80 N/A N/A $173.80 N/A N/A $221.20 N/A N/A $105.86 N/A N/A $21.78 N/A N/A $189.60 N/A N/A $110.60 N/A N/A $205.40 N/A N/A $94.80 N/A N/A $189.60 N/A N/A $221.20 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A N/A $94.80 N/A $316.00 $316.00 N/A 4010129 General Lab "Stepwise, Part 1 QST" 84163 301 $242.00 $- $9.01 $- $- $193.60 $- N/A $62.92 N/A N/A $15.06 N/A N/A $145.20 N/A N/A $121.00 N/A N/A $9.01 N/A N/A $164.56 N/A N/A $118.58 N/A N/A $94.38 N/A N/A $169.40 N/A N/A $193.60 N/A N/A $133.10 N/A N/A $169.40 N/A N/A $81.07 N/A N/A $9.01 N/A N/A $145.20 N/A N/A $84.70 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $145.20 N/A N/A $169.40 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A $242.00 $242.00 N/A 4010129 General Lab "Stepwise, Part 1 QST" 84702 301 $242.00 $- $9.01 $- $- $193.60 $- N/A $62.92 N/A N/A $15.06 N/A N/A $145.20 N/A N/A $121.00 N/A N/A $9.01 N/A N/A $164.56 N/A N/A $118.58 N/A N/A $94.38 N/A N/A $169.40 N/A N/A $193.60 N/A N/A $133.10 N/A N/A $169.40 N/A N/A $81.07 N/A N/A $9.01 N/A N/A $145.20 N/A N/A $84.70 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $145.20 N/A N/A $169.40 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A $242.00 $242.00 N/A 4010131 General Lab "Fecal Fat, Total, Quantitative QLS" 82710 301 $166.00 $- $10.79 $- $- $132.80 $- N/A $43.16 N/A N/A $18.02 N/A N/A $99.60 N/A N/A $83.00 N/A N/A $10.79 N/A N/A $112.88 N/A N/A $81.34 N/A N/A $64.74 N/A N/A $116.20 N/A N/A $132.80 N/A N/A $91.30 N/A N/A $116.20 N/A N/A $55.61 N/A N/A $10.79 N/A N/A $99.60 N/A N/A $58.10 N/A N/A $107.90 N/A N/A $49.80 N/A N/A $99.60 N/A N/A $116.20 N/A N/A $49.80 N/A N/A $49.80 N/A N/A $49.80 N/A N/A $49.80 N/A N/A $49.80 N/A N/A $49.80 N/A $166.00 $166.00 N/A 4010133 General Lab "Magnesium, RBC QST" 83735 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.19 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4010135 General Lab "Zinc, RBC QST" 84630 301 $350.00 $- $7.31 $- $- $280.00 $- N/A $91.00 N/A N/A $12.20 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $7.31 N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A $7.31 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 4010137 General Lab ColoVantage ® (Methylated Septin 9) QLS 81327 310 $590.00 $- $65.27 $- $- $472.00 $- N/A $153.40 N/A N/A $65.27 N/A N/A $354.00 N/A N/A $295.00 N/A N/A N/A N/A N/A $401.20 N/A N/A $289.10 N/A N/A $230.10 N/A N/A $413.00 N/A N/A $472.00 N/A N/A $324.50 N/A N/A $413.00 N/A N/A $197.65 N/A N/A N/A N/A N/A $354.00 N/A N/A $206.50 N/A N/A $383.50 N/A N/A $177.00 N/A N/A $354.00 N/A N/A $413.00 N/A N/A $177.00 N/A N/A $177.00 N/A N/A $177.00 N/A N/A $177.00 N/A N/A $177.00 N/A N/A $177.00 N/A $590.00 $590.00 N/A 4010139 General Lab Ethosuximide QST 80168 301 $161.00 $- $10.49 $- $- $128.80 $- N/A $41.86 N/A N/A $17.53 N/A N/A $96.60 N/A N/A $80.50 N/A N/A $10.49 N/A N/A $109.48 N/A N/A $78.89 N/A N/A $62.79 N/A N/A $112.70 N/A N/A $128.80 N/A N/A $88.55 N/A N/A $112.70 N/A N/A $53.94 N/A N/A $10.49 N/A N/A $96.60 N/A N/A $56.35 N/A N/A $104.65 N/A N/A $48.30 N/A N/A $96.60 N/A N/A $112.70 N/A N/A $48.30 N/A N/A $48.30 N/A N/A $48.30 N/A N/A $48.30 N/A N/A $48.30 N/A N/A $48.30 N/A $161.00 $161.00 N/A 4010141 General Lab "Giardia Antibody, IFA QST" 86674 302 $137.00 $- $9.44 $- $- $109.60 $- N/A $35.62 N/A N/A $15.79 N/A N/A $82.20 N/A N/A $68.50 N/A N/A $9.44 N/A N/A $93.16 N/A N/A $67.13 N/A N/A $53.43 N/A N/A $95.90 N/A N/A $109.60 N/A N/A $75.35 N/A N/A $95.90 N/A N/A $45.90 N/A N/A $9.44 N/A N/A $82.20 N/A N/A $47.95 N/A N/A $89.05 N/A N/A $41.10 N/A N/A $82.20 N/A N/A $95.90 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A $137.00 $137.00 N/A 4010143 General Lab Diphtheria Antitoxoid QST 86648 302 $150.00 $- $9.76 $- $- $120.00 $- N/A $39.00 N/A N/A $16.31 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $9.76 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $9.76 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4010143 General Lab Tetnus Antitoxoid Ab QST 86774 302 $150.00 $- $9.50 $- $- $120.00 $- N/A $39.00 N/A N/A $15.86 N/A N/A $90.00 N/A N/A $75.00 N/A N/A $9.50 N/A N/A $102.00 N/A N/A $73.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A $9.50 N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4010145 General Lab Dexamethasone QST 80299 301 $135.00 $- $8.78 $- $- $108.00 $- N/A $35.10 N/A N/A $14.54 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $8.78 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $8.78 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 4010147 General Lab Aspergillus fumigatus Ab QLS 86606 302 $58.00 $- $9.66 $- $- $46.40 $- N/A $15.08 N/A N/A $16.15 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $9.66 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $9.66 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010147 General Lab Aspergillus flavus Ab QLS 86606 302 $58.00 $- $9.66 $- $- $46.40 $- N/A $15.08 N/A N/A $16.15 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $9.66 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $9.66 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010147 General Lab Aspergillus niger Ab QLS 86606 302 $58.00 $- $9.66 $- $- $46.40 $- N/A $15.08 N/A N/A $16.15 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $9.66 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $9.66 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010147 General Lab "Blastomyces Antibody, ID QLS" 86612 302 $58.00 $- $8.28 $- $- $46.40 $- N/A $15.08 N/A N/A $13.84 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $8.28 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $8.28 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010147 General Lab "Coccidioides Antibody, ID QLS" 86635 302 $58.00 $- $7.37 $- $- $46.40 $- N/A $15.08 N/A N/A $12.30 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $7.37 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $7.37 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010147 General Lab "Histoplasma Antibody, ID QLS" 86698 302 $58.00 $- $8.02 $- $- $46.40 $- N/A $15.08 N/A N/A $13.40 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $8.02 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $8.02 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 4010149 General Lab Pain Management Pro 1 w/ Confirm Urine QST 80307 301 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $62.26 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $37.52 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $37.52 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 4010151 General Lab Ribosomal P Antibody QST 83516 302 $135.00 $- $7.40 $- $- $108.00 $- N/A $35.10 N/A N/A $12.37 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $7.40 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $7.40 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 4010153 General Lab Sjogren's Ab SS-A/SS-B QST 86235 302 $70.00 $- $10.74 $- $- $56.00 $- N/A $18.20 N/A N/A $17.95 N/A N/A $42.00 N/A N/A $35.00 N/A N/A $10.74 N/A N/A $47.60 N/A N/A $34.30 N/A N/A $27.30 N/A N/A $49.00 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $49.00 N/A N/A $23.45 N/A N/A $10.74 N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $49.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 4010155 General Lab Hepatitis Comp Profile 355 QST 86704 302 $92.00 $- $7.73 $- $- $73.60 $- N/A $23.92 N/A N/A $12.92 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $7.73 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $7.73 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 4010157 General Lab "Glucose,Pericardial Fl QST" 82945 301 $219.00 $- $2.52 $- $- $175.20 $- N/A $56.94 N/A N/A $4.20 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $2.52 N/A N/A $148.92 N/A N/A $107.31 N/A N/A $85.41 N/A N/A $153.30 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $153.30 N/A N/A $73.37 N/A N/A $2.52 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $153.30 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 4010159 General Lab Adiponectin QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010161 General Lab Chromatin (Nucleosomal) Ab QST 86235 302 $235.00 $- $10.74 $- $- $188.00 $- N/A $61.10 N/A N/A $17.95 N/A N/A $141.00 N/A N/A $117.50 N/A N/A $10.74 N/A N/A $159.80 N/A N/A $115.15 N/A N/A $91.65 N/A N/A $164.50 N/A N/A $188.00 N/A N/A $129.25 N/A N/A $164.50 N/A N/A $78.73 N/A N/A $10.74 N/A N/A $141.00 N/A N/A $82.25 N/A N/A $152.75 N/A N/A $70.50 N/A N/A $141.00 N/A N/A $164.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A $235.00 $235.00 N/A 4010163 General Lab "TNF-Alpha,High Sensitive QST" 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010165 General Lab "pH, Body Fluid QST" 83986 301 $33.00 $- $2.30 $- $- $26.40 $- N/A $8.58 N/A N/A $3.84 N/A N/A $19.80 N/A N/A $16.50 N/A N/A $2.30 N/A N/A $22.44 N/A N/A $16.17 N/A N/A $12.87 N/A N/A $23.10 N/A N/A $26.40 N/A N/A $18.15 N/A N/A $23.10 N/A N/A $11.06 N/A N/A $2.30 N/A N/A $19.80 N/A N/A $11.55 N/A N/A $21.45 N/A N/A $9.90 N/A N/A $19.80 N/A N/A $23.10 N/A N/A $9.90 N/A N/A $9.90 N/A N/A $9.90 N/A N/A $9.90 N/A N/A $9.90 N/A N/A $9.90 N/A $33.00 $33.00 N/A 4010167 General Lab "Anti-Mullerian Hormone (AMH), Female QST" 82397 301 $293.00 $- $9.07 $- $- $234.40 $- N/A $76.18 N/A N/A $15.14 N/A N/A $175.80 N/A N/A $146.50 N/A N/A $9.07 N/A N/A $199.24 N/A N/A $143.57 N/A N/A $114.27 N/A N/A $205.10 N/A N/A $234.40 N/A N/A $161.15 N/A N/A $205.10 N/A N/A $98.16 N/A N/A $9.07 N/A N/A $175.80 N/A N/A $102.55 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $175.80 N/A N/A $205.10 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A $293.00 $293.00 N/A 4010167 General Lab Leptin QST 82397 301 $293.00 $- $9.07 $- $- $234.40 $- N/A $76.18 N/A N/A $15.14 N/A N/A $175.80 N/A N/A $146.50 N/A N/A $9.07 N/A N/A $199.24 N/A N/A $143.57 N/A N/A $114.27 N/A N/A $205.10 N/A N/A $234.40 N/A N/A $161.15 N/A N/A $205.10 N/A N/A $98.16 N/A N/A $9.07 N/A N/A $175.80 N/A N/A $102.55 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $175.80 N/A N/A $205.10 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A $293.00 $293.00 N/A 4010169 General Lab SM/RNP Antibody QST 86235 302 $120.00 $- $10.74 $- $- $96.00 $- N/A $31.20 N/A N/A $17.95 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $10.74 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $10.74 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010171 General Lab Anti-Smith Antibody QST 86235 302 $235.00 $- $10.74 $- $- $188.00 $- N/A $61.10 N/A N/A $17.95 N/A N/A $141.00 N/A N/A $117.50 N/A N/A $10.74 N/A N/A $159.80 N/A N/A $115.15 N/A N/A $91.65 N/A N/A $164.50 N/A N/A $188.00 N/A N/A $129.25 N/A N/A $164.50 N/A N/A $78.73 N/A N/A $10.74 N/A N/A $141.00 N/A N/A $82.25 N/A N/A $152.75 N/A N/A $70.50 N/A N/A $141.00 N/A N/A $164.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A $235.00 $235.00 N/A 4010173 General Lab Apolipoprotein A1 QST 82172 301 $144.00 $- $9.94 $- $- $115.20 $- N/A $37.44 N/A N/A $16.62 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $9.94 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $9.94 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4010173 General Lab Apolipoprotein B QST 82172 301 $144.00 $- $9.94 $- $- $115.20 $- N/A $37.44 N/A N/A $16.62 N/A N/A $86.40 N/A N/A $72.00 N/A N/A $9.94 N/A N/A $97.92 N/A N/A $70.56 N/A N/A $56.16 N/A N/A $100.80 N/A N/A $115.20 N/A N/A $79.20 N/A N/A $100.80 N/A N/A $48.24 N/A N/A $9.94 N/A N/A $86.40 N/A N/A $50.40 N/A N/A $93.60 N/A N/A $43.20 N/A N/A $86.40 N/A N/A $100.80 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A N/A $43.20 N/A $144.00 $144.00 N/A 4010175 General Lab "Electrolytes, Stool QST" 84311 301 $36.00 $- $4.49 $- $- $28.80 $- N/A $9.36 N/A N/A $7.50 N/A N/A $21.60 N/A N/A $18.00 N/A N/A $4.49 N/A N/A $24.48 N/A N/A $17.64 N/A N/A $14.04 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A $4.49 N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $25.20 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 4010177 General Lab GM-1-Abs IgG/IgM QST 83520 301 $201.00 $- $8.31 $- $- $160.80 $- N/A $52.26 N/A N/A $13.88 N/A N/A $120.60 N/A N/A $100.50 N/A N/A $8.31 N/A N/A $136.68 N/A N/A $98.49 N/A N/A $78.39 N/A N/A $140.70 N/A N/A $160.80 N/A N/A $110.55 N/A N/A $140.70 N/A N/A $67.34 N/A N/A $8.31 N/A N/A $120.60 N/A N/A $70.35 N/A N/A $130.65 N/A N/A $60.30 N/A N/A $120.60 N/A N/A $140.70 N/A N/A $60.30 N/A N/A $60.30 N/A N/A $60.30 N/A N/A $60.30 N/A N/A $60.30 N/A N/A $60.30 N/A $201.00 $201.00 N/A 4010179 General Lab Igf Binding Protein 3 QST 83519 302 $125.00 $- $8.67 $- $- $100.00 $- N/A $32.50 N/A N/A $14.48 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $8.67 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $8.67 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010181 General Lab Estrone QST 82679 301 $209.00 $- $16.01 $- $- $167.20 $- N/A $54.34 N/A N/A $26.76 N/A N/A $125.40 N/A N/A $104.50 N/A N/A $16.01 N/A N/A $142.12 N/A N/A $102.41 N/A N/A $81.51 N/A N/A $146.30 N/A N/A $167.20 N/A N/A $114.95 N/A N/A $146.30 N/A N/A $70.02 N/A N/A $16.01 N/A N/A $125.40 N/A N/A $73.15 N/A N/A $135.85 N/A N/A $62.70 N/A N/A $125.40 N/A N/A $146.30 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A N/A $62.70 N/A $209.00 $209.00 N/A 4010183 General Lab Estriol QST 82677 301 $202.00 $- $15.51 $- $- $161.60 $- N/A $52.52 N/A N/A $25.93 N/A N/A $121.20 N/A N/A $101.00 N/A N/A $15.51 N/A N/A $137.36 N/A N/A $98.98 N/A N/A $78.78 N/A N/A $141.40 N/A N/A $161.60 N/A N/A $111.10 N/A N/A $141.40 N/A N/A $67.67 N/A N/A $15.51 N/A N/A $121.20 N/A N/A $70.70 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $121.20 N/A N/A $141.40 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A $202.00 $202.00 N/A 4010185 General Lab Bacterial Antigen Panel QST 86403 302 $81.00 $- $6.54 $- $- $64.80 $- N/A $21.06 N/A N/A $10.93 N/A N/A $48.60 N/A N/A $40.50 N/A N/A $6.54 N/A N/A $55.08 N/A N/A $39.69 N/A N/A $31.59 N/A N/A $56.70 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $56.70 N/A N/A $27.14 N/A N/A $6.54 N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $56.70 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 4010187 General Lab "Testosterone Free, Total, Bio QST" 82040 301 $70.00 $- $3.18 $- $- $56.00 $- N/A $18.20 N/A N/A $5.30 N/A N/A $42.00 N/A N/A $35.00 N/A N/A $3.18 N/A N/A $47.60 N/A N/A $34.30 N/A N/A $27.30 N/A N/A $49.00 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $49.00 N/A N/A $23.45 N/A N/A $3.18 N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $49.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 4010191 General Lab Lp-PLA2 Activity QST 83698 301 $314.00 $- $21.78 $- $- $251.20 $- N/A $81.64 N/A N/A $36.40 N/A N/A $188.40 N/A N/A $157.00 N/A N/A $21.78 N/A N/A $213.52 N/A N/A $153.86 N/A N/A $122.46 N/A N/A $219.80 N/A N/A $251.20 N/A N/A $172.70 N/A N/A $219.80 N/A N/A $105.19 N/A N/A $21.78 N/A N/A $188.40 N/A N/A $109.90 N/A N/A $204.10 N/A N/A $94.20 N/A N/A $188.40 N/A N/A $219.80 N/A N/A $94.20 N/A N/A $94.20 N/A N/A $94.20 N/A N/A $94.20 N/A N/A $94.20 N/A N/A $94.20 N/A $314.00 $314.00 N/A 4010193 General Lab Oxcarbazepine Metabolite QST 80183 301 $113.00 $- $8.51 $- $- $90.40 $- N/A $29.38 N/A N/A $14.11 N/A N/A $67.80 N/A N/A $56.50 N/A N/A $8.51 N/A N/A $76.84 N/A N/A $55.37 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A $8.51 N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4010195 General Lab Olive (RF342) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010199 General Lab "Histoplasma Quantitative Antigen, EIA QST" 87385 306 $101.00 $- $7.69 $- $- $80.80 $- N/A $26.26 N/A N/A $12.86 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $7.69 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $7.69 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4010200 General Lab Fungal Stain Send Out QST 87220 306 $132.00 $- $2.74 $- $- $105.60 $- N/A $34.32 N/A N/A $4.58 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.74 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.74 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 4010201 General Lab "SureSwab®,Trichomonas vaginalisRNA, Qualitative, TMA" 87661 306 $293.00 $- $22.50 $- $- $234.40 $- N/A $76.18 N/A N/A $37.34 N/A N/A $175.80 N/A N/A $146.50 N/A N/A $22.50 N/A N/A $199.24 N/A N/A $143.57 N/A N/A $114.27 N/A N/A $205.10 N/A N/A $234.40 N/A N/A $161.15 N/A N/A $205.10 N/A N/A $98.16 N/A N/A $22.50 N/A N/A $175.80 N/A N/A $102.55 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $175.80 N/A N/A $205.10 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A $293.00 $293.00 N/A 4010203 General Lab Trichinella Antibody (IgG) QST 86784 302 $106.00 $- $8.06 $- $- $84.80 $- N/A $27.56 N/A N/A $13.48 N/A N/A $63.60 N/A N/A $53.00 N/A N/A $8.06 N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A $8.06 N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 4010207 General Lab Gonadotropin Releasing Hormone QST 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4010209 General Lab "CHROMOSOME ANALYSIS, BLOOD QST" 88262 300 "$1,032.00 " $- $79.92 $- $- $825.60 $- N/A $268.32 N/A N/A $133.63 N/A N/A $619.20 N/A N/A $516.00 N/A N/A $79.92 N/A N/A $701.76 N/A N/A $505.68 N/A N/A $402.48 N/A N/A $722.40 N/A N/A $825.60 N/A N/A $567.60 N/A N/A $722.40 N/A N/A $345.72 N/A N/A $79.92 N/A N/A $619.20 N/A N/A $361.20 N/A N/A $670.80 N/A N/A $309.60 N/A N/A $619.20 N/A N/A $722.40 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A "$1,032.00 " "$1,032.00 " N/A 4010209 General Lab FMR1 METHYLATION ANALYSIS QST 81243 310 "$1,032.00 " $- $105.70 $- $- $825.60 $- N/A $268.32 N/A N/A $105.70 N/A N/A $619.20 N/A N/A $516.00 N/A N/A N/A N/A N/A $701.76 N/A N/A $505.68 N/A N/A $402.48 N/A N/A $722.40 N/A N/A $825.60 N/A N/A $567.60 N/A N/A $722.40 N/A N/A $345.72 N/A N/A N/A N/A N/A $619.20 N/A N/A $361.20 N/A N/A $670.80 N/A N/A $309.60 N/A N/A $619.20 N/A N/A $722.40 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A "$1,032.00 " "$1,032.00 " N/A 4010209 General Lab FRAGILE X PCR QST 88230 310 "$1,032.00 " $- $74.71 $- $- $825.60 $- N/A $268.32 N/A N/A $124.91 N/A N/A $619.20 N/A N/A $516.00 N/A N/A $74.71 N/A N/A $701.76 N/A N/A $505.68 N/A N/A $402.48 N/A N/A $722.40 N/A N/A $825.60 N/A N/A $567.60 N/A N/A $722.40 N/A N/A $345.72 N/A N/A $74.71 N/A N/A $619.20 N/A N/A $361.20 N/A N/A $670.80 N/A N/A $309.60 N/A N/A $619.20 N/A N/A $722.40 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A N/A $309.60 N/A "$1,032.00 " "$1,032.00 " N/A 4010211 General Lab ADRENAL AB QST 86255 302 $101.00 $- $7.73 $- $- $80.80 $- N/A $26.26 N/A N/A $12.92 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $7.73 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $7.73 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4010211 General Lab "ADRENAL AB, TITER QST" 86256 302 $101.00 $- $7.73 $- $- $80.80 $- N/A $26.26 N/A N/A $12.92 N/A N/A $60.60 N/A N/A $50.50 N/A N/A $7.73 N/A N/A $68.68 N/A N/A $49.49 N/A N/A $39.39 N/A N/A $70.70 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $70.70 N/A N/A $33.84 N/A N/A $7.73 N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $70.70 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 4010213 General Lab Candida Antigen Detection QST 86403 302 $160.00 $- $6.54 $- $- $128.00 $- N/A $41.60 N/A N/A $10.93 N/A N/A $96.00 N/A N/A $80.00 N/A N/A $6.54 N/A N/A $108.80 N/A N/A $78.40 N/A N/A $62.40 N/A N/A $112.00 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $112.00 N/A N/A $53.60 N/A N/A $6.54 N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $112.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 4010215 General Lab "Manganese, Blood QST" 83785 301 $205.00 $- $15.78 $- $- $164.00 $- N/A $53.30 N/A N/A $26.36 N/A N/A $123.00 N/A N/A $102.50 N/A N/A $15.78 N/A N/A $139.40 N/A N/A $100.45 N/A N/A $79.95 N/A N/A $143.50 N/A N/A $164.00 N/A N/A $112.75 N/A N/A $143.50 N/A N/A $68.68 N/A N/A $15.78 N/A N/A $123.00 N/A N/A $71.75 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $123.00 N/A N/A $143.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A $205.00 $205.00 N/A 4010217 General Lab Cytomegalovirus (CMV) QST 86644 302 $122.00 $- $9.24 $- $- $97.60 $- N/A $31.72 N/A N/A $15.43 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $9.24 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $9.24 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 4010219 General Lab Epstein Barr IgG Ab QST 86664 302 $127.00 $- $9.82 $- $- $101.60 $- N/A $33.02 N/A N/A $16.40 N/A N/A $76.20 N/A N/A $63.50 N/A N/A $9.82 N/A N/A $86.36 N/A N/A $62.23 N/A N/A $49.53 N/A N/A $88.90 N/A N/A $101.60 N/A N/A $69.85 N/A N/A $88.90 N/A N/A $42.55 N/A N/A $9.82 N/A N/A $76.20 N/A N/A $44.45 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $76.20 N/A N/A $88.90 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A $127.00 $127.00 N/A 4010221 General Lab "Amino Acid Analysis, Limited, Plasma QST" 82139 301 $143.00 $- $10.82 $- $- $114.40 $- N/A $37.18 N/A N/A $18.08 N/A N/A $85.80 N/A N/A $71.50 N/A N/A $10.82 N/A N/A $97.24 N/A N/A $70.07 N/A N/A $55.77 N/A N/A $100.10 N/A N/A $114.40 N/A N/A $78.65 N/A N/A $100.10 N/A N/A $47.91 N/A N/A $10.82 N/A N/A $85.80 N/A N/A $50.05 N/A N/A $92.95 N/A N/A $42.90 N/A N/A $85.80 N/A N/A $100.10 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A N/A $42.90 N/A $143.00 $143.00 N/A 4010223 General Lab Growth Hormone QST 83003 301 $142.00 $- $10.70 $- $- $113.60 $- N/A $36.92 N/A N/A $17.88 N/A N/A $85.20 N/A N/A $71.00 N/A N/A $10.70 N/A N/A $96.56 N/A N/A $69.58 N/A N/A $55.38 N/A N/A $99.40 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $99.40 N/A N/A $47.57 N/A N/A $10.70 N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $99.40 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 4010225 General Lab AChR Binding Ab QST 83519 302 $120.00 $- $8.67 $- $- $96.00 $- N/A $31.20 N/A N/A $14.48 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $8.67 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $8.67 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010225 General Lab "AQUAPORIN 4 (NMO) AB, IFA QST" 86255 302 $120.00 $- $7.73 $- $- $96.00 $- N/A $31.20 N/A N/A $12.92 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $7.73 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $7.73 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010225 General Lab Autoimmune Neurology Antibody Comprehensive Panel with Refle 86341 302 $120.00 $- $12.69 $- $- $96.00 $- N/A $31.20 N/A N/A $21.22 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $12.69 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $12.69 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010227 General Lab Myasthenia Gravis Panel 3 QST 86255 302 $125.00 $- $7.73 $- $- $100.00 $- N/A $32.50 N/A N/A $12.92 N/A N/A $75.00 N/A N/A $62.50 N/A N/A $7.73 N/A N/A $85.00 N/A N/A $61.25 N/A N/A $48.75 N/A N/A $87.50 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $87.50 N/A N/A $41.88 N/A N/A $7.73 N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $87.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 4010229 General Lab Pancreatic Elastase-1 QST 82656 301 $83.00 $- $7.40 $- $- $66.40 $- N/A $21.58 N/A N/A $12.37 N/A N/A $49.80 N/A N/A $41.50 N/A N/A $7.40 N/A N/A $56.44 N/A N/A $40.67 N/A N/A $32.37 N/A N/A $58.10 N/A N/A $66.40 N/A N/A $45.65 N/A N/A $58.10 N/A N/A $27.81 N/A N/A $7.40 N/A N/A $49.80 N/A N/A $29.05 N/A N/A $53.95 N/A N/A $24.90 N/A N/A $49.80 N/A N/A $58.10 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A $83.00 $83.00 N/A 4010231 General Lab "Liver Fibrosis, Fibro Test-ActiTest Panel QLS" 81596 300 $462.00 $- $56.30 $- $- $369.60 $- N/A $120.12 N/A N/A $56.30 N/A N/A $277.20 N/A N/A $231.00 N/A N/A N/A N/A N/A $314.16 N/A N/A $226.38 N/A N/A $180.18 N/A N/A $323.40 N/A N/A $369.60 N/A N/A $254.10 N/A N/A $323.40 N/A N/A $154.77 N/A N/A N/A N/A N/A $277.20 N/A N/A $161.70 N/A N/A $300.30 N/A N/A $138.60 N/A N/A $277.20 N/A N/A $323.40 N/A N/A $138.60 N/A N/A $138.60 N/A N/A $138.60 N/A N/A $138.60 N/A N/A $138.60 N/A N/A $138.60 N/A $462.00 $462.00 N/A 4010233 General Lab Crypto DFA QST 87015 306 $49.00 $- $4.29 $- $- $39.20 $- N/A $12.74 N/A N/A $7.16 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $4.29 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $4.29 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4010233 General Lab Crypto Source QST 87272 306 $49.00 $- $7.69 $- $- $39.20 $- N/A $12.74 N/A N/A $12.86 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $7.69 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $7.69 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4010235 General Lab Cyclo Isopora Source QST 87015 306 $49.00 $- $4.29 $- $- $39.20 $- N/A $12.74 N/A N/A $7.16 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $4.29 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $4.29 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4010235 General Lab Cyclospora and Isospora Examination QST 87207 300 $49.00 $- $3.85 $- $- $39.20 $- N/A $12.74 N/A N/A $6.43 N/A N/A $29.40 N/A N/A $24.50 N/A N/A $3.85 N/A N/A $33.32 N/A N/A $24.01 N/A N/A $19.11 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A $3.85 N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $34.30 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 4010237 General Lab Phenobarbital Level QST 80188 301 $120.00 $- $10.63 $- $- $96.00 $- N/A $31.20 N/A N/A $15.97 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $10.63 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $10.63 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010237 General Lab Primidone QST 80184 301 $120.00 $- $7.35 $- $- $96.00 $- N/A $31.20 N/A N/A $11.94 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $7.35 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $7.35 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4010239 General Lab HLA-B27 DNA Typing QST 81374 310 $518.00 $- $134.68 $- $- $414.40 $- N/A $134.68 N/A N/A $194.63 N/A N/A $310.80 N/A N/A $259.00 N/A N/A N/A N/A N/A $352.24 N/A N/A $253.82 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A N/A N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4010241 General Lab Soluble Transferrin Receptor QST 84238 301 $261.00 $- $23.46 $- $- $208.80 $- N/A $67.86 N/A N/A $39.22 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $23.46 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $23.46 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 4010243 General Lab "Methemoglobin, Blood QST" 83050 301 $55.00 $- $4.70 $- $- $44.00 $- N/A $14.30 N/A N/A $7.86 N/A N/A $33.00 N/A N/A $27.50 N/A N/A $4.70 N/A N/A $37.40 N/A N/A $26.95 N/A N/A $21.45 N/A N/A $38.50 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $38.50 N/A N/A $18.43 N/A N/A $4.70 N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $38.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 4010251 General Lab Respiratory Pathogen Panel QST 87581 306 $193.00 $- $22.51 $- $- $154.40 $- N/A $50.18 N/A N/A $37.63 N/A N/A $115.80 N/A N/A $96.50 N/A N/A $22.51 N/A N/A $131.24 N/A N/A $94.57 N/A N/A $75.27 N/A N/A $135.10 N/A N/A $154.40 N/A N/A $106.15 N/A N/A $135.10 N/A N/A $64.66 N/A N/A $22.51 N/A N/A $115.80 N/A N/A $67.55 N/A N/A $125.45 N/A N/A $57.90 N/A N/A $115.80 N/A N/A $135.10 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A N/A $57.90 N/A $193.00 $193.00 N/A 4010253 General Lab Chromosome Analysis Blood QST 88230 310 $957.00 $- $74.71 $- $- $765.60 $- N/A $248.82 N/A N/A $124.91 N/A N/A $574.20 N/A N/A $478.50 N/A N/A $74.71 N/A N/A $650.76 N/A N/A $468.93 N/A N/A $373.23 N/A N/A $669.90 N/A N/A $765.60 N/A N/A $526.35 N/A N/A $669.90 N/A N/A $320.60 N/A N/A $74.71 N/A N/A $574.20 N/A N/A $334.95 N/A N/A $622.05 N/A N/A $287.10 N/A N/A $574.20 N/A N/A $669.90 N/A N/A $287.10 N/A N/A $287.10 N/A N/A $287.10 N/A N/A $287.10 N/A N/A $287.10 N/A N/A $287.10 N/A $957.00 $957.00 N/A 4010257 General Lab "SARS Coronavirus with CoV-2 RNA, Qualitative Real-Time RT-PC" 87635 U0002 300 $66.00 $- $17.16 $- $- $61.57 $- N/A $17.16 N/A N/A $61.57 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A $32.34 N/A N/A $25.74 N/A N/A $46.20 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $46.20 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $46.20 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 4010257 General Lab "SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR QST" 87635 U0002 300 $66.00 $- $17.16 $- $- $61.57 $- N/A $17.16 N/A N/A $61.57 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A $32.34 N/A N/A $25.74 N/A N/A $46.20 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $46.20 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $46.20 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 4010257 General Lab "SARS-CoV-2 RNA, Qualitative Real-Time RT-PCR QST" 87635 U0002 300 $66.00 $- $17.16 $- $- $61.57 $- N/A $17.16 N/A N/A $61.57 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A $32.34 N/A N/A $25.74 N/A N/A $46.20 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $46.20 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $46.20 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 4010259 General Lab Respiratory Panel 2.1 (BioFire) 87631 0202U 300 "$2,378.00 " $- $137.54 $- $- "$1,902.40 " $- N/A $618.28 N/A N/A $137.54 N/A N/A "$1,426.80 " N/A N/A "$1,189.00 " N/A N/A N/A N/A N/A "$1,617.04 " N/A N/A "$1,165.22 " N/A N/A $927.42 N/A N/A "$1,664.60 " N/A N/A "$1,902.40 " N/A N/A "$1,307.90 " N/A N/A "$1,664.60 " N/A N/A $796.63 N/A N/A N/A N/A N/A "$1,426.80 " N/A N/A $832.30 N/A N/A "$1,545.70 " N/A N/A $713.40 N/A N/A "$1,426.80 " N/A N/A "$1,664.60 " N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A "$2,378.00 " "$2,378.00 " N/A 4010259 General Lab Respiratory Panel 2.1 (BioFire) 87631 0202U 300 "$2,378.00 " $- $137.54 $- $- "$1,902.40 " $- N/A $618.28 N/A N/A $137.54 N/A N/A "$1,426.80 " N/A N/A "$1,189.00 " N/A N/A N/A N/A N/A "$1,617.04 " N/A N/A "$1,165.22 " N/A N/A $927.42 N/A N/A "$1,664.60 " N/A N/A "$1,902.40 " N/A N/A "$1,307.90 " N/A N/A "$1,664.60 " N/A N/A $796.63 N/A N/A N/A N/A N/A "$1,426.80 " N/A N/A $832.30 N/A N/A "$1,545.70 " N/A N/A $713.40 N/A N/A "$1,426.80 " N/A N/A "$1,664.60 " N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A N/A $713.40 N/A "$2,378.00 " "$2,378.00 " N/A 4010261 General Lab SARSCoV2(COVID-19) IgG Abs Immnoassy QST 86769 302 $83.00 $- $21.58 $- $- $66.40 $- N/A $21.58 N/A N/A $50.56 N/A N/A $49.80 N/A N/A $41.50 N/A N/A N/A N/A N/A $56.44 N/A N/A $40.67 N/A N/A $32.37 N/A N/A $58.10 N/A N/A $66.40 N/A N/A $45.65 N/A N/A $58.10 N/A N/A $27.81 N/A N/A N/A N/A N/A $49.80 N/A N/A $29.05 N/A N/A $53.95 N/A N/A $24.90 N/A N/A $49.80 N/A N/A $58.10 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A N/A $24.90 N/A $83.00 $83.00 N/A 4010263 General Lab Police Draw 36415 300 $50.00 $- $2.51 $- $- $40.00 $- N/A $13.00 N/A N/A $3.35 N/A N/A $30.00 N/A N/A $25.00 N/A N/A $2.51 N/A N/A $34.00 N/A N/A $24.50 N/A N/A $19.50 N/A N/A $35.00 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $35.00 N/A N/A $16.75 N/A N/A $2.51 N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $35.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 4010265 General Lab BCR ABL1/ABL1% QST 81207 300 $695.00 $- $103.90 $- $- $556.00 $- N/A $180.70 N/A N/A $103.90 N/A N/A $417.00 N/A N/A $347.50 N/A N/A N/A N/A N/A $472.60 N/A N/A $340.55 N/A N/A $271.05 N/A N/A $486.50 N/A N/A $556.00 N/A N/A $382.25 N/A N/A $486.50 N/A N/A $232.83 N/A N/A N/A N/A N/A $417.00 N/A N/A $243.25 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $417.00 N/A N/A $486.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A $695.00 $695.00 N/A 4010265 General Lab BCR ABL1/ABL1% (IS) QST 81206 300 $695.00 $- $116.77 $- $- $556.00 $- N/A $180.70 N/A N/A $116.77 N/A N/A $417.00 N/A N/A $347.50 N/A N/A N/A N/A N/A $472.60 N/A N/A $340.55 N/A N/A $271.05 N/A N/A $486.50 N/A N/A $556.00 N/A N/A $382.25 N/A N/A $486.50 N/A N/A $232.83 N/A N/A N/A N/A N/A $417.00 N/A N/A $243.25 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $417.00 N/A N/A $486.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A $695.00 $695.00 N/A 4010267 General Lab Lymphocyte Subset Panel 4 QST 86360 302 $378.00 $- $30.13 $- $- $302.40 $- N/A $98.28 N/A N/A $50.38 N/A N/A $226.80 N/A N/A $189.00 N/A N/A $30.13 N/A N/A $257.04 N/A N/A $185.22 N/A N/A $147.42 N/A N/A $264.60 N/A N/A $302.40 N/A N/A $207.90 N/A N/A $264.60 N/A N/A $126.63 N/A N/A $30.13 N/A N/A $226.80 N/A N/A $132.30 N/A N/A $245.70 N/A N/A $113.40 N/A N/A $226.80 N/A N/A $264.60 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A $378.00 $378.00 N/A 4010267 General Lab Lymphocyte Subset Panel 4 QST 86360 302 $378.00 $- $30.13 $- $- $302.40 $- N/A $98.28 N/A N/A $50.38 N/A N/A $226.80 N/A N/A $189.00 N/A N/A $30.13 N/A N/A $257.04 N/A N/A $185.22 N/A N/A $147.42 N/A N/A $264.60 N/A N/A $302.40 N/A N/A $207.90 N/A N/A $264.60 N/A N/A $126.63 N/A N/A $30.13 N/A N/A $226.80 N/A N/A $132.30 N/A N/A $245.70 N/A N/A $113.40 N/A N/A $226.80 N/A N/A $264.60 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A $378.00 $378.00 N/A 4010269 General Lab Reticulocyte 85045 305 $142.00 $- $2.57 $- $- $113.60 $- N/A $36.92 N/A N/A $4.30 N/A N/A $85.20 N/A N/A $71.00 N/A N/A $2.57 N/A N/A $96.56 N/A N/A $69.58 N/A N/A $55.38 N/A N/A $99.40 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $99.40 N/A N/A $47.57 N/A N/A $2.57 N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $99.40 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 4010275 General Lab .Glucose Fasting 82947 301 $78.00 $- $2.52 $- $- $62.40 $- N/A $20.28 N/A N/A $4.20 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.52 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.52 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 4010277 General Lab .GTT-1 Hr 82950 301 $93.00 $- $3.05 $- $- $74.40 $- N/A $24.18 N/A N/A $5.09 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $3.05 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $3.05 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4010279 General Lab .GTT-2 Hr 82950 301 $93.00 $- $3.05 $- $- $74.40 $- N/A $24.18 N/A N/A $5.09 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $3.05 N/A N/A $63.24 N/A N/A $45.57 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A $3.05 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4010281 General Lab .GTT-3 Hr 82951 301 $246.00 $- $6.69 $- $- $196.80 $- N/A $63.96 N/A N/A $11.17 N/A N/A $147.60 N/A N/A $123.00 N/A N/A $6.69 N/A N/A $167.28 N/A N/A $120.54 N/A N/A $95.94 N/A N/A $172.20 N/A N/A $196.80 N/A N/A $135.30 N/A N/A $172.20 N/A N/A $82.41 N/A N/A $6.69 N/A N/A $147.60 N/A N/A $86.10 N/A N/A $159.90 N/A N/A $73.80 N/A N/A $147.60 N/A N/A $172.20 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A N/A $73.80 N/A $246.00 $246.00 N/A 4010285 General Lab "Allergy Panel 15, Cereal Group QST" 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 4010287 General Lab "Monkeypox Virus DNA, Qualitative Real-Time PCR QST" 87798 306 $445.00 $- $22.51 $- $- $356.00 $- N/A $115.70 N/A N/A $37.63 N/A N/A $267.00 N/A N/A $222.50 N/A N/A $22.51 N/A N/A $302.60 N/A N/A $218.05 N/A N/A $173.55 N/A N/A $311.50 N/A N/A $356.00 N/A N/A $244.75 N/A N/A $311.50 N/A N/A $149.08 N/A N/A $22.51 N/A N/A $267.00 N/A N/A $155.75 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $267.00 N/A N/A $311.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A $445.00 $445.00 N/A 4010297 General Lab hCG Quantitative 84702 301 $384.00 $- $9.01 $- $- $307.20 $- N/A $99.84 N/A N/A $15.06 N/A N/A $230.40 N/A N/A $192.00 N/A N/A $9.01 N/A N/A $261.12 N/A N/A $188.16 N/A N/A $149.76 N/A N/A $268.80 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $268.80 N/A N/A $128.64 N/A N/A $9.01 N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $268.80 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 4010301 General Lab C. Diff by Xpert 87493 306 $118.00 $- $22.51 $- $- $94.40 $- N/A $30.68 N/A N/A $37.63 N/A N/A $70.80 N/A N/A $59.00 N/A N/A $22.51 N/A N/A $80.24 N/A N/A $57.82 N/A N/A $46.02 N/A N/A $82.60 N/A N/A $94.40 N/A N/A $64.90 N/A N/A $82.60 N/A N/A $39.53 N/A N/A $22.51 N/A N/A $70.80 N/A N/A $41.30 N/A N/A $76.70 N/A N/A $35.40 N/A N/A $70.80 N/A N/A $82.60 N/A N/A $35.40 N/A N/A $35.40 N/A N/A $35.40 N/A N/A $35.40 N/A N/A $35.40 N/A N/A $35.40 N/A $118.00 $118.00 N/A 4010303 General Lab Chlamydia and Gonorrhoeae 0353U 300 $222.00 $- #N/A $- $- #N/A $- N/A $57.72 N/A N/A #N/A N/A N/A $133.20 N/A N/A $111.00 N/A N/A #N/A N/A N/A $150.96 N/A N/A $108.78 N/A N/A $86.58 N/A N/A $155.40 N/A N/A $177.60 N/A N/A $122.10 N/A N/A $155.40 N/A N/A $74.37 N/A N/A #N/A N/A N/A $133.20 N/A N/A $77.70 N/A N/A $144.30 N/A N/A $66.60 N/A N/A $133.20 N/A N/A $155.40 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A $222.00 $222.00 N/A 4010305 General Lab Chlamydia PCR Swab 87491 306 $110.00 $- $22.51 $- $- $88.00 $- N/A $28.60 N/A N/A $37.63 N/A N/A $66.00 N/A N/A $55.00 N/A N/A $22.51 N/A N/A $74.80 N/A N/A $53.90 N/A N/A $42.90 N/A N/A $77.00 N/A N/A $88.00 N/A N/A $60.50 N/A N/A $77.00 N/A N/A $36.85 N/A N/A $22.51 N/A N/A $66.00 N/A N/A $38.50 N/A N/A $71.50 N/A N/A $33.00 N/A N/A $66.00 N/A N/A $77.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A $110.00 $110.00 N/A 4010307 General Lab Flu/RSV PCR XPERT 87631 306 $449.00 $- #N/A $- $- #N/A $- N/A $116.74 N/A N/A $137.54 N/A N/A $269.40 N/A N/A $224.50 N/A N/A #N/A N/A N/A $305.32 N/A N/A $220.01 N/A N/A $175.11 N/A N/A $314.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $314.30 N/A N/A $150.42 N/A N/A #N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $314.30 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 4010309 General Lab Group B Strep by PCR 87653 306 $110.00 $- $22.51 $- $- $88.00 $- N/A $28.60 N/A N/A $37.63 N/A N/A $66.00 N/A N/A $55.00 N/A N/A $22.51 N/A N/A $74.80 N/A N/A $53.90 N/A N/A $42.90 N/A N/A $77.00 N/A N/A $88.00 N/A N/A $60.50 N/A N/A $77.00 N/A N/A $36.85 N/A N/A $22.51 N/A N/A $66.00 N/A N/A $38.50 N/A N/A $71.50 N/A N/A $33.00 N/A N/A $66.00 N/A N/A $77.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A $110.00 $110.00 N/A 4010313 General Lab MRSA Cult 1-87150|2-87150 306 $221.00 $- #N/A $- $- #N/A $- N/A $57.46 N/A N/A #N/A N/A N/A $132.60 N/A N/A $110.50 N/A N/A #N/A N/A N/A $150.28 N/A N/A $108.29 N/A N/A $86.19 N/A N/A $154.70 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $154.70 N/A N/A $74.04 N/A N/A #N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $154.70 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 4010315 General Lab RSV Rapid 87634 306 $222.00 $- $40.74 $- $- $177.60 $- N/A $57.72 N/A N/A $67.60 N/A N/A $133.20 N/A N/A $111.00 N/A N/A $40.74 N/A N/A $150.96 N/A N/A $108.78 N/A N/A $86.58 N/A N/A $155.40 N/A N/A $177.60 N/A N/A $122.10 N/A N/A $155.40 N/A N/A $74.37 N/A N/A $40.74 N/A N/A $133.20 N/A N/A $77.70 N/A N/A $144.30 N/A N/A $66.60 N/A N/A $133.20 N/A N/A $155.40 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A N/A $66.60 N/A $222.00 $222.00 N/A 4010317 General Lab SARS-CoV-2 (COVID-19) PCR (GeneXpert) 87635 306 $162.00 $- #N/A $- $- #N/A $- N/A $42.12 N/A N/A $61.57 N/A N/A $97.20 N/A N/A $81.00 N/A N/A #N/A N/A N/A $110.16 N/A N/A $79.38 N/A N/A $63.18 N/A N/A $113.40 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $113.40 N/A N/A $54.27 N/A N/A #N/A N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $113.40 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 4010319 General Lab SARS-CoV-2 (COVID-19)/Flu (GeneXpert) 0240U 300 $449.00 $- #N/A $- $- #N/A $- N/A $116.74 N/A N/A $171.16 N/A N/A $269.40 N/A N/A $224.50 N/A N/A #N/A N/A N/A $305.32 N/A N/A $220.01 N/A N/A $175.11 N/A N/A $314.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $314.30 N/A N/A $150.42 N/A N/A #N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $314.30 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 4010321 General Lab SARS-CoV-2 (COVID-19)/Flu/RSV (GeneXpert) 0241U 300 $449.00 $- #N/A $- $- #N/A $- N/A $116.74 N/A N/A $171.16 N/A N/A $269.40 N/A N/A $224.50 N/A N/A #N/A N/A N/A $305.32 N/A N/A $220.01 N/A N/A $175.11 N/A N/A $314.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $314.30 N/A N/A $150.42 N/A N/A #N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $314.30 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 4010323 General Lab Strep A PCR (GeneXpert) 87651 306 $110.00 $- $22.51 $- $- $88.00 $- N/A $28.60 N/A N/A $37.63 N/A N/A $66.00 N/A N/A $55.00 N/A N/A $22.51 N/A N/A $74.80 N/A N/A $53.90 N/A N/A $42.90 N/A N/A $77.00 N/A N/A $88.00 N/A N/A $60.50 N/A N/A $77.00 N/A N/A $36.85 N/A N/A $22.51 N/A N/A $66.00 N/A N/A $38.50 N/A N/A $71.50 N/A N/A $33.00 N/A N/A $66.00 N/A N/A $77.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A $110.00 $110.00 N/A 4010325 General Lab Trichomonas Vaginalis by Xpert 87661 306 $110.00 $- $22.50 $- $- $88.00 $- N/A $28.60 N/A N/A $37.34 N/A N/A $66.00 N/A N/A $55.00 N/A N/A $22.50 N/A N/A $74.80 N/A N/A $53.90 N/A N/A $42.90 N/A N/A $77.00 N/A N/A $88.00 N/A N/A $60.50 N/A N/A $77.00 N/A N/A $36.85 N/A N/A $22.50 N/A N/A $66.00 N/A N/A $38.50 N/A N/A $71.50 N/A N/A $33.00 N/A N/A $66.00 N/A N/A $77.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A N/A $33.00 N/A $110.00 $110.00 N/A 4010327 General Lab Xpress MVP (GeneXpert) 0352U 300 $449.00 $- #N/A $- $- #N/A $- N/A $116.74 N/A N/A #N/A N/A N/A $269.40 N/A N/A $224.50 N/A N/A #N/A N/A N/A $305.32 N/A N/A $220.01 N/A N/A $175.11 N/A N/A $314.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $314.30 N/A N/A $150.42 N/A N/A #N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $314.30 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 4010329 General Lab Chromosomal Microarray QST 81229 310 "$2,725.00 " $- #N/A $- $- #N/A $- N/A $708.50 N/A N/A $367.20 N/A N/A "$1,635.00 " N/A N/A "$1,362.50 " N/A N/A #N/A N/A N/A "$1,853.00 " N/A N/A "$1,335.25 " N/A N/A "$1,062.75 " N/A N/A "$1,907.50 " N/A N/A "$2,180.00 " N/A N/A "$1,498.75 " N/A N/A "$1,907.50 " N/A N/A $912.88 N/A N/A #N/A N/A N/A "$1,635.00 " N/A N/A $953.75 N/A N/A "$1,771.25 " N/A N/A $817.50 N/A N/A "$1,635.00 " N/A N/A "$1,907.50 " N/A N/A $817.50 N/A N/A $817.50 N/A N/A $817.50 N/A N/A $817.50 N/A N/A $817.50 N/A N/A $817.50 N/A "$2,725.00 " "$2,725.00 " N/A 4010331 General Lab General Health Pane 80050 - Bill only 80050 300 $135.00 $- $22.86 $- $- $108.00 $- N/A $35.10 N/A N/A $33.70 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $22.86 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $22.86 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 4020257 General Lab Bill RBC Pretreatment Serum 86978 300 $384.00 $- $16.75 $- $- $307.20 $- N/A $99.84 N/A N/A $19.93 N/A N/A $230.40 N/A N/A $192.00 N/A N/A $16.75 N/A N/A $261.12 N/A N/A $188.16 N/A N/A $149.76 N/A N/A $268.80 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $268.80 N/A N/A $128.64 N/A N/A $16.75 N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $268.80 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 4020282 General Lab Bill Physician BB Service XM 86077 305 $435.00 $- $24.60 $- $- $348.00 $- N/A $113.10 N/A N/A $39.78 N/A N/A $261.00 N/A N/A $217.50 N/A N/A $24.60 N/A N/A $295.80 N/A N/A $213.15 N/A N/A $169.65 N/A N/A $304.50 N/A N/A $348.00 N/A N/A $239.25 N/A N/A $304.50 N/A N/A $145.73 N/A N/A $24.60 N/A N/A $261.00 N/A N/A $152.25 N/A N/A $282.75 N/A N/A $130.50 N/A N/A $261.00 N/A N/A $304.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A N/A $130.50 N/A $435.00 $435.00 N/A 4020284 General Lab Bill RC Pretx Incubation w/ Enyzm 86971 390 $368.00 $- $11.16 $- $- $294.40 $- N/A $95.68 N/A N/A $13.48 N/A N/A $220.80 N/A N/A $184.00 N/A N/A $11.16 N/A N/A $250.24 N/A N/A $180.32 N/A N/A $143.52 N/A N/A $257.60 N/A N/A $294.40 N/A N/A $202.40 N/A N/A $257.60 N/A N/A $123.28 N/A N/A $11.16 N/A N/A $220.80 N/A N/A $128.80 N/A N/A $239.20 N/A N/A $110.40 N/A N/A $220.80 N/A N/A $257.60 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A $368.00 $368.00 N/A 4020290 General Lab Bill Antigen Type RBC 86905 300 $203.00 $- $2.46 $- $- $162.40 $- N/A $52.78 N/A N/A $4.09 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $2.46 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $2.46 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4020290 General Lab Bill Antigen Class I Patient 86905 300 $203.00 $- $2.46 $- $- $162.40 $- N/A $52.78 N/A N/A $4.09 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $2.46 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $2.46 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4020290 General Lab Bill Antigen Class II Patient 86905 300 $203.00 $- $2.46 $- $- $162.40 $- N/A $52.78 N/A N/A $4.09 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $2.46 N/A N/A $138.04 N/A N/A $99.47 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $2.46 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4020293 General Lab Bill Antigen Class I Unit 86902 300 $277.00 $- $2.46 $- $- $221.60 $- N/A $72.02 N/A N/A $4.09 N/A N/A $166.20 N/A N/A $138.50 N/A N/A $2.46 N/A N/A $188.36 N/A N/A $135.73 N/A N/A $108.03 N/A N/A $193.90 N/A N/A $221.60 N/A N/A $152.35 N/A N/A $193.90 N/A N/A $92.80 N/A N/A $2.46 N/A N/A $166.20 N/A N/A $96.95 N/A N/A $180.05 N/A N/A $83.10 N/A N/A $166.20 N/A N/A $193.90 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A $277.00 $277.00 N/A 4020293 General Lab Bill Antigen Class II Unit 86902 300 $277.00 $- $2.46 $- $- $221.60 $- N/A $72.02 N/A N/A $4.09 N/A N/A $166.20 N/A N/A $138.50 N/A N/A $2.46 N/A N/A $188.36 N/A N/A $135.73 N/A N/A $108.03 N/A N/A $193.90 N/A N/A $221.60 N/A N/A $152.35 N/A N/A $193.90 N/A N/A $92.80 N/A N/A $2.46 N/A N/A $166.20 N/A N/A $96.95 N/A N/A $180.05 N/A N/A $83.10 N/A N/A $166.20 N/A N/A $193.90 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A $277.00 $277.00 N/A 4021920 General Lab Bill Rh Phenotype 86906 302 $406.00 $- $4.98 $- $- $324.80 $- N/A $105.56 N/A N/A $8.32 N/A N/A $243.60 N/A N/A $203.00 N/A N/A $4.98 N/A N/A $276.08 N/A N/A $198.94 N/A N/A $158.34 N/A N/A $284.20 N/A N/A $324.80 N/A N/A $223.30 N/A N/A $284.20 N/A N/A $136.01 N/A N/A $4.98 N/A N/A $243.60 N/A N/A $142.10 N/A N/A $263.90 N/A N/A $121.80 N/A N/A $243.60 N/A N/A $284.20 N/A N/A $121.80 N/A N/A $121.80 N/A N/A $121.80 N/A N/A $121.80 N/A N/A $121.80 N/A N/A $121.80 N/A $406.00 $406.00 N/A 4024285 General Lab Bill RBC Pretx Incubation w/ Ch 86970 390 $339.00 $- $13.95 $- $- $271.20 $- N/A $88.14 N/A N/A $16.85 N/A N/A $203.40 N/A N/A $169.50 N/A N/A $13.95 N/A N/A $230.52 N/A N/A $166.11 N/A N/A $132.21 N/A N/A $237.30 N/A N/A $271.20 N/A N/A $186.45 N/A N/A $237.30 N/A N/A $113.57 N/A N/A $13.95 N/A N/A $203.40 N/A N/A $118.65 N/A N/A $220.35 N/A N/A $101.70 N/A N/A $203.40 N/A N/A $237.30 N/A N/A $101.70 N/A N/A $101.70 N/A N/A $101.70 N/A N/A $101.70 N/A N/A $101.70 N/A N/A $101.70 N/A $339.00 $339.00 N/A 4026903 General Lab Bill CMV Screening 86902 300 $189.00 $- $2.46 $- $- $151.20 $- N/A $49.14 N/A N/A $4.09 N/A N/A $113.40 N/A N/A $94.50 N/A N/A $2.46 N/A N/A $128.52 N/A N/A $92.61 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A $2.46 N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 4167002 General Lab Venous Blood Gas 4 82803 301 "$1,190.00 " $- $12.41 $- $- $952.00 $- N/A $309.40 N/A N/A $20.75 N/A N/A $714.00 N/A N/A $595.00 N/A N/A $12.41 N/A N/A $809.20 N/A N/A $583.10 N/A N/A $464.10 N/A N/A $833.00 N/A N/A $952.00 N/A N/A $654.50 N/A N/A $833.00 N/A N/A $398.65 N/A N/A $12.41 N/A N/A $714.00 N/A N/A $416.50 N/A N/A $773.50 N/A N/A $357.00 N/A N/A $714.00 N/A N/A $833.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A "$1,190.00 " "$1,190.00 " N/A 9000035 General Lab Acetaminophen Level 80143 301 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A N/A N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 9000118 General Lab Salicylate Level 80179 301 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A N/A N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 9009358 General Lab Zinc Level QST 84630 301 $334.00 $- $7.31 $- $- $267.20 $- N/A $86.84 N/A N/A $12.20 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $7.31 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $7.31 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 9009358 General Lab Zinc QLS 84630 301 $334.00 $- $7.31 $- $- $267.20 $- N/A $86.84 N/A N/A $12.20 N/A N/A $200.40 N/A N/A $167.00 N/A N/A $7.31 N/A N/A $227.12 N/A N/A $163.66 N/A N/A $130.26 N/A N/A $233.80 N/A N/A $267.20 N/A N/A $183.70 N/A N/A $233.80 N/A N/A $111.89 N/A N/A $7.31 N/A N/A $200.40 N/A N/A $116.90 N/A N/A $217.10 N/A N/A $100.20 N/A N/A $200.40 N/A N/A $233.80 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A N/A $100.20 N/A $334.00 $334.00 N/A 14001552 General Lab "Protein, Total, Synovial Fluid QLS" 84157 301 $196.00 $- $2.35 $- $- $156.80 $- N/A $50.96 N/A N/A $3.94 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $2.35 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $2.35 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 14001552 General Lab "Protein,Total,Synovial QST" 84157 301 $196.00 $- $2.35 $- $- $156.80 $- N/A $50.96 N/A N/A $3.94 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $2.35 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $2.35 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 18407825 General Lab Egg White 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407825 General Lab Egg White (F1) IgE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407826 General Lab Cow's Milk 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407826 General Lab Cow's Milk (f2) IgE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407827 General Lab Codfish 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407828 General Lab Wheat 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407828 General Lab Wheat (f4) IGE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407830 General Lab Sesame Seed 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407831 General Lab Peanut 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407831 General Lab Peanut IgE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407832 General Lab SOYBEAN (F14) IGE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 18407832 General Lab Soybean 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 18407833 General Lab Shrimp 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407833 General Lab Shrimp (F24) IgE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407835 General Lab Walnut 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 18407836 General Lab Scallop 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 24265493 General Lab Bill Red Cell Treatment - EGA/CHL/DTT 86970 390 $192.00 $- $13.95 $- $- $153.60 $- N/A $49.92 N/A N/A $16.85 N/A N/A $115.20 N/A N/A $96.00 N/A N/A $13.95 N/A N/A $130.56 N/A N/A $94.08 N/A N/A $74.88 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A $13.95 N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $57.60 N/A N/A $115.20 N/A N/A $134.40 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A N/A $57.60 N/A $192.00 $192.00 N/A 24265533 General Lab Bill Red Cell Separation 86905 302 $386.00 $- $2.46 $- $- $308.80 $- N/A $100.36 N/A N/A $4.09 N/A N/A $231.60 N/A N/A $193.00 N/A N/A $2.46 N/A N/A $262.48 N/A N/A $189.14 N/A N/A $150.54 N/A N/A $270.20 N/A N/A $308.80 N/A N/A $212.30 N/A N/A $270.20 N/A N/A $129.31 N/A N/A $2.46 N/A N/A $231.60 N/A N/A $135.10 N/A N/A $250.90 N/A N/A $115.80 N/A N/A $231.60 N/A N/A $270.20 N/A N/A $115.80 N/A N/A $115.80 N/A N/A $115.80 N/A N/A $115.80 N/A N/A $115.80 N/A N/A $115.80 N/A $386.00 $386.00 N/A 24319468 General Lab Carotene QST 82380 300 $58.00 $- $5.92 $- $- $46.40 $- N/A $15.08 N/A N/A $9.89 N/A N/A $34.80 N/A N/A $29.00 N/A N/A $5.92 N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A $5.92 N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 24359324 General Lab "Cortisol, Free 24 Hr Urine QST" 82530 301 $306.00 $- $10.72 $- $- $244.80 $- N/A $79.56 N/A N/A $17.92 N/A N/A $183.60 N/A N/A $153.00 N/A N/A $10.72 N/A N/A $208.08 N/A N/A $149.94 N/A N/A $119.34 N/A N/A $214.20 N/A N/A $244.80 N/A N/A $168.30 N/A N/A $214.20 N/A N/A $102.51 N/A N/A $10.72 N/A N/A $183.60 N/A N/A $107.10 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $183.60 N/A N/A $214.20 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A $306.00 $306.00 N/A 24359324 General Lab "Cortisol, Free, 24-Hr Urine w/Creatinine, LC/MS/MS QLS" 82530 301 $306.00 $- $10.72 $- $- $244.80 $- N/A $79.56 N/A N/A $17.92 N/A N/A $183.60 N/A N/A $153.00 N/A N/A $10.72 N/A N/A $208.08 N/A N/A $149.94 N/A N/A $119.34 N/A N/A $214.20 N/A N/A $244.80 N/A N/A $168.30 N/A N/A $214.20 N/A N/A $102.51 N/A N/A $10.72 N/A N/A $183.60 N/A N/A $107.10 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $183.60 N/A N/A $214.20 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A $306.00 $306.00 N/A 24385173 General Lab Calcitonin Level QLS 82308 301 $171.00 $- $17.18 $- $- $136.80 $- N/A $44.46 N/A N/A $28.72 N/A N/A $102.60 N/A N/A $85.50 N/A N/A $17.18 N/A N/A $116.28 N/A N/A $83.79 N/A N/A $66.69 N/A N/A $119.70 N/A N/A $136.80 N/A N/A $94.05 N/A N/A $119.70 N/A N/A $57.29 N/A N/A $17.18 N/A N/A $102.60 N/A N/A $59.85 N/A N/A $111.15 N/A N/A $51.30 N/A N/A $102.60 N/A N/A $119.70 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A N/A $51.30 N/A $171.00 $171.00 N/A 25135194 General Lab Health Fair Male 82947 301 $40.00 $- $2.52 $- $- $32.00 $- N/A $10.40 N/A N/A $4.20 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $2.52 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $2.52 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25135194 General Lab Health Fair Male 80061 301 $40.00 $- $8.60 $- $- $32.00 $- N/A $10.40 N/A N/A $14.36 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $8.60 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $8.60 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25135194 General Lab Health Fair Male 84153 301 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $19.73 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $11.80 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $11.80 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25135194 General Lab Health Fair Male 84443 301 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $18.02 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $10.79 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $10.79 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25135198 General Lab Health Fair Female BCH 82947 301 $30.00 $- $2.52 $- $- $24.00 $- N/A $7.80 N/A N/A $4.20 N/A N/A $18.00 N/A N/A $15.00 N/A N/A $2.52 N/A N/A $20.40 N/A N/A $14.70 N/A N/A $11.70 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A $2.52 N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A $9.00 N/A N/A $18.00 N/A N/A $21.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A $30.00 $30.00 N/A 25135198 General Lab Health Fair Female BCH 80061 301 $30.00 $- $7.80 $- $- $24.00 $- N/A $7.80 N/A N/A $14.36 N/A N/A $18.00 N/A N/A $15.00 N/A N/A $8.60 N/A N/A $20.40 N/A N/A $14.70 N/A N/A $11.70 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A $8.60 N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A $9.00 N/A N/A $18.00 N/A N/A $21.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A $30.00 $30.00 N/A 25135198 General Lab Health Fair Female BCH 84443 301 $30.00 $- $7.80 $- $- $24.00 $- N/A $7.80 N/A N/A $18.02 N/A N/A $18.00 N/A N/A $15.00 N/A N/A $10.79 N/A N/A $20.40 N/A N/A $14.70 N/A N/A $11.70 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A $10.79 N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A $9.00 N/A N/A $18.00 N/A N/A $21.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A N/A $9.00 N/A $30.00 $30.00 N/A 25629142 General Lab "Aripiprazole, Quantitative Serum QST" 80299 301 $135.00 $- $8.78 $- $- $108.00 $- N/A $35.10 N/A N/A $14.54 N/A N/A $81.00 N/A N/A $67.50 N/A N/A $8.78 N/A N/A $91.80 N/A N/A $66.15 N/A N/A $52.65 N/A N/A $94.50 N/A N/A $108.00 N/A N/A $74.25 N/A N/A $94.50 N/A N/A $45.23 N/A N/A $8.78 N/A N/A $81.00 N/A N/A $47.25 N/A N/A $87.75 N/A N/A $40.50 N/A N/A $81.00 N/A N/A $94.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A N/A $40.50 N/A $135.00 $135.00 N/A 25632484 General Lab Hazelnut 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 25632489 General Lab Almond 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 25632489 General Lab Almond (f20) IgE QST 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 25632502 General Lab Codfish (f3) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25632502 General Lab Salmon (f41) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25632502 General Lab Tuna 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25632502 General Lab Tuna (F40) IgE QST 86003 302 $40.00 $- $3.35 $- $- $32.00 $- N/A $10.40 N/A N/A $5.59 N/A N/A $24.00 N/A N/A $20.00 N/A N/A $3.35 N/A N/A $27.20 N/A N/A $19.60 N/A N/A $15.60 N/A N/A $28.00 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $28.00 N/A N/A $13.40 N/A N/A $3.35 N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $28.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 25632517 General Lab Cashew Nut 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 25632518 General Lab Salmon 86003 302 $42.00 $- $3.35 $- $- $33.60 $- N/A $10.92 N/A N/A $5.59 N/A N/A $25.20 N/A N/A $21.00 N/A N/A $3.35 N/A N/A $28.56 N/A N/A $20.58 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A $3.35 N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 40000126 General Lab "Tobramycin, Peak QLS" 80200 301 $446.00 $- $10.34 $- $- $356.80 $- N/A $115.96 N/A N/A $17.28 N/A N/A $267.60 N/A N/A $223.00 N/A N/A $10.34 N/A N/A $303.28 N/A N/A $218.54 N/A N/A $173.94 N/A N/A $312.20 N/A N/A $356.80 N/A N/A $245.30 N/A N/A $312.20 N/A N/A $149.41 N/A N/A $10.34 N/A N/A $267.60 N/A N/A $156.10 N/A N/A $289.90 N/A N/A $133.80 N/A N/A $267.60 N/A N/A $312.20 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A $446.00 $446.00 N/A 40004446 General Lab Reticulocyte Count QST 85045 305 $132.00 $- $2.57 $- $- $105.60 $- N/A $34.32 N/A N/A $4.30 N/A N/A $79.20 N/A N/A $66.00 N/A N/A $2.57 N/A N/A $89.76 N/A N/A $64.68 N/A N/A $51.48 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A $2.57 N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $92.40 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 40010055 General Lab "IL-6, Highly Sensitive QST" 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 40010055 General Lab Interleukin-6 QLS 83520 301 $448.00 $- $8.31 $- $- $358.40 $- N/A $116.48 N/A N/A $13.88 N/A N/A $268.80 N/A N/A $224.00 N/A N/A $8.31 N/A N/A $304.64 N/A N/A $219.52 N/A N/A $174.72 N/A N/A $313.60 N/A N/A $358.40 N/A N/A $246.40 N/A N/A $313.60 N/A N/A $150.08 N/A N/A $8.31 N/A N/A $268.80 N/A N/A $156.80 N/A N/A $291.20 N/A N/A $134.40 N/A N/A $268.80 N/A N/A $313.60 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 40053331 General Lab "Cortisol, Total QST" 82533 301 $237.00 $- $10.46 $- $- $189.60 $- N/A $61.62 N/A N/A $17.48 N/A N/A $142.20 N/A N/A $118.50 N/A N/A $10.46 N/A N/A $161.16 N/A N/A $116.13 N/A N/A $92.43 N/A N/A $165.90 N/A N/A $189.60 N/A N/A $130.35 N/A N/A $165.90 N/A N/A $79.40 N/A N/A $10.46 N/A N/A $142.20 N/A N/A $82.95 N/A N/A $154.05 N/A N/A $71.10 N/A N/A $142.20 N/A N/A $165.90 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A N/A $71.10 N/A $237.00 $237.00 N/A 40080327 General Lab "Dihydrotestosterone, LC/MS/MS QST" 80327 G0480 301 $350.00 $- $0.01 $- $- $280.00 $- N/A $91.00 N/A N/A $0.01 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 40080327 General Lab Dihydrotestosterone QST 80327 G0480 301 $350.00 $- $0.01 $- $- $280.00 $- N/A $91.00 N/A N/A $0.01 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A $171.50 N/A N/A $136.50 N/A N/A $245.00 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $245.00 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $245.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 40085379 General Lab Innovance D-Dimer QLS 85379 305 $188.00 $- $6.54 $- $- $150.40 $- N/A $48.88 N/A N/A $10.91 N/A N/A $112.80 N/A N/A $94.00 N/A N/A $6.54 N/A N/A $127.84 N/A N/A $92.12 N/A N/A $73.32 N/A N/A $131.60 N/A N/A $150.40 N/A N/A $103.40 N/A N/A $131.60 N/A N/A $62.98 N/A N/A $6.54 N/A N/A $112.80 N/A N/A $65.80 N/A N/A $122.20 N/A N/A $56.40 N/A N/A $112.80 N/A N/A $131.60 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A N/A $56.40 N/A $188.00 $188.00 N/A 40087556 General Lab M. Avium Complex Mic Panel QLS 87556 306 $637.00 $- $22.51 $- $- $509.60 $- N/A $165.62 N/A N/A $37.63 N/A N/A $382.20 N/A N/A $318.50 N/A N/A $22.51 N/A N/A $433.16 N/A N/A $312.13 N/A N/A $248.43 N/A N/A $445.90 N/A N/A $509.60 N/A N/A $350.35 N/A N/A $445.90 N/A N/A $213.40 N/A N/A $22.51 N/A N/A $382.20 N/A N/A $222.95 N/A N/A $414.05 N/A N/A $191.10 N/A N/A $382.20 N/A N/A $445.90 N/A N/A $191.10 N/A N/A $191.10 N/A N/A $191.10 N/A N/A $191.10 N/A N/A $191.10 N/A N/A $191.10 N/A $637.00 $637.00 N/A 40101119 General Lab "Chloride, Feces QST" 82438 301 $74.00 $- $3.14 $- $- $59.20 $- N/A $19.24 N/A N/A $5.24 N/A N/A $44.40 N/A N/A $37.00 N/A N/A $3.14 N/A N/A $50.32 N/A N/A $36.26 N/A N/A $28.86 N/A N/A $51.80 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $51.80 N/A N/A $24.79 N/A N/A $3.14 N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $51.80 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 40101201 General Lab "Trichomonas vaginalisRNA, Qualitative, TMA, Males" 87661 306 $293.00 $- $22.50 $- $- $234.40 $- N/A $76.18 N/A N/A $37.34 N/A N/A $175.80 N/A N/A $146.50 N/A N/A $22.50 N/A N/A $199.24 N/A N/A $143.57 N/A N/A $114.27 N/A N/A $205.10 N/A N/A $234.40 N/A N/A $161.15 N/A N/A $205.10 N/A N/A $98.16 N/A N/A $22.50 N/A N/A $175.80 N/A N/A $102.55 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $175.80 N/A N/A $205.10 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A $293.00 $293.00 N/A 90036592 General Lab "Porphyrins, Fractionated, Quant, Random Ur QLS" 84120 301 $269.00 $- $9.44 $- $- $215.20 $- N/A $69.94 N/A N/A $15.77 N/A N/A $161.40 N/A N/A $134.50 N/A N/A $9.44 N/A N/A $182.92 N/A N/A $131.81 N/A N/A $104.91 N/A N/A $188.30 N/A N/A $215.20 N/A N/A $147.95 N/A N/A $188.30 N/A N/A $90.12 N/A N/A $9.44 N/A N/A $161.40 N/A N/A $94.15 N/A N/A $174.85 N/A N/A $80.70 N/A N/A $161.40 N/A N/A $188.30 N/A N/A $80.70 N/A N/A $80.70 N/A N/A $80.70 N/A N/A $80.70 N/A N/A $80.70 N/A N/A $80.70 N/A $269.00 $269.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QLS 81261 G0452 300 $249.00 $- $64.74 $- $- $199.20 $- N/A $64.74 N/A N/A $125.09 N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QLS 81264 G0452 300 $249.00 $- $64.74 $- $- $199.20 $- N/A $64.74 N/A N/A $158.90 N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QLS 81342 G0452 300 $249.00 $- $64.74 $- $- $199.20 $- N/A $64.74 N/A N/A $193.20 N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QLS 81340 G0452 300 $249.00 $- $64.74 $- $- $231.00 $- N/A $64.74 N/A N/A $231.00 N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QLS 84999 G0452 300 $249.00 $- $64.74 $- $- $199.20 $- N/A $64.74 N/A N/A N/A N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90081261 General Lab Lymphocyte Subset Panel 5 QST 84999 300 $249.00 $- $64.74 $- $- $199.20 $- N/A $64.74 N/A N/A N/A N/A N/A $149.40 N/A N/A $124.50 N/A N/A N/A N/A N/A $169.32 N/A N/A $122.01 N/A N/A $97.11 N/A N/A $174.30 N/A N/A $199.20 N/A N/A $136.95 N/A N/A $174.30 N/A N/A $83.42 N/A N/A N/A N/A N/A $149.40 N/A N/A $87.15 N/A N/A $161.85 N/A N/A $74.70 N/A N/A $149.40 N/A N/A $174.30 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A N/A $74.70 N/A $249.00 $249.00 N/A 90084120 General Lab "Porphyrins, Fract, Quant, 24Hr Ur QLS" 84120 301 $422.00 $- $9.44 $- $- $337.60 $- N/A $109.72 N/A N/A $15.77 N/A N/A $253.20 N/A N/A $211.00 N/A N/A $9.44 N/A N/A $286.96 N/A N/A $206.78 N/A N/A $164.58 N/A N/A $295.40 N/A N/A $337.60 N/A N/A $232.10 N/A N/A $295.40 N/A N/A $141.37 N/A N/A $9.44 N/A N/A $253.20 N/A N/A $147.70 N/A N/A $274.30 N/A N/A $126.60 N/A N/A $253.20 N/A N/A $295.40 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A $422.00 $422.00 N/A 90084120 General Lab "Porphyrins, Fract, Quant, 24Hr Ur QLS" 84110 301 $422.00 $- $5.42 $- $- $337.60 $- N/A $109.72 N/A N/A $9.05 N/A N/A $253.20 N/A N/A $211.00 N/A N/A $5.42 N/A N/A $286.96 N/A N/A $206.78 N/A N/A $164.58 N/A N/A $295.40 N/A N/A $337.60 N/A N/A $232.10 N/A N/A $295.40 N/A N/A $141.37 N/A N/A $5.42 N/A N/A $253.20 N/A N/A $147.70 N/A N/A $274.30 N/A N/A $126.60 N/A N/A $253.20 N/A N/A $295.40 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A N/A $126.60 N/A $422.00 $422.00 N/A 90084439 General Lab Free T4 84439 301 $281.00 $- $5.79 $- $- $224.80 $- N/A $73.06 N/A N/A $9.67 N/A N/A $168.60 N/A N/A $140.50 N/A N/A $5.79 N/A N/A $191.08 N/A N/A $137.69 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $5.79 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $182.65 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 90084439 General Lab "T4 Free, Direct Dialysis QLS" 84439 301 $281.00 $- $5.79 $- $- $224.80 $- N/A $73.06 N/A N/A $9.67 N/A N/A $168.60 N/A N/A $140.50 N/A N/A $5.79 N/A N/A $191.08 N/A N/A $137.69 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $5.79 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $182.65 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 90084439 General Lab "T4, Free Direct Dialysis QST" 84439 301 $281.00 $- $5.79 $- $- $224.80 $- N/A $73.06 N/A N/A $9.67 N/A N/A $168.60 N/A N/A $140.50 N/A N/A $5.79 N/A N/A $191.08 N/A N/A $137.69 N/A N/A $109.59 N/A N/A $196.70 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $196.70 N/A N/A $94.14 N/A N/A $5.79 N/A N/A $168.60 N/A N/A $98.35 N/A N/A $182.65 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $196.70 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 90086355 General Lab "T and B Cells,Total QLS" 86355 302 $190.00 $- $24.19 $- $- $152.00 $- N/A $49.40 N/A N/A $40.44 N/A N/A $114.00 N/A N/A $95.00 N/A N/A $24.19 N/A N/A $129.20 N/A N/A $93.10 N/A N/A $74.10 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A $24.19 N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A $57.00 N/A N/A $114.00 N/A N/A $133.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A $190.00 $190.00 N/A 90086355 General Lab "T and B Cells,Total QLS" 86359 302 $190.00 $- $49.40 $- $- $152.00 $- N/A $49.40 N/A N/A N/A N/A N/A $114.00 N/A N/A $95.00 N/A N/A N/A N/A N/A $129.20 N/A N/A $93.10 N/A N/A $74.10 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A N/A N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A $57.00 N/A N/A $114.00 N/A N/A $133.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A $190.00 $190.00 N/A 90086355 General Lab "T AND B Cells, Total QST" 86359 302 $190.00 $- $49.40 $- $- $152.00 $- N/A $49.40 N/A N/A N/A N/A N/A $114.00 N/A N/A $95.00 N/A N/A N/A N/A N/A $129.20 N/A N/A $93.10 N/A N/A $74.10 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A N/A N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A $57.00 N/A N/A $114.00 N/A N/A $133.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A $190.00 $190.00 N/A 90186711 General Lab Stratify JCV AB (Windex) QLS 86711 302 "$2,367.00 " $- $15.43 $- $- "$1,893.60 " $- N/A $615.42 N/A N/A $15.43 N/A N/A "$1,420.20 " N/A N/A "$1,183.50 " N/A N/A N/A N/A N/A "$1,609.56 " N/A N/A "$1,159.83 " N/A N/A $923.13 N/A N/A "$1,656.90 " N/A N/A "$1,893.60 " N/A N/A "$1,301.85 " N/A N/A "$1,656.90 " N/A N/A $792.95 N/A N/A N/A N/A N/A "$1,420.20 " N/A N/A $828.45 N/A N/A "$1,538.55 " N/A N/A $710.10 N/A N/A "$1,420.20 " N/A N/A "$1,656.90 " N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A "$2,367.00 " "$2,367.00 " N/A 90186711 General Lab Stratify JCV Ab w/ rflx to Inhibition QST 86711 302 "$2,367.00 " $- $15.43 $- $- "$1,893.60 " $- N/A $615.42 N/A N/A $15.43 N/A N/A "$1,420.20 " N/A N/A "$1,183.50 " N/A N/A N/A N/A N/A "$1,609.56 " N/A N/A "$1,159.83 " N/A N/A $923.13 N/A N/A "$1,656.90 " N/A N/A "$1,893.60 " N/A N/A "$1,301.85 " N/A N/A "$1,656.90 " N/A N/A $792.95 N/A N/A N/A N/A N/A "$1,420.20 " N/A N/A $828.45 N/A N/A "$1,538.55 " N/A N/A $710.10 N/A N/A "$1,420.20 " N/A N/A "$1,656.90 " N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A N/A $710.10 N/A "$2,367.00 " "$2,367.00 " N/A 90188305 General Lab "Bill IV-Path, GM, TC" 88305 310 $373.00 $- $34.33 $- $- $298.40 $- N/A $96.98 N/A N/A $56.77 N/A N/A $223.80 N/A N/A $186.50 N/A N/A $34.33 N/A N/A $253.64 N/A N/A $182.77 N/A N/A $145.47 N/A N/A $261.10 N/A N/A $298.40 N/A N/A $205.15 N/A N/A $261.10 N/A N/A $124.96 N/A N/A $34.33 N/A N/A $223.80 N/A N/A $130.55 N/A N/A $242.45 N/A N/A $111.90 N/A N/A $223.80 N/A N/A $261.10 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A N/A $111.90 N/A $373.00 $373.00 N/A 90188342 General Lab "Bill IHC, 1 AB, TC" 88342 310 $473.00 $- $52.52 $- $- $378.40 $- N/A $122.98 N/A N/A $94.06 N/A N/A $283.80 N/A N/A $236.50 N/A N/A $52.52 N/A N/A $321.64 N/A N/A $231.77 N/A N/A $184.47 N/A N/A $331.10 N/A N/A $378.40 N/A N/A $260.15 N/A N/A $331.10 N/A N/A $158.46 N/A N/A $52.52 N/A N/A $283.80 N/A N/A $165.55 N/A N/A $307.45 N/A N/A $141.90 N/A N/A $283.80 N/A N/A $331.10 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A N/A $141.90 N/A $473.00 $473.00 N/A 91000651 General Lab "PSA, Total (Diagnostic) (f) QLS" 84153 G0103 301 $292.00 $- $11.80 $- $- $233.60 $- N/A $75.92 N/A N/A $19.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $11.80 N/A N/A $198.56 N/A N/A $143.08 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $160.60 N/A N/A $204.40 N/A N/A $97.82 N/A N/A $11.80 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $189.80 N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 94000203 General Lab "HIV 1 RNA, QL TMA QST" 87536 302 $656.00 $- $54.57 $- $- $524.80 $- N/A $170.56 N/A N/A $91.22 N/A N/A $393.60 N/A N/A $328.00 N/A N/A $54.57 N/A N/A $446.08 N/A N/A $321.44 N/A N/A $255.84 N/A N/A $459.20 N/A N/A $524.80 N/A N/A $360.80 N/A N/A $459.20 N/A N/A $219.76 N/A N/A $54.57 N/A N/A $393.60 N/A N/A $229.60 N/A N/A $426.40 N/A N/A $196.80 N/A N/A $393.60 N/A N/A $459.20 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A $656.00 $656.00 N/A 94000203 General Lab "HIV 1 RNA, Quant PCR QST" 87536 306 $656.00 $- $54.57 $- $- $524.80 $- N/A $170.56 N/A N/A $91.22 N/A N/A $393.60 N/A N/A $328.00 N/A N/A $54.57 N/A N/A $446.08 N/A N/A $321.44 N/A N/A $255.84 N/A N/A $459.20 N/A N/A $524.80 N/A N/A $360.80 N/A N/A $459.20 N/A N/A $219.76 N/A N/A $54.57 N/A N/A $393.60 N/A N/A $229.60 N/A N/A $426.40 N/A N/A $196.80 N/A N/A $393.60 N/A N/A $459.20 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A $656.00 $656.00 N/A 94000203 General Lab "HIV-1 RNA, Quant Real-Time PCR QLS" 87536 306 $656.00 $- $54.57 $- $- $524.80 $- N/A $170.56 N/A N/A $91.22 N/A N/A $393.60 N/A N/A $328.00 N/A N/A $54.57 N/A N/A $446.08 N/A N/A $321.44 N/A N/A $255.84 N/A N/A $459.20 N/A N/A $524.80 N/A N/A $360.80 N/A N/A $459.20 N/A N/A $219.76 N/A N/A $54.57 N/A N/A $393.60 N/A N/A $229.60 N/A N/A $426.40 N/A N/A $196.80 N/A N/A $393.60 N/A N/A $459.20 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A N/A $196.80 N/A $656.00 $656.00 N/A 94000428 General Lab Lamotrigine (Lamictal) Level QST 80175 301 $243.00 $- $8.51 $- $- $194.40 $- N/A $63.18 N/A N/A $14.11 N/A N/A $145.80 N/A N/A $121.50 N/A N/A $8.51 N/A N/A $165.24 N/A N/A $119.07 N/A N/A $94.77 N/A N/A $170.10 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $170.10 N/A N/A $81.41 N/A N/A $8.51 N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $170.10 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 94000428 General Lab Lamotrigine QLS 80175 301 $243.00 $- $8.51 $- $- $194.40 $- N/A $63.18 N/A N/A $14.11 N/A N/A $145.80 N/A N/A $121.50 N/A N/A $8.51 N/A N/A $165.24 N/A N/A $119.07 N/A N/A $94.77 N/A N/A $170.10 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $170.10 N/A N/A $81.41 N/A N/A $8.51 N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $170.10 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 94000615 General Lab Lipid Panel QLS 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 94000615 General Lab Lipid Panel QST 80061 301 $261.00 $- $8.60 $- $- $208.80 $- N/A $67.86 N/A N/A $14.36 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $8.60 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $8.60 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 94001552 General Lab "Protein, Pleural Fluid QLS" 84157 301 $196.00 $- $2.35 $- $- $156.80 $- N/A $50.96 N/A N/A $3.94 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $2.35 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $2.35 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 94001552 General Lab "Protein, Total, Pleural Fluid QST" 84157 301 $196.00 $- $2.35 $- $- $156.80 $- N/A $50.96 N/A N/A $3.94 N/A N/A $117.60 N/A N/A $98.00 N/A N/A $2.35 N/A N/A $133.28 N/A N/A $96.04 N/A N/A $76.44 N/A N/A $137.20 N/A N/A $156.80 N/A N/A $107.80 N/A N/A $137.20 N/A N/A $65.66 N/A N/A $2.35 N/A N/A $117.60 N/A N/A $68.60 N/A N/A $127.40 N/A N/A $58.80 N/A N/A $117.60 N/A N/A $137.20 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A N/A $58.80 N/A $196.00 $196.00 N/A 94003121 General Lab Potassium QLS 84132 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 94003121 General Lab Potassium QST 84132 301 $92.00 $- $2.96 $- $- $73.60 $- N/A $23.92 N/A N/A $4.93 N/A N/A $55.20 N/A N/A $46.00 N/A N/A $2.96 N/A N/A $62.56 N/A N/A $45.08 N/A N/A $35.88 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A $2.96 N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $27.60 N/A N/A $55.20 N/A N/A $64.40 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A N/A $27.60 N/A $92.00 $92.00 N/A 94005651 General Lab "Potassium, Random Urine QLS" 84133 301 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A N/A N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 94005651 General Lab "Potassium, Random Urine QLS" 82570 301 $84.00 $- $3.32 $- $- $67.20 $- N/A $21.84 N/A N/A $5.54 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $3.32 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $3.32 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 94005651 General Lab Potassium/Creatinine Rand Ur Panel 84133 301 $84.00 $- $2.77 $- $- $67.20 $- N/A $21.84 N/A N/A $4.61 N/A N/A $50.40 N/A N/A $42.00 N/A N/A $2.77 N/A N/A $57.12 N/A N/A $41.16 N/A N/A $32.76 N/A N/A $58.80 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $58.80 N/A N/A $28.14 N/A N/A $2.77 N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $58.80 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 94006104 General Lab Prothrombin with INR 85610 305 $78.00 $- $2.53 $- $- $62.40 $- N/A $20.28 N/A N/A $4.21 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $2.53 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $2.53 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 94006155 General Lab LD QLS 83615 301 $121.00 $- $3.88 $- $- $96.80 $- N/A $31.46 N/A N/A $6.48 N/A N/A $72.60 N/A N/A $60.50 N/A N/A $3.88 N/A N/A $82.28 N/A N/A $59.29 N/A N/A $47.19 N/A N/A $84.70 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $84.70 N/A N/A $40.54 N/A N/A $3.88 N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $84.70 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 94006155 General Lab LD QST 83615 301 $121.00 $- $3.88 $- $- $96.80 $- N/A $31.46 N/A N/A $6.48 N/A N/A $72.60 N/A N/A $60.50 N/A N/A $3.88 N/A N/A $82.28 N/A N/A $59.29 N/A N/A $47.19 N/A N/A $84.70 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $84.70 N/A N/A $40.54 N/A N/A $3.88 N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $84.70 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 94006500 General Lab Sed Rate By Modified Westergren QST 85652 305 $51.00 $- $1.74 $- $- $40.80 $- N/A $13.26 N/A N/A $2.89 N/A N/A $30.60 N/A N/A $25.50 N/A N/A $1.74 N/A N/A $34.68 N/A N/A $24.99 N/A N/A $19.89 N/A N/A $35.70 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $35.70 N/A N/A $17.09 N/A N/A $1.74 N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $35.70 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 94006500 General Lab Sed Rate By Modified Westergren QST 85652 305 $51.00 $- $1.74 $- $- $40.80 $- N/A $13.26 N/A N/A $2.89 N/A N/A $30.60 N/A N/A $25.50 N/A N/A $1.74 N/A N/A $34.68 N/A N/A $24.99 N/A N/A $19.89 N/A N/A $35.70 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $35.70 N/A N/A $17.09 N/A N/A $1.74 N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $35.70 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 94006908 General Lab Lipase QLS 83690 301 $321.00 $- $4.42 $- $- $256.80 $- N/A $83.46 N/A N/A $7.39 N/A N/A $192.60 N/A N/A $160.50 N/A N/A $4.42 N/A N/A $218.28 N/A N/A $157.29 N/A N/A $125.19 N/A N/A $224.70 N/A N/A $256.80 N/A N/A $176.55 N/A N/A $224.70 N/A N/A $107.54 N/A N/A $4.42 N/A N/A $192.60 N/A N/A $112.35 N/A N/A $208.65 N/A N/A $96.30 N/A N/A $192.60 N/A N/A $224.70 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A $321.00 $321.00 N/A 94006908 General Lab Lipase QST 83690 301 $321.00 $- $4.42 $- $- $256.80 $- N/A $83.46 N/A N/A $7.39 N/A N/A $192.60 N/A N/A $160.50 N/A N/A $4.42 N/A N/A $218.28 N/A N/A $157.29 N/A N/A $125.19 N/A N/A $224.70 N/A N/A $256.80 N/A N/A $176.55 N/A N/A $224.70 N/A N/A $107.54 N/A N/A $4.42 N/A N/A $192.60 N/A N/A $112.35 N/A N/A $208.65 N/A N/A $96.30 N/A N/A $192.60 N/A N/A $224.70 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A N/A $96.30 N/A $321.00 $321.00 N/A 94007300 General Lab PTT QLS 85730 305 $120.00 $- $3.86 $- $- $96.00 $- N/A $31.20 N/A N/A $6.43 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $3.86 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $3.86 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 94007300 General Lab "Partial Thromboplastin Time, Active QST" 85730 305 $120.00 $- $3.86 $- $- $96.00 $- N/A $31.20 N/A N/A $6.43 N/A N/A $72.00 N/A N/A $60.00 N/A N/A $3.86 N/A N/A $81.60 N/A N/A $58.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A $3.86 N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 94007351 General Lab Magnesium QLS 83735 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.19 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 94007351 General Lab Magnesium QST 83735 301 $130.00 $- $4.30 $- $- $104.00 $- N/A $33.80 N/A N/A $7.19 N/A N/A $78.00 N/A N/A $65.00 N/A N/A $4.30 N/A N/A $88.40 N/A N/A $63.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A $4.30 N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 1-4000018|2-4000026 General Lab 1-FSH QLS|2-LH QLS 83001 301 $626.00 $- $162.76 $- $- $500.80 $- N/A $162.76 N/A N/A N/A N/A N/A $375.60 N/A N/A $313.00 N/A N/A N/A N/A N/A $425.68 N/A N/A $306.74 N/A N/A $244.14 N/A N/A $438.20 N/A N/A $500.80 N/A N/A $344.30 N/A N/A $438.20 N/A N/A $209.71 N/A N/A N/A N/A N/A $375.60 N/A N/A $219.10 N/A N/A $406.90 N/A N/A $187.80 N/A N/A $375.60 N/A N/A $438.20 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A $626.00 $626.00 N/A 1-4000018|2-4000026 General Lab 1-FSH QLS|2-LH QLS 83002 301 $626.00 $- $162.76 $- $- $500.80 $- N/A $162.76 N/A N/A N/A N/A N/A $375.60 N/A N/A $313.00 N/A N/A N/A N/A N/A $425.68 N/A N/A $306.74 N/A N/A $244.14 N/A N/A $438.20 N/A N/A $500.80 N/A N/A $344.30 N/A N/A $438.20 N/A N/A $209.71 N/A N/A N/A N/A N/A $375.60 N/A N/A $219.10 N/A N/A $406.90 N/A N/A $187.80 N/A N/A $375.60 N/A N/A $438.20 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A N/A $187.80 N/A $626.00 $626.00 N/A 4000881 Laboratory Charge Culture Type Immunologic 87147 306 $72.00 $- $3.23 $- $- $57.60 $- N/A $18.72 N/A N/A $5.39 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $3.23 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $3.23 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4010071 Laboratory Charge Microbe Susceptible Diffuse 87181 306 $72.00 $- $1.09 $- $- $57.60 $- N/A $18.72 N/A N/A $1.80 N/A N/A $43.20 N/A N/A $36.00 N/A N/A $1.09 N/A N/A $48.96 N/A N/A $35.28 N/A N/A $28.08 N/A N/A $50.40 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $50.40 N/A N/A $24.12 N/A N/A $1.09 N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $50.40 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 4010080 Laboratory Charge Culture Anaerobe Ident Each 87076 306 $124.00 $- $5.19 $- $- $99.20 $- N/A $32.24 N/A N/A $8.66 N/A N/A $74.40 N/A N/A $62.00 N/A N/A $5.19 N/A N/A $84.32 N/A N/A $60.76 N/A N/A $48.36 N/A N/A $86.80 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $86.80 N/A N/A $41.54 N/A N/A $5.19 N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $86.80 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 4010082 Laboratory Charge 87106 306 $127.00 $- $6.63 $- $- $101.60 $- N/A $33.02 N/A N/A $11.06 N/A N/A $76.20 N/A N/A $63.50 N/A N/A $6.63 N/A N/A $86.36 N/A N/A $62.23 N/A N/A $49.53 N/A N/A $88.90 N/A N/A $101.60 N/A N/A $69.85 N/A N/A $88.90 N/A N/A $42.55 N/A N/A $6.63 N/A N/A $76.20 N/A N/A $44.45 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $76.20 N/A N/A $88.90 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A $127.00 $127.00 N/A 990000 Misc Charges Emp Consideration Repymnt 99999 1 $59.00 $- $15.34 $- $- $47.20 $- N/A $15.34 N/A N/A N/A N/A N/A $35.40 N/A N/A $29.50 N/A N/A N/A N/A N/A $40.12 N/A N/A $28.91 N/A N/A $23.01 N/A N/A $41.30 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $41.30 N/A N/A $19.77 N/A N/A N/A N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $41.30 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 3020156 Misc Charges 93017 TREADMILL CHARGE 93017 482 $899.00 $- $32.93 $- $- $719.20 $- N/A $233.74 N/A N/A $53.00 N/A N/A $539.40 N/A N/A $449.50 N/A N/A $32.93 N/A N/A $611.32 N/A N/A $440.51 N/A N/A $350.61 N/A N/A $629.30 N/A N/A $719.20 N/A N/A $494.45 N/A N/A $629.30 N/A N/A $301.17 N/A N/A $32.93 N/A N/A $539.40 N/A N/A $314.65 N/A N/A $584.35 N/A N/A $269.70 N/A N/A $539.40 N/A N/A $629.30 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A N/A $269.70 N/A $899.00 $899.00 N/A 3020553 Misc Charges ISOLATION FEE CHARGE 270 $182.00 $- $47.32 $- $- $145.60 $- N/A $47.32 N/A N/A N/A N/A $109.20 N/A N/A $91.00 N/A N/A N/A N/A N/A $123.76 N/A N/A $89.18 N/A N/A $70.98 N/A N/A $127.40 N/A N/A $145.60 N/A N/A $100.10 N/A N/A $127.40 N/A N/A $60.97 N/A N/A N/A N/A N/A $109.20 N/A N/A $63.70 N/A N/A $118.30 N/A N/A $54.60 N/A N/A $109.20 N/A N/A $127.40 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A $182.00 $182.00 N/A 3020570 Misc Charges 43760 CHANGE G-TUBE CHARGE 43760 361 $801.00 $- $208.26 $- $- $640.80 $- N/A $208.26 N/A N/A N/A N/A N/A $480.60 N/A N/A $400.50 N/A N/A N/A N/A N/A $544.68 N/A N/A $392.49 N/A N/A $312.39 N/A N/A $560.70 N/A N/A $640.80 N/A N/A $440.55 N/A N/A $560.70 N/A N/A $268.34 N/A N/A N/A N/A N/A $480.60 N/A N/A $280.35 N/A N/A $520.65 N/A N/A $240.30 N/A N/A $480.60 N/A N/A $560.70 N/A N/A $240.30 N/A N/A $240.30 N/A N/A $240.30 N/A N/A $240.30 N/A N/A $240.30 N/A N/A $240.30 N/A $801.00 $801.00 N/A 3022787 Misc Charges WALL SUCTION SET UP CHARGE 270 $58.00 $- $15.08 $- $- $46.40 $- N/A $15.08 N/A N/A N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A $28.42 N/A N/A $22.62 N/A N/A $40.60 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $40.60 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $40.60 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 3022994 Misc Charges C P M CHARGE 270 $190.00 $- $49.40 $- $- $152.00 $- N/A $49.40 N/A N/A N/A N/A $114.00 N/A N/A $95.00 N/A N/A N/A N/A N/A $129.20 N/A N/A $93.10 N/A N/A $74.10 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A N/A N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A $57.00 N/A N/A $114.00 N/A N/A $133.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A N/A $57.00 N/A $190.00 $190.00 N/A 3024532 Misc Charges TREADMILL SUPPLIES CHARGE 270 $68.00 $- $17.68 $- $- $54.40 $- N/A $17.68 N/A N/A N/A N/A $40.80 N/A N/A $34.00 N/A N/A N/A N/A N/A $46.24 N/A N/A $33.32 N/A N/A $26.52 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A N/A N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $47.60 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 3025010 Misc Charges 92610 EVAL ORAL SWALLOW FUNCT CHARGE 92610 444 $561.00 $- $60.31 $- $- $448.80 $- N/A $145.86 N/A N/A $78.38 N/A N/A $336.60 N/A N/A $280.50 N/A N/A $60.31 N/A N/A $381.48 N/A N/A $274.89 N/A N/A $218.79 N/A N/A $392.70 N/A N/A $448.80 N/A N/A $308.55 N/A N/A $392.70 N/A N/A $187.94 N/A N/A $60.31 N/A N/A $336.60 N/A N/A $196.35 N/A N/A $364.65 N/A N/A $168.30 N/A N/A $336.60 N/A N/A $392.70 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A $561.00 $561.00 N/A 3026365 Misc Charges 96365 OUT PATIENT IV THERAPY ST CHARGE 96365 260 $648.00 $- $57.70 $- $- $518.40 $- N/A $168.48 N/A N/A $90.83 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $57.70 N/A N/A $440.64 N/A N/A $317.52 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $57.70 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 3026430 Misc Charges 36430 TRANSFUSION BLOOD PRODUCT CHARGE 36430 391 $962.00 $- $30.40 $- $- $769.60 $- N/A $250.12 N/A N/A $41.04 N/A N/A $577.20 N/A N/A $481.00 N/A N/A $30.40 N/A N/A $654.16 N/A N/A $471.38 N/A N/A $375.18 N/A N/A $673.40 N/A N/A $769.60 N/A N/A $529.10 N/A N/A $673.40 N/A N/A $322.27 N/A N/A $30.40 N/A N/A $577.20 N/A N/A $336.70 N/A N/A $625.30 N/A N/A $288.60 N/A N/A $577.20 N/A N/A $673.40 N/A N/A $288.60 N/A N/A $288.60 N/A N/A $288.60 N/A N/A $288.60 N/A N/A $288.60 N/A N/A $288.60 N/A $962.00 $962.00 N/A 3026568 Misc Charges 36569 INSERT PICC CATH CHARGE 36569 360 "$5,290.00 " $- $82.34 $- $- "$4,232.00 " $- N/A "$1,375.40 " N/A N/A $104.84 N/A N/A "$3,174.00 " N/A N/A "$2,645.00 " N/A N/A $82.34 N/A N/A "$3,597.20 " N/A N/A "$2,592.10 " N/A N/A "$2,063.10 " N/A N/A "$3,703.00 " N/A N/A "$4,232.00 " N/A N/A "$2,909.50 " N/A N/A "$3,703.00 " N/A N/A "$1,772.15 " N/A N/A $82.34 N/A N/A "$3,174.00 " N/A N/A "$1,851.50 " N/A N/A "$3,438.50 " N/A N/A "$1,587.00 " N/A N/A "$3,174.00 " N/A N/A "$3,703.00 " N/A N/A "$1,587.00 " N/A N/A "$1,587.00 " N/A N/A "$1,587.00 " N/A N/A "$1,587.00 " N/A N/A "$1,587.00 " N/A N/A "$1,587.00 " N/A "$5,290.00 " "$5,290.00 " N/A 3026570 Misc Charges 36569 INSERT PICC W/O SUBCUT PO CHARGE 36569 490 "$2,894.00 " $- $82.34 $- $- "$2,315.20 " $- N/A $752.44 N/A N/A $104.84 N/A N/A "$1,736.40 " N/A N/A "$1,447.00 " N/A N/A $82.34 N/A N/A "$1,967.92 " N/A N/A "$1,418.06 " N/A N/A "$1,128.66 " N/A N/A "$2,025.80 " N/A N/A "$2,315.20 " N/A N/A "$1,591.70 " N/A N/A "$2,025.80 " N/A N/A $969.49 N/A N/A $82.34 N/A N/A "$1,736.40 " N/A N/A "$1,012.90 " N/A N/A "$1,881.10 " N/A N/A $868.20 N/A N/A "$1,736.40 " N/A N/A "$2,025.80 " N/A N/A $868.20 N/A N/A $868.20 N/A N/A $868.20 N/A N/A $868.20 N/A N/A $868.20 N/A N/A $868.20 N/A "$2,894.00 " "$2,894.00 " N/A 3027281 Misc Charges TRACTION SET UP FEE CHARGE 270 $106.00 $- $27.56 $- $- $84.80 $- N/A $27.56 N/A N/A N/A N/A $63.60 N/A N/A $53.00 N/A N/A N/A N/A N/A $72.08 N/A N/A $51.94 N/A N/A $41.34 N/A N/A $74.20 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $74.20 N/A N/A $35.51 N/A N/A N/A N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $74.20 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 3027299 Misc Charges TRACTION RENTAL FEE CHARGE 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A $27.44 N/A N/A $21.84 N/A N/A $39.20 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $39.20 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $39.20 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 3027331 Misc Charges CONTINUOUS SUCTION CHARGE 270 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A $47.04 N/A N/A $37.44 N/A N/A $67.20 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $67.20 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $67.20 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 3027414 Misc Charges TRAPEZE DAILY CHARGE CHARGE 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A $21.56 N/A N/A $17.16 N/A N/A $30.80 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $30.80 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $30.80 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 3027448 Misc Charges RESP ISOLATION DAY 1 CHARGE 270 $521.00 $- $135.46 $- $- $416.80 $- N/A $135.46 N/A N/A N/A N/A $312.60 N/A N/A $260.50 N/A N/A N/A N/A N/A $354.28 N/A N/A $255.29 N/A N/A $203.19 N/A N/A $364.70 N/A N/A $416.80 N/A N/A $286.55 N/A N/A $364.70 N/A N/A $174.54 N/A N/A N/A N/A N/A $312.60 N/A N/A $182.35 N/A N/A $338.65 N/A N/A $156.30 N/A N/A $312.60 N/A N/A $364.70 N/A N/A $156.30 N/A N/A $156.30 N/A N/A $156.30 N/A N/A $156.30 N/A N/A $156.30 N/A N/A $156.30 N/A $521.00 $521.00 N/A 3027455 Misc Charges RESP ISOLATION PER D CHARGE 270 $391.00 $- $101.66 $- $- $312.80 $- N/A $101.66 N/A N/A N/A N/A $234.60 N/A N/A $195.50 N/A N/A N/A N/A N/A $265.88 N/A N/A $191.59 N/A N/A $152.49 N/A N/A $273.70 N/A N/A $312.80 N/A N/A $215.05 N/A N/A $273.70 N/A N/A $130.99 N/A N/A N/A N/A N/A $234.60 N/A N/A $136.85 N/A N/A $254.15 N/A N/A $117.30 N/A N/A $234.60 N/A N/A $273.70 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A $391.00 $391.00 N/A 3030047 Misc Charges 93041 CARDIAC MONITOR CHARGE 93041 730 $399.00 $- $4.86 $- $- $319.20 $- N/A $103.74 N/A N/A $7.45 N/A N/A $239.40 N/A N/A $199.50 N/A N/A $4.86 N/A N/A $271.32 N/A N/A $195.51 N/A N/A $155.61 N/A N/A $279.30 N/A N/A $319.20 N/A N/A $219.45 N/A N/A $279.30 N/A N/A $133.67 N/A N/A $4.86 N/A N/A $239.40 N/A N/A $139.65 N/A N/A $259.35 N/A N/A $119.70 N/A N/A $239.40 N/A N/A $279.30 N/A N/A $119.70 N/A N/A $119.70 N/A N/A $119.70 N/A N/A $119.70 N/A N/A $119.70 N/A N/A $119.70 N/A $399.00 $399.00 N/A 3030058 Misc Charges 92960 CARDIOVERSION IN ICU CHARGE 92960 480 "$1,934.00 " $- $100.90 $- $- "$1,547.20 " $- N/A $502.84 N/A N/A $140.33 N/A N/A "$1,160.40 " N/A N/A $967.00 N/A N/A $100.90 N/A N/A "$1,315.12 " N/A N/A $947.66 N/A N/A $754.26 N/A N/A "$1,353.80 " N/A N/A "$1,547.20 " N/A N/A "$1,063.70 " N/A N/A "$1,353.80 " N/A N/A $647.89 N/A N/A $100.90 N/A N/A "$1,160.40 " N/A N/A $676.90 N/A N/A "$1,257.10 " N/A N/A $580.20 N/A N/A "$1,160.40 " N/A N/A "$1,353.80 " N/A N/A $580.20 N/A N/A $580.20 N/A N/A $580.20 N/A N/A $580.20 N/A N/A $580.20 N/A N/A $580.20 N/A "$1,934.00 " "$1,934.00 " N/A 3030066 Misc Charges 33210 TEMPORARY PACEMAKER CHARGE 33210 480 $78.00 $- $20.28 $- $- $207.53 $- N/A $20.28 N/A N/A $207.53 N/A N/A $46.80 N/A N/A $39.00 N/A N/A $160.34 N/A N/A $53.04 N/A N/A $38.22 N/A N/A $30.42 N/A N/A $54.60 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $54.60 N/A N/A $26.13 N/A N/A $160.34 N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $54.60 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 3030077 Misc Charges ART LINE DAILY MONIT CHARGE 480 $189.00 $- $49.14 $- $- $151.20 $- N/A $49.14 N/A N/A N/A N/A $113.40 N/A N/A $94.50 N/A N/A N/A N/A N/A $128.52 N/A N/A $92.61 N/A N/A $73.71 N/A N/A $132.30 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $132.30 N/A N/A $63.32 N/A N/A N/A N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $132.30 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 3030088 Misc Charges CODE 99 NURSING 1/2H CHARGE 480 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A $85.26 N/A N/A $67.86 N/A N/A $121.80 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $121.80 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $121.80 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 3030096 Misc Charges DYNAMAP (ICU) CHARGE 270 $227.00 $- $59.02 $- $- $181.60 $- N/A $59.02 N/A N/A N/A N/A $136.20 N/A N/A $113.50 N/A N/A N/A N/A N/A $154.36 N/A N/A $111.23 N/A N/A $88.53 N/A N/A $158.90 N/A N/A $181.60 N/A N/A $124.85 N/A N/A $158.90 N/A N/A $76.05 N/A N/A N/A N/A N/A $136.20 N/A N/A $79.45 N/A N/A $147.55 N/A N/A $68.10 N/A N/A $136.20 N/A N/A $158.90 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A N/A $68.10 N/A $227.00 $227.00 N/A 3033217 Misc Charges 33206 PACEMAKER INSERT - T CHARGE 33206 360 $122.00 $- $31.72 $- $- $536.75 $- N/A $31.72 N/A N/A $536.75 N/A N/A $73.20 N/A N/A $61.00 N/A N/A $411.43 N/A N/A $82.96 N/A N/A $59.78 N/A N/A $47.58 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A $411.43 N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $85.40 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 3033710 Misc Charges 93503 SWAN GANZ CARDIAC - CHARGE 93503 480 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $150.40 N/A N/A $204.00 N/A N/A $170.00 N/A N/A $108.23 N/A N/A $231.20 N/A N/A $166.60 N/A N/A $132.60 N/A N/A $238.00 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $238.00 N/A N/A $113.90 N/A N/A $108.23 N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $238.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 3070200 Misc Charges 90845 PSYCHOANALYSIS CHARGE 90845 914 "$1,613.00 " $- $74.48 $- $- "$1,290.40 " $- N/A $419.38 N/A N/A $86.32 N/A N/A $967.80 N/A N/A $806.50 N/A N/A $74.48 N/A N/A "$1,096.84 " N/A N/A $790.37 N/A N/A $629.07 N/A N/A "$1,129.10 " N/A N/A "$1,290.40 " N/A N/A $887.15 N/A N/A "$1,129.10 " N/A N/A $540.36 N/A N/A $74.48 N/A N/A $967.80 N/A N/A $564.55 N/A N/A "$1,048.45 " N/A N/A $483.90 N/A N/A $967.80 N/A N/A "$1,129.10 " N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A "$1,613.00 " "$1,613.00 " N/A 3070210 Misc Charges 90846 FAMILY PSYCHOTHERAPY W/O CHARGE 90846 916 "$1,867.00 " $- $98.40 $- $- "$1,493.60 " $- N/A $485.42 N/A N/A $98.40 N/A N/A "$1,120.20 " N/A N/A $933.50 N/A N/A N/A N/A N/A "$1,269.56 " N/A N/A $914.83 N/A N/A $728.13 N/A N/A "$1,306.90 " N/A N/A "$1,493.60 " N/A N/A "$1,026.85 " N/A N/A "$1,306.90 " N/A N/A $625.45 N/A N/A N/A N/A N/A "$1,120.20 " N/A N/A $653.45 N/A N/A "$1,213.55 " N/A N/A $560.10 N/A N/A "$1,120.20 " N/A N/A "$1,306.90 " N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A "$1,867.00 " "$1,867.00 " N/A 3070215 Misc Charges 90847 FAMILY PSYCHOTHERAPY CONJ CHARGE 90847 916 "$1,867.00 " $- $86.26 $- $- "$1,493.60 " $- N/A $485.42 N/A N/A $98.40 N/A N/A "$1,120.20 " N/A N/A $933.50 N/A N/A $86.26 N/A N/A "$1,269.56 " N/A N/A $914.83 N/A N/A $728.13 N/A N/A "$1,306.90 " N/A N/A "$1,493.60 " N/A N/A "$1,026.85 " N/A N/A "$1,306.90 " N/A N/A $625.45 N/A N/A $86.26 N/A N/A "$1,120.20 " N/A N/A $653.45 N/A N/A "$1,213.55 " N/A N/A $560.10 N/A N/A "$1,120.20 " N/A N/A "$1,306.90 " N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A N/A $560.10 N/A "$1,867.00 " "$1,867.00 " N/A 3070220 Misc Charges 90849 MULTI-FAMILY GROUP PSYCH CHARGE 90849 915 $889.00 $- $48.00 $- $- $711.20 $- N/A $231.14 N/A N/A $48.00 N/A N/A $533.40 N/A N/A $444.50 N/A N/A N/A N/A N/A $604.52 N/A N/A $435.61 N/A N/A $346.71 N/A N/A $622.30 N/A N/A $711.20 N/A N/A $488.95 N/A N/A $622.30 N/A N/A $297.82 N/A N/A N/A N/A N/A $533.40 N/A N/A $311.15 N/A N/A $577.85 N/A N/A $266.70 N/A N/A $533.40 N/A N/A $622.30 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A $889.00 $889.00 N/A 3070225 Misc Charges 90853 GROUP PSYCHTX CHARGE 90853 915 $889.00 $- $20.88 $- $- $711.20 $- N/A $231.14 N/A N/A $48.00 N/A N/A $533.40 N/A N/A $444.50 N/A N/A $20.88 N/A N/A $604.52 N/A N/A $435.61 N/A N/A $346.71 N/A N/A $622.30 N/A N/A $711.20 N/A N/A $488.95 N/A N/A $622.30 N/A N/A $297.82 N/A N/A $20.88 N/A N/A $533.40 N/A N/A $311.15 N/A N/A $577.85 N/A N/A $266.70 N/A N/A $533.40 N/A N/A $622.30 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A N/A $266.70 N/A $889.00 $889.00 N/A 3070230 Misc Charges 90865 NARCOSYNTHESIS FOR PSYCH/ CHARGE 90865 914 "$1,613.00 " $- $144.54 $- $- "$1,290.40 " $- N/A $419.38 N/A N/A $144.54 N/A N/A $967.80 N/A N/A $806.50 N/A N/A N/A N/A N/A "$1,096.84 " N/A N/A $790.37 N/A N/A $629.07 N/A N/A "$1,129.10 " N/A N/A "$1,290.40 " N/A N/A $887.15 N/A N/A "$1,129.10 " N/A N/A $540.36 N/A N/A N/A N/A N/A $967.80 N/A N/A $564.55 N/A N/A "$1,048.45 " N/A N/A $483.90 N/A N/A $967.80 N/A N/A "$1,129.10 " N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A N/A $483.90 N/A "$1,613.00 " "$1,613.00 " N/A 3070235 Misc Charges 90867 THERAPEUTIC REPETITIVE TM CHARGE 90867 901 "$1,188.00 " $- $300.00 $- $- $950.40 $- N/A $308.88 N/A N/A $300.00 N/A N/A $712.80 N/A N/A $594.00 N/A N/A N/A N/A N/A $807.84 N/A N/A $582.12 N/A N/A $463.32 N/A N/A $831.60 N/A N/A $950.40 N/A N/A $653.40 N/A N/A $831.60 N/A N/A $397.98 N/A N/A N/A N/A N/A $712.80 N/A N/A $415.80 N/A N/A $772.20 N/A N/A $356.40 N/A N/A $712.80 N/A N/A $831.60 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A "$1,188.00 " "$1,188.00 " N/A 3070240 Misc Charges 90868 THERAPEUTIC REPRTITIVE TM CHARGE 90868 901 "$1,188.00 " $- $276.00 $- $- $950.40 $- N/A $308.88 N/A N/A $276.00 N/A N/A $712.80 N/A N/A $594.00 N/A N/A N/A N/A N/A $807.84 N/A N/A $582.12 N/A N/A $463.32 N/A N/A $831.60 N/A N/A $950.40 N/A N/A $653.40 N/A N/A $831.60 N/A N/A $397.98 N/A N/A N/A N/A N/A $712.80 N/A N/A $415.80 N/A N/A $772.20 N/A N/A $356.40 N/A N/A $712.80 N/A N/A $831.60 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A N/A $356.40 N/A "$1,188.00 " "$1,188.00 " N/A 3079998 Misc Charges 43760 TEST CHANGE G TUBE CHARGE 43760 761 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A N/A N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A $3.43 N/A N/A $2.73 N/A N/A $4.90 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.90 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.90 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 3079999 Misc Charges TEST PULL UPS CHARGE 270 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A $3.43 N/A N/A $2.73 N/A N/A $4.90 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.90 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.90 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 3270200 Misc Charges 92960 CARDIOVERSION ELECTIVE CHARGE 92960 940 "$1,713.00 " $- $100.90 $- $- "$1,370.40 " $- N/A $445.38 N/A N/A $140.33 N/A N/A "$1,027.80 " N/A N/A $856.50 N/A N/A $100.90 N/A N/A "$1,164.84 " N/A N/A $839.37 N/A N/A $668.07 N/A N/A "$1,199.10 " N/A N/A "$1,370.40 " N/A N/A $942.15 N/A N/A "$1,199.10 " N/A N/A $573.86 N/A N/A $100.90 N/A N/A "$1,027.80 " N/A N/A $599.55 N/A N/A "$1,113.45 " N/A N/A $513.90 N/A N/A "$1,027.80 " N/A N/A "$1,199.10 " N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A "$1,713.00 " "$1,713.00 " N/A 3270900 Misc Charges ADMIN OF INFLUENZA charge G0008 G0008 771 $382.00 $- $10.66 $- $- $305.60 $- N/A $99.32 N/A N/A $10.66 N/A N/A $229.20 N/A N/A $191.00 N/A N/A N/A N/A N/A $259.76 N/A N/A $187.18 N/A N/A $148.98 N/A N/A $267.40 N/A N/A $305.60 N/A N/A $210.10 N/A N/A $267.40 N/A N/A $127.97 N/A N/A N/A N/A N/A $229.20 N/A N/A $133.70 N/A N/A $248.30 N/A N/A $114.60 N/A N/A $229.20 N/A N/A $267.40 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A $382.00 $382.00 N/A 3271000 Misc Charges ADMIN OF PNEUMOCOCCAL VAC CHARGE G0009 G0009 771 $382.00 $- $10.66 $- $- $305.60 $- N/A $99.32 N/A N/A $10.66 N/A N/A $229.20 N/A N/A $191.00 N/A N/A N/A N/A N/A $259.76 N/A N/A $187.18 N/A N/A $148.98 N/A N/A $267.40 N/A N/A $305.60 N/A N/A $210.10 N/A N/A $267.40 N/A N/A $127.97 N/A N/A N/A N/A N/A $229.20 N/A N/A $133.70 N/A N/A $248.30 N/A N/A $114.60 N/A N/A $229.20 N/A N/A $267.40 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A N/A $114.60 N/A $382.00 $382.00 N/A 3271110 Misc Charges EACH ADDT’L SEQ IV PUSH DIFFERENT DRUG 96375 260 $613.00 $- $18.59 $- $- $490.40 $- N/A $159.38 N/A N/A $26.93 N/A N/A $367.80 N/A N/A $306.50 N/A N/A $18.59 N/A N/A $416.84 N/A N/A $300.37 N/A N/A $239.07 N/A N/A $429.10 N/A N/A $490.40 N/A N/A $337.15 N/A N/A $429.10 N/A N/A $205.36 N/A N/A $18.59 N/A N/A $367.80 N/A N/A $214.55 N/A N/A $398.45 N/A N/A $183.90 N/A N/A $367.80 N/A N/A $429.10 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A $613.00 $613.00 N/A 3271120 Misc Charges EACH ADDT’L SEQ IV PUSH SAME DRUG 96376 260 $277.00 $- $12.00 $- $- $221.60 $- N/A $72.02 N/A N/A $17.51 N/A N/A $166.20 N/A N/A $138.50 N/A N/A $12.00 N/A N/A $188.36 N/A N/A $135.73 N/A N/A $108.03 N/A N/A $193.90 N/A N/A $221.60 N/A N/A $152.35 N/A N/A $193.90 N/A N/A $92.80 N/A N/A $12.00 N/A N/A $166.20 N/A N/A $96.95 N/A N/A $180.05 N/A N/A $83.10 N/A N/A $166.20 N/A N/A $193.90 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A N/A $83.10 N/A $277.00 $277.00 N/A 3272100 Misc Charges 96360 IV HYDRATION INFUSION 31 CHARGE 96360 260 "$1,098.00 " $- $47.80 $- $- $878.40 $- N/A $285.48 N/A N/A $70.40 N/A N/A $658.80 N/A N/A $549.00 N/A N/A $47.80 N/A N/A $746.64 N/A N/A $538.02 N/A N/A $428.22 N/A N/A $768.60 N/A N/A $878.40 N/A N/A $603.90 N/A N/A $768.60 N/A N/A $367.83 N/A N/A $47.80 N/A N/A $658.80 N/A N/A $384.30 N/A N/A $713.70 N/A N/A $329.40 N/A N/A $658.80 N/A N/A $768.60 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A N/A $329.40 N/A "$1,098.00 " "$1,098.00 " N/A 3272110 Misc Charges 96361 IV HYDRATION INFUSION EA CHARGE 96361 260 $403.00 $- $12.56 $- $- $322.40 $- N/A $104.78 N/A N/A $18.34 N/A N/A $241.80 N/A N/A $201.50 N/A N/A $12.56 N/A N/A $274.04 N/A N/A $197.47 N/A N/A $157.17 N/A N/A $282.10 N/A N/A $322.40 N/A N/A $221.65 N/A N/A $282.10 N/A N/A $135.01 N/A N/A $12.56 N/A N/A $241.80 N/A N/A $141.05 N/A N/A $261.95 N/A N/A $120.90 N/A N/A $241.80 N/A N/A $282.10 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A $403.00 $403.00 N/A 3275170 Misc Charges 51700 FOLEY CATHETER IRRIGATION CHARGE 51700 490 $687.00 $- $39.30 $- $- $549.60 $- N/A $178.62 N/A N/A $55.39 N/A N/A $412.20 N/A N/A $343.50 N/A N/A $39.30 N/A N/A $467.16 N/A N/A $336.63 N/A N/A $267.93 N/A N/A $480.90 N/A N/A $549.60 N/A N/A $377.85 N/A N/A $480.90 N/A N/A $230.15 N/A N/A $39.30 N/A N/A $412.20 N/A N/A $240.45 N/A N/A $446.55 N/A N/A $206.10 N/A N/A $412.20 N/A N/A $480.90 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A N/A $206.10 N/A $687.00 $687.00 N/A 3275172 Misc Charges 51702 FOLEY CATHETER CHANGE CHARGE 51702 490 $261.00 $- $26.77 $- $- $208.80 $- N/A $67.86 N/A N/A $38.30 N/A N/A $156.60 N/A N/A $130.50 N/A N/A $26.77 N/A N/A $177.48 N/A N/A $127.89 N/A N/A $101.79 N/A N/A $182.70 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $182.70 N/A N/A $87.44 N/A N/A $26.77 N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $182.70 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 3275500 Misc Charges 96523 IRR.OF IMPLNTD VENOUS DVC CHARGE 96523 260 $218.00 $- $20.80 $- $- $174.40 $- N/A $56.68 N/A N/A $31.94 N/A N/A $130.80 N/A N/A $109.00 N/A N/A $20.80 N/A N/A $148.24 N/A N/A $106.82 N/A N/A $85.02 N/A N/A $152.60 N/A N/A $174.40 N/A N/A $119.90 N/A N/A $152.60 N/A N/A $73.03 N/A N/A $20.80 N/A N/A $130.80 N/A N/A $76.30 N/A N/A $141.70 N/A N/A $65.40 N/A N/A $130.80 N/A N/A $152.60 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A $218.00 $218.00 N/A 3275515 Misc Charges 36589 REM VEN CATH W/O PORT/PMP CHARGE 36589 490 "$2,658.00 " $- $125.03 $- $- "$2,126.40 " $- N/A $691.08 N/A N/A $165.74 N/A N/A "$1,594.80 " N/A N/A "$1,329.00 " N/A N/A $125.03 N/A N/A "$1,807.44 " N/A N/A "$1,302.42 " N/A N/A "$1,036.62 " N/A N/A "$1,860.60 " N/A N/A "$2,126.40 " N/A N/A "$1,461.90 " N/A N/A "$1,860.60 " N/A N/A $890.43 N/A N/A $125.03 N/A N/A "$1,594.80 " N/A N/A $930.30 N/A N/A "$1,727.70 " N/A N/A $797.40 N/A N/A "$1,594.80 " N/A N/A "$1,860.60 " N/A N/A $797.40 N/A N/A $797.40 N/A N/A $797.40 N/A N/A $797.40 N/A N/A $797.40 N/A N/A $797.40 N/A "$2,658.00 " "$2,658.00 " N/A 3275520 Misc Charges 36592 LAB COLLECTION VIA PICC CHARGE 36592 300 $218.00 $- $23.36 $- $- $174.40 $- N/A $56.68 N/A N/A $32.60 N/A N/A $130.80 N/A N/A $109.00 N/A N/A $23.36 N/A N/A $148.24 N/A N/A $106.82 N/A N/A $85.02 N/A N/A $152.60 N/A N/A $174.40 N/A N/A $119.90 N/A N/A $152.60 N/A N/A $73.03 N/A N/A $23.36 N/A N/A $130.80 N/A N/A $76.30 N/A N/A $141.70 N/A N/A $65.40 N/A N/A $130.80 N/A N/A $152.60 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A N/A $65.40 N/A $218.00 $218.00 N/A 3275600 Misc Charges "96367 IV THERAPY PROPHYLAXIS,AD CHARGE" 96367 260 $290.00 $- $25.09 $- $- $232.00 $- N/A $75.40 N/A N/A $38.21 N/A N/A $174.00 N/A N/A $145.00 N/A N/A $25.09 N/A N/A $197.20 N/A N/A $142.10 N/A N/A $113.10 N/A N/A $203.00 N/A N/A $232.00 N/A N/A $159.50 N/A N/A $203.00 N/A N/A $97.15 N/A N/A $25.09 N/A N/A $174.00 N/A N/A $101.50 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $174.00 N/A N/A $203.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A $290.00 $290.00 N/A 3275999 Misc Charges 99195 PHLEBOTOMY CHARGE 99195 940 $274.00 $- $71.24 $- $- $219.20 $- N/A $71.24 N/A N/A $124.26 N/A N/A $164.40 N/A N/A $137.00 N/A N/A $83.42 N/A N/A $186.32 N/A N/A $134.26 N/A N/A $106.86 N/A N/A $191.80 N/A N/A $219.20 N/A N/A $150.70 N/A N/A $191.80 N/A N/A $91.79 N/A N/A $83.42 N/A N/A $164.40 N/A N/A $95.90 N/A N/A $178.10 N/A N/A $82.20 N/A N/A $164.40 N/A N/A $191.80 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A N/A $82.20 N/A $274.00 $274.00 N/A 3276360 Misc Charges 96374 IV PUSH SGL/INITIAL USE CHARGE 96374 260 $289.00 $- $47.18 $- $- $231.20 $- N/A $75.14 N/A N/A $69.14 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $47.18 N/A N/A $196.52 N/A N/A $141.61 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $47.18 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3276365 Misc Charges OUTPT IV THERAPY START 96365 260 $603.00 $- $57.70 $- $- $482.40 $- N/A $156.78 N/A N/A $90.83 N/A N/A $361.80 N/A N/A $301.50 N/A N/A $57.70 N/A N/A $410.04 N/A N/A $295.47 N/A N/A $235.17 N/A N/A $422.10 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $422.10 N/A N/A $202.01 N/A N/A $57.70 N/A N/A $361.80 N/A N/A $211.05 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $422.10 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 3276366 Misc Charges 96366 OUTPATIENT IV THERAPY ADD CHARGE 96366 260 $131.00 $- $15.44 $- $- $104.80 $- N/A $34.06 N/A N/A $25.92 N/A N/A $78.60 N/A N/A $65.50 N/A N/A $15.44 N/A N/A $89.08 N/A N/A $64.19 N/A N/A $51.09 N/A N/A $91.70 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $91.70 N/A N/A $43.89 N/A N/A $15.44 N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $91.70 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 3276372 Misc Charges 96372 OUT PATIENT IM/SQ INJECTI CHARGE 96372 260 $131.00 $- $20.89 $- $- $104.80 $- N/A $34.06 N/A N/A $30.88 N/A N/A $78.60 N/A N/A $65.50 N/A N/A $20.89 N/A N/A $89.08 N/A N/A $64.19 N/A N/A $51.09 N/A N/A $91.70 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $91.70 N/A N/A $43.89 N/A N/A $20.89 N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $91.70 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 3416115 Misc Charges 11732 EA. ADDL NAIL AVULSION CHARGE 11732 450 $312.00 $- $17.87 $- $- $249.60 $- N/A $81.12 N/A N/A $19.48 N/A N/A $187.20 N/A N/A $156.00 N/A N/A $17.87 N/A N/A $212.16 N/A N/A $152.88 N/A N/A $121.68 N/A N/A $218.40 N/A N/A $249.60 N/A N/A $171.60 N/A N/A $218.40 N/A N/A $104.52 N/A N/A $17.87 N/A N/A $187.20 N/A N/A $109.20 N/A N/A $202.80 N/A N/A $93.60 N/A N/A $187.20 N/A N/A $218.40 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A N/A $93.60 N/A $312.00 $312.00 N/A 4000078 Misc Charges 82962 ACCUCHECK 82962 301 $38.00 $- $1.16 $- $- $30.40 $- N/A $9.88 N/A N/A $1.93 N/A N/A $22.80 N/A N/A $19.00 N/A N/A $1.16 N/A N/A $25.84 N/A N/A $18.62 N/A N/A $14.82 N/A N/A $26.60 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $26.60 N/A N/A $12.73 N/A N/A $1.16 N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $26.60 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 4000725 Misc Charges Culture Any Other 87070 306 $169.00 $- $5.53 $- $- $135.20 $- N/A $43.94 N/A N/A $9.24 N/A N/A $101.40 N/A N/A $84.50 N/A N/A $5.53 N/A N/A $114.92 N/A N/A $82.81 N/A N/A $65.91 N/A N/A $118.30 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $118.30 N/A N/A $56.62 N/A N/A $5.53 N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $118.30 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 4142013 Misc Charges 90832 INDIV/FAMILY 30 MIN THERA 90832 914 $463.00 $- $67.20 $- $- $370.40 $- N/A $120.38 N/A N/A $67.20 N/A N/A $277.80 N/A N/A $231.50 N/A N/A N/A N/A N/A $314.84 N/A N/A $226.87 N/A N/A $180.57 N/A N/A $324.10 N/A N/A $370.40 N/A N/A $254.65 N/A N/A $324.10 N/A N/A $155.11 N/A N/A N/A N/A N/A $277.80 N/A N/A $162.05 N/A N/A $300.95 N/A N/A $138.90 N/A N/A $277.80 N/A N/A $324.10 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A $463.00 $463.00 N/A 4142015 Misc Charges 90834 INDIV/FAMILY 45 MIN THERA 90834 914 $463.00 $- $96.00 $- $- $370.40 $- N/A $120.38 N/A N/A $96.00 N/A N/A $277.80 N/A N/A $231.50 N/A N/A N/A N/A N/A $314.84 N/A N/A $226.87 N/A N/A $180.57 N/A N/A $324.10 N/A N/A $370.40 N/A N/A $254.65 N/A N/A $324.10 N/A N/A $155.11 N/A N/A N/A N/A N/A $277.80 N/A N/A $162.05 N/A N/A $300.95 N/A N/A $138.90 N/A N/A $277.80 N/A N/A $324.10 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A $463.00 $463.00 N/A 4148531 Misc Charges 90853 GROUP THERAPY 90853 G0410 915 $289.00 $- $20.88 $- $- $231.20 $- N/A $75.14 N/A N/A $48.00 N/A N/A $173.40 N/A N/A $144.50 N/A N/A $20.88 N/A N/A $196.52 N/A N/A $141.61 N/A N/A $112.71 N/A N/A $202.30 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $202.30 N/A N/A $96.82 N/A N/A $20.88 N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $202.30 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 4148533 Misc Charges INTERACTIVE GROUP THERAPY HOULRY 90853 915 $247.00 $- $20.88 $- $- $197.60 $- N/A $64.22 N/A N/A $48.00 N/A N/A $148.20 N/A N/A $123.50 N/A N/A $20.88 N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A $20.88 N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4148533 Misc Charges INTERACTIVE GROUP THERAPY HOURLY G0411 G0411 915 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $133.04 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A $121.03 N/A N/A $96.33 N/A N/A $172.90 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $172.90 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $172.90 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 4160001 Misc Charges PEF METER 271 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A $47.04 N/A N/A $37.44 N/A N/A $67.20 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $67.20 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $67.20 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 4160106 Misc Charges SPIROMETRY (PFT) 94010 460 $651.00 $- $30.27 $- $- $520.80 $- N/A $169.26 N/A N/A $44.89 N/A N/A $390.60 N/A N/A $325.50 N/A N/A $30.27 N/A N/A $442.68 N/A N/A $318.99 N/A N/A $253.89 N/A N/A $455.70 N/A N/A $520.80 N/A N/A $358.05 N/A N/A $455.70 N/A N/A $218.09 N/A N/A $30.27 N/A N/A $390.60 N/A N/A $227.85 N/A N/A $423.15 N/A N/A $195.30 N/A N/A $390.60 N/A N/A $455.70 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A N/A $195.30 N/A $651.00 $651.00 N/A 4160601 Misc Charges BRONCHOSPASM EVALUAT 94060 460 "$1,175.00 " $- $50.95 $- $- $940.00 $- N/A $305.50 N/A N/A $77.09 N/A N/A $705.00 N/A N/A $587.50 N/A N/A $50.95 N/A N/A $799.00 N/A N/A $575.75 N/A N/A $458.25 N/A N/A $822.50 N/A N/A $940.00 N/A N/A $646.25 N/A N/A $822.50 N/A N/A $393.63 N/A N/A $50.95 N/A N/A $705.00 N/A N/A $411.25 N/A N/A $763.75 N/A N/A $352.50 N/A N/A $705.00 N/A N/A $822.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A "$1,175.00 " "$1,175.00 " N/A 4162402 Misc Charges GAS DILUTION/WASHOUT DETE 94727 460 $617.00 $- $35.26 $- $- $493.60 $- N/A $160.42 N/A N/A $57.00 N/A N/A $370.20 N/A N/A $308.50 N/A N/A $35.26 N/A N/A $419.56 N/A N/A $302.33 N/A N/A $240.63 N/A N/A $431.90 N/A N/A $493.60 N/A N/A $339.35 N/A N/A $431.90 N/A N/A $206.70 N/A N/A $35.26 N/A N/A $370.20 N/A N/A $215.95 N/A N/A $401.05 N/A N/A $185.10 N/A N/A $370.20 N/A N/A $431.90 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A $617.00 $617.00 N/A 4163712 Misc Charges PULSE OXIMETRY 94760 460 $24.00 $- $2.74 $- $- $19.20 $- N/A $6.24 N/A N/A $4.18 N/A N/A $14.40 N/A N/A $12.00 N/A N/A $2.74 N/A N/A $16.32 N/A N/A $11.76 N/A N/A $9.36 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A $2.74 N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $16.80 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 4167202 Misc Charges DIFFUSING CAPACITY-CARBON 94729 460 $659.00 $- $45.64 $- $- $527.20 $- N/A $171.34 N/A N/A $75.22 N/A N/A $395.40 N/A N/A $329.50 N/A N/A $45.64 N/A N/A $448.12 N/A N/A $322.91 N/A N/A $257.01 N/A N/A $461.30 N/A N/A $527.20 N/A N/A $362.45 N/A N/A $461.30 N/A N/A $220.77 N/A N/A $45.64 N/A N/A $395.40 N/A N/A $230.65 N/A N/A $428.35 N/A N/A $197.70 N/A N/A $395.40 N/A N/A $461.30 N/A N/A $197.70 N/A N/A $197.70 N/A N/A $197.70 N/A N/A $197.70 N/A N/A $197.70 N/A N/A $197.70 N/A $659.00 $659.00 N/A 5051626 Nutrition Services Charges DIETARY TRAINING CHARGE 942 $137.00 $- $35.62 $- $- $109.60 $- N/A $35.62 N/A N/A $51.79 N/A N/A $82.20 N/A N/A $68.50 N/A N/A N/A N/A N/A $93.16 N/A N/A $80.83 N/A N/A $53.43 N/A N/A $95.90 N/A N/A $109.60 N/A N/A $60.28 N/A N/A $95.90 N/A N/A N/A N/A N/A N/A N/A N/A $82.20 N/A N/A $47.95 N/A N/A $89.05 N/A N/A $41.10 N/A N/A $82.20 N/A N/A N/A N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A N/A $41.10 N/A $137.00 $137.00 N/A 4506979 Occupational Therapy Charges Iontophoresis Charges 97033 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $33.91 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.10 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.10 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506984 Occupational Therapy Charges Therapeutic Exercise Charges 97110 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $32.48 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $26.50 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $26.50 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550201 Occupational Therapy Charges Community/Work Reintegration Charges 97537 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $30.36 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550204 Occupational Therapy Charges Contrast baths 97014 G0283 430 $99.00 $- $13.33 $- $- $111.00 $- N/A $25.74 N/A N/A $16.36 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $13.33 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $13.33 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550204 Occupational Therapy Charges Unattended Electrical Therapy Charge 97014 G0283 430 $99.00 $- $13.33 $- $- $111.00 $- N/A $25.74 N/A N/A $16.36 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $13.33 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $13.33 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550206 Occupational Therapy Charges Massage Charge Units 97124 430 $99.00 $- $21.82 $- $- $111.00 $- N/A $25.74 N/A N/A $26.65 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $21.82 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $21.82 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550211 Occupational Therapy Charges Whirlpool Full Body Charge 97022 430 $195.00 $- $19.69 $- $- $156.00 $- N/A $50.70 N/A N/A $24.53 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $19.69 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $19.69 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4550215 Occupational Therapy Charges OT Low Complex Units 97165 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4550216 Occupational Therapy Charges OT Moderate Complex Units 97166 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4550217 Occupational Therapy Charges OT High Complex Units 97167 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4556950 Occupational Therapy Charges Wheelchair Charge 97542 430 $99.00 $- $25.29 $- $- $111.00 $- N/A $25.74 N/A N/A $30.71 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $25.29 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $25.29 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556953 Occupational Therapy Charges ADL Training Charges 97535 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $35.32 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $28.92 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $28.92 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556954 Occupational Therapy Charges Cognitive Skills Development Charges 97127 G0515 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A N/A N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Occupational Therapy Charges Neuromuscular Reeducation Charges 97112 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $33.90 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.71 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.71 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Occupational Therapy Charges Therapeutic Activities Charges 97530 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $35.69 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $28.93 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $28.93 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Occupational Therapy Charges OT Paraffin Bath Charge 97018 430 $99.00 $- $9.29 $- $- $111.00 $- N/A $25.74 N/A N/A $11.63 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $9.29 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $9.29 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556960 Occupational Therapy Charges Contrast Bath Charges 97034 430 $99.00 $- $15.09 $- $- $111.00 $- N/A $25.74 N/A N/A $18.42 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $15.09 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $15.09 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556961 Occupational Therapy Charges Ultrasound Charges 97035 430 $99.00 $- $10.57 $- $- $111.00 $- N/A $25.74 N/A N/A $12.76 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $10.57 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $10.57 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556964 Occupational Therapy Charges Attended E-Stim Charges 97032 430 $99.00 $- $15.94 $- $- $111.00 $- N/A $25.74 N/A N/A $19.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $15.94 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $15.94 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556964 Occupational Therapy Charges Group therapy 97150 430 $99.00 $- $14.37 $- $- $111.00 $- N/A $25.74 N/A N/A $17.56 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $14.37 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $14.37 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556964 Occupational Therapy Charges Yes 97150 430 $99.00 $- $14.37 $- $- $111.00 $- N/A $25.74 N/A N/A $17.56 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $14.37 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $14.37 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556966 Occupational Therapy Charges Joint Mobilization Charges 97140 430 $99.00 $- $24.72 $- $- $111.00 $- N/A $25.74 N/A N/A $30.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $24.72 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $24.72 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556966 Occupational Therapy Charges Manual Therapy Charge Units 97140 430 $99.00 $- $24.72 $- $- $111.00 $- N/A $25.74 N/A N/A $30.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $24.72 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $24.72 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557106 Occupational Therapy Charges OT Low Complex Units 97165 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4557108 Occupational Therapy Charges OTBU: OT Therapeutic Exercise Charges 97110 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $32.48 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $26.50 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $26.50 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557110 Occupational Therapy Charges Therapeutic Activities Charges 97530 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $35.69 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $28.93 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $28.93 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557112 Occupational Therapy Charges OTBU: OT ADL Training Charges 97535 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $35.32 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $28.92 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $28.92 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557114 Occupational Therapy Charges OT Moderate Complex Units 97166 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4557116 Occupational Therapy Charges OT High Complex Units 97167 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4557118 Occupational Therapy Charges Manual Therapy Charge Units 97140 430 $99.00 $- $24.72 $- $- $111.00 $- N/A $25.74 N/A N/A $30.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $24.72 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $24.72 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557120 Occupational Therapy Charges OT BU: OT Neuromuscular Reeducation Charges 97112 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $33.90 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.71 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.71 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557120 Occupational Therapy Charges OTBU: OT Wheelchair Charge 97542 430 $99.00 $- $25.29 $- $- $111.00 $- N/A $25.74 N/A N/A $30.71 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $25.29 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $25.29 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557122 Occupational Therapy Charges OT ReEval Units 97168 434 $195.00 $- $42.49 $- $- $156.00 $- N/A $50.70 N/A N/A $52.33 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $42.49 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $42.49 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4557124 Occupational Therapy Charges OT BU: OT Massage Charge Units 97124 430 $99.00 $- $21.82 $- $- $111.00 $- N/A $25.74 N/A N/A $26.65 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $21.82 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $21.82 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557128 Occupational Therapy Charges Orthotic Mgmt and Training Charges 97760 430 $93.00 $- $24.18 $- $- $111.00 $- N/A $24.18 N/A N/A $39.32 N/A N/A $55.80 N/A N/A $46.50 N/A N/A $31.96 N/A N/A $63.24 N/A N/A $111.00 N/A N/A $36.27 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $200 per visit N/A N/A $65.10 N/A N/A $31.16 N/A N/A $31.96 N/A N/A $55.80 N/A N/A $32.55 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $27.90 N/A N/A $55.80 N/A N/A $65.10 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 4557130 Occupational Therapy Charges Prosthetic Charge 97761 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $34.01 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.73 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.73 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557132 Occupational Therapy Charges Cognitive Skills Development Charges 97532 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A N/A N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557134 Occupational Therapy Charges Orthotic Mgmt and Training Charges 97760 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $39.32 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $31.96 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $31.96 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557202 Occupational Therapy Charges OT Orthotic Mgmt/Train Establish Charge 97763 430 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $56.80 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $39.61 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $39.61 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4553310 OT Tx/Procedures "OT Cog Ther Intervent,First 15 Min Units" 97129 430 $99.00 $- $23.95 $- $- $111.00 $- N/A $25.74 N/A N/A $23.95 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4553310 OT Tx/Procedures "OT Cog Ther Intervent, First 15 Min Asst" 97129 430 $99.00 $- $23.95 $- $- $111.00 $- N/A $25.74 N/A N/A $23.95 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4553320 OT Tx/Procedures "OT Cog Ther Intervent, Addl 15 Min Units" 97130 430 $99.00 $- $23.24 $- $- $111.00 $- N/A $25.74 N/A N/A $23.24 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4553320 OT Tx/Procedures "OT Cog Ther Intervent, Addl 15 Min Asst" 97130 430 $99.00 $- $23.24 $- $- $111.00 $- N/A $25.74 N/A N/A $23.24 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4557100 OT Tx/Procedures Occupational Therapy Eval and Treatment 97166 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4557102 OT Tx/Procedures Occupational Therapy Evaluation and Treatment LTC 97166 434 $387.00 $- $64.24 $- $- $309.60 $- N/A $100.62 N/A N/A $79.12 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $64.24 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $64.24 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 3239281 Patient Care Level 1 99281 450 $389.00 $- $18.18 $- $- $311.20 $- N/A $101.14 N/A N/A $147.04 N/A N/A $233.40 N/A N/A $194.50 N/A N/A $18.18 N/A N/A $264.52 N/A N/A $229.51 N/A N/A $151.71 N/A N/A $272.30 N/A N/A $311.20 N/A N/A $171.16 N/A N/A $272.30 N/A N/A $130.32 N/A N/A $18.18 N/A N/A $233.40 N/A N/A $136.15 N/A N/A $252.85 N/A N/A $116.70 N/A N/A $233.40 N/A N/A $272.30 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A N/A $116.70 N/A $389.00 $389.00 N/A 3239282 Patient Care Level 2 99282 450 $672.00 $- $35.76 $- $- $537.60 $- N/A $174.72 N/A N/A $254.02 N/A N/A $403.20 N/A N/A $336.00 N/A N/A $35.76 N/A N/A $456.96 N/A N/A $396.48 N/A N/A $262.08 N/A N/A $470.40 N/A N/A $537.60 N/A N/A $295.68 N/A N/A $470.40 N/A N/A $225.12 N/A N/A $35.76 N/A N/A $403.20 N/A N/A $235.20 N/A N/A $436.80 N/A N/A $201.60 N/A N/A $403.20 N/A N/A $470.40 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A N/A $201.60 N/A $672.00 $672.00 N/A 3239283 Patient Care Level 3 99283 450 "$1,505.00 " $- $53.28 $- $- "$1,204.00 " $- N/A $391.30 N/A N/A $568.89 N/A N/A $903.00 N/A N/A $752.50 N/A N/A $53.28 N/A N/A "$1,023.40 " N/A N/A $887.95 N/A N/A $586.95 N/A N/A "$1,053.50 " N/A N/A "$1,204.00 " N/A N/A $662.20 N/A N/A "$1,053.50 " N/A N/A $504.18 N/A N/A $53.28 N/A N/A $903.00 N/A N/A $526.75 N/A N/A $978.25 N/A N/A $451.50 N/A N/A $903.00 N/A N/A "$1,053.50 " N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A N/A $451.50 N/A "$1,505.00 " "$1,505.00 " N/A 3239284 Patient Care Level 4 99284 450 "$2,534.00 " $- $101.66 $- $- "$2,027.20 " $- N/A $658.84 N/A N/A $957.85 N/A N/A "$1,520.40 " N/A N/A "$1,267.00 " N/A N/A $101.66 N/A N/A "$1,723.12 " N/A N/A "$1,495.06 " N/A N/A $988.26 N/A N/A "$1,773.80 " N/A N/A "$2,027.20 " N/A N/A "$1,114.96 " N/A N/A "$1,773.80 " N/A N/A $848.89 N/A N/A $101.66 N/A N/A "$1,520.40 " N/A N/A $886.90 N/A N/A "$1,647.10 " N/A N/A $760.20 N/A N/A "$1,520.40 " N/A N/A "$1,773.80 " N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A N/A $760.20 N/A "$2,534.00 " "$2,534.00 " N/A 3239285 Patient Care Level 5 99285 450 "$3,402.00 " $- $149.31 $- $- "$2,721.60 " $- N/A $884.52 N/A N/A "$1,285.96 " N/A N/A "$2,041.20 " N/A N/A "$1,701.00 " N/A N/A $149.31 N/A N/A "$2,313.36 " N/A N/A "$2,007.18 " N/A N/A "$1,326.78 " N/A N/A "$2,381.40 " N/A N/A "$2,721.60 " N/A N/A "$1,496.88 " N/A N/A "$2,381.40 " N/A N/A "$1,139.67 " N/A N/A $149.31 N/A N/A "$2,041.20 " N/A N/A "$1,190.70 " N/A N/A "$2,211.30 " N/A N/A "$1,020.60 " N/A N/A "$2,041.20 " N/A N/A "$2,381.40 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A N/A "$1,020.60 " N/A "$3,402.00 " "$3,402.00 " N/A 4557202 Patient Care Orthotic Fitting/Training/Manag Details 97763 430 $99.00 $- $25.74 $- $- $79.20 $- N/A $25.74 N/A N/A $37.42 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $39.61 N/A N/A $67.32 N/A N/A $58.41 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $43.56 N/A N/A $69.30 N/A N/A $33.17 N/A N/A $39.61 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 867365 Person Management ROOM/BED: MST Hospice P-Single 115 $831.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $831.00 $831.00 N/A 3020064 Person Management ROOM/BED: MST P-Single 110 "$2,544.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,544.00 " "$2,544.00 " N/A 3020065 Person Management ROOM/BED: MST S - Semi-Private 120 "$2,418.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,418.00 " "$2,418.00 " N/A 3020065 Person Management ROOM/BED: MST Semi-Private 120 "$2,418.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,418.00 " "$2,418.00 " N/A 3020081 Person Management ROOM/BED: MST Intermediate P-Single 160 $- "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $- $- N/A 3020082 Person Management ROOM/BED:MSTTelemetry P-Single 110 "$2,741.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,741.00 " "$2,741.00 " N/A 3020084 Person Management ROOM/BED: MST Isolation P-Single 164 "$2,899.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,899.00 " "$2,899.00 " N/A 3020084 Person Management ROOM/BED: MST Isolation P-Single 164 "$2,899.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,899.00 " "$2,899.00 " N/A 3020086 Person Management ROOM/BED: MST Telemetry P-Single 110 "$2,741.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,741.00 " "$2,741.00 " N/A 3020090 Person Management ROOM/BED: MST Camera Room 110 "$3,052.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,052.00 " "$3,052.00 " N/A 3020091 Person Management ROOM/BED: MST P-Single 110 "$2,544.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,544.00 " "$2,544.00 " N/A 3020092 Person Management ROOM/BED: MST Swing P-Single 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3020093 Person Management ROOM/BED: TRU Swing P-Single 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,547.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3040040 Person Management ROOM/BED: TRU Swing P-Single Overflow 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,547.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3040045 Person Management ROOM/BED: MST Swing P-Single 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3040046 Person Management ROOM/BED: TRU Swing P-Single Overflow 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,547.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3070010 Person Management ROOM/BED: Gero P-Single 114 "$2,544.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,544.00 " "$2,544.00 " N/A 3070020 Person Management ROOM/BED: Gero Semi Private 124 "$2,418.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$2,418.00 " "$2,418.00 " N/A 3080025 Person Management ROOM/BED: TRU SWING P-SINGLE 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,547.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 3080030 Person Management ROOM/BED: TRU Swing Semi-Private 120 $- "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $- $- N/A 3080035 Person Management ROOM/BED: TMU P-Single Overflow 110 "$1,956.00 " "$1,472.00 " $- $- "$3,673.00 " $- $- "$1,871.00 " N/A N/A "$2,500.00 " N/A N/A "$3,000.00 " N/A N/A "$2,500.00 " N/A N/A "$1,538.00 " N/A N/A "$2,631.00 " N/A N/A "$2,353.00 " N/A N/A "$3,673.00 " N/A N/A "$1,850.00 " N/A N/A "$3,435.00 " N/A N/A "$2,747.00 " N/A N/A "$1,472.00 " N/A N/A "$1,716.00 " N/A N/A "$1,538.00 " N/A N/A "$2,250.00 " N/A N/A "$2,115.72 " N/A N/A "$3,096.00 " N/A N/A "$3,052.00 " N/A N/A "$2,800.00 " N/A N/A "$1,472.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$1,956.00 " "$1,956.00 " N/A 4245000 Person Management ROOM/BED: Gero Skilled P-Single 160 $453.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $453.00 $453.00 N/A 4245001 Person Management ROOM/BED: Gero Skilled Semi-Private 160 $422.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $422.00 $422.00 N/A 4245002 Person Management ROOM/BED: TRU Skilled P-Single 110 $453.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $453.00 $453.00 N/A 4245003 Person Management ROOM/BED: TRU Skilled Semi-Private 120 $422.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $422.00 $422.00 N/A 4245004 Person Management ROOM/BED: TRU Skilled P-Single Overflow 110 $453.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $453.00 $453.00 N/A 4245005 Person Management ROOM/BED: MST Skilled P-Single 110 $453.00 $250.00 $- $- "$3,673.00 " $- $- $350.00 N/A N/A $350.00 N/A N/A $600.00 N/A N/A $630.00 N/A N/A $250.00 N/A N/A $836.97 N/A N/A $722.00 N/A N/A N/A N/A N/A N/A N/A N/A $809.00 N/A N/A "$1,681.00 " N/A N/A $429.00 N/A N/A N/A N/A N/A $250.00 N/A N/A N/A N/A N/A N/A N/A N/A $779.00 N/A N/A "$2,185.00 " N/A N/A "$1,200.00 " N/A N/A $683.76 N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A "$3,673.00 " N/A N/A $453.00 $453.00 N/A 4500102 Physical Therapy Charges Massage Charge Units 97124 420 $99.00 $- $21.82 $- $- $111.00 $- N/A $25.74 N/A N/A $26.65 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $21.82 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $21.82 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4500103 Physical Therapy Charges Unattended Electrical Therapy Charge 97014 G0283 420 $99.00 $- $13.33 $- $- $111.00 $- N/A $25.74 N/A N/A $16.36 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $13.33 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $13.33 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4500105 Physical Therapy Charges Selective Debridement Addition Charge 97598 420 $99.00 $- $9.64 $- $- $111.00 $- N/A $25.74 N/A N/A $13.20 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $9.64 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $9.64 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4500106 Physical Therapy Charges "Selective Debridement Charge:Yes, total wound surface area," 97597 420 $195.00 $- $20.13 $- $- $156.00 $- N/A $50.70 N/A N/A $27.50 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $20.13 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $20.13 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4500107 Physical Therapy Charges Prosthetic Training Charges 97761 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $34.01 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.73 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.73 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4500108 Physical Therapy Charges PT Wound VAC >50 Charge:Yes 97606 420 $387.00 $- $24.90 $- $- $309.60 $- N/A $100.62 N/A N/A $34.62 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $24.90 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $24.90 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4500109 Physical Therapy Charges Wound Vac Charge 97605 420 $292.00 $- $22.53 $- $- $233.60 $- N/A $75.92 N/A N/A $30.90 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $22.53 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $22.53 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4500109 Physical Therapy Charges Wound Vac Charge 97605 420 $292.00 $- $22.53 $- $- $233.60 $- N/A $75.92 N/A N/A $30.90 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $22.53 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $22.53 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4500315 Physical Therapy Charges PT Low Complex Units 97161 424 $387.00 $- $66.32 $- $- $309.60 $- N/A $100.62 N/A N/A $81.67 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $66.32 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $66.32 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4500315 Physical Therapy Charges PT Low Complex Units 97161 424 $387.00 $- $66.32 $- $- $309.60 $- N/A $100.62 N/A N/A $81.67 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $66.32 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $66.32 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4500316 Physical Therapy Charges PT Moderate Complex Units 97162 424 $387.00 $- $66.32 $- $- $309.60 $- N/A $100.62 N/A N/A $81.67 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $66.32 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $66.32 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4500317 Physical Therapy Charges PT High Complex Units 97163 424 $387.00 $- $66.32 $- $- $309.60 $- N/A $100.62 N/A N/A $81.67 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $66.32 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $66.32 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4500500 Physical Therapy Charges PT Canalith Repositioning Charge 95992 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $43.38 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $31.53 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $31.53 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506938 Physical Therapy Charges Wheelchair Management Charges 97542 420 $99.00 $- $25.29 $- $- $111.00 $- N/A $25.74 N/A N/A $30.71 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $25.29 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $25.29 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506972 Physical Therapy Charges Group Therapy Charge 97150 420 $99.00 $- $14.37 $- $- $111.00 $- N/A $25.74 N/A N/A $17.56 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $14.37 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $14.37 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506977 Physical Therapy Charges Gait Training Charges 97116 420 $99.00 $- $23.56 $- $- $111.00 $- N/A $25.74 N/A N/A $28.68 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $23.56 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $23.56 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506978 Physical Therapy Charges Mechanical Traction Charge 97012 420 $195.00 $- $13.22 $- $- $156.00 $- N/A $50.70 N/A N/A $16.22 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $13.22 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $13.22 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4506980 Physical Therapy Charges Whirlpool Full Body Charge 97022 420 $195.00 $- $19.69 $- $- $156.00 $- N/A $50.70 N/A N/A $24.53 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $19.69 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $19.69 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4506983 Physical Therapy Charges Aquatic Therapy Charges 97113 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $44.54 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $35.88 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $35.88 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506988 Physical Therapy Charges Manual Therapy Charge Units 97140 420 $99.00 $- $24.72 $- $- $111.00 $- N/A $25.74 N/A N/A $30.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $24.72 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $24.72 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506988 Physical Therapy Charges Mobilization 97140 420 $99.00 $- $24.72 $- $- $111.00 $- N/A $25.74 N/A N/A $30.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $24.72 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $24.72 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506990 Physical Therapy Charges Orthotic Mgmt and Training Charges 97760 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $39.32 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $31.96 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $31.96 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4506994 Physical Therapy Charges Ultrasound Charges 97035 420 $99.00 $- $10.57 $- $- $111.00 $- N/A $25.74 N/A N/A $12.76 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $10.57 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $10.57 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4507037 Physical Therapy Charges 97164 424 $186.00 $- $45.14 $- $- $148.80 $- N/A $48.36 N/A N/A $55.58 N/A N/A $111.60 N/A N/A $93.00 N/A N/A $45.14 N/A N/A $126.48 N/A N/A $111.00 N/A N/A $72.54 N/A N/A $130.20 N/A N/A $148.80 N/A N/A $200 per visit N/A N/A $130.20 N/A N/A $62.31 N/A N/A $45.14 N/A N/A $111.60 N/A N/A $65.10 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $55.80 N/A N/A $111.60 N/A N/A $130.20 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A $186.00 $186.00 N/A 4507037 Physical Therapy Charges Reevaluation Charge 97164 424 $186.00 $- $45.14 $- $- $148.80 $- N/A $48.36 N/A N/A $55.58 N/A N/A $111.60 N/A N/A $93.00 N/A N/A $45.14 N/A N/A $126.48 N/A N/A $111.00 N/A N/A $72.54 N/A N/A $130.20 N/A N/A $148.80 N/A N/A $200 per visit N/A N/A $130.20 N/A N/A $62.31 N/A N/A $45.14 N/A N/A $111.60 N/A N/A $65.10 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $55.80 N/A N/A $111.60 N/A N/A $130.20 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A N/A $55.80 N/A $186.00 $186.00 N/A 4507039 Physical Therapy Charges Orthotic Mgmt and Training Charges 97760 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $39.32 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $31.96 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $31.96 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4507041 Physical Therapy Charges Dressing Debride Partial Burns Initial or Subseq SM 16020 420 $358.00 $- $48.56 $- $- $286.40 $- N/A $93.08 N/A N/A $57.96 N/A N/A $214.80 N/A N/A $179.00 N/A N/A $48.56 N/A N/A $243.44 N/A N/A $111.00 N/A N/A $139.62 N/A N/A $250.60 N/A N/A $286.40 N/A N/A $200 per visit N/A N/A $250.60 N/A N/A $119.93 N/A N/A $48.56 N/A N/A $214.80 N/A N/A $125.30 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $107.40 N/A N/A $214.80 N/A N/A $250.60 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A $358.00 $358.00 N/A 4507043 Physical Therapy Charges Dressing Debridement Partial Burns Initial or Subsequent Med 16025 420 $419.00 $- $100.23 $- $- $335.20 $- N/A $108.94 N/A N/A $118.73 N/A N/A $251.40 N/A N/A $209.50 N/A N/A $100.23 N/A N/A $284.92 N/A N/A $111.00 N/A N/A $163.41 N/A N/A $293.30 N/A N/A $335.20 N/A N/A $200 per visit N/A N/A $293.30 N/A N/A $140.37 N/A N/A $100.23 N/A N/A $251.40 N/A N/A $146.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $125.70 N/A N/A $251.40 N/A N/A $293.30 N/A N/A $125.70 N/A N/A $125.70 N/A N/A $125.70 N/A N/A $125.70 N/A N/A $125.70 N/A N/A $125.70 N/A $419.00 $419.00 N/A 4507045 Physical Therapy Charges DRESSING DEBRIDEMENT PARTIAL THICKNESS BURNS INITIAL OR SUBS 16030 420 $457.00 $- $111.00 $- $- $365.60 $- N/A $118.82 N/A N/A $141.76 N/A N/A $274.20 N/A N/A $228.50 N/A N/A $121.21 N/A N/A $310.76 N/A N/A $111.00 N/A N/A $178.23 N/A N/A $319.90 N/A N/A $365.60 N/A N/A $200 per visit N/A N/A $319.90 N/A N/A $153.10 N/A N/A $121.21 N/A N/A $274.20 N/A N/A $159.95 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $137.10 N/A N/A $274.20 N/A N/A $319.90 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A N/A $137.10 N/A $457.00 $457.00 N/A 4509999 Physical Therapy Charges DRESSING DEBRIDEMENT PARTIAL THICKNESS BURNS INITIAL OR SUBS 16020 420 $358.00 $- $48.56 $- $- $286.40 $- N/A $93.08 N/A N/A $57.96 N/A N/A $214.80 N/A N/A $179.00 N/A N/A $48.56 N/A N/A $243.44 N/A N/A $111.00 N/A N/A $139.62 N/A N/A $250.60 N/A N/A $286.40 N/A N/A $200 per visit N/A N/A $250.60 N/A N/A $119.93 N/A N/A $48.56 N/A N/A $214.80 N/A N/A $125.30 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $107.40 N/A N/A $214.80 N/A N/A $250.60 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A N/A $107.40 N/A $358.00 $358.00 N/A 4550201 Physical Therapy Charges Attended E-Stim Charges 97032 420 $99.00 $- $15.94 $- $- $111.00 $- N/A $25.74 N/A N/A $19.40 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $15.94 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $15.94 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550204 Physical Therapy Charges PT Contrast Bath Charges 97014 G0283 430 $99.00 $- $13.33 $- $- $111.00 $- N/A $25.74 N/A N/A $16.36 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $13.33 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $13.33 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550205 Physical Therapy Charges Iontophoresis Charges 97033 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $33.91 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.10 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.10 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4550206 Physical Therapy Charges Massage Charge Units 97124 430 $99.00 $- $21.82 $- $- $111.00 $- N/A $25.74 N/A N/A $26.65 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $21.82 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $21.82 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Physical Therapy Charges Neuromuscular Reeducation Charges 97112 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $33.90 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $27.71 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $27.71 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Physical Therapy Charges Therapeutic Activities Charge 97530 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $35.69 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $28.93 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $28.93 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Physical Therapy Charges Therapeutic Exercise Charges 97110 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $32.48 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $26.50 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $26.50 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556959 Physical Therapy Charges PT Paraffin Bath Charge 97018 420 $99.00 $- $9.29 $- $- $111.00 $- N/A $25.74 N/A N/A $11.63 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $9.29 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $9.29 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556961 Physical Therapy Charges Checkout for Prosth/Orth Use Charges 97035 420 $99.00 $- $10.57 $- $- $111.00 $- N/A $25.74 N/A N/A $12.76 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $10.57 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $10.57 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4556961 Physical Therapy Charges Vasopneumatic Device Charge 97016 420 $99.00 $- $16.05 $- $- $111.00 $- N/A $25.74 N/A N/A $20.26 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $16.05 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $16.05 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 49055250 Procedure Charge "Vasectomy, unilateral or bilateral Technical Charge" 55250 490 "$5,126.00 " $- $665.81 $- $- "$4,100.80 " $- N/A "$1,332.76 " N/A N/A $950.00 N/A N/A "$3,075.60 " N/A N/A "$2,563.00 " N/A N/A $665.81 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,999.14 " N/A N/A "$2,332.33 " N/A N/A "$4,100.80 " N/A N/A N/A N/A N/A "$3,331.90 " N/A N/A $789.71 N/A N/A $665.81 N/A N/A $789.71 N/A N/A "$1,794.10 " N/A N/A $939.00 N/A N/A "$1,537.80 " N/A N/A "$1,273.00 " N/A N/A "$3,331.90 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A "$5,126.00 " "$5,126.00 " N/A 9.6094E+11 Procedure Charge 93971 Unilateral Venous Reflux 93971 960 $- $- $- $- $- $- $210.06 N/A N/A $68.27 N/A N/A N/A N/A N/A $157.55 N/A N/A $131.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $103.72 N/A N/A $119.47 N/A N/A $210.06 N/A N/A $- N/A N/A $170.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $91.90 N/A N/A N/A N/A N/A $78.77 N/A N/A N/A N/A N/A $170.68 N/A N/A $78.77 N/A N/A $78.77 N/A N/A $78.77 N/A N/A $78.77 N/A N/A $78.77 N/A N/A $78.77 N/A N/A $- 9.60976E+11 Procedure Charge Negative pressure wound therapy (e.g. vacuum-assisted drainage collection)<50 sq cm 97605 960 $- $- $- $- $- $- $73.25 N/A N/A $23.81 N/A N/A N/A N/A N/A $54.94 N/A N/A $45.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.17 N/A N/A $41.66 N/A N/A $73.25 N/A N/A $- N/A N/A $59.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.05 N/A N/A N/A N/A N/A $27.47 N/A N/A N/A N/A N/A $59.51 N/A N/A $27.47 N/A N/A $27.47 N/A N/A $27.47 N/A N/A $27.47 N/A N/A $27.47 N/A N/A $27.47 N/A N/A $- 9.75101E+11 Procedure Charge Drain Skin Abscess Complex/Multiple Charge 10061 975 $- $- $- $- $- $- $878.00 N/A N/A $121.77 N/A N/A $750.00 N/A N/A $281.00 N/A N/A $234.17 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $184.99 N/A N/A $213.09 N/A N/A $374.67 N/A N/A $- N/A N/A $304.42 N/A N/A $115.49 N/A N/A N/A N/A N/A $115.49 N/A N/A $163.92 N/A N/A $700.00 N/A N/A $140.50 N/A N/A $474.00 N/A N/A $304.42 N/A N/A $140.50 N/A N/A $140.50 N/A N/A $140.50 N/A N/A $140.50 N/A N/A $140.50 N/A N/A $140.50 N/A N/A $- 9.7511E+11 Procedure Charge Debride Skin/Soft Tissue Charge 11042 975 $- $- $- $- $- $- "$1,177.00 " N/A N/A $74.02 N/A N/A $950.00 N/A N/A $170.81 N/A N/A $142.34 N/A N/A $99.69 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $112.45 N/A N/A $129.53 N/A N/A $227.74 N/A N/A $- N/A N/A $185.04 N/A N/A $161.45 N/A N/A $99.69 N/A N/A $161.45 N/A N/A $99.64 N/A N/A $939.00 N/A N/A $85.40 N/A N/A $474.00 N/A N/A $185.04 N/A N/A $85.40 N/A N/A $85.40 N/A N/A $85.40 N/A N/A $85.40 N/A N/A $85.40 N/A N/A $85.40 N/A N/A $- 9.7511E+11 Procedure Charge 11044 Debridement bone muscle and/or fascia first 20 sq cm or less 11044 975 $- $- $- $- $- $- "$1,177.00 " N/A N/A $178.34 N/A N/A $950.00 N/A N/A $411.56 N/A N/A $342.97 N/A N/A $416.34 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $270.95 N/A N/A $312.10 N/A N/A $548.75 N/A N/A $- N/A N/A $445.86 N/A N/A $576.39 N/A N/A $416.34 N/A N/A $576.39 N/A N/A $240.08 N/A N/A $939.00 N/A N/A $205.78 N/A N/A $686.00 N/A N/A $445.86 N/A N/A $205.78 N/A N/A $205.78 N/A N/A $205.78 N/A N/A $205.78 N/A N/A $205.78 N/A N/A $205.78 N/A N/A $- 9.75114E+11 Procedure Charge 11403 Exc benign trunk/arms/legs; 2.1 - 3.0 cm 11403 975 $- $- $- $- $- $- $878.00 N/A N/A $113.13 N/A N/A $750.00 N/A N/A $261.06 N/A N/A $217.55 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $171.86 N/A N/A $197.97 N/A N/A $348.08 N/A N/A $- N/A N/A $282.82 N/A N/A $124.87 N/A N/A N/A N/A N/A $124.87 N/A N/A $152.29 N/A N/A $700.00 N/A N/A $130.53 N/A N/A $686.00 N/A N/A $282.82 N/A N/A $130.53 N/A N/A $130.53 N/A N/A $130.53 N/A N/A $130.53 N/A N/A $130.53 N/A N/A $130.53 N/A N/A $- 9.7514E+11 Procedure Charge Adj tissue xfer/rearrangementforeheadcheekchinmouthhands/ft 10.1cm-30.0cm Tech Chg 14041 975 $- $- $- $- $- $- "$1,603.66 " N/A N/A $521.19 N/A N/A "$1,150.00 " N/A N/A "$1,202.75 " N/A N/A "$1,002.29 " N/A N/A $623.73 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A $791.81 N/A N/A $912.08 N/A N/A "$1,603.66 " N/A N/A $- N/A N/A "$1,302.98 " N/A N/A $819.95 N/A N/A $623.73 N/A N/A $819.95 N/A N/A $701.60 N/A N/A "$1,071.00 " N/A N/A $601.37 N/A N/A "$1,061.00 " N/A N/A "$1,302.98 " N/A N/A $601.37 N/A N/A $601.37 N/A N/A $601.37 N/A N/A $601.37 N/A N/A $601.37 N/A N/A $601.37 N/A N/A $- 9.75219E+11 Procedure Charge Excise Tumor Soft Tissue Back/ Flank >3 Cm 21931 975 $- $- $- $- $- $- "$2,266.00 " N/A N/A $276.24 N/A N/A "$1,150.00 " N/A N/A $637.47 N/A N/A $531.23 N/A N/A $625.09 N/A N/A "$2,266.00 " N/A N/A "$1,343.00 " N/A N/A $419.67 N/A N/A $483.41 N/A N/A $849.96 N/A N/A $- N/A N/A $690.59 N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A $371.86 N/A N/A "$1,071.00 " N/A N/A $318.74 N/A N/A "$1,273.00 " N/A N/A $690.59 N/A N/A $318.74 N/A N/A $318.74 N/A N/A $318.74 N/A N/A $318.74 N/A N/A $318.74 N/A N/A $318.74 N/A N/A $- 9.75276E+11 Procedure Charge Excision tumor leg or ankle area; subcutaneous. 27618 975 $- $- $- $- $- $- "$1,177.00 " N/A N/A $284.37 N/A N/A $950.00 N/A N/A $656.24 N/A N/A $546.87 N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $432.03 N/A N/A $497.65 N/A N/A $874.99 N/A N/A $- N/A N/A $710.93 N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A $382.81 N/A N/A $939.00 N/A N/A $328.12 N/A N/A "$1,061.00 " N/A N/A $710.93 N/A N/A $328.12 N/A N/A $328.12 N/A N/A $328.12 N/A N/A $328.12 N/A N/A $328.12 N/A N/A $328.12 N/A N/A $- 9.75366E+11 Procedure Charge 36590 Removal of tunneled CVAD with subcutaneous port or pump central or peripheral insertion 36590 975 $- $- $- $- $- $- $878.00 N/A N/A $130.73 N/A N/A $750.00 N/A N/A $301.68 N/A N/A $251.40 N/A N/A $381.21 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $198.61 N/A N/A $228.77 N/A N/A $402.24 N/A N/A $- N/A N/A $326.82 N/A N/A $318.59 N/A N/A $381.21 N/A N/A $318.59 N/A N/A $175.98 N/A N/A $700.00 N/A N/A $150.84 N/A N/A $686.00 N/A N/A $326.82 N/A N/A $150.84 N/A N/A $150.84 N/A N/A $150.84 N/A N/A $150.84 N/A N/A $150.84 N/A N/A $150.84 N/A N/A $- 9.75385E+11 Procedure Charge Biopsy or excision of lymph node(s); open deep cervical node(s) 38510 975 $- $- $- $- $- $- "$1,273.00 " N/A N/A $308.30 N/A N/A $950.00 N/A N/A $711.46 N/A N/A $592.88 N/A N/A $967.04 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $468.38 N/A N/A $539.52 N/A N/A $948.61 N/A N/A $- N/A N/A $770.74 N/A N/A "$1,118.44 " N/A N/A $967.04 N/A N/A "$1,118.44 " N/A N/A $415.02 N/A N/A $939.00 N/A N/A $355.73 N/A N/A "$1,273.00 " N/A N/A $770.74 N/A N/A $355.73 N/A N/A $355.73 N/A N/A $355.73 N/A N/A $355.73 N/A N/A $355.73 N/A N/A $355.73 N/A N/A $- 9.75432E+11 Procedure Charge 43202 Esophagoscopy flexible transoral; w/ biopsy single or multiple 43202 975 $- $- $- $- $- $- "$1,061.00 " N/A N/A $210.85 N/A N/A $750.00 N/A N/A $486.59 N/A N/A $405.49 N/A N/A $329.44 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $320.34 N/A N/A $369.00 N/A N/A $648.78 N/A N/A $- N/A N/A $527.14 N/A N/A $663.06 N/A N/A $329.44 N/A N/A $663.06 N/A N/A $283.84 N/A N/A $700.00 N/A N/A $243.29 N/A N/A "$1,061.00 " N/A N/A $527.14 N/A N/A $243.29 N/A N/A $243.29 N/A N/A $243.29 N/A N/A $243.29 N/A N/A $243.29 N/A N/A $243.29 N/A N/A $- 9.75454E+11 Procedure Charge 45378 COLONOSCOPY 45378 975 $- $- $- $- $- $- "$1,177.00 " N/A N/A $197.96 N/A N/A $950.00 N/A N/A $456.83 N/A N/A $380.69 N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $300.75 N/A N/A $346.43 N/A N/A $609.10 N/A N/A $- N/A N/A $494.90 N/A N/A $385.98 N/A N/A $332.71 N/A N/A $385.98 N/A N/A $266.48 N/A N/A $939.00 N/A N/A $228.41 N/A N/A "$1,061.00 " N/A N/A $494.90 N/A N/A $228.41 N/A N/A $228.41 N/A N/A $228.41 N/A N/A $228.41 N/A N/A $228.41 N/A N/A $228.41 N/A N/A $- 9.75476E+11 Procedure Charge Laparoscopy Surgical; Cholecystectomy Charge 47562 975 $- $- $- $- $- $- "$2,818.00 " N/A N/A $391.66 N/A N/A "$1,550.00 " N/A N/A $903.83 N/A N/A $753.20 N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$1,887.00 " N/A N/A $595.02 N/A N/A $685.41 N/A N/A "$1,205.11 " N/A N/A $- N/A N/A $979.15 N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A $527.24 N/A N/A "$1,505.00 " N/A N/A $451.92 N/A N/A "$2,818.00 " N/A N/A $979.15 N/A N/A $451.92 N/A N/A $451.92 N/A N/A $451.92 N/A N/A $451.92 N/A N/A $451.92 N/A N/A $451.92 N/A N/A $- 9.75476E+11 Procedure Charge 47563 Laparoscopy surgical cholecystectomy with cholangiography 47563 975 $- $- $- $- $- $- "$2,818.00 " N/A N/A $426.23 N/A N/A "$1,550.00 " N/A N/A $983.60 N/A N/A $819.67 N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$1,887.00 " N/A N/A $647.54 N/A N/A $745.90 N/A N/A "$1,311.47 " N/A N/A $- N/A N/A "$1,065.57 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A $573.77 N/A N/A "$1,505.00 " N/A N/A $491.80 N/A N/A "$2,818.00 " N/A N/A "$1,065.57 " N/A N/A $491.80 N/A N/A $491.80 N/A N/A $491.80 N/A N/A $491.80 N/A N/A $491.80 N/A N/A $491.80 N/A N/A $- 9.75493E+11 Procedure Charge 49320 LAPAROSCOPY 49320 975 $- $- $- $- $- $- "$2,194.07 " N/A N/A $193.29 N/A N/A "$1,150.00 " N/A N/A $446.06 N/A N/A $371.72 N/A N/A "$1,589.51 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A $293.66 N/A N/A $338.27 N/A N/A $594.75 N/A N/A $- N/A N/A $483.24 N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A $260.20 N/A N/A "$1,071.00 " N/A N/A $223.03 N/A N/A "$1,872.00 " N/A N/A $483.24 N/A N/A $223.03 N/A N/A $223.03 N/A N/A $223.03 N/A N/A $223.03 N/A N/A $223.03 N/A N/A $223.03 N/A N/A $- 9.75495E+11 Procedure Charge Repair Initial Inguinal Hernia Age 5 Yrs or Over; Reducible Charge 49505 975 $- $- $- $- $- $- "$1,656.00 " N/A N/A $309.78 N/A N/A "$1,350.00 " N/A N/A $714.88 N/A N/A $595.73 N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A $470.63 N/A N/A $542.11 N/A N/A $953.17 N/A N/A $- N/A N/A $774.45 N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A $417.01 N/A N/A "$1,321.00 " N/A N/A $357.44 N/A N/A "$1,441.00 " N/A N/A $774.45 N/A N/A $357.44 N/A N/A $357.44 N/A N/A $357.44 N/A N/A $357.44 N/A N/A $357.44 N/A N/A $357.44 N/A N/A $- 9.75495E+11 Procedure Charge Repair recurrent inguinal hernia any age reducible 49520 975 $- $- $- $- $- $- "$2,620.00 " N/A N/A $375.89 N/A N/A "$1,350.00 " N/A N/A $867.44 N/A N/A $722.87 N/A N/A "$1,154.72 " N/A N/A "$2,257.00 " N/A N/A "$2,620.00 " N/A N/A $571.07 N/A N/A $657.81 N/A N/A "$1,156.59 " N/A N/A $- N/A N/A $939.73 N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A $506.01 N/A N/A "$2,090.00 " N/A N/A $433.72 N/A N/A "$1,441.00 " N/A N/A $939.73 N/A N/A $433.72 N/A N/A $433.72 N/A N/A $433.72 N/A N/A $433.72 N/A N/A $433.72 N/A N/A $433.72 N/A N/A $- 9.75496E+11 Procedure Charge Repair umbilical hernia age 5 years or older reducible 49585 975 $- $- $- $- $- $- "$1,656.00 " N/A N/A $264.75 N/A N/A "$1,350.00 " N/A N/A $610.96 N/A N/A $509.14 N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A $402.22 N/A N/A $463.31 N/A N/A $814.62 N/A N/A $- N/A N/A $661.88 N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A $356.39 N/A N/A "$1,321.00 " N/A N/A $305.48 N/A N/A "$1,441.00 " N/A N/A $661.88 N/A N/A $305.48 N/A N/A $305.48 N/A N/A $305.48 N/A N/A $305.48 N/A N/A $305.48 N/A N/A $305.48 N/A N/A $- 9.75645E+11 Procedure Charge Inj Anesthetic Agent; Other Peripheral Nerve or Branch Charge 64450 975 $- $- $- $- $- $- $878.00 N/A N/A $43.37 N/A N/A $750.00 N/A N/A $100.08 N/A N/A $83.40 N/A N/A $98.89 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $65.89 N/A N/A $75.89 N/A N/A $133.44 N/A N/A $- N/A N/A $108.42 N/A N/A $48.36 N/A N/A $98.89 N/A N/A $48.36 N/A N/A $58.38 N/A N/A $700.00 N/A N/A $50.04 N/A N/A $686.00 N/A N/A $108.42 N/A N/A $50.04 N/A N/A $50.04 N/A N/A $50.04 N/A N/A $50.04 N/A N/A $50.04 N/A N/A $50.04 N/A N/A $- 4507101 PT Tx/Procedures PT Orthotic Mgmt/Train Establish Rehab Units 97763 420 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A $56.80 N/A N/A $59.40 N/A N/A $49.50 N/A N/A $39.61 N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A $39.61 N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 3230534 Radiology BCH CLOSED TX HUMERAL EPICONDYLAR FX W/M 24565 450 "$1,341.00 " $- $348.66 $- $- "$1,072.80 " $- N/A $348.66 N/A N/A Included in ER case rate N/A N/A $804.60 N/A N/A $670.50 N/A N/A $434.76 N/A N/A $911.88 N/A N/A $791.19 N/A N/A $522.99 N/A N/A $938.70 N/A N/A "$1,072.80 " N/A N/A $737.55 N/A N/A $938.70 N/A N/A $449.24 N/A N/A $434.76 N/A N/A $804.60 N/A N/A $469.35 N/A N/A $911.88 N/A N/A $402.30 N/A N/A $804.60 N/A N/A $938.70 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A N/A $402.30 N/A "$1,341.00 " "$1,341.00 " N/A 4050001 Radiology Xray Abdomen 1 View 74018 320 $394.00 $- $26.20 $- $- $315.20 $- N/A $102.44 N/A N/A $31.26 N/A N/A $236.40 N/A N/A $197.00 N/A N/A $26.20 N/A N/A $267.92 N/A N/A $224.58 N/A N/A $153.66 N/A N/A $275.80 N/A N/A $315.20 N/A N/A $216.70 N/A N/A $275.80 N/A N/A $131.99 N/A N/A $26.20 N/A N/A $236.40 N/A N/A $137.90 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $236.40 N/A N/A $275.80 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A $394.00 $394.00 N/A 4050001 Radiology Xray Abdomen 1 View 74018 320 $394.00 $- $26.20 $- $- $315.20 $- N/A $102.44 N/A N/A $31.26 N/A N/A $236.40 N/A N/A $197.00 N/A N/A $26.20 N/A N/A $267.92 N/A N/A $224.58 N/A N/A $153.66 N/A N/A $275.80 N/A N/A $315.20 N/A N/A $216.70 N/A N/A $275.80 N/A N/A $131.99 N/A N/A $26.20 N/A N/A $236.40 N/A N/A $137.90 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $236.40 N/A N/A $275.80 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A $394.00 $394.00 N/A 4050002 Radiology Xray Clavicle Comp Lt 73000 320 $536.00 $- $29.24 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $29.24 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $29.24 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4050002 Radiology Xray Clavicle Comp Rt 73000 320 $536.00 $- $29.24 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $29.24 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $29.24 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4050002 Radiology Xray Clavicle Comp Bil 73000 320 $536.00 $- $29.24 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $29.24 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $29.24 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4050003 Radiology Xray Fluoro Guide Ndl Placement 77003 320 "$1,002.00 " $- $89.22 $- $- $801.60 $- N/A $260.52 N/A N/A $112.22 N/A N/A $601.20 N/A N/A $501.00 N/A N/A $89.22 N/A N/A $681.36 N/A N/A $571.14 N/A N/A $390.78 N/A N/A $701.40 N/A N/A $801.60 N/A N/A $551.10 N/A N/A $701.40 N/A N/A $335.67 N/A N/A $89.22 N/A N/A $601.20 N/A N/A $350.70 N/A N/A $651.30 N/A N/A $300.60 N/A N/A $601.20 N/A N/A $701.40 N/A N/A $300.60 N/A N/A $300.60 N/A N/A $300.60 N/A N/A $300.60 N/A N/A $300.60 N/A N/A $300.60 N/A "$1,002.00 " "$1,002.00 " N/A 4050017 Radiology Xray Fluoro Over 1 Hour 76001 320 "$1,011.00 " $- $262.86 $- $- $808.80 $- N/A $262.86 N/A N/A N/A N/A N/A $606.60 N/A N/A $505.50 N/A N/A N/A N/A N/A $687.48 N/A N/A $576.27 N/A N/A $394.29 N/A N/A $707.70 N/A N/A $808.80 N/A N/A $556.05 N/A N/A $707.70 N/A N/A $338.69 N/A N/A N/A N/A N/A $606.60 N/A N/A $353.85 N/A N/A $657.15 N/A N/A $303.30 N/A N/A $606.60 N/A N/A $707.70 N/A N/A $303.30 N/A N/A $303.30 N/A N/A $303.30 N/A N/A $303.30 N/A N/A $303.30 N/A N/A $303.30 N/A "$1,011.00 " "$1,011.00 " N/A 4050048 Radiology BCH Gastroview Q9963 Q9963 636 $179.00 $- $0.57 $- $- $0.57 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.57 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.57 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $179.00 $179.00 N/A 4050101 Radiology Xray Scapula Comp Lt 73010 320 $643.00 $- $32.45 $- $- $514.40 $- N/A $167.18 N/A N/A $39.26 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $32.45 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $32.45 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050101 Radiology Xray Scapula Comp Rt 73010 320 $643.00 $- $32.45 $- $- $514.40 $- N/A $167.18 N/A N/A $39.26 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $32.45 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $32.45 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050101 Radiology Xray Scapula Comp Bil 73010 320 $643.00 $- $32.45 $- $- $514.40 $- N/A $167.18 N/A N/A $39.26 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $32.45 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $32.45 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050102 Radiology Xray Spine Entire AP +Lateral 72082 320 $463.00 $- $61.40 $- $- $370.40 $- N/A $120.38 N/A N/A $72.84 N/A N/A $277.80 N/A N/A $231.50 N/A N/A $61.40 N/A N/A $314.84 N/A N/A $263.91 N/A N/A $180.57 N/A N/A $324.10 N/A N/A $370.40 N/A N/A $254.65 N/A N/A $324.10 N/A N/A $155.11 N/A N/A $61.40 N/A N/A $277.80 N/A N/A $162.05 N/A N/A $300.95 N/A N/A $138.90 N/A N/A $277.80 N/A N/A $324.10 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A N/A $138.90 N/A $463.00 $463.00 N/A 4050103 Radiology Xray Chest 1 View 71045 320 $536.00 $- $19.01 $- $- $428.80 $- N/A $139.36 N/A N/A $22.68 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $19.01 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $19.01 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4050200 Radiology Xray Shoulder 1 View Lt 73020 320 $503.00 $- $23.93 $- $- $402.40 $- N/A $130.78 N/A N/A $28.73 N/A N/A $301.80 N/A N/A $251.50 N/A N/A $23.93 N/A N/A $342.04 N/A N/A $286.71 N/A N/A $196.17 N/A N/A $352.10 N/A N/A $402.40 N/A N/A $276.65 N/A N/A $352.10 N/A N/A $168.51 N/A N/A $23.93 N/A N/A $301.80 N/A N/A $176.05 N/A N/A $326.95 N/A N/A $150.90 N/A N/A $301.80 N/A N/A $352.10 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A $503.00 $503.00 N/A 4050200 Radiology Xray Shoulder 1 View Rt 73020 320 $503.00 $- $23.93 $- $- $402.40 $- N/A $130.78 N/A N/A $28.73 N/A N/A $301.80 N/A N/A $251.50 N/A N/A $23.93 N/A N/A $342.04 N/A N/A $286.71 N/A N/A $196.17 N/A N/A $352.10 N/A N/A $402.40 N/A N/A $276.65 N/A N/A $352.10 N/A N/A $168.51 N/A N/A $23.93 N/A N/A $301.80 N/A N/A $176.05 N/A N/A $326.95 N/A N/A $150.90 N/A N/A $301.80 N/A N/A $352.10 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A $503.00 $503.00 N/A 4050200 Radiology Xray Shoulder 1 View Bil 73020 320 $503.00 $- $23.93 $- $- $402.40 $- N/A $130.78 N/A N/A $28.73 N/A N/A $301.80 N/A N/A $251.50 N/A N/A $23.93 N/A N/A $342.04 N/A N/A $286.71 N/A N/A $196.17 N/A N/A $352.10 N/A N/A $402.40 N/A N/A $276.65 N/A N/A $352.10 N/A N/A $168.51 N/A N/A $23.93 N/A N/A $301.80 N/A N/A $176.05 N/A N/A $326.95 N/A N/A $150.90 N/A N/A $301.80 N/A N/A $352.10 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A N/A $150.90 N/A $503.00 $503.00 N/A 4050202 Radiology Xray Chest 2 Views 71046 320 $648.00 $- $29.27 $- $- $518.40 $- N/A $168.48 N/A N/A $34.92 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $29.27 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $29.27 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4050225 Radiology Xray Abdomen Comp +Chest 1 View 74022 320 $996.00 $- $49.20 $- $- $796.80 $- N/A $258.96 N/A N/A $58.48 N/A N/A $597.60 N/A N/A $498.00 N/A N/A $49.20 N/A N/A $677.28 N/A N/A $567.72 N/A N/A $388.44 N/A N/A $697.20 N/A N/A $796.80 N/A N/A $547.80 N/A N/A $697.20 N/A N/A $333.66 N/A N/A $49.20 N/A N/A $597.60 N/A N/A $348.60 N/A N/A $647.40 N/A N/A $298.80 N/A N/A $597.60 N/A N/A $697.20 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A $996.00 $996.00 N/A 4050236 Radiology Xray Chest 2 Views w/ Fluoro 71046 320 $854.00 $- $29.27 $- $- $683.20 $- N/A $222.04 N/A N/A $34.92 N/A N/A $512.40 N/A N/A $427.00 N/A N/A $29.27 N/A N/A $580.72 N/A N/A $486.78 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $29.27 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $555.10 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 4050309 Radiology Xray Shoulder Comp Min 2 Views Lt 73030 320 $643.00 $- $31.36 $- $- $514.40 $- N/A $167.18 N/A N/A $37.63 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $31.36 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $31.36 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050309 Radiology Xray Shoulder Comp Min 2 Views Rt 73030 320 $643.00 $- $31.36 $- $- $514.40 $- N/A $167.18 N/A N/A $37.63 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $31.36 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $31.36 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050350 Radiology Xray Chest Decubitus Rt 71046 320 $415.00 $- $29.27 $- $- $332.00 $- N/A $107.90 N/A N/A $34.92 N/A N/A $249.00 N/A N/A $207.50 N/A N/A $29.27 N/A N/A $282.20 N/A N/A $236.55 N/A N/A $161.85 N/A N/A $290.50 N/A N/A $332.00 N/A N/A $228.25 N/A N/A $290.50 N/A N/A $139.03 N/A N/A $29.27 N/A N/A $249.00 N/A N/A $145.25 N/A N/A $269.75 N/A N/A $124.50 N/A N/A $249.00 N/A N/A $290.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A $415.00 $415.00 N/A 4050351 Radiology Xray Chest Decubitus Lt 71046 320 $415.00 $- $29.27 $- $- $332.00 $- N/A $107.90 N/A N/A $34.92 N/A N/A $249.00 N/A N/A $207.50 N/A N/A $29.27 N/A N/A $282.20 N/A N/A $236.55 N/A N/A $161.85 N/A N/A $290.50 N/A N/A $332.00 N/A N/A $228.25 N/A N/A $290.50 N/A N/A $139.03 N/A N/A $29.27 N/A N/A $249.00 N/A N/A $145.25 N/A N/A $269.75 N/A N/A $124.50 N/A N/A $249.00 N/A N/A $290.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A $415.00 $415.00 N/A 4050352 Radiology Xray Chest Decubitus Bil 71046 320 $415.00 $- $29.27 $- $- $332.00 $- N/A $107.90 N/A N/A $34.92 N/A N/A $249.00 N/A N/A $207.50 N/A N/A $29.27 N/A N/A $282.20 N/A N/A $236.55 N/A N/A $161.85 N/A N/A $290.50 N/A N/A $332.00 N/A N/A $228.25 N/A N/A $290.50 N/A N/A $139.03 N/A N/A $29.27 N/A N/A $249.00 N/A N/A $145.25 N/A N/A $269.75 N/A N/A $124.50 N/A N/A $249.00 N/A N/A $290.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A $415.00 $415.00 N/A 4050355 Radiology Xray Spine Lumbosacral Myelography 72265 320 "$2,652.00 " $- $126.12 $- $- "$2,121.60 " $- N/A $689.52 N/A N/A $150.76 N/A N/A "$1,591.20 " N/A N/A "$1,326.00 " N/A N/A $126.12 N/A N/A "$1,803.36 " N/A N/A "$1,511.64 " N/A N/A "$1,034.28 " N/A N/A "$1,856.40 " N/A N/A "$2,121.60 " N/A N/A "$1,458.60 " N/A N/A "$1,856.40 " N/A N/A $888.42 N/A N/A $126.12 N/A N/A "$1,591.20 " N/A N/A $928.20 N/A N/A "$1,723.80 " N/A N/A $795.60 N/A N/A "$1,591.20 " N/A N/A "$1,856.40 " N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A "$2,652.00 " "$2,652.00 " N/A 4050357 Radiology Xray LE Infant Min 2 Views Bil 73592 320 $803.00 $- $28.52 $- $- $642.40 $- N/A $208.78 N/A N/A $33.92 N/A N/A $481.80 N/A N/A $401.50 N/A N/A $28.52 N/A N/A $546.04 N/A N/A $457.71 N/A N/A $313.17 N/A N/A $562.10 N/A N/A $642.40 N/A N/A $441.65 N/A N/A $562.10 N/A N/A $269.01 N/A N/A $28.52 N/A N/A $481.80 N/A N/A $281.05 N/A N/A $521.95 N/A N/A $240.90 N/A N/A $481.80 N/A N/A $562.10 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A $803.00 $803.00 N/A 4050359 Radiology Xray UE Infant Min 2 Views Bil 73092 320 "$1,272.00 " $- $28.52 $- $- "$1,017.60 " $- N/A $330.72 N/A N/A $39.55 N/A N/A $763.20 N/A N/A $636.00 N/A N/A $28.52 N/A N/A $864.96 N/A N/A $725.04 N/A N/A $496.08 N/A N/A $890.40 N/A N/A "$1,017.60 " N/A N/A $699.60 N/A N/A $890.40 N/A N/A $426.12 N/A N/A $28.52 N/A N/A $763.20 N/A N/A $445.20 N/A N/A $826.80 N/A N/A $381.60 N/A N/A $763.20 N/A N/A $890.40 N/A N/A $381.60 N/A N/A $381.60 N/A N/A $381.60 N/A N/A $381.60 N/A N/A $381.60 N/A N/A $381.60 N/A "$1,272.00 " "$1,272.00 " N/A 4050396 Radiology BCH Cystagrafin Q9967 Q9967 636 $229.00 $- $0.73 $- $- $0.73 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $229.00 $229.00 N/A 4050409 Radiology Xray Spine Cerv 2 or 3 Views 72040 320 $299.00 $- $36.27 $- $- $239.20 $- N/A $77.74 N/A N/A $43.16 N/A N/A $179.40 N/A N/A $149.50 N/A N/A $36.27 N/A N/A $203.32 N/A N/A $170.43 N/A N/A $116.61 N/A N/A $209.30 N/A N/A $239.20 N/A N/A $164.45 N/A N/A $209.30 N/A N/A $100.17 N/A N/A $36.27 N/A N/A $179.40 N/A N/A $104.65 N/A N/A $194.35 N/A N/A $89.70 N/A N/A $179.40 N/A N/A $209.30 N/A N/A $89.70 N/A N/A $89.70 N/A N/A $89.70 N/A N/A $89.70 N/A N/A $89.70 N/A N/A $89.70 N/A $299.00 $299.00 N/A 4050416 Radiology Xray Shoulder Arthrography Lt 73040 320 "$1,672.00 " $- $105.69 $- $- "$1,337.60 " $- N/A $434.72 N/A N/A $128.09 N/A N/A "$1,003.20 " N/A N/A $836.00 N/A N/A $105.69 N/A N/A "$1,136.96 " N/A N/A $953.04 N/A N/A $652.08 N/A N/A "$1,170.40 " N/A N/A "$1,337.60 " N/A N/A $919.60 N/A N/A "$1,170.40 " N/A N/A $560.12 N/A N/A $105.69 N/A N/A "$1,003.20 " N/A N/A $585.20 N/A N/A "$1,086.80 " N/A N/A $501.60 N/A N/A "$1,003.20 " N/A N/A "$1,170.40 " N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A "$1,672.00 " "$1,672.00 " N/A 4050416 Radiology Xray Shoulder Arthrography Rt 73040 320 "$1,672.00 " $- $105.69 $- $- "$1,337.60 " $- N/A $434.72 N/A N/A $128.09 N/A N/A "$1,003.20 " N/A N/A $836.00 N/A N/A $105.69 N/A N/A "$1,136.96 " N/A N/A $953.04 N/A N/A $652.08 N/A N/A "$1,170.40 " N/A N/A "$1,337.60 " N/A N/A $919.60 N/A N/A "$1,170.40 " N/A N/A $560.12 N/A N/A $105.69 N/A N/A "$1,003.20 " N/A N/A $585.20 N/A N/A "$1,086.80 " N/A N/A $501.60 N/A N/A "$1,003.20 " N/A N/A "$1,170.40 " N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A "$1,672.00 " "$1,672.00 " N/A 4050416 Radiology Xray Shoulder Arthrography Bil 73040 320 "$1,672.00 " $- $105.69 $- $- "$1,337.60 " $- N/A $434.72 N/A N/A $128.09 N/A N/A "$1,003.20 " N/A N/A $836.00 N/A N/A $105.69 N/A N/A "$1,136.96 " N/A N/A $953.04 N/A N/A $652.08 N/A N/A "$1,170.40 " N/A N/A "$1,337.60 " N/A N/A $919.60 N/A N/A "$1,170.40 " N/A N/A $560.12 N/A N/A $105.69 N/A N/A "$1,003.20 " N/A N/A $585.20 N/A N/A "$1,086.80 " N/A N/A $501.60 N/A N/A "$1,003.20 " N/A N/A "$1,170.40 " N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A N/A $501.60 N/A "$1,672.00 " "$1,672.00 " N/A 4050507 Radiology Xray AC Joints w/ or w/o Weights Bil 73050 320 $643.00 $- $40.21 $- $- $514.40 $- N/A $167.18 N/A N/A $49.24 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $40.21 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $40.21 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050508 Radiology Xray Spine Cerv Comp w/ Flex +Ext 72050 320 $996.00 $- $48.89 $- $- $796.80 $- N/A $258.96 N/A N/A $58.24 N/A N/A $597.60 N/A N/A $498.00 N/A N/A $48.89 N/A N/A $677.28 N/A N/A $567.72 N/A N/A $388.44 N/A N/A $697.20 N/A N/A $796.80 N/A N/A $547.80 N/A N/A $697.20 N/A N/A $333.66 N/A N/A $48.89 N/A N/A $597.60 N/A N/A $348.60 N/A N/A $647.40 N/A N/A $298.80 N/A N/A $597.60 N/A N/A $697.20 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A $996.00 $996.00 N/A 4050508 Radiology Xray Spine Cerv Min 4 Views 72050 320 $996.00 $- $48.89 $- $- $796.80 $- N/A $258.96 N/A N/A $58.24 N/A N/A $597.60 N/A N/A $498.00 N/A N/A $48.89 N/A N/A $677.28 N/A N/A $567.72 N/A N/A $388.44 N/A N/A $697.20 N/A N/A $796.80 N/A N/A $547.80 N/A N/A $697.20 N/A N/A $333.66 N/A N/A $48.89 N/A N/A $597.60 N/A N/A $348.60 N/A N/A $647.40 N/A N/A $298.80 N/A N/A $597.60 N/A N/A $697.20 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A $996.00 $996.00 N/A 4050606 Radiology Xray Humerus Min 2 Views Lt 73060 320 $600.00 $- $29.22 $- $- $480.00 $- N/A $156.00 N/A N/A $35.11 N/A N/A $360.00 N/A N/A $300.00 N/A N/A $29.22 N/A N/A $408.00 N/A N/A $342.00 N/A N/A $234.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A $29.22 N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $360.00 N/A N/A $420.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A $600.00 $600.00 N/A 4050606 Radiology Xray Humerus Min 2 Views Rt 73060 320 $600.00 $- $29.22 $- $- $480.00 $- N/A $156.00 N/A N/A $35.11 N/A N/A $360.00 N/A N/A $300.00 N/A N/A $29.22 N/A N/A $408.00 N/A N/A $342.00 N/A N/A $234.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A $29.22 N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $360.00 N/A N/A $420.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A $600.00 $600.00 N/A 4050606 Radiology Xray Humerus Min 2 Views Bil 73060 320 $600.00 $- $29.22 $- $- $480.00 $- N/A $156.00 N/A N/A $35.11 N/A N/A $360.00 N/A N/A $300.00 N/A N/A $29.22 N/A N/A $408.00 N/A N/A $342.00 N/A N/A $234.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A $29.22 N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $360.00 N/A N/A $420.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A $600.00 $600.00 N/A 4050629 Radiology Xray Bone Survey Ltd Mets 77074 320 $655.00 $- $71.02 $- $- $524.00 $- N/A $170.30 N/A N/A $83.64 N/A N/A $393.00 N/A N/A $327.50 N/A N/A $71.02 N/A N/A $445.40 N/A N/A $373.35 N/A N/A $255.45 N/A N/A $458.50 N/A N/A $524.00 N/A N/A $360.25 N/A N/A $458.50 N/A N/A $219.43 N/A N/A $71.02 N/A N/A $393.00 N/A N/A $229.25 N/A N/A $425.75 N/A N/A $196.50 N/A N/A $393.00 N/A N/A $458.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A N/A $196.50 N/A $655.00 $655.00 N/A 4050705 Radiology Xray Elbow 2 Views Lt 73070 320 $275.00 $- $28.54 $- $- $220.00 $- N/A $71.50 N/A N/A $34.75 N/A N/A $165.00 N/A N/A $137.50 N/A N/A $28.54 N/A N/A $187.00 N/A N/A $156.75 N/A N/A $107.25 N/A N/A $192.50 N/A N/A $220.00 N/A N/A $151.25 N/A N/A $192.50 N/A N/A $92.13 N/A N/A $28.54 N/A N/A $165.00 N/A N/A $96.25 N/A N/A $178.75 N/A N/A $82.50 N/A N/A $165.00 N/A N/A $192.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A $275.00 $275.00 N/A 4050705 Radiology Xray Elbow 2 Views Rt 73070 320 $275.00 $- $28.54 $- $- $220.00 $- N/A $71.50 N/A N/A $34.75 N/A N/A $165.00 N/A N/A $137.50 N/A N/A $28.54 N/A N/A $187.00 N/A N/A $156.75 N/A N/A $107.25 N/A N/A $192.50 N/A N/A $220.00 N/A N/A $151.25 N/A N/A $192.50 N/A N/A $92.13 N/A N/A $28.54 N/A N/A $165.00 N/A N/A $96.25 N/A N/A $178.75 N/A N/A $82.50 N/A N/A $165.00 N/A N/A $192.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A $275.00 $275.00 N/A 4050705 Radiology 73070 320 $275.00 $- $28.54 $- $- $220.00 $- N/A $71.50 N/A N/A $34.75 N/A N/A $165.00 N/A N/A $137.50 N/A N/A $28.54 N/A N/A $187.00 N/A N/A $156.75 N/A N/A $107.25 N/A N/A $192.50 N/A N/A $220.00 N/A N/A $151.25 N/A N/A $192.50 N/A N/A $92.13 N/A N/A $28.54 N/A N/A $165.00 N/A N/A $96.25 N/A N/A $178.75 N/A N/A $82.50 N/A N/A $165.00 N/A N/A $192.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A $275.00 $275.00 N/A 4050722 Radiology Xray Spine Thoracic 3 Views 72072 320 $802.00 $- $37.65 $- $- $641.60 $- N/A $208.52 N/A N/A $44.64 N/A N/A $481.20 N/A N/A $401.00 N/A N/A $37.65 N/A N/A $545.36 N/A N/A $457.14 N/A N/A $312.78 N/A N/A $561.40 N/A N/A $641.60 N/A N/A $441.10 N/A N/A $561.40 N/A N/A $268.67 N/A N/A $37.65 N/A N/A $481.20 N/A N/A $280.70 N/A N/A $521.30 N/A N/A $240.60 N/A N/A $481.20 N/A N/A $561.40 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A $802.00 $802.00 N/A 4050804 Radiology Xray Elbow Comp Min 3 Views Lt 73080 320 $643.00 $- $33.84 $- $- $514.40 $- N/A $167.18 N/A N/A $40.73 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.84 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.84 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050804 Radiology Xray Elbow Comp Min 3 Views Rt 73080 320 $643.00 $- $33.84 $- $- $514.40 $- N/A $167.18 N/A N/A $40.73 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.84 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.84 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4050805 Radiology Xray Spine Thoracolumbar 2 Views 72080 320 $648.00 $- $36.62 $- $- $518.40 $- N/A $168.48 N/A N/A $44.38 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $36.62 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $36.62 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4050903 Radiology Xray Forearm 2 Views Lt 73090 320 $580.00 $- $28.17 $- $- $464.00 $- N/A $150.80 N/A N/A $33.92 N/A N/A $348.00 N/A N/A $290.00 N/A N/A $28.17 N/A N/A $394.40 N/A N/A $330.60 N/A N/A $226.20 N/A N/A $406.00 N/A N/A $464.00 N/A N/A $319.00 N/A N/A $406.00 N/A N/A $194.30 N/A N/A $28.17 N/A N/A $348.00 N/A N/A $203.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $348.00 N/A N/A $406.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A $580.00 $580.00 N/A 4050903 Radiology Xray Forearm 2 Views Rt 73090 320 $580.00 $- $28.17 $- $- $464.00 $- N/A $150.80 N/A N/A $33.92 N/A N/A $348.00 N/A N/A $290.00 N/A N/A $28.17 N/A N/A $394.40 N/A N/A $330.60 N/A N/A $226.20 N/A N/A $406.00 N/A N/A $464.00 N/A N/A $319.00 N/A N/A $406.00 N/A N/A $194.30 N/A N/A $28.17 N/A N/A $348.00 N/A N/A $203.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $348.00 N/A N/A $406.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A $580.00 $580.00 N/A 4051000 Radiology Xray Wrist 2 Views Rt 73100 320 $536.00 $- $31.76 $- $- $428.80 $- N/A $139.36 N/A N/A $39.28 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $31.76 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $31.76 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051000 Radiology Xray Wrist 2 Views Lt 73100 320 $536.00 $- $31.76 $- $- $428.80 $- N/A $139.36 N/A N/A $39.28 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $31.76 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $31.76 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051000 Radiology Xray Wrist 2 Views Bil 73100 320 $536.00 $- $31.76 $- $- $428.80 $- N/A $139.36 N/A N/A $39.28 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $31.76 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $31.76 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051001 Radiology Xray Spine Lumbosacral 2 or 3 Views 72100 320 $363.00 $- $36.27 $- $- $290.40 $- N/A $94.38 N/A N/A $43.57 N/A N/A $217.80 N/A N/A $181.50 N/A N/A $36.27 N/A N/A $246.84 N/A N/A $206.91 N/A N/A $141.57 N/A N/A $254.10 N/A N/A $290.40 N/A N/A $199.65 N/A N/A $254.10 N/A N/A $121.61 N/A N/A $36.27 N/A N/A $217.80 N/A N/A $127.05 N/A N/A $235.95 N/A N/A $108.90 N/A N/A $217.80 N/A N/A $254.10 N/A N/A $108.90 N/A N/A $108.90 N/A N/A $108.90 N/A N/A $108.90 N/A N/A $108.90 N/A N/A $108.90 N/A $363.00 $363.00 N/A 4051002 Radiology Xray Ribs Min 3 Views Rt w/ PA Chest 71100 320 $648.00 $- $33.04 $- $- $518.40 $- N/A $168.48 N/A N/A $39.01 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $33.04 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $33.04 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4051002 Radiology Xray Ribs Min 3 Views Lt w/ PA Chest 71100 320 $648.00 $- $33.04 $- $- $518.40 $- N/A $168.48 N/A N/A $39.01 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $33.04 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $33.04 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4051005 Radiology Xray Spine Lumbosacral >3 Views w/Flex+Ext 72120 320 $680.00 $- $40.89 $- $- $544.00 $- N/A $176.80 N/A N/A $51.60 N/A N/A $408.00 N/A N/A $340.00 N/A N/A $40.89 N/A N/A $462.40 N/A N/A $387.60 N/A N/A $265.20 N/A N/A $476.00 N/A N/A $544.00 N/A N/A $374.00 N/A N/A $476.00 N/A N/A $227.80 N/A N/A $40.89 N/A N/A $408.00 N/A N/A $238.00 N/A N/A $442.00 N/A N/A $204.00 N/A N/A $408.00 N/A N/A $476.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A N/A $204.00 N/A $680.00 $680.00 N/A 4051100 Radiology Xray Spine Lumbosacral Min 4 Views w/ Obl 72110 320 $996.00 $- $49.60 $- $- $796.80 $- N/A $258.96 N/A N/A $59.04 N/A N/A $597.60 N/A N/A $498.00 N/A N/A $49.60 N/A N/A $677.28 N/A N/A $567.72 N/A N/A $388.44 N/A N/A $697.20 N/A N/A $796.80 N/A N/A $547.80 N/A N/A $697.20 N/A N/A $333.66 N/A N/A $49.60 N/A N/A $597.60 N/A N/A $348.60 N/A N/A $647.40 N/A N/A $298.80 N/A N/A $597.60 N/A N/A $697.20 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A $996.00 $996.00 N/A 4051101 Radiology Xray Ribs Min 4 Views Bil w/ PA Chest 71110 320 $600.00 $- $41.11 $- $- $480.00 $- N/A $156.00 N/A N/A $48.95 N/A N/A $360.00 N/A N/A $300.00 N/A N/A $41.11 N/A N/A $408.00 N/A N/A $342.00 N/A N/A $234.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A $41.11 N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $360.00 N/A N/A $420.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A $600.00 $600.00 N/A 4051102 Radiology Xray Mandible Comp Min 4 Views 70110 320 $854.00 $- $40.09 $- $- $683.20 $- N/A $222.04 N/A N/A $47.78 N/A N/A $512.40 N/A N/A $427.00 N/A N/A $40.09 N/A N/A $580.72 N/A N/A $486.78 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $40.09 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $555.10 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 4051102 Radiology Xray Mandible Comp Min 4 Views 70110 320 $854.00 $- $40.09 $- $- $683.20 $- N/A $222.04 N/A N/A $47.78 N/A N/A $512.40 N/A N/A $427.00 N/A N/A $40.09 N/A N/A $580.72 N/A N/A $486.78 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $40.09 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $555.10 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 4051110 Radiology Xray Wrist Comp Min 3 Views Rt 73110 320 $532.00 $- $38.09 $- $- $425.60 $- N/A $138.32 N/A N/A $45.96 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $38.09 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $38.09 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4051110 Radiology Xray Wrist Comp Min 3 Views Lt 73110 320 $532.00 $- $38.09 $- $- $425.60 $- N/A $138.32 N/A N/A $45.96 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $38.09 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $38.09 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4051142 Radiology Xray Spine Lumbosacral Comp w/ Bending 72114 320 $996.00 $- $64.87 $- $- $796.80 $- N/A $258.96 N/A N/A $77.56 N/A N/A $597.60 N/A N/A $498.00 N/A N/A $64.87 N/A N/A $677.28 N/A N/A $567.72 N/A N/A $388.44 N/A N/A $697.20 N/A N/A $796.80 N/A N/A $547.80 N/A N/A $697.20 N/A N/A $333.66 N/A N/A $64.87 N/A N/A $597.60 N/A N/A $348.60 N/A N/A $647.40 N/A N/A $298.80 N/A N/A $597.60 N/A N/A $697.20 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A N/A $298.80 N/A $996.00 $996.00 N/A 4051200 Radiology Xray Sternum Min 2 Views 71120 320 $648.00 $- $32.00 $- $- $518.40 $- N/A $168.48 N/A N/A $37.86 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $32.00 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $32.00 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4051208 Radiology Xray Hand 2 Views Lt 73120 320 $536.00 $- $27.81 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.81 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.81 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051208 Radiology Xray Hand 2 Views Rt 73120 320 $536.00 $- $27.81 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.81 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.81 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051208 Radiology Xray Hand 2 Views Bil 73120 320 $536.00 $- $27.81 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.81 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.81 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4051307 Radiology Xray Hand Min 3 Views Lt 73130 320 $643.00 $- $33.12 $- $- $514.40 $- N/A $167.18 N/A N/A $39.53 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.12 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.12 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4051307 Radiology Xray Hand Min 3 Views Rt 73130 320 $643.00 $- $33.12 $- $- $514.40 $- N/A $167.18 N/A N/A $39.53 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.12 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.12 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4051406 Radiology Xray Fingers Min 2 Views Lt 73140 320 $480.00 $- $33.55 $- $- $384.00 $- N/A $124.80 N/A N/A $41.22 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $33.55 N/A N/A $326.40 N/A N/A $273.60 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $33.55 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4051406 Radiology Xray Fingers Min 2 Views Rt 73140 320 $480.00 $- $33.55 $- $- $384.00 $- N/A $124.80 N/A N/A $41.22 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $33.55 N/A N/A $326.40 N/A N/A $273.60 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $33.55 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4051406 Radiology Xray Fingers Min 2 Views Bil 73140 320 $480.00 $- $33.55 $- $- $384.00 $- N/A $124.80 N/A N/A $41.22 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $33.55 N/A N/A $326.40 N/A N/A $273.60 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $33.55 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4051508 Radiology Xray Facial Bones Comp Min 3 Views 70150 320 $854.00 $- $42.91 $- $- $683.20 $- N/A $222.04 N/A N/A $51.38 N/A N/A $512.40 N/A N/A $427.00 N/A N/A $42.91 N/A N/A $580.72 N/A N/A $486.78 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $42.91 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $555.10 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 4051607 Radiology Xray Nasal Bones Comp Min 3 Views 70160 320 $648.00 $- $34.19 $- $- $518.40 $- N/A $168.48 N/A N/A $40.73 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $34.19 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $34.19 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4051704 Radiology Xray Pelvis 1 View 72170 320 $536.00 $- $29.25 $- $- $428.80 $- N/A $139.36 N/A N/A $35.24 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $29.25 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $29.25 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4052001 Radiology Xray Orbits Comp Min 4 Views Bil 70200 320 $802.00 $- $43.94 $- $- $641.60 $- N/A $208.52 N/A N/A $52.55 N/A N/A $481.20 N/A N/A $401.00 N/A N/A $43.94 N/A N/A $545.36 N/A N/A $457.14 N/A N/A $312.78 N/A N/A $561.40 N/A N/A $641.60 N/A N/A $441.10 N/A N/A $561.40 N/A N/A $268.67 N/A N/A $43.94 N/A N/A $481.20 N/A N/A $280.70 N/A N/A $521.30 N/A N/A $240.60 N/A N/A $481.20 N/A N/A $561.40 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A N/A $240.60 N/A $802.00 $802.00 N/A 4052025 Radiology Xray SI Joints 1 or 2 Views 72202 320 $331.00 $- $35.22 $- $- $264.80 $- N/A $86.06 N/A N/A $41.89 N/A N/A $198.60 N/A N/A $165.50 N/A N/A $35.22 N/A N/A $225.08 N/A N/A $188.67 N/A N/A $129.09 N/A N/A $231.70 N/A N/A $264.80 N/A N/A $182.05 N/A N/A $231.70 N/A N/A $110.89 N/A N/A $35.22 N/A N/A $198.60 N/A N/A $115.85 N/A N/A $215.15 N/A N/A $99.30 N/A N/A $198.60 N/A N/A $231.70 N/A N/A $99.30 N/A N/A $99.30 N/A N/A $99.30 N/A N/A $99.30 N/A N/A $99.30 N/A N/A $99.30 N/A $331.00 $331.00 N/A 4052205 Radiology Xray Esophagus (Fluoro) 74220 320 $675.00 $- $92.31 $- $- $540.00 $- N/A $175.50 N/A N/A $110.12 N/A N/A $405.00 N/A N/A $337.50 N/A N/A $92.31 N/A N/A $459.00 N/A N/A $384.75 N/A N/A $263.25 N/A N/A $472.50 N/A N/A $540.00 N/A N/A $371.25 N/A N/A $472.50 N/A N/A $226.13 N/A N/A $92.31 N/A N/A $405.00 N/A N/A $236.25 N/A N/A $438.75 N/A N/A $202.50 N/A N/A $405.00 N/A N/A $472.50 N/A N/A $202.50 N/A N/A $202.50 N/A N/A $202.50 N/A N/A $202.50 N/A N/A $202.50 N/A N/A $202.50 N/A $675.00 $675.00 N/A 4052207 Radiology Xray Sacrum +Coccyx Min 2 Views 72220 320 $643.00 $- $29.22 $- $- $514.40 $- N/A $167.18 N/A N/A $35.11 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $29.22 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $29.22 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4052209 Radiology Xray Sinuses Paranasal Comp Min 3 Views 70220 320 $854.00 $- $39.01 $- $- $683.20 $- N/A $222.04 N/A N/A $46.98 N/A N/A $512.40 N/A N/A $427.00 N/A N/A $39.01 N/A N/A $580.72 N/A N/A $486.78 N/A N/A $333.06 N/A N/A $597.80 N/A N/A $683.20 N/A N/A $469.70 N/A N/A $597.80 N/A N/A $286.09 N/A N/A $39.01 N/A N/A $512.40 N/A N/A $298.90 N/A N/A $555.10 N/A N/A $256.20 N/A N/A $512.40 N/A N/A $597.80 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A N/A $256.20 N/A $854.00 $854.00 N/A 4052301 Radiology Xray Fluoro Modified Esophagram 74230 320 "$1,161.00 " $- $92.19 $- $- $928.80 $- N/A $301.86 N/A N/A $109.16 N/A N/A $696.60 N/A N/A $580.50 N/A N/A $92.19 N/A N/A $789.48 N/A N/A $661.77 N/A N/A $452.79 N/A N/A $812.70 N/A N/A $928.80 N/A N/A $638.55 N/A N/A $812.70 N/A N/A $388.94 N/A N/A $92.19 N/A N/A $696.60 N/A N/A $406.35 N/A N/A $754.65 N/A N/A $348.30 N/A N/A $696.60 N/A N/A $812.70 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A "$1,161.00 " "$1,161.00 " N/A 4052411 Radiology Xray UGI w/ KUB 74246 320 "$1,149.00 " $- $129.92 $- $- $919.20 $- N/A $298.74 N/A N/A $154.68 N/A N/A $689.40 N/A N/A $574.50 N/A N/A $129.92 N/A N/A $781.32 N/A N/A $654.93 N/A N/A $448.11 N/A N/A $804.30 N/A N/A $919.20 N/A N/A $631.95 N/A N/A $804.30 N/A N/A $384.92 N/A N/A $129.92 N/A N/A $689.40 N/A N/A $402.15 N/A N/A $746.85 N/A N/A $344.70 N/A N/A $689.40 N/A N/A $804.30 N/A N/A $344.70 N/A N/A $344.70 N/A N/A $344.70 N/A N/A $344.70 N/A N/A $344.70 N/A N/A $344.70 N/A "$1,149.00 " "$1,149.00 " N/A 4052413 Radiology Xray Spine Cerv Myelography 72240 320 "$3,028.00 " $- $129.19 $- $- "$2,422.40 " $- N/A $787.28 N/A N/A $153.46 N/A N/A "$1,816.80 " N/A N/A "$1,514.00 " N/A N/A $129.19 N/A N/A "$2,059.04 " N/A N/A "$1,725.96 " N/A N/A "$1,180.92 " N/A N/A "$2,119.60 " N/A N/A "$2,422.40 " N/A N/A "$1,665.40 " N/A N/A "$2,119.60 " N/A N/A "$1,014.38 " N/A N/A $129.19 N/A N/A "$1,816.80 " N/A N/A "$1,059.80 " N/A N/A "$1,968.20 " N/A N/A $908.40 N/A N/A "$1,816.80 " N/A N/A "$2,119.60 " N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A "$3,028.00 " "$3,028.00 " N/A 4052452 Radiology Xray UGI w/ Air Cont w/ SB 74249 320 "$1,591.00 " $- $413.66 $- $- "$1,272.80 " $- N/A $413.66 N/A N/A N/A N/A N/A $954.60 N/A N/A $795.50 N/A N/A N/A N/A N/A "$1,081.88 " N/A N/A $906.87 N/A N/A $620.49 N/A N/A "$1,113.70 " N/A N/A "$1,272.80 " N/A N/A $875.05 N/A N/A "$1,113.70 " N/A N/A $532.99 N/A N/A N/A N/A N/A $954.60 N/A N/A $556.85 N/A N/A "$1,034.15 " N/A N/A $477.30 N/A N/A $954.60 N/A N/A "$1,113.70 " N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A "$1,591.00 " "$1,591.00 " N/A 4052502 Radiology Xray Fluoro SB Series 74250 320 "$1,161.00 " $- $109.35 $- $- $928.80 $- N/A $301.86 N/A N/A $123.77 N/A N/A $696.60 N/A N/A $580.50 N/A N/A $109.35 N/A N/A $789.48 N/A N/A $661.77 N/A N/A $452.79 N/A N/A $812.70 N/A N/A $928.80 N/A N/A $638.55 N/A N/A $812.70 N/A N/A $388.94 N/A N/A $109.35 N/A N/A $696.60 N/A N/A $406.35 N/A N/A $754.65 N/A N/A $348.30 N/A N/A $696.60 N/A N/A $812.70 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A "$1,161.00 " "$1,161.00 " N/A 4052502 Radiology 74250 320 "$1,161.00 " $- $109.35 $- $- $928.80 $- N/A $301.86 N/A N/A $123.77 N/A N/A $696.60 N/A N/A $580.50 N/A N/A $109.35 N/A N/A $789.48 N/A N/A $661.77 N/A N/A $452.79 N/A N/A $812.70 N/A N/A $928.80 N/A N/A $638.55 N/A N/A $812.70 N/A N/A $388.94 N/A N/A $109.35 N/A N/A $696.60 N/A N/A $406.35 N/A N/A $754.65 N/A N/A $348.30 N/A N/A $696.60 N/A N/A $812.70 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A N/A $348.30 N/A "$1,161.00 " "$1,161.00 " N/A 4052561 Radiology Xray Spine Thoracic Myelography 72255 320 "$3,028.00 " $- $122.78 $- $- "$2,422.40 " $- N/A $787.28 N/A N/A $146.16 N/A N/A "$1,816.80 " N/A N/A "$1,514.00 " N/A N/A $122.78 N/A N/A "$2,059.04 " N/A N/A "$1,725.96 " N/A N/A "$1,180.92 " N/A N/A "$2,119.60 " N/A N/A "$2,422.40 " N/A N/A "$1,665.40 " N/A N/A "$2,119.60 " N/A N/A "$1,014.38 " N/A N/A $122.78 N/A N/A "$1,816.80 " N/A N/A "$1,059.80 " N/A N/A "$1,968.20 " N/A N/A $908.40 N/A N/A "$1,816.80 " N/A N/A "$2,119.60 " N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A N/A $908.40 N/A "$3,028.00 " "$3,028.00 " N/A 4052605 Radiology Xray Skull Comp Min 4 Views 70260 320 $500.00 $- $47.74 $- $- $400.00 $- N/A $130.00 N/A N/A $56.42 N/A N/A $300.00 N/A N/A $250.00 N/A N/A $47.74 N/A N/A $340.00 N/A N/A $285.00 N/A N/A $195.00 N/A N/A $350.00 N/A N/A $400.00 N/A N/A $275.00 N/A N/A $350.00 N/A N/A $167.50 N/A N/A $47.74 N/A N/A $300.00 N/A N/A $175.00 N/A N/A $325.00 N/A N/A $150.00 N/A N/A $300.00 N/A N/A $350.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A $500.00 $500.00 N/A 4052610 Radiology Xray Skull < 4 Views 70250 320 $648.00 $- $37.61 $- $- $518.40 $- N/A $168.48 N/A N/A $45.00 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $37.61 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $37.61 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4052700 Radiology Xray Barium Enema w/ or w/o KUB 74270 320 "$1,720.00 " $- $159.06 $- $- "$1,376.00 " $- N/A $447.20 N/A N/A $183.20 N/A N/A "$1,032.00 " N/A N/A $860.00 N/A N/A $159.06 N/A N/A "$1,169.60 " N/A N/A $980.40 N/A N/A $670.80 N/A N/A "$1,204.00 " N/A N/A "$1,376.00 " N/A N/A $946.00 N/A N/A "$1,204.00 " N/A N/A $576.20 N/A N/A $159.06 N/A N/A "$1,032.00 " N/A N/A $602.00 N/A N/A "$1,118.00 " N/A N/A $516.00 N/A N/A "$1,032.00 " N/A N/A "$1,204.00 " N/A N/A $516.00 N/A N/A $516.00 N/A N/A $516.00 N/A N/A $516.00 N/A N/A $516.00 N/A N/A $516.00 N/A "$1,720.00 " "$1,720.00 " N/A 4052704 Radiology Xray Spine Puncture Lumbar Diag 62270 361 "$1,623.00 " $- $70.68 $- $- "$1,298.40 " $- N/A $421.98 N/A N/A $91.70 N/A N/A $973.80 N/A N/A $811.50 N/A N/A $70.68 N/A N/A "$1,103.64 " N/A N/A $925.11 N/A N/A $632.97 N/A N/A "$1,136.10 " N/A N/A "$1,298.40 " N/A N/A $892.65 N/A N/A "$1,136.10 " N/A N/A $543.71 N/A N/A $70.68 N/A N/A $973.80 N/A N/A $568.05 N/A N/A "$1,054.95 " N/A N/A $486.90 N/A N/A $973.80 N/A N/A "$1,136.10 " N/A N/A $486.90 N/A N/A $486.90 N/A N/A $486.90 N/A N/A $486.90 N/A N/A $486.90 N/A N/A $486.90 N/A "$1,623.00 " "$1,623.00 " N/A 4052809 Radiology Xray Barium Enema w/ Air Cont 74280 320 "$1,335.00 " $- $199.48 $- $- "$1,068.00 " $- N/A $347.10 N/A N/A $199.48 N/A N/A $801.00 N/A N/A $667.50 N/A N/A $222.12 N/A N/A $907.80 N/A N/A $760.95 N/A N/A $520.65 N/A N/A $934.50 N/A N/A "$1,068.00 " N/A N/A $734.25 N/A N/A $934.50 N/A N/A $447.23 N/A N/A $222.12 N/A N/A $801.00 N/A N/A $467.25 N/A N/A $867.75 N/A N/A $400.50 N/A N/A $801.00 N/A N/A $934.50 N/A N/A $400.50 N/A N/A $400.50 N/A N/A $400.50 N/A N/A $400.50 N/A N/A $400.50 N/A N/A $400.50 N/A "$1,335.00 " "$1,335.00 " N/A 4053030 Radiology Xray Shoulder Comp Min 2 Views Bil 73030 320 $648.00 $- $31.36 $- $- $518.40 $- N/A $168.48 N/A N/A $37.63 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $31.36 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $31.36 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053080 Radiology Xray Elbow Comp Min 3 Views Bil 73080 320 $648.00 $- $33.84 $- $- $518.40 $- N/A $168.48 N/A N/A $40.73 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $33.84 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $33.84 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053090 Radiology Xray Forearm 2 Views Bil 73090 320 $438.00 $- $28.17 $- $- $350.40 $- N/A $113.88 N/A N/A $33.92 N/A N/A $262.80 N/A N/A $219.00 N/A N/A $28.17 N/A N/A $297.84 N/A N/A $249.66 N/A N/A $170.82 N/A N/A $306.60 N/A N/A $350.40 N/A N/A $240.90 N/A N/A $306.60 N/A N/A $146.73 N/A N/A $28.17 N/A N/A $262.80 N/A N/A $153.30 N/A N/A $284.70 N/A N/A $131.40 N/A N/A $262.80 N/A N/A $306.60 N/A N/A $131.40 N/A N/A $131.40 N/A N/A $131.40 N/A N/A $131.40 N/A N/A $131.40 N/A N/A $131.40 N/A $438.00 $438.00 N/A 4053110 Radiology Xray Wrist Comp Min 3 Views Bil 73110 320 $648.00 $- $38.09 $- $- $518.40 $- N/A $168.48 N/A N/A $45.96 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $38.09 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $38.09 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053130 Radiology Xray Hand Min 3 Views Bil 73130 320 $648.00 $- $33.12 $- $- $518.40 $- N/A $168.48 N/A N/A $39.53 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $33.12 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $33.12 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053306 Radiology CT TMJ Open +Closed Bil 70330 320 $648.00 $425.00 $49.34 $- $831.09 $861.00 $- N/A $168.48 N/A $425.00 $425.00 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $49.34 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $217.08 N/A N/A $49.34 N/A N/A $388.80 N/A N/A $701.79 N/A N/A $707.00 N/A N/A $194.40 N/A N/A $388.80 N/A $831.09 $831.09 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053501 Radiology Xray Hip 1 View Lt 73501 320 $793.00 $- $29.06 $- $- $634.40 $- N/A $206.18 N/A N/A $34.48 N/A N/A $475.80 N/A N/A $396.50 N/A N/A $29.06 N/A N/A $539.24 N/A N/A $452.01 N/A N/A $309.27 N/A N/A $555.10 N/A N/A $634.40 N/A N/A $436.15 N/A N/A $555.10 N/A N/A $265.66 N/A N/A $29.06 N/A N/A $475.80 N/A N/A $277.55 N/A N/A $515.45 N/A N/A $237.90 N/A N/A $475.80 N/A N/A $555.10 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A $793.00 $793.00 N/A 4053501 Radiology Xray Hip 1 View Rt 73501 320 $793.00 $- $29.06 $- $- $634.40 $- N/A $206.18 N/A N/A $34.48 N/A N/A $475.80 N/A N/A $396.50 N/A N/A $29.06 N/A N/A $539.24 N/A N/A $452.01 N/A N/A $309.27 N/A N/A $555.10 N/A N/A $634.40 N/A N/A $436.15 N/A N/A $555.10 N/A N/A $265.66 N/A N/A $29.06 N/A N/A $475.80 N/A N/A $277.55 N/A N/A $515.45 N/A N/A $237.90 N/A N/A $475.80 N/A N/A $555.10 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A N/A $237.90 N/A $793.00 $793.00 N/A 4053502 Radiology Xray Hip 2-3 Views Lt w/ Pelvis 73502 320 $810.00 $- $40.68 $- $- $648.00 $- N/A $210.60 N/A N/A $48.25 N/A N/A $486.00 N/A N/A $405.00 N/A N/A $40.68 N/A N/A $550.80 N/A N/A $461.70 N/A N/A $315.90 N/A N/A $567.00 N/A N/A $648.00 N/A N/A $445.50 N/A N/A $567.00 N/A N/A $271.35 N/A N/A $40.68 N/A N/A $486.00 N/A N/A $283.50 N/A N/A $526.50 N/A N/A $243.00 N/A N/A $486.00 N/A N/A $567.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A $810.00 $810.00 N/A 4053502 Radiology Xray Hip 2-3 Views Rt w/ Pelvis 73502 320 $810.00 $- $40.68 $- $- $648.00 $- N/A $210.60 N/A N/A $48.25 N/A N/A $486.00 N/A N/A $405.00 N/A N/A $40.68 N/A N/A $550.80 N/A N/A $461.70 N/A N/A $315.90 N/A N/A $567.00 N/A N/A $648.00 N/A N/A $445.50 N/A N/A $567.00 N/A N/A $271.35 N/A N/A $40.68 N/A N/A $486.00 N/A N/A $283.50 N/A N/A $526.50 N/A N/A $243.00 N/A N/A $486.00 N/A N/A $567.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A N/A $243.00 N/A $810.00 $810.00 N/A 4053503 Radiology Xray Hip Min 4 Views Lt w/ Pelvis 73503 320 "$1,340.00 " $- $50.84 $- $- "$1,072.00 " $- N/A $348.40 N/A N/A $60.31 N/A N/A $804.00 N/A N/A $670.00 N/A N/A $50.84 N/A N/A $911.20 N/A N/A $763.80 N/A N/A $522.60 N/A N/A $938.00 N/A N/A "$1,072.00 " N/A N/A $737.00 N/A N/A $938.00 N/A N/A $448.90 N/A N/A $50.84 N/A N/A $804.00 N/A N/A $469.00 N/A N/A $871.00 N/A N/A $402.00 N/A N/A $804.00 N/A N/A $938.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A "$1,340.00 " "$1,340.00 " N/A 4053503 Radiology Xray Hip Min 4 Views Rt w/ Pelvis 73503 320 "$1,340.00 " $- $50.84 $- $- "$1,072.00 " $- N/A $348.40 N/A N/A $60.31 N/A N/A $804.00 N/A N/A $670.00 N/A N/A $50.84 N/A N/A $911.20 N/A N/A $763.80 N/A N/A $522.60 N/A N/A $938.00 N/A N/A "$1,072.00 " N/A N/A $737.00 N/A N/A $938.00 N/A N/A $448.90 N/A N/A $50.84 N/A N/A $804.00 N/A N/A $469.00 N/A N/A $871.00 N/A N/A $402.00 N/A N/A $804.00 N/A N/A $938.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A N/A $402.00 N/A "$1,340.00 " "$1,340.00 " N/A 4053551 Radiology Xray Femur 1 View Lt 73551 320 $- $- $- $- $- $32.41 $- N/A $- N/A N/A $32.41 N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4053551 Radiology Xray Femur 1 View Rt 73551 320 $- $- $- $- $- $32.41 $- N/A $- N/A N/A $32.41 N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4053551 Radiology Xray Femur 1 View Bil 73551 320 $- $- $- $- $- $32.41 $- N/A $- N/A N/A $32.41 N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $27.32 N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A $- $- N/A 4053564 Radiology Xray Knee Comp Min 4 Views Bil 73564 320 $648.00 $- $43.72 $- $- $518.40 $- N/A $168.48 N/A N/A $53.62 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $43.72 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $43.72 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053590 Radiology Xray Tibia +Fibula 2 Views Bil 73590 320 $611.00 $- $27.79 $- $- $488.80 $- N/A $158.86 N/A N/A $33.50 N/A N/A $366.60 N/A N/A $305.50 N/A N/A $27.79 N/A N/A $415.48 N/A N/A $348.27 N/A N/A $238.29 N/A N/A $427.70 N/A N/A $488.80 N/A N/A $336.05 N/A N/A $427.70 N/A N/A $204.69 N/A N/A $27.79 N/A N/A $366.60 N/A N/A $213.85 N/A N/A $397.15 N/A N/A $183.30 N/A N/A $366.60 N/A N/A $427.70 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A $611.00 $611.00 N/A 4053603 Radiology Xray Neck Soft Tissue 70360 320 $557.00 $- $29.22 $- $- $445.60 $- N/A $144.82 N/A N/A $33.50 N/A N/A $334.20 N/A N/A $278.50 N/A N/A $29.22 N/A N/A $378.76 N/A N/A $317.49 N/A N/A $217.23 N/A N/A $389.90 N/A N/A $445.60 N/A N/A $306.35 N/A N/A $389.90 N/A N/A $186.60 N/A N/A $29.22 N/A N/A $334.20 N/A N/A $194.95 N/A N/A $362.05 N/A N/A $167.10 N/A N/A $334.20 N/A N/A $389.90 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A N/A $167.10 N/A $557.00 $557.00 N/A 4053610 Radiology Xray Ankle Comp Min 3 Views Bil 73610 320 $648.00 $- $33.84 $- $- $518.40 $- N/A $168.48 N/A N/A $40.73 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $33.84 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $33.84 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053630 Radiology Xray Foot Comp Min 3 Views Bil 73630 320 $648.00 $- $31.70 $- $- $518.40 $- N/A $168.48 N/A N/A $38.33 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $31.70 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $31.70 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4053660 Radiology Xray Toe(s) Min 2 Views Bil 73660 320 $429.00 $- $30.71 $- $- $343.20 $- N/A $111.54 N/A N/A $37.20 N/A N/A $257.40 N/A N/A $214.50 N/A N/A $30.71 N/A N/A $291.72 N/A N/A $244.53 N/A N/A $167.31 N/A N/A $300.30 N/A N/A $343.20 N/A N/A $235.95 N/A N/A $300.30 N/A N/A $143.72 N/A N/A $30.71 N/A N/A $257.40 N/A N/A $150.15 N/A N/A $278.85 N/A N/A $128.70 N/A N/A $257.40 N/A N/A $300.30 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A $429.00 $429.00 N/A 4053747 Radiology BCH Sinografin Q9967 Q9967 636 $11.00 $- $0.73 $- $- $0.73 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $11.00 $11.00 N/A 4054020 Radiology Xray Abdomen 2 Views 74019 320 $415.00 $- $32.00 $- $- $332.00 $- N/A $107.90 N/A N/A $38.18 N/A N/A $249.00 N/A N/A $207.50 N/A N/A $32.00 N/A N/A $282.20 N/A N/A $236.55 N/A N/A $161.85 N/A N/A $290.50 N/A N/A $332.00 N/A N/A $228.25 N/A N/A $290.50 N/A N/A $139.03 N/A N/A $32.00 N/A N/A $249.00 N/A N/A $145.25 N/A N/A $269.75 N/A N/A $124.50 N/A N/A $249.00 N/A N/A $290.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A N/A $124.50 N/A $415.00 $415.00 N/A 4054102 Radiology Xray IVP 74410 320 "$1,069.00 " $- $111.80 $- $- $855.20 $- N/A $277.94 N/A N/A $134.57 N/A N/A $641.40 N/A N/A $534.50 N/A N/A $111.80 N/A N/A $726.92 N/A N/A $609.33 N/A N/A $416.91 N/A N/A $748.30 N/A N/A $855.20 N/A N/A $587.95 N/A N/A $748.30 N/A N/A $358.12 N/A N/A $111.80 N/A N/A $641.40 N/A N/A $374.15 N/A N/A $694.85 N/A N/A $320.70 N/A N/A $641.40 N/A N/A $748.30 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A "$1,069.00 " "$1,069.00 " N/A 4054516 Radiology Xray Urethrocystography Retrograde 74420 320 "$1,069.00 " $- $115.35 $- $- $855.20 $- N/A $277.94 N/A N/A $139.79 N/A N/A $641.40 N/A N/A $534.50 N/A N/A $115.35 N/A N/A $726.92 N/A N/A $609.33 N/A N/A $416.91 N/A N/A $748.30 N/A N/A $855.20 N/A N/A $587.95 N/A N/A $748.30 N/A N/A $358.12 N/A N/A $115.35 N/A N/A $641.40 N/A N/A $374.15 N/A N/A $694.85 N/A N/A $320.70 N/A N/A $641.40 N/A N/A $748.30 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A N/A $320.70 N/A "$1,069.00 " "$1,069.00 " N/A 4055100 Radiology Xray Hip Comp Min 2 Views Lt 73502 320 $648.00 $- $40.68 $- $- $518.40 $- N/A $168.48 N/A N/A $48.25 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $40.68 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $40.68 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055100 Radiology Xray Hip Comp Min 2 Views Rt 73502 320 $648.00 $- $40.68 $- $- $518.40 $- N/A $168.48 N/A N/A $48.25 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $40.68 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $40.68 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055100 Radiology Xray Hip Min 2 Views Bil w/ Pelvis 73521 320 $648.00 $- $38.91 $- $- $518.40 $- N/A $168.48 N/A N/A $46.15 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $38.91 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $38.91 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055506 Radiology Xray Femur 2 Views Bil 73552 320 $648.00 $- $168.48 $- $- $518.40 $- N/A $168.48 N/A N/A N/A N/A N/A $388.80 N/A N/A $324.00 N/A N/A N/A N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A N/A N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055506 Radiology Xray Femur 2 Views Lt 73552 320 $648.00 $- $31.89 $- $- $518.40 $- N/A $168.48 N/A N/A $37.82 N/A N/A $388.80 N/A N/A $324.00 N/A N/A $31.89 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $31.89 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055506 Radiology Xray Femur 2 Views Rt 73552 320 $648.00 $- $31.89 $- $- $518.40 $- N/A $168.48 N/A N/A N/A N/A N/A $388.80 N/A N/A $324.00 N/A N/A $31.89 N/A N/A $440.64 N/A N/A $369.36 N/A N/A $252.72 N/A N/A $453.60 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $453.60 N/A N/A $217.08 N/A N/A $31.89 N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $453.60 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 4055605 Radiology Xray Knee 1 or 2 Views Lt 73560 320 $445.00 $- $31.02 $- $- $356.00 $- N/A $115.70 N/A N/A $38.05 N/A N/A $267.00 N/A N/A $222.50 N/A N/A $31.02 N/A N/A $302.60 N/A N/A $253.65 N/A N/A $173.55 N/A N/A $311.50 N/A N/A $356.00 N/A N/A $244.75 N/A N/A $311.50 N/A N/A $149.08 N/A N/A $31.02 N/A N/A $267.00 N/A N/A $155.75 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $267.00 N/A N/A $311.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A $445.00 $445.00 N/A 4055605 Radiology Xray Knee 1 or 2 Views Rt 73560 320 $445.00 $- $31.02 $- $- $356.00 $- N/A $115.70 N/A N/A $38.05 N/A N/A $267.00 N/A N/A $222.50 N/A N/A $31.02 N/A N/A $302.60 N/A N/A $253.65 N/A N/A $173.55 N/A N/A $311.50 N/A N/A $356.00 N/A N/A $244.75 N/A N/A $311.50 N/A N/A $149.08 N/A N/A $31.02 N/A N/A $267.00 N/A N/A $155.75 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $267.00 N/A N/A $311.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A $445.00 $445.00 N/A 4055605 Radiology Xray Knee 1 or 2 Views Bil 73560 320 $445.00 $- $31.02 $- $- $356.00 $- N/A $115.70 N/A N/A $38.05 N/A N/A $267.00 N/A N/A $222.50 N/A N/A $31.02 N/A N/A $302.60 N/A N/A $253.65 N/A N/A $173.55 N/A N/A $311.50 N/A N/A $356.00 N/A N/A $244.75 N/A N/A $311.50 N/A N/A $149.08 N/A N/A $31.02 N/A N/A $267.00 N/A N/A $155.75 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $267.00 N/A N/A $311.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A $445.00 $445.00 N/A 4055647 Radiology Xray Knee Comp Min 4 Views Lt 73564 320 $532.00 $- $43.72 $- $- $425.60 $- N/A $138.32 N/A N/A $53.62 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $43.72 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $43.72 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4055647 Radiology Xray Knee Comp Min 4 Views Rt 73564 320 $532.00 $- $43.72 $- $- $425.60 $- N/A $138.32 N/A N/A $53.62 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $43.72 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $43.72 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4055651 Radiology Xray Knee Standing AP Bil 73565 320 $643.00 $- $36.00 $- $- $514.40 $- N/A $167.18 N/A N/A $44.08 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $36.00 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $36.00 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4055902 Radiology Xray Tibia +Fibula 2 Views Lt 73590 320 $611.00 $- $27.79 $- $- $488.80 $- N/A $158.86 N/A N/A $33.50 N/A N/A $366.60 N/A N/A $305.50 N/A N/A $27.79 N/A N/A $415.48 N/A N/A $348.27 N/A N/A $238.29 N/A N/A $427.70 N/A N/A $488.80 N/A N/A $336.05 N/A N/A $427.70 N/A N/A $204.69 N/A N/A $27.79 N/A N/A $366.60 N/A N/A $213.85 N/A N/A $397.15 N/A N/A $183.30 N/A N/A $366.60 N/A N/A $427.70 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A $611.00 $611.00 N/A 4055902 Radiology Xray Tibia +Fibula 2 Views Rt 73590 320 $611.00 $- $27.79 $- $- $488.80 $- N/A $158.86 N/A N/A $33.50 N/A N/A $366.60 N/A N/A $305.50 N/A N/A $27.79 N/A N/A $415.48 N/A N/A $348.27 N/A N/A $238.29 N/A N/A $427.70 N/A N/A $488.80 N/A N/A $336.05 N/A N/A $427.70 N/A N/A $204.69 N/A N/A $27.79 N/A N/A $366.60 N/A N/A $213.85 N/A N/A $397.15 N/A N/A $183.30 N/A N/A $366.60 N/A N/A $427.70 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A N/A $183.30 N/A $611.00 $611.00 N/A 4056009 Radiology Xray Ankle 2 Views Bil 73600 320 $536.00 $- $28.88 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.88 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.88 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056009 Radiology Xray Ankle 2 Views Lt 73600 320 $536.00 $- $28.88 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.88 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.88 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056009 Radiology Xray Ankle 2 Views Rt 73600 320 $536.00 $- $28.88 $- $- $428.80 $- N/A $139.36 N/A N/A $35.14 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.88 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.88 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056108 Radiology Xray Ankle Comp Min 3 Views Lt 73610 320 $643.00 $- $33.84 $- $- $514.40 $- N/A $167.18 N/A N/A $40.73 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.84 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.84 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4056108 Radiology Xray Ankle Comp Min 3 Views Rt 73610 320 $643.00 $- $33.84 $- $- $514.40 $- N/A $167.18 N/A N/A $40.73 N/A N/A $385.80 N/A N/A $321.50 N/A N/A $33.84 N/A N/A $437.24 N/A N/A $366.51 N/A N/A $250.77 N/A N/A $450.10 N/A N/A $514.40 N/A N/A $353.65 N/A N/A $450.10 N/A N/A $215.41 N/A N/A $33.84 N/A N/A $385.80 N/A N/A $225.05 N/A N/A $417.95 N/A N/A $192.90 N/A N/A $385.80 N/A N/A $450.10 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A N/A $192.90 N/A $643.00 $643.00 N/A 4056207 Radiology Xray Foot 2 Views Lt 73620 320 $536.00 $- $27.46 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.46 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.46 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056207 Radiology Xray Foot 2 Views Rt 73620 320 $536.00 $- $27.46 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.46 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.46 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056207 Radiology Xray Foot 2 Views Bil 73620 320 $536.00 $- $27.46 $- $- $428.80 $- N/A $139.36 N/A N/A $33.53 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $27.46 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $27.46 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056306 Radiology Xray Foot Comp Min 3 Views Lt 73630 320 $532.00 $- $31.70 $- $- $425.60 $- N/A $138.32 N/A N/A $38.33 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $31.70 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $31.70 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4056306 Radiology Xray Foot Comp Min 3 Views Rt 73630 320 $532.00 $- $31.70 $- $- $425.60 $- N/A $138.32 N/A N/A $38.33 N/A N/A $319.20 N/A N/A $266.00 N/A N/A $31.70 N/A N/A $361.76 N/A N/A $303.24 N/A N/A $207.48 N/A N/A $372.40 N/A N/A $425.60 N/A N/A $292.60 N/A N/A $372.40 N/A N/A $178.22 N/A N/A $31.70 N/A N/A $319.20 N/A N/A $186.20 N/A N/A $345.80 N/A N/A $159.60 N/A N/A $319.20 N/A N/A $372.40 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A N/A $159.60 N/A $532.00 $532.00 N/A 4056504 Radiology Xray Heel Min 2 Views Lt 73650 320 $536.00 $- $28.52 $- $- $428.80 $- N/A $139.36 N/A N/A $34.73 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.52 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.52 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056504 Radiology Xray Heel Min 2 Views Rt 73650 320 $536.00 $- $28.52 $- $- $428.80 $- N/A $139.36 N/A N/A $34.73 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.52 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.52 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056504 Radiology Xray Heel Min 2 Views Bil 73650 320 $536.00 $- $28.52 $- $- $428.80 $- N/A $139.36 N/A N/A $34.73 N/A N/A $321.60 N/A N/A $268.00 N/A N/A $28.52 N/A N/A $364.48 N/A N/A $305.52 N/A N/A $209.04 N/A N/A $375.20 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $375.20 N/A N/A $179.56 N/A N/A $28.52 N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $375.20 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 4056603 Radiology Xray Toe(s) Min 2 Views Lt 73660 320 $480.00 $- $30.71 $- $- $384.00 $- N/A $124.80 N/A N/A $37.20 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $30.71 N/A N/A $326.40 N/A N/A $273.60 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $30.71 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4056603 Radiology Xray Toe(s) Min 2 Views Rt 73660 320 $480.00 $- $30.71 $- $- $384.00 $- N/A $124.80 N/A N/A $37.20 N/A N/A $288.00 N/A N/A $240.00 N/A N/A $30.71 N/A N/A $326.40 N/A N/A $273.60 N/A N/A $187.20 N/A N/A $336.00 N/A N/A $384.00 N/A N/A $264.00 N/A N/A $336.00 N/A N/A $160.80 N/A N/A $30.71 N/A N/A $288.00 N/A N/A $168.00 N/A N/A $312.00 N/A N/A $144.00 N/A N/A $288.00 N/A N/A $336.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A N/A $144.00 N/A $480.00 $480.00 N/A 4057000 Radiology XR Fluoro Up to 1 Hour 76000 320 $963.00 $- $50.53 $- $- $770.40 $- N/A $250.38 N/A N/A $62.42 N/A N/A $577.80 N/A N/A $481.50 N/A N/A $50.53 N/A N/A $654.84 N/A N/A $548.91 N/A N/A $375.57 N/A N/A $674.10 N/A N/A $770.40 N/A N/A $529.65 N/A N/A $674.10 N/A N/A $322.61 N/A N/A $50.53 N/A N/A $577.80 N/A N/A $337.05 N/A N/A $625.95 N/A N/A $288.90 N/A N/A $577.80 N/A N/A $674.10 N/A N/A $288.90 N/A N/A $288.90 N/A N/A $288.90 N/A N/A $288.90 N/A N/A $288.90 N/A N/A $288.90 N/A $963.00 $963.00 N/A 4069010 Radiology CT Chest w/o contrast 71250 352 "$2,316.00 " $- $189.73 $- $- "$1,852.80 " $- N/A $602.16 N/A N/A $255.00 N/A N/A "$1,389.60 " N/A N/A "$1,158.00 " N/A N/A $189.73 N/A N/A "$1,574.88 " N/A N/A "$1,320.12 " N/A N/A $903.24 N/A N/A "$1,621.20 " N/A N/A "$1,852.80 " N/A N/A "$1,273.80 " N/A N/A "$1,621.20 " N/A N/A $775.86 N/A N/A $189.73 N/A N/A "$1,389.60 " N/A N/A $810.60 N/A N/A "$1,505.40 " N/A N/A $694.80 N/A N/A "$1,389.60 " N/A N/A "$1,621.20 " N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A "$2,316.00 " "$2,316.00 " N/A 4069015 Radiology CT Chest w/ Contrast 71260 352 "$3,205.00 " $- $237.68 $- $- "$2,564.00 " $- N/A $833.30 N/A N/A $319.06 N/A N/A "$1,923.00 " N/A N/A "$1,602.50 " N/A N/A $237.68 N/A N/A "$2,179.40 " N/A N/A "$1,826.85 " N/A N/A "$1,249.95 " N/A N/A "$2,243.50 " N/A N/A "$2,564.00 " N/A N/A "$1,762.75 " N/A N/A "$2,243.50 " N/A N/A "$1,073.68 " N/A N/A $237.68 N/A N/A "$1,923.00 " N/A N/A "$1,121.75 " N/A N/A "$2,083.25 " N/A N/A $961.50 N/A N/A "$1,923.00 " N/A N/A "$2,243.50 " N/A N/A $961.50 N/A N/A $961.50 N/A N/A $961.50 N/A N/A $961.50 N/A N/A $961.50 N/A N/A $961.50 N/A "$3,205.00 " "$3,205.00 " N/A 4069020 Radiology CT Chest w/ + w/o contrast 71270 352 "$4,398.00 " $- $286.81 $- $- "$3,518.40 " $- N/A "$1,143.48 " N/A N/A $386.87 N/A N/A "$2,638.80 " N/A N/A "$2,199.00 " N/A N/A $286.81 N/A N/A "$2,990.64 " N/A N/A "$2,506.86 " N/A N/A "$1,715.22 " N/A N/A "$3,078.60 " N/A N/A "$3,518.40 " N/A N/A "$2,418.90 " N/A N/A "$3,078.60 " N/A N/A "$1,473.33 " N/A N/A $286.81 N/A N/A "$2,638.80 " N/A N/A "$1,539.30 " N/A N/A "$2,858.70 " N/A N/A "$1,319.40 " N/A N/A "$2,638.80 " N/A N/A "$3,078.60 " N/A N/A "$1,319.40 " N/A N/A "$1,319.40 " N/A N/A "$1,319.40 " N/A N/A "$1,319.40 " N/A N/A "$1,319.40 " N/A N/A "$1,319.40 " N/A "$4,398.00 " "$4,398.00 " N/A 4060102 Radiology CT Abdomen +Pelvis w/o Cont 74176 352 "$3,106.00 " $425.00 $214.09 $- $831.09 "$2,484.80 " $- N/A $807.56 N/A $425.00 $425.00 N/A N/A "$1,863.60 " N/A N/A "$1,553.00 " N/A N/A $214.09 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,211.34 " N/A N/A "$2,174.20 " N/A N/A "$2,484.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,040.51 " N/A N/A $214.09 N/A N/A "$1,863.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $931.80 N/A N/A "$1,863.60 " N/A $831.09 "$2,174.20 " N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A "$3,106.00 " "$3,106.00 " N/A 4060103 Radiology CT Abdomen +Pelvis w/ Cont 74177 352 "$4,139.00 " $425.00 $321.59 $- $831.09 "$3,311.20 " $- N/A "$1,076.14 " N/A $425.00 $425.00 N/A N/A "$2,483.40 " N/A N/A "$2,069.50 " N/A N/A $321.59 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,614.21 " N/A N/A "$2,897.30 " N/A N/A "$3,311.20 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,386.57 " N/A N/A $321.59 N/A N/A "$2,483.40 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,241.70 " N/A N/A "$2,483.40 " N/A $831.09 "$2,897.30 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A "$4,139.00 " "$4,139.00 " N/A 4060104 Radiology CT Abdomen +Pelvis w/ + w/o Cont 74178 352 "$4,451.00 " $425.00 $374.55 $- $831.09 "$3,560.80 " $- N/A "$1,157.26 " N/A $425.00 $425.00 N/A N/A "$2,670.60 " N/A N/A "$2,225.50 " N/A N/A $374.55 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,735.89 " N/A N/A "$3,115.70 " N/A N/A "$3,560.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,491.09 " N/A N/A $374.55 N/A N/A "$2,670.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,335.30 " N/A N/A "$2,670.60 " N/A $831.09 "$3,115.70 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A "$4,451.00 " "$4,451.00 " N/A 4060105 Radiology CT UE w/ Cont Lt 73201 352 "$3,385.00 " $425.00 $232.15 $- $831.09 "$2,708.00 " $- N/A $880.10 N/A $425.00 $425.00 N/A N/A "$2,031.00 " N/A N/A "$1,692.50 " N/A N/A $232.15 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,320.15 " N/A N/A "$2,369.50 " N/A N/A "$2,708.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,133.98 " N/A N/A $232.15 N/A N/A "$2,031.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,015.50 " N/A N/A "$2,031.00 " N/A $831.09 "$2,369.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A "$3,385.00 " "$3,385.00 " N/A 4060105 Radiology CT UE w/ Cont Rt 73201 352 "$3,385.00 " $425.00 $232.15 $- $831.09 "$2,708.00 " $- N/A $880.10 N/A $425.00 $425.00 N/A N/A "$2,031.00 " N/A N/A "$1,692.50 " N/A N/A $232.15 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,320.15 " N/A N/A "$2,369.50 " N/A N/A "$2,708.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,133.98 " N/A N/A $232.15 N/A N/A "$2,031.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,015.50 " N/A N/A "$2,031.00 " N/A $831.09 "$2,369.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A N/A "$1,015.50 " N/A "$3,385.00 " "$3,385.00 " N/A 4060106 Radiology CT UE w/ + w/o Cont Lt 73202 352 "$3,232.00 " $425.00 $296.34 $- $831.09 "$2,585.60 " $- N/A $840.32 N/A $425.00 $425.00 N/A N/A "$1,939.20 " N/A N/A "$1,616.00 " N/A N/A $296.34 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,260.48 " N/A N/A "$2,262.40 " N/A N/A "$2,585.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,082.72 " N/A N/A $296.34 N/A N/A "$1,939.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $969.60 N/A N/A "$1,939.20 " N/A $831.09 "$2,262.40 " N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A "$3,232.00 " "$3,232.00 " N/A 4060106 Radiology CT UE w/ + w/o Cont Rt 73202 352 "$3,232.00 " $425.00 $296.34 $- $831.09 "$2,585.60 " $- N/A $840.32 N/A $425.00 $425.00 N/A N/A "$1,939.20 " N/A N/A "$1,616.00 " N/A N/A $296.34 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,260.48 " N/A N/A "$2,262.40 " N/A N/A "$2,585.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,082.72 " N/A N/A $296.34 N/A N/A "$1,939.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $969.60 N/A N/A "$1,939.20 " N/A $831.09 "$2,262.40 " N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A N/A $969.60 N/A "$3,232.00 " "$3,232.00 " N/A 4060154 Radiology CT Angio Abdomen + Pelvis w/Runoff 75635 350 "$4,836.00 " $425.00 $414.38 $- $831.09 "$3,868.80 " $- N/A "$1,257.36 " N/A $425.00 $425.00 N/A N/A "$2,901.60 " N/A N/A "$2,418.00 " N/A N/A $414.38 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,886.04 " N/A N/A "$3,385.20 " N/A N/A "$3,868.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,620.06 " N/A N/A $414.38 N/A N/A "$2,901.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,450.80 " N/A N/A "$2,901.60 " N/A $831.09 "$3,385.20 " N/A N/A "$1,450.80 " N/A N/A "$1,450.80 " N/A N/A "$1,450.80 " N/A N/A "$1,450.80 " N/A N/A "$1,450.80 " N/A N/A "$1,450.80 " N/A "$4,836.00 " "$4,836.00 " N/A 4060220 Radiology Isovue 370 100 ml Q9967 Q9967 636 $749.00 $425.00 $0.73 $- $831.09 $861.00 $- N/A $194.74 N/A $425.00 $425.00 N/A N/A $449.40 N/A N/A $374.50 N/A N/A $0.73 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $292.11 N/A N/A $524.30 N/A N/A $599.20 N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $250.92 N/A N/A $0.73 N/A N/A $449.40 N/A N/A $701.79 N/A N/A $707.00 N/A N/A $224.70 N/A N/A $449.40 N/A $831.09 $524.30 N/A N/A $224.70 N/A N/A $224.70 N/A N/A $224.70 N/A N/A $224.70 N/A N/A $224.70 N/A N/A $224.70 N/A $749.00 $749.00 N/A 4060225 Radiology CT Spine Thoracic w/ Cont 72130 352 "$3,480.00 " $425.00 $286.30 $- $831.09 "$2,784.00 " $- N/A $904.80 N/A $425.00 $425.00 N/A N/A "$2,088.00 " N/A N/A "$1,740.00 " N/A N/A $286.30 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,357.20 " N/A N/A "$2,436.00 " N/A N/A "$2,784.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,165.80 " N/A N/A $286.30 N/A N/A "$2,088.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,044.00 " N/A N/A "$2,088.00 " N/A $831.09 "$2,436.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A "$3,480.00 " "$3,480.00 " N/A 4060230 Radiology CT Spine Thoracic w/ + w/o Cont 72130 352 "$3,920.00 " $425.00 $286.30 $- $831.09 "$3,136.00 " $- N/A "$1,019.20 " N/A $425.00 $425.00 N/A N/A "$2,352.00 " N/A N/A "$1,960.00 " N/A N/A $286.30 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,528.80 " N/A N/A "$2,744.00 " N/A N/A "$3,136.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,313.20 " N/A N/A $286.30 N/A N/A "$2,352.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,176.00 " N/A N/A "$2,352.00 " N/A $831.09 "$2,744.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A "$3,920.00 " "$3,920.00 " N/A 4060492 Radiology CT Angio Neck w/ Cont 70492 350 "$4,618.00 " $425.00 $289.54 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $289.54 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $289.54 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 "$3,232.60 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4060510 Radiology CT Angio Head 70496 351 "$4,758.00 " $425.00 $425.00 $- $831.09 "$3,806.40 " $- N/A "$1,237.08 " N/A $425.00 $425.00 N/A N/A "$2,854.80 " N/A N/A "$2,379.00 " N/A N/A $444.28 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,855.62 " N/A N/A "$3,330.60 " N/A N/A "$3,806.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,593.93 " N/A N/A $444.28 N/A N/A "$2,854.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,427.40 " N/A N/A "$2,854.80 " N/A $831.09 "$3,330.60 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A "$4,758.00 " "$4,758.00 " N/A 4060510 Radiology CT Angio Head +Angio Neck w/ + w/o Cont 70496 351 "$4,758.00 " $425.00 $425.00 $- $831.09 "$3,806.40 " $- N/A "$1,237.08 " N/A $425.00 $425.00 N/A N/A "$2,854.80 " N/A N/A "$2,379.00 " N/A N/A $444.28 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,855.62 " N/A N/A "$3,330.60 " N/A N/A "$3,806.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,593.93 " N/A N/A $444.28 N/A N/A "$2,854.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,427.40 " N/A N/A "$2,854.80 " N/A $831.09 "$3,330.60 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A N/A "$1,427.40 " N/A "$4,758.00 " "$4,758.00 " N/A 4060520 Radiology CT Angio Abdomen +Pelvis w/ Cont 74174 352 "$5,451.00 " $425.00 $425.00 $- $831.09 "$4,360.80 " $- N/A "$1,417.26 " N/A $425.00 $425.00 N/A N/A "$3,270.60 " N/A N/A "$2,725.50 " N/A N/A $540.15 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$2,125.89 " N/A N/A "$3,815.70 " N/A N/A "$4,360.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,826.09 " N/A N/A $540.15 N/A N/A "$3,270.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,635.30 " N/A N/A "$3,270.60 " N/A $831.09 "$3,815.70 " N/A N/A "$1,635.30 " N/A N/A "$1,635.30 " N/A N/A "$1,635.30 " N/A N/A "$1,635.30 " N/A N/A "$1,635.30 " N/A N/A "$1,635.30 " N/A "$5,451.00 " "$5,451.00 " N/A 4060525 Radiology CT Angio Abdomen w/ Cont 74175 352 "$4,079.00 " $425.00 $383.99 $- $831.09 "$3,263.20 " $- N/A "$1,060.54 " N/A $425.00 $425.00 N/A N/A "$2,447.40 " N/A N/A "$2,039.50 " N/A N/A $383.99 N/A N/A "$2,773.72 " N/A N/A "$2,325.03 " N/A N/A "$1,590.81 " N/A N/A "$2,855.30 " N/A N/A "$3,263.20 " N/A N/A "$2,243.45 " N/A N/A "$2,855.30 " N/A N/A "$1,366.47 " N/A N/A $383.99 N/A N/A "$2,447.40 " N/A N/A "$1,427.65 " N/A N/A "$2,651.35 " N/A N/A "$1,223.70 " N/A N/A "$2,447.40 " N/A $831.09 "$2,855.30 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A "$4,079.00 " "$4,079.00 " N/A 4060530 Radiology BCH CT Angio Neck 70498 352 "$4,079.00 " $425.00 $425.00 $- $831.09 "$3,263.20 " $- N/A "$1,060.54 " N/A $425.00 $425.00 N/A N/A "$2,447.40 " N/A N/A "$2,039.50 " N/A N/A $461.33 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,590.81 " N/A N/A "$2,855.30 " N/A N/A "$3,263.20 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,366.47 " N/A N/A $461.33 N/A N/A "$2,447.40 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,223.70 " N/A N/A "$2,447.40 " N/A $831.09 $831.09 N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A N/A "$1,223.70 " N/A "$4,079.00 " "$4,079.00 " N/A 4060535 Radiology CT Orbit Sella etc. or IAC w/ + w/o Cont 70482 351 "$3,920.00 " $425.00 $321.52 $- $831.09 "$3,136.00 " $- N/A "$1,019.20 " N/A $425.00 $425.00 N/A N/A "$2,352.00 " N/A N/A "$1,960.00 " N/A N/A $321.52 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,528.80 " N/A N/A "$2,744.00 " N/A N/A "$3,136.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,313.20 " N/A N/A $321.52 N/A N/A "$2,352.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,176.00 " N/A N/A "$2,352.00 " N/A $831.09 $831.09 N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A N/A "$1,176.00 " N/A "$3,920.00 " "$3,920.00 " N/A 4061258 Radiology CT Spine Cervical w/o Cont 72125 352 "$2,432.00 " $425.00 $193.91 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $193.91 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $193.91 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4061274 Radiology CT Spine Lumbar w/ Cont 72132 352 "$4,158.00 " $425.00 $237.02 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $237.02 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $237.02 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4061276 Radiology CT Spine Cervical w/ Cont 72126 352 "$3,480.00 " $425.00 $237.72 $- $831.09 "$2,784.00 " $- N/A $904.80 N/A $425.00 $425.00 N/A N/A "$2,088.00 " N/A N/A "$1,740.00 " N/A N/A $237.72 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,357.20 " N/A N/A "$2,436.00 " N/A N/A "$2,784.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,165.80 " N/A N/A $237.72 N/A N/A "$2,088.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,044.00 " N/A N/A "$2,088.00 " N/A $831.09 $831.09 N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A N/A "$1,044.00 " N/A "$3,480.00 " "$3,480.00 " N/A 4061282 Radiology CT Spine Thoracic w/o Cont 72128 352 "$2,432.00 " $425.00 $190.13 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $190.13 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $190.13 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4061316 Radiology CT Spine Lumbar w/o Cont 72131 352 "$2,432.00 " $425.00 $189.41 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $189.41 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $189.41 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4061504 Radiology CT Abdomen w/o Cont 74150 352 "$2,432.00 " $425.00 $152.87 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $152.87 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $152.87 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4061603 Radiology CT Abdomen w/ Cont 74160 352 "$4,158.00 " $425.00 $238.34 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $238.34 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $238.34 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4061702 Radiology CT Abdomen w/ + w/o Cont 74170 352 "$4,618.00 " $425.00 $275.42 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $275.42 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $275.42 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4061928 Radiology CT Pelvis w/o Cont 72192 352 "$2,432.00 " $425.00 $149.46 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $149.46 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $149.46 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4061936 Radiology CT Pelvis w/ Cont 72193 352 "$4,158.00 " $425.00 $233.92 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $233.92 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $233.92 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4061944 Radiology CT Pelvis w/ + w/o Cont 72194 352 "$4,618.00 " $425.00 $273.96 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $273.96 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $273.96 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4062008 Radiology CT UE w/o Cont Lt 73200 352 "$2,432.00 " $425.00 $189.81 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $189.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $189.81 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4062008 Radiology CT UE w/o Cont Rt 73200 352 "$2,432.00 " $425.00 $189.81 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $189.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $189.81 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4062127 Radiology CT Spine Cervical w/ + w/o Cont 72127 350 "$3,626.00 " $425.00 $283.10 $- $831.09 "$2,900.80 " $- N/A $942.76 N/A $425.00 $425.00 N/A N/A "$2,175.60 " N/A N/A "$1,813.00 " N/A N/A $283.10 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,414.14 " N/A N/A "$2,538.20 " N/A N/A "$2,900.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,214.71 " N/A N/A $283.10 N/A N/A "$2,175.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,087.80 " N/A N/A "$2,175.60 " N/A $831.09 $831.09 N/A N/A "$1,087.80 " N/A N/A "$1,087.80 " N/A N/A "$1,087.80 " N/A N/A "$1,087.80 " N/A N/A "$1,087.80 " N/A N/A "$1,087.80 " N/A "$3,626.00 " "$3,626.00 " N/A 4062133 Radiology CT Spine Lumbar w/ + w/o Cont 72133 350 "$2,998.00 " $425.00 $283.46 $- $831.09 "$2,398.40 " $- N/A $779.48 N/A $425.00 $425.00 N/A N/A "$1,798.80 " N/A N/A "$1,499.00 " N/A N/A $283.46 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,169.22 " N/A N/A "$2,098.60 " N/A N/A "$2,398.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,004.33 " N/A N/A $283.46 N/A N/A "$1,798.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $899.40 N/A N/A "$1,798.80 " N/A $831.09 $831.09 N/A N/A $899.40 N/A N/A $899.40 N/A N/A $899.40 N/A N/A $899.40 N/A N/A $899.40 N/A N/A $899.40 N/A "$2,998.00 " "$2,998.00 " N/A 4062505 Radiology CT Chest w/o Cont 71250 352 "$2,432.00 " $425.00 $189.73 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $189.73 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $189.73 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4062604 Radiology CT Angio Chest PE w/ Cont 71275 352 "$4,158.00 " $425.00 $370.81 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $370.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $370.81 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4062604 Radiology CT Angio Chest +Abdomen +Pelvis w/ Cont 71275 352 "$4,158.00 " $425.00 $370.81 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $370.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $370.81 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4062604 Radiology CT Chest w/ Cont 71260 352 "$4,158.00 " $425.00 $237.68 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $237.68 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $237.68 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4062703 Radiology CT Chest w/ + w/o Cont 71270 352 "$4,618.00 " $425.00 $286.81 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $286.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $286.81 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4063607 Radiology CT Biopsy 77012 352 "$3,070.00 " $425.00 $126.23 $- $831.09 "$2,456.00 " $- N/A $798.20 N/A $425.00 $425.00 N/A N/A "$1,842.00 " N/A N/A "$1,535.00 " N/A N/A $126.23 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,197.30 " N/A N/A "$2,149.00 " N/A N/A "$2,456.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,028.45 " N/A N/A $126.23 N/A N/A "$1,842.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $921.00 N/A N/A "$1,842.00 " N/A $831.09 $831.09 N/A N/A $921.00 N/A N/A $921.00 N/A N/A $921.00 N/A N/A $921.00 N/A N/A $921.00 N/A N/A $921.00 N/A "$3,070.00 " "$3,070.00 " N/A 4063801 Radiology CT Ltd or Localized Fol-Up 76380 350 $909.00 $425.00 $150.00 $- $831.09 $861.00 $- N/A $236.34 N/A $425.00 $425.00 N/A N/A $545.40 N/A N/A $454.50 N/A N/A $150.00 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $354.51 N/A N/A $636.30 N/A N/A $727.20 N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $304.52 N/A N/A $150.00 N/A N/A $545.40 N/A N/A $701.79 N/A N/A $707.00 N/A N/A $272.70 N/A N/A $545.40 N/A $831.09 $831.09 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A N/A $272.70 N/A $909.00 $909.00 N/A 4064366 Radiology CT Sinus Ltd 70486 350 "$2,432.00 " $425.00 $205.15 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $205.15 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $205.15 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4064502 Radiology CT Head or Brain w/o Cont 70450 351 "$2,432.00 " $425.00 $122.53 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $122.53 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $122.53 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4064601 Radiology CT Head or Brain w/ Cont 70460 351 "$4,158.00 " $425.00 $167.51 $- $831.09 "$3,326.40 " $- N/A "$1,081.08 " N/A $425.00 $425.00 N/A N/A "$2,494.80 " N/A N/A "$2,079.00 " N/A N/A $167.51 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,621.62 " N/A N/A "$2,910.60 " N/A N/A "$3,326.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,392.93 " N/A N/A $167.51 N/A N/A "$2,494.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,247.40 " N/A N/A "$2,494.80 " N/A $831.09 $831.09 N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A N/A "$1,247.40 " N/A "$4,158.00 " "$4,158.00 " N/A 4064700 Radiology CT Head or Brain w/ + w/o Cont 70470 351 "$4,618.00 " $425.00 $201.40 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $201.40 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $201.40 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4064809 Radiology CT Orbit Sella etc. or IAC w/o Cont 70480 351 "$2,432.00 " $425.00 $249.34 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $249.34 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $249.34 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4064817 Radiology CT Orbit Sella etc. or IAC w/ Cont 70481 351 "$2,627.00 " $425.00 $290.74 $- $831.09 "$2,101.60 " $- N/A $683.02 N/A $425.00 $425.00 N/A N/A "$1,576.20 " N/A N/A "$1,313.50 " N/A N/A $290.74 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,024.53 " N/A N/A "$1,838.90 " N/A N/A "$2,101.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $880.05 N/A N/A $290.74 N/A N/A "$1,576.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $788.10 N/A N/A "$1,576.20 " N/A $831.09 $831.09 N/A N/A $788.10 N/A N/A $788.10 N/A N/A $788.10 N/A N/A $788.10 N/A N/A $788.10 N/A N/A $788.10 N/A "$2,627.00 " "$2,627.00 " N/A 4064866 Radiology CT Maxillofacial w/o Cont 70486 351 "$2,432.00 " $425.00 $205.15 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $205.15 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $205.15 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4064874 Radiology CT Maxillofacial w/ Cont 70487 351 "$3,200.00 " $425.00 $248.59 $- $831.09 "$2,560.00 " $- N/A $832.00 N/A $425.00 $425.00 N/A N/A "$1,920.00 " N/A N/A "$1,600.00 " N/A N/A $248.59 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,248.00 " N/A N/A "$2,240.00 " N/A N/A "$2,560.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,072.00 " N/A N/A $248.59 N/A N/A "$1,920.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $960.00 N/A N/A "$1,920.00 " N/A $831.09 $831.09 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A "$3,200.00 " "$3,200.00 " N/A 4064882 Radiology CT Maxillofacial w/ + w/o Cont 70488 351 "$4,618.00 " $425.00 $297.77 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $297.77 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $297.77 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4064908 Radiology CT Neck Soft Tissue w/o Cont 70490 351 "$2,432.00 " $425.00 $202.80 $- $831.09 "$1,945.60 " $- N/A $632.32 N/A $425.00 $425.00 N/A N/A "$1,459.20 " N/A N/A "$1,216.00 " N/A N/A $202.80 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $948.48 N/A N/A "$1,702.40 " N/A N/A "$1,945.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $814.72 N/A N/A $202.80 N/A N/A "$1,459.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $729.60 N/A N/A "$1,459.20 " N/A $831.09 $831.09 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A N/A $729.60 N/A "$2,432.00 " "$2,432.00 " N/A 4064916 Radiology CT Neck Soft Tissue w/ Cont 70491 351 "$4,052.00 " $425.00 $243.47 $- $831.09 "$3,241.60 " $- N/A "$1,053.52 " N/A $425.00 $425.00 N/A N/A "$2,431.20 " N/A N/A "$2,026.00 " N/A N/A $243.47 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,580.28 " N/A N/A "$2,836.40 " N/A N/A "$3,241.60 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,357.42 " N/A N/A $243.47 N/A N/A "$2,431.20 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,215.60 " N/A N/A "$2,431.20 " N/A $831.09 $831.09 N/A N/A "$1,215.60 " N/A N/A "$1,215.60 " N/A N/A "$1,215.60 " N/A N/A "$1,215.60 " N/A N/A "$1,215.60 " N/A N/A "$1,215.60 " N/A "$4,052.00 " "$4,052.00 " N/A 4064924 Radiology CT Neck Soft Tissue w/ + w/o Cont 70492 351 "$4,618.00 " $425.00 $289.54 $- $831.09 "$3,694.40 " $- N/A "$1,200.68 " N/A $425.00 $425.00 N/A N/A "$2,770.80 " N/A N/A "$2,309.00 " N/A N/A $289.54 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,801.02 " N/A N/A "$3,232.60 " N/A N/A "$3,694.40 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,547.03 " N/A N/A $289.54 N/A N/A "$2,770.80 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,385.40 " N/A N/A "$2,770.80 " N/A $831.09 $831.09 N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A N/A "$1,385.40 " N/A "$4,618.00 " "$4,618.00 " N/A 4067007 Radiology CT LE w/o Cont Lt 73700 352 "$2,061.00 " $425.00 $189.81 $- $831.09 "$1,648.80 " $- N/A $535.86 N/A $425.00 $425.00 N/A N/A "$1,236.60 " N/A N/A "$1,030.50 " N/A N/A $189.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $803.79 N/A N/A "$1,442.70 " N/A N/A "$1,648.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $690.44 N/A N/A $189.81 N/A N/A "$1,236.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $618.30 N/A N/A "$1,236.60 " N/A $831.09 $831.09 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A "$2,061.00 " "$2,061.00 " N/A 4067007 Radiology CT LE w/o Cont Rt 73700 352 "$2,061.00 " $425.00 $189.81 $- $831.09 "$1,648.80 " $- N/A $535.86 N/A $425.00 $425.00 N/A N/A "$1,236.60 " N/A N/A "$1,030.50 " N/A N/A $189.81 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $803.79 N/A N/A "$1,442.70 " N/A N/A "$1,648.80 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $690.44 N/A N/A $189.81 N/A N/A "$1,236.60 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $618.30 N/A N/A "$1,236.60 " N/A $831.09 $831.09 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A N/A $618.30 N/A "$2,061.00 " "$2,061.00 " N/A 4067015 Radiology CT LE w/ Cont Lt 73701 352 "$2,279.00 " $425.00 $234.99 $- $831.09 "$1,823.20 " $- N/A $592.54 N/A $425.00 $425.00 N/A N/A "$1,367.40 " N/A N/A "$1,139.50 " N/A N/A $234.99 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $888.81 N/A N/A "$1,595.30 " N/A N/A "$1,823.20 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $763.47 N/A N/A $234.99 N/A N/A "$1,367.40 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $683.70 N/A N/A "$1,367.40 " N/A $831.09 $831.09 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A "$2,279.00 " "$2,279.00 " N/A 4067015 Radiology CT LE w/ Cont Rt 73701 352 "$2,279.00 " $425.00 $234.99 $- $831.09 "$1,823.20 " $- N/A $592.54 N/A $425.00 $425.00 N/A N/A "$1,367.40 " N/A N/A "$1,139.50 " N/A N/A $234.99 N/A N/A $632.07 N/A N/A $861.00 N/A N/A $888.81 N/A N/A "$1,595.30 " N/A N/A "$1,823.20 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A $763.47 N/A N/A $234.99 N/A N/A "$1,367.40 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A $683.70 N/A N/A "$1,367.40 " N/A $831.09 $831.09 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A N/A $683.70 N/A "$2,279.00 " "$2,279.00 " N/A 4067020 Radiology CT LE w/ + w/o Cont Lt 73702 352 "$3,540.00 " $425.00 $293.86 $- $831.09 "$2,832.00 " $- N/A $920.40 N/A $425.00 $425.00 N/A N/A "$2,124.00 " N/A N/A "$1,770.00 " N/A N/A $293.86 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,380.60 " N/A N/A "$2,478.00 " N/A N/A "$2,832.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,185.90 " N/A N/A $293.86 N/A N/A "$2,124.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,062.00 " N/A N/A "$2,124.00 " N/A $831.09 $831.09 N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A "$3,540.00 " "$3,540.00 " N/A 4067020 Radiology CT LE w/ + w/o Cont Rt 73702 352 "$3,540.00 " $425.00 $293.86 $- $831.09 "$2,832.00 " $- N/A $920.40 N/A $425.00 $425.00 N/A N/A "$2,124.00 " N/A N/A "$1,770.00 " N/A N/A $293.86 N/A N/A $632.07 N/A N/A $861.00 N/A N/A "$1,380.60 " N/A N/A "$2,478.00 " N/A N/A "$2,832.00 " N/A N/A $694.00 N/A $521.00 $521.00 N/A N/A "$1,185.90 " N/A N/A $293.86 N/A N/A "$2,124.00 " N/A N/A $701.79 N/A N/A $707.00 N/A N/A "$1,062.00 " N/A N/A "$2,124.00 " N/A $831.09 $831.09 N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A N/A "$1,062.00 " N/A "$3,540.00 " "$3,540.00 " N/A 4068991 Radiology BCH Isovue 300 100mL Q9967 Q9967 636 $457.00 $- $0.73 $- $- $0.73 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $0.73 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $457.00 $457.00 N/A 4070001 Radiology BCH I131 Theraputic Thyr A9530 A9530 636 $160.00 $- $- $- $- $- $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $160.00 $160.00 N/A 4070025 Radiology BCH I131 Sodium Iodine Capsul A9528 A9528 636 $272.00 $- $21.54 $- $- $21.54 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $21.54 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $21.54 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $272.00 $272.00 N/A 4070710 Radiology MRI LE Non Joint w/o Cont Bil 73718 610 "$4,155.00 " $770.00 $365.75 $- "$1,227.27 " "$3,324.00 " $- N/A "$1,080.30 " N/A $650 per service date $650 per service date N/A N/A "$2,493.00 " N/A N/A "$2,077.50 " N/A N/A $365.75 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,620.45 " N/A N/A $618 per service date N/A N/A "$3,324.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,391.93 " N/A N/A $365.75 N/A N/A "$2,493.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,246.50 " N/A N/A "$2,493.00 " N/A "$1,227.27 " N/A N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A "$4,155.00 " "$4,155.00 " N/A 4070710 Radiology MRI LE Non Joint w/o Cont Lt 73718 610 "$4,155.00 " $770.00 $365.75 $- "$1,227.27 " "$3,324.00 " $- N/A "$1,080.30 " N/A $650 per service date $650 per service date N/A N/A "$2,493.00 " N/A N/A "$2,077.50 " N/A N/A $365.75 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,620.45 " N/A N/A $618 per service date N/A N/A "$3,324.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,391.93 " N/A N/A $365.75 N/A N/A "$2,493.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,246.50 " N/A N/A "$2,493.00 " N/A "$1,227.27 " N/A N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A "$4,155.00 " "$4,155.00 " N/A 4070710 Radiology MRI LE Non Joint w/o Cont Rt 73718 610 "$4,155.00 " $770.00 $365.75 $- "$1,227.27 " "$3,324.00 " $- N/A "$1,080.30 " N/A $650 per service date $650 per service date N/A N/A "$2,493.00 " N/A N/A "$2,077.50 " N/A N/A $365.75 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,620.45 " N/A N/A $618 per service date N/A N/A "$3,324.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,391.93 " N/A N/A $365.75 N/A N/A "$2,493.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,246.50 " N/A N/A "$2,493.00 " N/A "$1,227.27 " N/A N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A N/A "$1,246.50 " N/A "$4,155.00 " "$4,155.00 " N/A 4070720 Radiology MRI LE Non Joint w/ Cont Bil 73719 610 "$4,212.00 " $770.00 $417.17 $- "$1,227.27 " "$3,369.60 " $- N/A "$1,095.12 " N/A $650 per service date $650 per service date N/A N/A "$2,527.20 " N/A N/A "$2,106.00 " N/A N/A $417.17 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,642.68 " N/A N/A $618 per service date N/A N/A "$3,369.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,411.02 " N/A N/A $417.17 N/A N/A "$2,527.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,263.60 " N/A N/A "$2,527.20 " N/A "$1,227.27 " N/A N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A "$4,212.00 " "$4,212.00 " N/A 4070720 Radiology MRI LE Non Joint w/ Cont Lt 73719 610 "$4,212.00 " $770.00 $417.17 $- "$1,227.27 " "$3,369.60 " $- N/A "$1,095.12 " N/A $650 per service date $650 per service date N/A N/A "$2,527.20 " N/A N/A "$2,106.00 " N/A N/A $417.17 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,642.68 " N/A N/A $618 per service date N/A N/A "$3,369.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,411.02 " N/A N/A $417.17 N/A N/A "$2,527.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,263.60 " N/A N/A "$2,527.20 " N/A "$1,227.27 " N/A N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A "$4,212.00 " "$4,212.00 " N/A 4070720 Radiology MRI LE Non Joint w/ Cont Rt 73719 610 "$4,212.00 " $770.00 $417.17 $- "$1,227.27 " "$3,369.60 " $- N/A "$1,095.12 " N/A $650 per service date $650 per service date N/A N/A "$2,527.20 " N/A N/A "$2,106.00 " N/A N/A $417.17 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,642.68 " N/A N/A $618 per service date N/A N/A "$3,369.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,411.02 " N/A N/A $417.17 N/A N/A "$2,527.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,263.60 " N/A N/A "$2,527.20 " N/A "$1,227.27 " N/A N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A N/A "$1,263.60 " N/A "$4,212.00 " "$4,212.00 " N/A 4070730 Radiology MRI LE Non Joint w/ + w/o Cont Bil 73720 610 "$4,912.00 " $770.00 $512.49 $- "$1,227.27 " "$3,929.60 " $- N/A "$1,277.12 " N/A $650 per service date $650 per service date N/A N/A "$2,947.20 " N/A N/A "$2,456.00 " N/A N/A $512.49 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,915.68 " N/A N/A $618 per service date N/A N/A "$3,929.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,645.52 " N/A N/A $512.49 N/A N/A "$2,947.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,473.60 " N/A N/A "$2,947.20 " N/A "$1,227.27 " N/A N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A "$4,912.00 " "$4,912.00 " N/A 4070730 Radiology MRI LE Non Joint w/ + w/o Cont Lt 73720 610 "$4,912.00 " $770.00 $512.49 $- "$1,227.27 " "$3,929.60 " $- N/A "$1,277.12 " N/A $650 per service date $650 per service date N/A N/A "$2,947.20 " N/A N/A "$2,456.00 " N/A N/A $512.49 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,915.68 " N/A N/A $618 per service date N/A N/A "$3,929.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,645.52 " N/A N/A $512.49 N/A N/A "$2,947.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,473.60 " N/A N/A "$2,947.20 " N/A "$1,227.27 " N/A N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A "$4,912.00 " "$4,912.00 " N/A 4070730 Radiology MRI LE Non Joint w/ + w/o Cont Rt 73720 610 "$4,912.00 " $770.00 $512.49 $- "$1,227.27 " "$3,929.60 " $- N/A "$1,277.12 " N/A $650 per service date $650 per service date N/A N/A "$2,947.20 " N/A N/A "$2,456.00 " N/A N/A $512.49 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,915.68 " N/A N/A $618 per service date N/A N/A "$3,929.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,645.52 " N/A N/A $512.49 N/A N/A "$2,947.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,473.60 " N/A N/A "$2,947.20 " N/A "$1,227.27 " N/A N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A N/A "$1,473.60 " N/A "$4,912.00 " "$4,912.00 " N/A 4071930 Radiology NM Abscess Loc Whole Body 78806 341 "$3,828.00 " $- $995.28 $- $- "$3,062.40 " $- N/A $995.28 N/A N/A N/A N/A N/A "$2,296.80 " N/A N/A "$1,914.00 " N/A N/A N/A N/A N/A "$2,603.04 " N/A N/A "$2,181.96 " N/A N/A "$1,492.92 " N/A N/A "$2,679.60 " N/A N/A "$3,062.40 " N/A N/A "$2,105.40 " N/A N/A "$2,679.60 " N/A N/A "$1,282.38 " N/A N/A N/A N/A N/A "$2,296.80 " N/A N/A "$1,339.80 " N/A N/A "$2,488.20 " N/A N/A "$1,148.40 " N/A N/A "$2,296.80 " N/A N/A "$2,679.60 " N/A N/A "$1,148.40 " N/A N/A "$1,148.40 " N/A N/A "$1,148.40 " N/A N/A "$1,148.40 " N/A N/A "$1,148.40 " N/A N/A "$1,148.40 " N/A "$3,828.00 " "$3,828.00 " N/A 4071948 Radiology BCH Indium Radionuclide A9548 A9548 636 "$4,038.00 " $- $307.99 $- $- $307.99 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $307.99 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $307.99 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A "$4,038.00 " "$4,038.00 " N/A 4072151 Radiology NM Liver +Spleen Static Only 78215 341 "$2,485.00 " $- $196.39 $- $- "$1,988.00 " $- N/A $646.10 N/A N/A $236.74 N/A N/A "$1,491.00 " N/A N/A "$1,242.50 " N/A N/A $196.39 N/A N/A "$1,689.80 " N/A N/A "$1,416.45 " N/A N/A $969.15 N/A N/A "$1,739.50 " N/A N/A "$1,988.00 " N/A N/A "$1,366.75 " N/A N/A "$1,739.50 " N/A N/A $832.48 N/A N/A $196.39 N/A N/A "$1,491.00 " N/A N/A $869.75 N/A N/A "$1,615.25 " N/A N/A $745.50 N/A N/A "$1,491.00 " N/A N/A "$1,739.50 " N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A "$2,485.00 " "$2,485.00 " N/A 4072235 Radiology NM Hepa Duct System w/ Pharm 78227 340 "$1,609.00 " $- $418.34 $- $- "$1,287.20 " $- N/A $418.34 N/A N/A $421.90 N/A N/A $965.40 N/A N/A $804.50 N/A N/A $453.24 N/A N/A "$1,094.12 " N/A N/A $917.13 N/A N/A $627.51 N/A N/A "$1,126.30 " N/A N/A "$1,287.20 " N/A N/A $884.95 N/A N/A "$1,126.30 " N/A N/A $539.02 N/A N/A $453.24 N/A N/A $965.40 N/A N/A $563.15 N/A N/A "$1,045.85 " N/A N/A $482.70 N/A N/A $965.40 N/A N/A "$1,126.30 " N/A N/A $482.70 N/A N/A $482.70 N/A N/A $482.70 N/A N/A $482.70 N/A N/A $482.70 N/A N/A $482.70 N/A "$1,609.00 " "$1,609.00 " N/A 4072245 Radiology NM Hepa Duct System 78227 340 "$2,485.00 " $- $421.90 $- $- "$1,988.00 " $- N/A $646.10 N/A N/A $421.90 N/A N/A "$1,491.00 " N/A N/A "$1,242.50 " N/A N/A $453.24 N/A N/A "$1,689.80 " N/A N/A "$1,416.45 " N/A N/A $969.15 N/A N/A "$1,739.50 " N/A N/A "$1,988.00 " N/A N/A "$1,366.75 " N/A N/A "$1,739.50 " N/A N/A $832.48 N/A N/A $453.24 N/A N/A "$1,491.00 " N/A N/A $869.75 N/A N/A "$1,615.25 " N/A N/A $745.50 N/A N/A "$1,491.00 " N/A N/A "$1,739.50 " N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A N/A $745.50 N/A "$2,485.00 " "$2,485.00 " N/A 4072789 Radiology NM GI Blood Loss 78278 341 "$2,612.00 " $- $351.82 $- $- "$2,089.60 " $- N/A $679.12 N/A N/A $356.62 N/A N/A "$1,567.20 " N/A N/A "$1,306.00 " N/A N/A $351.82 N/A N/A "$1,776.16 " N/A N/A "$1,488.84 " N/A N/A "$1,018.68 " N/A N/A "$1,828.40 " N/A N/A "$2,089.60 " N/A N/A "$1,436.60 " N/A N/A "$1,828.40 " N/A N/A $875.02 N/A N/A $351.82 N/A N/A "$1,567.20 " N/A N/A $914.20 N/A N/A "$1,697.80 " N/A N/A $783.60 N/A N/A "$1,567.20 " N/A N/A "$1,828.40 " N/A N/A $783.60 N/A N/A $783.60 N/A N/A $783.60 N/A N/A $783.60 N/A N/A $783.60 N/A N/A $783.60 N/A "$2,612.00 " "$2,612.00 " N/A 4073151 Radiology NM Bone 3 Phase Study 78315 340 "$2,348.00 " $- $351.06 $- $- "$1,878.40 " $- N/A $610.48 N/A N/A $364.66 N/A N/A "$1,408.80 " N/A N/A "$1,174.00 " N/A N/A $351.06 N/A N/A "$1,596.64 " N/A N/A "$1,338.36 " N/A N/A $915.72 N/A N/A "$1,643.60 " N/A N/A "$1,878.40 " N/A N/A "$1,291.40 " N/A N/A "$1,643.60 " N/A N/A $786.58 N/A N/A $351.06 N/A N/A "$1,408.80 " N/A N/A $821.80 N/A N/A "$1,526.20 " N/A N/A $704.40 N/A N/A "$1,408.80 " N/A N/A "$1,643.60 " N/A N/A $704.40 N/A N/A $704.40 N/A N/A $704.40 N/A N/A $704.40 N/A N/A $704.40 N/A N/A $704.40 N/A "$2,348.00 " "$2,348.00 " N/A 4074641 Radiology BCH TC 99M A9503 A9503 636 $227.00 $- $23.50 $- $- $23.50 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.50 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.50 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $227.00 $227.00 N/A 4074650 Radiology BCH MAG III Dose A9562 A9562 636 "$1,122.00 " $- $- $- $- $- $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A "$1,122.00 " "$1,122.00 " N/A 4074652 Radiology BCH 99 MTCPYP Dose A9538 A9538 255 $278.00 $- $29.96 $- $- $29.96 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $29.96 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $29.96 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $278.00 $278.00 N/A 4075808 Radiology NM Pulm Perf w/ Vent 78580 341 "$1,657.00 " $- $241.05 $- $- "$1,325.60 " $- N/A $430.82 N/A N/A $287.60 N/A N/A $994.20 N/A N/A $828.50 N/A N/A $241.05 N/A N/A "$1,126.76 " N/A N/A $944.49 N/A N/A $646.23 N/A N/A "$1,159.90 " N/A N/A "$1,325.60 " N/A N/A $911.35 N/A N/A "$1,159.90 " N/A N/A $555.10 N/A N/A $241.05 N/A N/A $994.20 N/A N/A $579.95 N/A N/A "$1,077.05 " N/A N/A $497.10 N/A N/A $994.20 N/A N/A "$1,159.90 " N/A N/A $497.10 N/A N/A $497.10 N/A N/A $497.10 N/A N/A $497.10 N/A N/A $497.10 N/A N/A $497.10 N/A "$1,657.00 " "$1,657.00 " N/A 4077933 Radiology BCH I 123 A9516 A9516 254 $324.00 $- $30.02 $- $- $30.02 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $30.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $30.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $324.00 $324.00 N/A 4077936 Radiology BCH Xenon A9558 A9558 636 $613.00 $- $- $- $- $- $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $613.00 $613.00 N/A 4078010 Radiology NM Thyroid Only 78012 340 "$1,212.00 " $- $77.50 $- $- $969.60 $- N/A $315.12 N/A N/A $97.73 N/A N/A $727.20 N/A N/A $606.00 N/A N/A $77.50 N/A N/A $824.16 N/A N/A $690.84 N/A N/A $472.68 N/A N/A $848.40 N/A N/A $969.60 N/A N/A $666.60 N/A N/A $848.40 N/A N/A $406.02 N/A N/A $77.50 N/A N/A $727.20 N/A N/A $424.20 N/A N/A $787.80 N/A N/A $363.60 N/A N/A $727.20 N/A N/A $848.40 N/A N/A $363.60 N/A N/A $363.60 N/A N/A $363.60 N/A N/A $363.60 N/A N/A $363.60 N/A N/A $363.60 N/A "$1,212.00 " "$1,212.00 " N/A 4078070 Radiology NM Parathyroid 78070 340 "$1,574.00 " $- $300.29 $- $- "$1,259.20 " $- N/A $409.24 N/A N/A $318.07 N/A N/A $944.40 N/A N/A $787.00 N/A N/A $300.29 N/A N/A "$1,070.32 " N/A N/A $897.18 N/A N/A $613.86 N/A N/A "$1,101.80 " N/A N/A "$1,259.20 " N/A N/A $865.70 N/A N/A "$1,101.80 " N/A N/A $527.29 N/A N/A $300.29 N/A N/A $944.40 N/A N/A $550.90 N/A N/A "$1,023.10 " N/A N/A $472.20 N/A N/A $944.40 N/A N/A "$1,101.80 " N/A N/A $472.20 N/A N/A $472.20 N/A N/A $472.20 N/A N/A $472.20 N/A N/A $472.20 N/A N/A $472.20 N/A "$1,574.00 " "$1,574.00 " N/A 4078190 Radiology BCH Sulfur Colloid Dose A9541 A9541 636 $399.00 $- $37.02 $- $- $37.02 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $37.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $37.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $399.00 $399.00 N/A 4078192 Radiology BCH MAA Dose A9540 A9540 636 $218.00 $- $23.40 $- $- $23.40 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.40 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.40 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $218.00 $218.00 N/A 4078195 Radiology BCH Choletec Dose A9537 A9537 636 $338.00 $- $34.02 $- $- $34.02 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $34.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $34.02 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $338.00 $338.00 N/A 4078205 Radiology NM Liver Spect 78206 340 "$1,555.00 " $- $404.30 $- $- "$1,244.00 " $- N/A $404.30 N/A N/A N/A N/A N/A $933.00 N/A N/A $777.50 N/A N/A N/A N/A N/A "$1,057.40 " N/A N/A $886.35 N/A N/A $606.45 N/A N/A "$1,088.50 " N/A N/A "$1,244.00 " N/A N/A $855.25 N/A N/A "$1,088.50 " N/A N/A $520.93 N/A N/A N/A N/A N/A $933.00 N/A N/A $544.25 N/A N/A "$1,010.75 " N/A N/A $466.50 N/A N/A $933.00 N/A N/A "$1,088.50 " N/A N/A $466.50 N/A N/A $466.50 N/A N/A $466.50 N/A N/A $466.50 N/A N/A $466.50 N/A N/A $466.50 N/A "$1,555.00 " "$1,555.00 " N/A 4078264 Radiology NM Gastric Emptying Study 78264 340 "$2,694.00 " $- $290.33 $- $- "$2,155.20 " $- N/A $700.44 N/A N/A $346.58 N/A N/A "$1,616.40 " N/A N/A "$1,347.00 " N/A N/A $290.33 N/A N/A "$1,831.92 " N/A N/A "$1,535.58 " N/A N/A "$1,050.66 " N/A N/A "$1,885.80 " N/A N/A "$2,155.20 " N/A N/A "$1,481.70 " N/A N/A "$1,885.80 " N/A N/A $902.49 N/A N/A $290.33 N/A N/A "$1,616.40 " N/A N/A $942.90 N/A N/A "$1,751.10 " N/A N/A $808.20 N/A N/A "$1,616.40 " N/A N/A "$1,885.80 " N/A N/A $808.20 N/A N/A $808.20 N/A N/A $808.20 N/A N/A $808.20 N/A N/A $808.20 N/A N/A $808.20 N/A "$2,694.00 " "$2,694.00 " N/A 4078270 Radiology NM Gastric Mucosa 78290 340 "$2,054.00 " $- $337.45 $- $- "$1,643.20 " $- N/A $534.04 N/A N/A $339.96 N/A N/A "$1,232.40 " N/A N/A "$1,027.00 " N/A N/A $337.45 N/A N/A "$1,396.72 " N/A N/A "$1,170.78 " N/A N/A $801.06 N/A N/A "$1,437.80 " N/A N/A "$1,643.20 " N/A N/A "$1,129.70 " N/A N/A "$1,437.80 " N/A N/A $688.09 N/A N/A $337.45 N/A N/A "$1,232.40 " N/A N/A $718.90 N/A N/A "$1,335.10 " N/A N/A $616.20 N/A N/A "$1,232.40 " N/A N/A "$1,437.80 " N/A N/A $616.20 N/A N/A $616.20 N/A N/A $616.20 N/A N/A $616.20 N/A N/A $616.20 N/A N/A $616.20 N/A "$2,054.00 " "$2,054.00 " N/A 4078306 Radiology NM Bone Whole Body 78306 340 "$3,106.00 " $- $252.93 $- $- "$2,484.80 " $- N/A $807.56 N/A N/A $303.47 N/A N/A "$1,863.60 " N/A N/A "$1,553.00 " N/A N/A $252.93 N/A N/A "$2,112.08 " N/A N/A "$1,770.42 " N/A N/A "$1,211.34 " N/A N/A "$2,174.20 " N/A N/A "$2,484.80 " N/A N/A "$1,708.30 " N/A N/A "$2,174.20 " N/A N/A "$1,040.51 " N/A N/A $252.93 N/A N/A "$1,863.60 " N/A N/A "$1,087.10 " N/A N/A "$2,018.90 " N/A N/A $931.80 N/A N/A "$1,863.60 " N/A N/A "$2,174.20 " N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A "$3,106.00 " "$3,106.00 " N/A 4078340 Radiology NM Tumor Loc Whole Body 78802 340 "$7,089.00 " $- $324.69 $- $- "$5,671.20 " $- N/A "$1,843.14 " N/A N/A $391.45 N/A N/A "$4,253.40 " N/A N/A "$3,544.50 " N/A N/A $324.69 N/A N/A "$4,820.52 " N/A N/A "$4,040.73 " N/A N/A "$2,764.71 " N/A N/A "$4,962.30 " N/A N/A "$5,671.20 " N/A N/A "$3,898.95 " N/A N/A "$4,962.30 " N/A N/A "$2,374.82 " N/A N/A $324.69 N/A N/A "$4,253.40 " N/A N/A "$2,481.15 " N/A N/A "$4,607.85 " N/A N/A "$2,126.70 " N/A N/A "$4,253.40 " N/A N/A "$4,962.30 " N/A N/A "$2,126.70 " N/A N/A "$2,126.70 " N/A N/A "$2,126.70 " N/A N/A "$2,126.70 " N/A N/A "$2,126.70 " N/A N/A "$2,126.70 " N/A "$7,089.00 " "$7,089.00 " N/A 4078478 Radiology NM Cardiac Blood Pool Gated Single 78453 340 "$4,554.00 " $- $308.82 $- $- "$3,643.20 " $- N/A "$1,184.04 " N/A N/A $367.91 N/A N/A "$2,732.40 " N/A N/A "$2,277.00 " N/A N/A $308.82 N/A N/A "$3,096.72 " N/A N/A "$2,595.78 " N/A N/A "$1,776.06 " N/A N/A "$3,187.80 " N/A N/A "$3,643.20 " N/A N/A "$2,504.70 " N/A N/A "$3,187.80 " N/A N/A "$1,525.59 " N/A N/A $308.82 N/A N/A "$2,732.40 " N/A N/A "$1,593.90 " N/A N/A "$2,960.10 " N/A N/A "$1,366.20 " N/A N/A "$2,732.40 " N/A N/A "$3,187.80 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A "$4,554.00 " "$4,554.00 " N/A 4078480 Radiology NM Myocard Perf Spect Mult Rest+Stress 78452 340 "$4,554.00 " $- $479.65 $- $- "$3,643.20 " $- N/A "$1,184.04 " N/A N/A $589.97 N/A N/A "$2,732.40 " N/A N/A "$2,277.00 " N/A N/A $479.65 N/A N/A "$3,096.72 " N/A N/A "$2,595.78 " N/A N/A "$1,776.06 " N/A N/A "$3,187.80 " N/A N/A "$3,643.20 " N/A N/A "$2,504.70 " N/A N/A "$3,187.80 " N/A N/A "$1,525.59 " N/A N/A $479.65 N/A N/A "$2,732.40 " N/A N/A "$1,593.90 " N/A N/A "$2,960.10 " N/A N/A "$1,366.20 " N/A N/A "$2,732.40 " N/A N/A "$3,187.80 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A N/A "$1,366.20 " N/A "$4,554.00 " "$4,554.00 " N/A 4078590 Radiology NM Pulm Perf +Vent Quantitative 78582 340 "$2,911.00 " $- $338.18 $- $- "$2,328.80 " $- N/A $756.86 N/A N/A $457.74 N/A N/A "$1,746.60 " N/A N/A "$1,455.50 " N/A N/A $338.18 N/A N/A "$1,979.48 " N/A N/A "$1,659.27 " N/A N/A "$1,135.29 " N/A N/A "$2,037.70 " N/A N/A "$2,328.80 " N/A N/A "$1,601.05 " N/A N/A "$2,037.70 " N/A N/A $975.19 N/A N/A $338.18 N/A N/A "$1,746.60 " N/A N/A "$1,018.85 " N/A N/A "$1,892.15 " N/A N/A $873.30 N/A N/A "$1,746.60 " N/A N/A "$2,037.70 " N/A N/A $873.30 N/A N/A $873.30 N/A N/A $873.30 N/A N/A $873.30 N/A N/A $873.30 N/A N/A $873.30 N/A "$2,911.00 " "$2,911.00 " N/A 4078708 Radiology NM Kidney w/ Flow w/ Pharm 78708 340 "$3,200.00 " $- $173.09 $- $- "$2,560.00 " $- N/A $832.00 N/A N/A $204.74 N/A N/A "$1,920.00 " N/A N/A "$1,600.00 " N/A N/A $173.09 N/A N/A "$2,176.00 " N/A N/A "$1,824.00 " N/A N/A "$1,248.00 " N/A N/A "$2,240.00 " N/A N/A "$2,560.00 " N/A N/A "$1,760.00 " N/A N/A "$2,240.00 " N/A N/A "$1,072.00 " N/A N/A $173.09 N/A N/A "$1,920.00 " N/A N/A "$1,120.00 " N/A N/A "$2,080.00 " N/A N/A $960.00 N/A N/A "$1,920.00 " N/A N/A "$2,240.00 " N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A "$3,200.00 " "$3,200.00 " N/A 4078708 Radiology NM Kidney w/ Flow w/o Pharm 78708 340 "$3,200.00 " $- $173.09 $- $- "$2,560.00 " $- N/A $832.00 N/A N/A $204.74 N/A N/A "$1,920.00 " N/A N/A "$1,600.00 " N/A N/A $173.09 N/A N/A "$2,176.00 " N/A N/A "$1,824.00 " N/A N/A "$1,248.00 " N/A N/A "$2,240.00 " N/A N/A "$2,560.00 " N/A N/A "$1,760.00 " N/A N/A "$2,240.00 " N/A N/A "$1,072.00 " N/A N/A $173.09 N/A N/A "$1,920.00 " N/A N/A "$1,120.00 " N/A N/A "$2,080.00 " N/A N/A $960.00 N/A N/A "$1,920.00 " N/A N/A "$2,240.00 " N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A "$3,200.00 " "$3,200.00 " N/A 4078708 Radiology NM Kidney w/ Flow w/ + w/o Pharm 78708 340 "$3,200.00 " $- $173.09 $- $- "$2,560.00 " $- N/A $832.00 N/A N/A $204.74 N/A N/A "$1,920.00 " N/A N/A "$1,600.00 " N/A N/A $173.09 N/A N/A "$2,176.00 " N/A N/A "$1,824.00 " N/A N/A "$1,248.00 " N/A N/A "$2,240.00 " N/A N/A "$2,560.00 " N/A N/A "$1,760.00 " N/A N/A "$2,240.00 " N/A N/A "$1,072.00 " N/A N/A $173.09 N/A N/A "$1,920.00 " N/A N/A "$1,120.00 " N/A N/A "$2,080.00 " N/A N/A $960.00 N/A N/A "$1,920.00 " N/A N/A "$2,240.00 " N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A N/A $960.00 N/A "$3,200.00 " "$3,200.00 " N/A 4079500 Radiology BCH Cardiolito A9521 A9521 636 "$4,055.00 " $- $406.58 $- $- $406.58 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $406.58 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $406.58 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A "$4,055.00 " "$4,055.00 " N/A 4079502 Radiology BCH Myoview A9502 A9502 636 $656.00 $- $68.18 $- $- $68.18 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $68.18 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $68.18 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $656.00 $656.00 N/A 4079503 Radiology BCH MDP Up To 30Mci A9503 A9503 636 $227.00 $- $23.50 $- $- $23.50 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.50 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $23.50 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $227.00 $227.00 N/A 4079505 Radiology BCH Thallium Per Mci A9505 A9505 636 $259.00 $- $25.16 $- $- $25.16 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $25.16 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $25.16 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $259.00 $259.00 N/A 4079510 Radiology BCH Inj Sincalide 5M J2805 J2805 636 $480.00 $- $- $- $- $- $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $480.00 $480.00 N/A 4079723 Radiology BCH Ceretec A9521 A9521 636 "$4,055.00 " $- $406.58 $- $- $406.58 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $406.58 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $406.58 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A "$4,055.00 " "$4,055.00 " N/A 4079919 Radiology BCH Radionuclide A9699 A9699 636 $225.00 $- $- $- $- $- $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A N/A N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $225.00 $225.00 N/A 4079990 Radiology NM Unlisted Procedure 78999 341 "$1,388.00 " $- $360.88 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A N/A N/A N/A $832.80 N/A N/A $694.00 N/A N/A N/A N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A N/A N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4082833 Radiology US Abdomen Aorta Ltd 76775 402 "$1,175.00 " $- $64.74 $- $- $940.00 $- N/A $305.50 N/A N/A $129.95 N/A N/A $705.00 N/A N/A $587.50 N/A N/A $64.74 N/A N/A $799.00 N/A N/A $669.75 N/A N/A $458.25 N/A N/A $822.50 N/A N/A $940.00 N/A N/A $646.25 N/A N/A $822.50 N/A N/A $393.63 N/A N/A $64.74 N/A N/A $705.00 N/A N/A $411.25 N/A N/A $763.75 N/A N/A $352.50 N/A N/A $705.00 N/A N/A $822.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A "$1,175.00 " "$1,175.00 " N/A 4082833 Radiology US Renal Comp 76775 402 "$1,175.00 " $- $64.74 $- $- $940.00 $- N/A $305.50 N/A N/A $129.95 N/A N/A $705.00 N/A N/A $587.50 N/A N/A $64.74 N/A N/A $799.00 N/A N/A $669.75 N/A N/A $458.25 N/A N/A $822.50 N/A N/A $940.00 N/A N/A $646.25 N/A N/A $822.50 N/A N/A $393.63 N/A N/A $64.74 N/A N/A $705.00 N/A N/A $411.25 N/A N/A $763.75 N/A N/A $352.50 N/A N/A $705.00 N/A N/A $822.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A N/A $352.50 N/A "$1,175.00 " "$1,175.00 " N/A 4083975 Radiology US Abdomen Comp w/ Doppler 93975 921 "$1,388.00 " $- $289.20 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $289.20 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $302.45 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $302.45 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4085210 Radiology US Guide Abdomen Paracentesis 49082 402 "$2,442.00 " $- $65.93 $- $- "$1,953.60 " $- N/A $634.92 N/A N/A $79.97 N/A N/A "$1,465.20 " N/A N/A "$1,221.00 " N/A N/A $65.93 N/A N/A "$1,660.56 " N/A N/A "$1,391.94 " N/A N/A $952.38 N/A N/A "$1,709.40 " N/A N/A "$1,953.60 " N/A N/A "$1,343.10 " N/A N/A "$1,709.40 " N/A N/A $818.07 N/A N/A $65.93 N/A N/A "$1,465.20 " N/A N/A $854.70 N/A N/A "$1,587.30 " N/A N/A $732.60 N/A N/A "$1,465.20 " N/A N/A "$1,709.40 " N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A "$2,442.00 " "$2,442.00 " N/A 4085215 Radiology US Guide Paracentesis 49083 402 "$2,442.00 " $- $97.40 $- $- "$1,953.60 " $- N/A $634.92 N/A N/A $123.41 N/A N/A "$1,465.20 " N/A N/A "$1,221.00 " N/A N/A $97.40 N/A N/A "$1,660.56 " N/A N/A "$1,391.94 " N/A N/A $952.38 N/A N/A "$1,709.40 " N/A N/A "$1,953.60 " N/A N/A "$1,343.10 " N/A N/A "$1,709.40 " N/A N/A $818.07 N/A N/A $97.40 N/A N/A "$1,465.20 " N/A N/A $854.70 N/A N/A "$1,587.30 " N/A N/A $732.60 N/A N/A "$1,465.20 " N/A N/A "$1,709.40 " N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A N/A $732.60 N/A "$2,442.00 " "$2,442.00 " N/A 4085225 Radiology US Thoracentesis 32555 402 "$2,220.00 " $- $101.19 $- $- "$1,776.00 " $- N/A $577.20 N/A N/A $117.98 N/A N/A "$1,332.00 " N/A N/A "$1,110.00 " N/A N/A $101.19 N/A N/A "$1,509.60 " N/A N/A "$1,265.40 " N/A N/A $865.80 N/A N/A "$1,554.00 " N/A N/A "$1,776.00 " N/A N/A "$1,221.00 " N/A N/A "$1,554.00 " N/A N/A $743.70 N/A N/A $101.19 N/A N/A "$1,332.00 " N/A N/A $777.00 N/A N/A "$1,443.00 " N/A N/A $666.00 N/A N/A "$1,332.00 " N/A N/A "$1,554.00 " N/A N/A $666.00 N/A N/A $666.00 N/A N/A $666.00 N/A N/A $666.00 N/A N/A $666.00 N/A N/A $666.00 N/A "$2,220.00 " "$2,220.00 " N/A 4085354 Radiology US Thyroid 76536 402 "$1,224.00 " $- $121.62 $- $- $979.20 $- N/A $318.24 N/A N/A $146.46 N/A N/A $734.40 N/A N/A $612.00 N/A N/A $121.62 N/A N/A $832.32 N/A N/A $697.68 N/A N/A $477.36 N/A N/A $856.80 N/A N/A $979.20 N/A N/A $673.20 N/A N/A $856.80 N/A N/A $410.04 N/A N/A $121.62 N/A N/A $734.40 N/A N/A $428.40 N/A N/A $795.60 N/A N/A $367.20 N/A N/A $734.40 N/A N/A $856.80 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A "$1,224.00 " "$1,224.00 " N/A 4086537 Radiology US Chest 76604 320 $836.00 $- $87.89 $- $- $668.80 $- N/A $217.36 N/A N/A $105.11 N/A N/A $501.60 N/A N/A $418.00 N/A N/A $87.89 N/A N/A $568.48 N/A N/A $476.52 N/A N/A $326.04 N/A N/A $585.20 N/A N/A $668.80 N/A N/A $459.80 N/A N/A $585.20 N/A N/A $280.06 N/A N/A $87.89 N/A N/A $501.60 N/A N/A $292.60 N/A N/A $543.40 N/A N/A $250.80 N/A N/A $501.60 N/A N/A $585.20 N/A N/A $250.80 N/A N/A $250.80 N/A N/A $250.80 N/A N/A $250.80 N/A N/A $250.80 N/A N/A $250.80 N/A $836.00 $836.00 N/A 4086538 Radiology US Extremity Nonvascular Comp Lt 76881 320 $818.00 $- $117.96 $- $- $654.40 $- N/A $212.68 N/A N/A $145.97 N/A N/A $490.80 N/A N/A $409.00 N/A N/A $117.96 N/A N/A $556.24 N/A N/A $466.26 N/A N/A $319.02 N/A N/A $572.60 N/A N/A $654.40 N/A N/A $449.90 N/A N/A $572.60 N/A N/A $274.03 N/A N/A $117.96 N/A N/A $490.80 N/A N/A $286.30 N/A N/A $531.70 N/A N/A $245.40 N/A N/A $490.80 N/A N/A $572.60 N/A N/A $245.40 N/A N/A $245.40 N/A N/A $245.40 N/A N/A $245.40 N/A N/A $245.40 N/A N/A $245.40 N/A $818.00 $818.00 N/A 4086538 Radiology US Extremity 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N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A "$1,393.00 " "$1,393.00 " N/A 4087410 Radiology US Soft Tissue Neck 76536 402 "$1,224.00 " $- $121.62 $- $- $979.20 $- N/A $318.24 N/A N/A $146.46 N/A N/A $734.40 N/A N/A $612.00 N/A N/A $121.62 N/A N/A $832.32 N/A N/A $697.68 N/A N/A $477.36 N/A N/A $856.80 N/A N/A $979.20 N/A N/A $673.20 N/A N/A $856.80 N/A N/A $410.04 N/A N/A $121.62 N/A N/A $734.40 N/A N/A $428.40 N/A N/A $795.60 N/A N/A $367.20 N/A N/A $734.40 N/A N/A $856.80 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A "$1,224.00 " "$1,224.00 " N/A 4088051 Radiology US Pregnant < 14 Weeks 1st Gest 76801 402 $602.00 $- $125.10 $- $- $481.60 $- N/A $156.52 N/A N/A $150.34 N/A N/A $361.20 N/A N/A $301.00 N/A N/A $125.10 N/A N/A $409.36 N/A N/A $343.14 N/A N/A $234.78 N/A N/A $421.40 N/A N/A $481.60 N/A N/A $331.10 N/A N/A $421.40 N/A N/A $201.67 N/A N/A $125.10 N/A N/A $361.20 N/A N/A $210.70 N/A N/A $391.30 N/A N/A $180.60 N/A N/A $361.20 N/A N/A $421.40 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A $602.00 $602.00 N/A 4088051 Radiology US Pregnant < 14 Weeks 1st Gest 76805 402 $602.00 $- $144.99 $- $- $481.60 $- N/A $156.52 N/A N/A $172.43 N/A N/A $361.20 N/A N/A $301.00 N/A N/A $144.99 N/A N/A $409.36 N/A N/A $343.14 N/A N/A $234.78 N/A N/A $421.40 N/A N/A $481.60 N/A N/A $331.10 N/A N/A $421.40 N/A N/A $201.67 N/A N/A $144.99 N/A N/A $361.20 N/A N/A $210.70 N/A N/A $391.30 N/A N/A $180.60 N/A N/A $361.20 N/A N/A $421.40 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A $602.00 $602.00 N/A 4088051 Radiology US Pregnant > 14 Weeks 1st Gest 76805 402 $602.00 $- $144.99 $- $- $481.60 $- N/A $156.52 N/A N/A $172.43 N/A N/A $361.20 N/A N/A $301.00 N/A N/A $144.99 N/A N/A $409.36 N/A N/A $343.14 N/A N/A $234.78 N/A N/A $421.40 N/A N/A $481.60 N/A N/A $331.10 N/A N/A $421.40 N/A N/A $201.67 N/A N/A $144.99 N/A N/A $361.20 N/A N/A $210.70 N/A N/A $391.30 N/A N/A $180.60 N/A N/A $361.20 N/A N/A $421.40 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A $602.00 $602.00 N/A 4088051 Radiology US Pregnant > 14 Weeks 1st Gest 76801 402 $602.00 $- $125.10 $- $- $481.60 $- N/A $156.52 N/A N/A $150.34 N/A N/A $361.20 N/A N/A $301.00 N/A N/A $125.10 N/A N/A $409.36 N/A N/A $343.14 N/A N/A $234.78 N/A N/A $421.40 N/A N/A $481.60 N/A N/A $331.10 N/A N/A $421.40 N/A N/A $201.67 N/A N/A $125.10 N/A N/A $361.20 N/A N/A $210.70 N/A N/A $391.30 N/A N/A $180.60 N/A N/A $361.20 N/A N/A $421.40 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A N/A $180.60 N/A $602.00 $602.00 N/A 4088301 Radiology US Transvaginal 76830 402 "$1,224.00 " $- $88.73 $- $- $979.20 $- N/A $318.24 N/A N/A $88.73 N/A N/A $734.40 N/A N/A $612.00 N/A N/A $125.65 N/A N/A $832.32 N/A N/A $697.68 N/A N/A $477.36 N/A N/A $856.80 N/A N/A $979.20 N/A N/A $673.20 N/A N/A $856.80 N/A N/A $410.04 N/A N/A $125.65 N/A N/A $734.40 N/A N/A $428.40 N/A N/A $795.60 N/A N/A $367.20 N/A N/A $734.40 N/A N/A $856.80 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A N/A $367.20 N/A "$1,224.00 " "$1,224.00 " N/A 4088564 Radiology US Pelvic Non-OB Comp 76856 402 "$1,393.00 " $- $123.51 $- $- "$1,114.40 " $- N/A $362.18 N/A N/A $148.58 N/A N/A $835.80 N/A N/A $696.50 N/A N/A $123.51 N/A N/A $947.24 N/A N/A $794.01 N/A N/A $543.27 N/A N/A $975.10 N/A N/A "$1,114.40 " N/A N/A $766.15 N/A N/A $975.10 N/A N/A $466.66 N/A N/A $123.51 N/A N/A $835.80 N/A N/A $487.55 N/A N/A $905.45 N/A N/A $417.90 N/A N/A $835.80 N/A N/A $975.10 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A "$1,393.00 " "$1,393.00 " N/A 4088564 Radiology US Pelvis Non-OB Comp Transvaginal 76856 402 "$1,393.00 " $- $123.51 $- $- "$1,114.40 " $- N/A $362.18 N/A N/A $148.58 N/A N/A $835.80 N/A N/A $696.50 N/A N/A $123.51 N/A N/A $947.24 N/A N/A $794.01 N/A N/A $543.27 N/A N/A $975.10 N/A N/A "$1,114.40 " N/A N/A $766.15 N/A N/A $975.10 N/A N/A $466.66 N/A N/A $123.51 N/A N/A $835.80 N/A N/A $487.55 N/A N/A $905.45 N/A N/A $417.90 N/A N/A $835.80 N/A N/A $975.10 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A N/A $417.90 N/A "$1,393.00 " "$1,393.00 " N/A 4088570 Radiology US Bladder +Residual Post Voiding 76857 402 $908.00 $- $53.38 $- $- $726.40 $- N/A $236.08 N/A N/A $97.85 N/A N/A $544.80 N/A N/A $454.00 N/A N/A $53.38 N/A N/A $617.44 N/A N/A $517.56 N/A N/A $354.12 N/A N/A $635.60 N/A N/A $726.40 N/A N/A $499.40 N/A N/A $635.60 N/A N/A $304.18 N/A N/A $53.38 N/A N/A $544.80 N/A N/A $317.80 N/A N/A $590.20 N/A N/A $272.40 N/A N/A $544.80 N/A N/A $635.60 N/A N/A $272.40 N/A N/A $272.40 N/A N/A $272.40 N/A N/A $272.40 N/A N/A $272.40 N/A N/A $272.40 N/A $908.00 $908.00 N/A 4088704 Radiology US Carotid Duplex Bil 93880 921 "$2,135.00 " $- $161.01 $- $- "$1,708.00 " $- N/A $555.10 N/A N/A $220.58 N/A N/A "$1,281.00 " N/A N/A "$1,067.50 " N/A N/A $161.01 N/A N/A "$1,451.80 " N/A N/A "$1,216.95 " N/A N/A $832.65 N/A N/A "$1,494.50 " N/A N/A "$1,708.00 " N/A N/A "$1,174.25 " N/A N/A "$1,494.50 " N/A N/A $715.23 N/A N/A $161.01 N/A N/A "$1,281.00 " N/A N/A $747.25 N/A N/A "$1,387.75 " N/A N/A $640.50 N/A N/A "$1,281.00 " N/A N/A "$1,494.50 " N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A "$2,135.00 " "$2,135.00 " N/A 4088705 Radiology US Scrotum +Contents 76870 402 "$1,282.00 " $- $73.17 $- $- "$1,025.60 " $- N/A $333.32 N/A N/A $148.76 N/A N/A $769.20 N/A N/A $641.00 N/A N/A $73.17 N/A N/A $871.76 N/A N/A $730.74 N/A N/A $499.98 N/A N/A $897.40 N/A N/A "$1,025.60 " N/A N/A $705.10 N/A N/A $897.40 N/A N/A $429.47 N/A N/A $73.17 N/A N/A $769.20 N/A N/A $448.70 N/A N/A $833.30 N/A N/A $384.60 N/A N/A $769.20 N/A N/A $897.40 N/A N/A $384.60 N/A N/A $384.60 N/A N/A $384.60 N/A N/A $384.60 N/A N/A $384.60 N/A N/A $384.60 N/A "$1,282.00 " "$1,282.00 " N/A 4089108 Radiology US LE Art Duplex Bil 93925 921 "$1,492.00 " $- $207.87 $- $- "$1,193.60 " $- N/A $387.92 N/A N/A $232.24 N/A N/A $895.20 N/A N/A $746.00 N/A N/A $207.87 N/A N/A "$1,014.56 " N/A N/A $850.44 N/A N/A $581.88 N/A N/A "$1,044.40 " N/A N/A "$1,193.60 " N/A N/A $820.60 N/A N/A "$1,044.40 " N/A N/A $499.82 N/A N/A $207.87 N/A N/A $895.20 N/A N/A $522.20 N/A N/A $969.80 N/A N/A $447.60 N/A N/A $895.20 N/A N/A "$1,044.40 " N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A N/A $447.60 N/A "$1,492.00 " "$1,492.00 " N/A 4089257 Radiology US LE Veins Duplex Bil 93970 921 "$2,135.00 " $- $158.18 $- $- "$1,708.00 " $- N/A $555.10 N/A N/A $227.12 N/A N/A "$1,281.00 " N/A N/A "$1,067.50 " N/A N/A $158.18 N/A N/A "$1,451.80 " N/A N/A "$1,216.95 " N/A N/A $832.65 N/A N/A "$1,494.50 " N/A N/A "$1,708.00 " N/A N/A "$1,174.25 " N/A N/A "$1,494.50 " N/A N/A $715.23 N/A N/A $158.18 N/A N/A "$1,281.00 " N/A N/A $747.25 N/A N/A "$1,387.75 " N/A N/A $640.50 N/A N/A "$1,281.00 " N/A N/A "$1,494.50 " N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A "$2,135.00 " "$2,135.00 " N/A 4089257 Radiology US UE Veins Duplex Bil 93970 921 "$2,135.00 " $- $158.18 $- $- "$1,708.00 " $- N/A $555.10 N/A N/A $227.12 N/A N/A "$1,281.00 " N/A N/A "$1,067.50 " N/A N/A $158.18 N/A N/A "$1,451.80 " N/A N/A "$1,216.95 " N/A N/A $832.65 N/A N/A "$1,494.50 " N/A N/A "$1,708.00 " N/A N/A "$1,174.25 " N/A N/A "$1,494.50 " N/A N/A $715.23 N/A N/A $158.18 N/A N/A "$1,281.00 " N/A N/A $747.25 N/A N/A "$1,387.75 " N/A N/A $640.50 N/A N/A "$1,281.00 " N/A N/A "$1,494.50 " N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A N/A $640.50 N/A "$2,135.00 " "$2,135.00 " N/A 4089261 Radiology US LE Art Duplex Lt 93926 921 "$1,388.00 " $- $119.22 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $148.72 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $119.22 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $119.22 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089261 Radiology US LE Art Duplex Rt 93926 921 "$1,388.00 " $- $119.22 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $148.72 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $119.22 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $119.22 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089312 Radiology US UE Art Duplex Lt 93931 402 "$1,388.00 " $- $133.05 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $137.45 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $133.05 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $133.05 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089312 Radiology US UE Art Duplex Rt 93931 402 "$1,388.00 " $- $133.05 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $137.45 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $133.05 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $133.05 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089356 Radiology US Guide Ndl Placement 76942 402 "$1,594.00 " $- $72.41 $- $- "$1,275.20 " $- N/A $414.44 N/A N/A $245.11 N/A N/A $956.40 N/A N/A $797.00 N/A N/A $72.41 N/A N/A "$1,083.92 " N/A N/A $908.58 N/A N/A $621.66 N/A N/A "$1,115.80 " N/A N/A "$1,275.20 " N/A N/A $876.70 N/A N/A "$1,115.80 " N/A N/A $533.99 N/A N/A $72.41 N/A N/A $956.40 N/A N/A $557.90 N/A N/A "$1,036.10 " N/A N/A $478.20 N/A N/A $956.40 N/A N/A "$1,115.80 " N/A N/A $478.20 N/A N/A $478.20 N/A N/A $478.20 N/A N/A $478.20 N/A N/A $478.20 N/A N/A $478.20 N/A "$1,594.00 " "$1,594.00 " N/A 4089711 Radiology US LE Veins Duplex Lt 93971 921 "$1,388.00 " $- $96.02 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $140.48 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $96.02 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $96.02 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089711 Radiology US LE Veins Duplex Rt 93971 921 "$1,388.00 " $- $96.02 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $140.48 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $96.02 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $96.02 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089711 Radiology US UE Veins Duplex Lt 93971 921 "$1,388.00 " $- $96.02 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $140.48 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $96.02 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $96.02 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4089711 Radiology US UE Veins Duplex Rt 93971 921 "$1,388.00 " $- $96.02 $- $- "$1,110.40 " $- N/A $360.88 N/A N/A $140.48 N/A N/A $832.80 N/A N/A $694.00 N/A N/A $96.02 N/A N/A $943.84 N/A N/A $791.16 N/A N/A $541.32 N/A N/A $971.60 N/A N/A "$1,110.40 " N/A N/A $763.40 N/A N/A $971.60 N/A N/A $464.98 N/A N/A $96.02 N/A N/A $832.80 N/A N/A $485.80 N/A N/A $902.20 N/A N/A $416.40 N/A N/A $832.80 N/A N/A $971.60 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A N/A $416.40 N/A "$1,388.00 " "$1,388.00 " N/A 4090542 Radiology MRI Soft Tissue Neck w/ Cont 70542 610 "$4,524.00 " $770.00 $410.77 $- "$1,227.27 " "$3,619.20 " $- N/A "$1,176.24 " N/A $650 per service date $650 per service date N/A N/A "$2,714.40 " N/A N/A "$2,262.00 " N/A N/A $410.77 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,764.36 " N/A N/A $618 per service date N/A N/A "$3,619.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,515.54 " N/A N/A $410.77 N/A N/A "$2,714.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,357.20 " N/A N/A "$2,714.40 " N/A "$1,227.27 " N/A N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A "$4,524.00 " "$4,524.00 " N/A 4090542 Radiology MRI Soft Tissue Neck w/o Cont 70542 610 "$4,524.00 " $770.00 $410.77 $- "$1,227.27 " "$3,619.20 " $- N/A "$1,176.24 " N/A $650 per service date $650 per service date N/A N/A "$2,714.40 " N/A N/A "$2,262.00 " N/A N/A $410.77 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,764.36 " N/A N/A $618 per service date N/A N/A "$3,619.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,515.54 " N/A N/A $410.77 N/A N/A "$2,714.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,357.20 " N/A N/A "$2,714.40 " N/A "$1,227.27 " N/A N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A N/A "$1,357.20 " N/A "$4,524.00 " "$4,524.00 " N/A 4090543 Radiology MRI Face Neck Orbit w/ + w/o Cont 70543 610 "$7,689.00 " $770.00 $502.55 $- "$1,227.27 " "$6,151.20 " $- N/A "$1,999.14 " N/A $650 per service date $650 per service date N/A N/A "$4,613.40 " N/A N/A "$3,844.50 " N/A N/A $502.55 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,998.71 " N/A N/A $618 per service date N/A N/A "$6,151.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$2,575.82 " N/A N/A $502.55 N/A N/A "$4,613.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$2,306.70 " N/A N/A "$4,613.40 " N/A "$1,227.27 " N/A N/A N/A "$2,306.70 " N/A N/A "$2,306.70 " N/A N/A "$2,306.70 " N/A N/A "$2,306.70 " N/A N/A "$2,306.70 " N/A N/A "$2,306.70 " N/A "$7,689.00 " "$7,689.00 " N/A 4090544 Radiology MRA Head w/o Cont 70544 610 "$3,747.00 " $- $403.66 $- $- "$2,997.60 " $- N/A $974.22 N/A N/A $510.00 N/A N/A "$2,248.20 " N/A N/A "$1,873.50 " N/A N/A $403.66 N/A N/A "$2,547.96 " N/A N/A "$2,135.79 " N/A N/A "$1,461.33 " N/A N/A "$2,622.90 " N/A N/A "$2,997.60 " N/A N/A "$2,060.85 " N/A N/A "$2,622.90 " N/A N/A "$1,255.25 " N/A N/A $403.66 N/A N/A "$2,248.20 " N/A N/A "$1,311.45 " N/A N/A "$2,435.55 " N/A N/A "$1,124.10 " N/A N/A "$2,248.20 " N/A N/A "$2,622.90 " N/A N/A "$1,124.10 " N/A N/A "$1,124.10 " N/A N/A "$1,124.10 " N/A N/A "$1,124.10 " N/A N/A "$1,124.10 " N/A N/A "$1,124.10 " N/A "$3,747.00 " "$3,747.00 " N/A 4090545 Radiology MRA Head w/ Cont 70545 610 "$4,005.00 " $- $397.98 $- $- "$3,204.00 " $- N/A "$1,041.30 " N/A N/A $510.00 N/A N/A "$2,403.00 " N/A N/A "$2,002.50 " N/A N/A $397.98 N/A N/A "$2,723.40 " N/A N/A "$2,282.85 " N/A N/A "$1,561.95 " N/A N/A "$2,803.50 " N/A N/A "$3,204.00 " N/A N/A "$2,202.75 " N/A N/A "$2,803.50 " N/A N/A "$1,341.68 " N/A N/A $397.98 N/A N/A "$2,403.00 " N/A N/A "$1,401.75 " N/A N/A "$2,603.25 " N/A N/A "$1,201.50 " N/A N/A "$2,403.00 " N/A N/A "$2,803.50 " N/A N/A "$1,201.50 " N/A N/A "$1,201.50 " N/A N/A "$1,201.50 " N/A N/A "$1,201.50 " N/A N/A "$1,201.50 " N/A N/A "$1,201.50 " N/A "$4,005.00 " "$4,005.00 " N/A 4090546 Radiology MRA Head w/ + w/o Cont 70546 610 "$4,283.00 " $- $510.00 $- $- "$3,426.40 " $- N/A "$1,113.58 " N/A N/A $510.00 N/A N/A "$2,569.80 " N/A N/A "$2,141.50 " N/A N/A $606.92 N/A N/A "$2,912.44 " N/A N/A "$2,441.31 " N/A N/A "$1,670.37 " N/A N/A "$2,998.10 " N/A N/A "$3,426.40 " N/A N/A "$2,355.65 " N/A N/A "$2,998.10 " N/A N/A "$1,434.81 " N/A N/A $606.92 N/A N/A "$2,569.80 " N/A N/A "$1,499.05 " N/A N/A "$2,783.95 " N/A N/A "$1,284.90 " N/A N/A "$2,569.80 " N/A N/A "$2,998.10 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A "$4,283.00 " "$4,283.00 " N/A 4090547 Radiology MRA Neck w/o Cont 70547 610 "$3,666.00 " $- $404.73 $- $- "$2,932.80 " $- N/A $953.16 N/A N/A $510.00 N/A N/A "$2,199.60 " N/A N/A "$1,833.00 " N/A N/A $404.73 N/A N/A "$2,492.88 " N/A N/A "$2,089.62 " N/A N/A "$1,429.74 " N/A N/A "$2,566.20 " N/A N/A "$2,932.80 " N/A N/A "$2,016.30 " N/A N/A "$2,566.20 " N/A N/A "$1,228.11 " N/A N/A $404.73 N/A N/A "$2,199.60 " N/A N/A "$1,283.10 " N/A N/A "$2,382.90 " N/A N/A "$1,099.80 " N/A N/A "$2,199.60 " N/A N/A "$2,566.20 " N/A N/A "$1,099.80 " N/A N/A "$1,099.80 " N/A N/A "$1,099.80 " N/A N/A "$1,099.80 " N/A N/A "$1,099.80 " N/A N/A "$1,099.80 " N/A "$3,666.00 " "$3,666.00 " N/A 4090548 Radiology MRA Neck w/ Cont 70548 610 "$3,993.00 " $- $424.98 $- $- "$3,194.40 " $- N/A "$1,038.18 " N/A N/A $510.00 N/A N/A "$2,395.80 " N/A N/A "$1,996.50 " N/A N/A $424.98 N/A N/A "$2,715.24 " N/A N/A "$2,276.01 " N/A N/A "$1,557.27 " N/A N/A "$2,795.10 " N/A N/A "$3,194.40 " N/A N/A "$2,196.15 " N/A N/A "$2,795.10 " N/A N/A "$1,337.66 " N/A N/A $424.98 N/A N/A "$2,395.80 " N/A N/A "$1,397.55 " N/A N/A "$2,595.45 " N/A N/A "$1,197.90 " N/A N/A "$2,395.80 " N/A N/A "$2,795.10 " N/A N/A "$1,197.90 " N/A N/A "$1,197.90 " N/A N/A "$1,197.90 " N/A N/A "$1,197.90 " N/A N/A "$1,197.90 " N/A N/A "$1,197.90 " N/A "$3,993.00 " "$3,993.00 " N/A 4090549 Radiology MRA Neck w/ + w/o Cont 70549 610 "$5,140.00 " $- $510.00 $- $- "$4,112.00 " $- N/A "$1,336.40 " N/A N/A $510.00 N/A N/A "$3,084.00 " N/A N/A "$2,570.00 " N/A N/A $610.81 N/A N/A "$3,495.20 " N/A N/A "$2,929.80 " N/A N/A "$2,004.60 " N/A N/A "$3,598.00 " N/A N/A "$4,112.00 " N/A N/A "$2,827.00 " N/A N/A "$3,598.00 " N/A N/A "$1,721.90 " N/A N/A $610.81 N/A N/A "$3,084.00 " N/A N/A "$1,799.00 " N/A N/A "$3,341.00 " N/A N/A "$1,542.00 " N/A N/A "$3,084.00 " N/A N/A "$3,598.00 " N/A N/A "$1,542.00 " N/A N/A "$1,542.00 " N/A N/A "$1,542.00 " N/A N/A "$1,542.00 " N/A N/A "$1,542.00 " N/A N/A "$1,542.00 " N/A "$5,140.00 " "$5,140.00 " N/A 4090553 Radiology MRI Brain w/ + w/o Cont 70553 611 "$5,946.00 " $770.00 $390.07 $- "$1,227.27 " "$4,756.80 " $- N/A "$1,545.96 " N/A $650 per service date $650 per service date N/A N/A "$3,567.60 " N/A N/A "$2,973.00 " N/A N/A $390.07 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,318.94 " N/A N/A $618 per service date N/A N/A "$4,756.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,991.91 " N/A N/A $390.07 N/A N/A "$3,567.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,783.80 " N/A N/A "$3,567.60 " N/A "$1,227.27 " N/A N/A N/A "$1,783.80 " N/A N/A "$1,783.80 " N/A N/A "$1,783.80 " N/A N/A "$1,783.80 " N/A N/A "$1,783.80 " N/A N/A "$1,783.80 " N/A "$5,946.00 " "$5,946.00 " N/A 4090556 Radiology MRI Brain w/ Cont 70552 611 "$4,823.00 " $770.00 $330.91 $- "$1,227.27 " "$3,858.40 " $- N/A "$1,253.98 " N/A $650 per service date $650 per service date N/A N/A "$2,893.80 " N/A N/A "$2,411.50 " N/A N/A $330.91 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,880.97 " N/A N/A $618 per service date N/A N/A "$3,858.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,615.71 " N/A N/A $330.91 N/A N/A "$2,893.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,446.90 " N/A N/A "$2,893.80 " N/A "$1,227.27 " N/A N/A N/A "$1,446.90 " N/A N/A "$1,446.90 " N/A N/A "$1,446.90 " N/A N/A "$1,446.90 " N/A N/A "$1,446.90 " N/A N/A "$1,446.90 " N/A "$4,823.00 " "$4,823.00 " N/A 4090557 Radiology MRI UE Joint w/ Cont Lt 73222 610 "$4,246.00 " $770.00 $388.03 $- "$1,227.27 " "$3,396.80 " $- N/A "$1,103.96 " N/A $650 per service date $650 per service date N/A N/A "$2,547.60 " N/A N/A "$2,123.00 " N/A N/A $388.03 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,655.94 " N/A N/A $618 per service date N/A N/A "$3,396.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,422.41 " N/A N/A $388.03 N/A N/A "$2,547.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,273.80 " N/A N/A "$2,547.60 " N/A "$1,227.27 " N/A N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A "$4,246.00 " "$4,246.00 " N/A 4090557 Radiology MRI UE Joint w/ Cont Rt 73222 610 "$4,246.00 " $770.00 $388.03 $- "$1,227.27 " "$3,396.80 " $- N/A "$1,103.96 " N/A $650 per service date $650 per service date N/A N/A "$2,547.60 " N/A N/A "$2,123.00 " N/A N/A $388.03 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,655.94 " N/A N/A $618 per service date N/A N/A "$3,396.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,422.41 " N/A N/A $388.03 N/A N/A "$2,547.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,273.80 " N/A N/A "$2,547.60 " N/A "$1,227.27 " N/A N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A "$4,246.00 " "$4,246.00 " N/A 4090557 Radiology MRI UE Non Joint w/ Cont Lt 73219 610 "$4,246.00 " $770.00 $415.74 $- "$1,227.27 " "$3,396.80 " $- N/A "$1,103.96 " N/A $650 per service date $650 per service date N/A N/A "$2,547.60 " N/A N/A "$2,123.00 " N/A N/A $415.74 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,655.94 " N/A N/A $618 per service date N/A N/A "$3,396.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,422.41 " N/A N/A $415.74 N/A N/A "$2,547.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,273.80 " N/A N/A "$2,547.60 " N/A "$1,227.27 " N/A N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A "$4,246.00 " "$4,246.00 " N/A 4090557 Radiology MRI UE Non Joint w/ Cont Rt 73219 610 "$4,246.00 " $770.00 $415.74 $- "$1,227.27 " "$3,396.80 " $- N/A "$1,103.96 " N/A $650 per service date $650 per service date N/A N/A "$2,547.60 " N/A N/A "$2,123.00 " N/A N/A $415.74 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,655.94 " N/A N/A $618 per service date N/A N/A "$3,396.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,422.41 " N/A N/A $415.74 N/A N/A "$2,547.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,273.80 " N/A N/A "$2,547.60 " N/A "$1,227.27 " N/A N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A N/A "$1,273.80 " N/A "$4,246.00 " "$4,246.00 " N/A 4091268 Radiology BCH Gadolinum A9579 A9579 636 $36.00 $- $3.59 $- $- $3.59 $- N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $3.59 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A $3.59 N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A N/A Not Reimbursed N/A $36.00 $36.00 N/A 4091415 Radiology MRI Spine Cervical w/o Cont 72141 612 "$4,283.00 " $770.00 $241.19 $- "$1,227.27 " "$3,426.40 " $- N/A "$1,113.58 " N/A $650 per service date $650 per service date N/A N/A "$2,569.80 " N/A N/A "$2,141.50 " N/A N/A $241.19 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,670.37 " N/A N/A $618 per service date N/A N/A "$3,426.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,434.81 " N/A N/A $241.19 N/A N/A "$2,569.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,284.90 " N/A N/A "$2,569.80 " N/A "$1,227.27 " N/A N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A N/A "$1,284.90 " N/A "$4,283.00 " "$4,283.00 " N/A 4091423 Radiology MRI Spine Cervical w/ Cont 72142 612 "$4,682.00 " $770.00 $331.97 $- "$1,227.27 " "$3,745.60 " $- N/A "$1,217.32 " N/A $650 per service date $650 per service date N/A N/A "$2,809.20 " N/A N/A "$2,341.00 " N/A N/A $331.97 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,825.98 " N/A N/A $618 per service date N/A N/A "$3,745.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,568.47 " N/A N/A $331.97 N/A N/A "$2,809.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,404.60 " N/A N/A "$2,809.20 " N/A "$1,227.27 " N/A N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A "$4,682.00 " "$4,682.00 " N/A 4091464 Radiology MRI Spine Thoracic w/o Cont 72146 612 "$3,482.00 " $770.00 $241.19 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $241.19 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $241.19 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4091472 Radiology MRI Spine Thoracic w/ Cont 72147 612 "$4,620.00 " $770.00 $328.77 $- "$1,227.27 " "$3,696.00 " $- N/A "$1,201.20 " N/A $650 per service date $650 per service date N/A N/A "$2,772.00 " N/A N/A "$2,310.00 " N/A N/A $328.77 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,801.80 " N/A N/A $618 per service date N/A N/A "$3,696.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,547.70 " N/A N/A $328.77 N/A N/A "$2,772.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,386.00 " N/A N/A "$2,772.00 " N/A "$1,227.27 " N/A N/A N/A "$1,386.00 " N/A N/A "$1,386.00 " N/A N/A "$1,386.00 " N/A N/A "$1,386.00 " N/A N/A "$1,386.00 " N/A N/A "$1,386.00 " N/A "$4,620.00 " "$4,620.00 " N/A 4091480 Radiology MRI Spine Lumbar w/o Cont 72148 612 "$4,314.00 " $770.00 $241.57 $- "$1,227.27 " "$3,451.20 " $- N/A "$1,121.64 " N/A $650 per service date $650 per service date N/A N/A "$2,588.40 " N/A N/A "$2,157.00 " N/A N/A $241.57 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,682.46 " N/A N/A $618 per service date N/A N/A "$3,451.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,445.19 " N/A N/A $241.57 N/A N/A "$2,588.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,294.20 " N/A N/A "$2,588.40 " N/A "$1,227.27 " N/A N/A N/A "$1,294.20 " N/A N/A "$1,294.20 " N/A N/A "$1,294.20 " N/A N/A "$1,294.20 " N/A N/A "$1,294.20 " N/A N/A "$1,294.20 " N/A "$4,314.00 " "$4,314.00 " N/A 4091498 Radiology MRI Spine Lumbar w/ Cont 72149 612 "$4,612.00 " $770.00 $327.72 $- "$1,227.27 " "$3,689.60 " $- N/A "$1,199.12 " N/A $650 per service date $650 per service date N/A N/A "$2,767.20 " N/A N/A "$2,306.00 " N/A N/A $327.72 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,798.68 " N/A N/A $618 per service date N/A N/A "$3,689.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,545.02 " N/A N/A $327.72 N/A N/A "$2,767.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,383.60 " N/A N/A "$2,767.20 " N/A "$1,227.27 " N/A N/A N/A "$1,383.60 " N/A N/A "$1,383.60 " N/A N/A "$1,383.60 " N/A N/A "$1,383.60 " N/A N/A "$1,383.60 " N/A N/A "$1,383.60 " N/A "$4,612.00 " "$4,612.00 " N/A 4091560 Radiology MRI Spine Cervical w/ + w/o Cont 72156 612 "$5,984.00 " $770.00 $390.42 $- "$1,227.27 " "$4,787.20 " $- N/A "$1,555.84 " N/A $650 per service date $650 per service date N/A N/A "$3,590.40 " N/A N/A "$2,992.00 " N/A N/A $390.42 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,333.76 " N/A N/A $618 per service date N/A N/A "$4,787.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$2,004.64 " N/A N/A $390.42 N/A N/A "$3,590.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,795.20 " N/A N/A "$3,590.40 " N/A "$1,227.27 " N/A N/A N/A "$1,795.20 " N/A N/A "$1,795.20 " N/A N/A "$1,795.20 " N/A N/A "$1,795.20 " N/A N/A "$1,795.20 " N/A N/A "$1,795.20 " N/A "$5,984.00 " "$5,984.00 " N/A 4091819 Radiology MRI Abdomen w/o Cont 74181 610 "$4,207.00 " $770.00 $335.00 $- "$1,227.27 " "$3,365.60 " $- N/A "$1,093.82 " N/A $650 per service date $650 per service date N/A N/A "$2,524.20 " N/A N/A "$2,103.50 " N/A N/A $335.00 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,640.73 " N/A N/A $618 per service date N/A N/A "$3,365.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,409.35 " N/A N/A $335.00 N/A N/A "$2,524.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,262.10 " N/A N/A "$2,524.20 " N/A "$1,227.27 " N/A N/A N/A "$1,262.10 " N/A N/A "$1,262.10 " N/A N/A "$1,262.10 " N/A N/A "$1,262.10 " N/A N/A "$1,262.10 " N/A N/A "$1,262.10 " N/A "$4,207.00 " "$4,207.00 " N/A 4091969 Radiology MRI Pelvis w/ Cont 72196 610 "$4,484.00 " $770.00 $421.93 $- "$1,227.27 " "$3,587.20 " $- N/A "$1,165.84 " N/A $650 per service date $650 per service date N/A N/A "$2,690.40 " N/A N/A "$2,242.00 " N/A N/A $421.93 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,748.76 " N/A N/A $618 per service date N/A N/A "$3,587.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,502.14 " N/A N/A $421.93 N/A N/A "$2,690.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,345.20 " N/A N/A "$2,690.40 " N/A "$1,227.27 " N/A N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A "$4,484.00 " "$4,484.00 " N/A 4091969 Radiology MRI Pelvis w/o Cont 72196 610 "$4,484.00 " $770.00 $421.93 $- "$1,227.27 " "$3,587.20 " $- N/A "$1,165.84 " N/A $650 per service date $650 per service date N/A N/A "$2,690.40 " N/A N/A "$2,242.00 " N/A N/A $421.93 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,748.76 " N/A N/A $618 per service date N/A N/A "$3,587.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,502.14 " N/A N/A $421.93 N/A N/A "$2,690.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,345.20 " N/A N/A "$2,690.40 " N/A "$1,227.27 " N/A N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A N/A "$1,345.20 " N/A "$4,484.00 " "$4,484.00 " N/A 4092157 Radiology MRI Spine Thoracic w/ + w/o Cont 72157 610 "$5,963.00 " $770.00 $390.77 $- "$1,227.27 " "$4,770.40 " $- N/A "$1,550.38 " N/A $650 per service date $650 per service date N/A N/A "$3,577.80 " N/A N/A "$2,981.50 " N/A N/A $390.77 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,325.57 " N/A N/A $618 per service date N/A N/A "$4,770.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,997.61 " N/A N/A $390.77 N/A N/A "$3,577.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,788.90 " N/A N/A "$3,577.80 " N/A "$1,227.27 " N/A N/A N/A "$1,788.90 " N/A N/A "$1,788.90 " N/A N/A "$1,788.90 " N/A N/A "$1,788.90 " N/A N/A "$1,788.90 " N/A N/A "$1,788.90 " N/A "$5,963.00 " "$5,963.00 " N/A 4092158 Radiology MRI Spine Lumbar w/ + w/o Cont 72158 612 "$5,985.00 " $770.00 $389.39 $- "$1,227.27 " "$4,788.00 " $- N/A "$1,556.10 " N/A $650 per service date $650 per service date N/A N/A "$3,591.00 " N/A N/A "$2,992.50 " N/A N/A $389.39 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,334.15 " N/A N/A $618 per service date N/A N/A "$4,788.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$2,004.98 " N/A N/A $389.39 N/A N/A "$3,591.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,795.50 " N/A N/A "$3,591.00 " N/A "$1,227.27 " N/A N/A N/A "$1,795.50 " N/A N/A "$1,795.50 " N/A N/A "$1,795.50 " N/A N/A "$1,795.50 " N/A N/A "$1,795.50 " N/A N/A "$1,795.50 " N/A "$5,985.00 " "$5,985.00 " N/A 4092206 Radiology MRI UE Joint w/ + w/o Cont Bil 73223 610 "$4,584.00 " $770.00 $480.51 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $480.51 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $480.51 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092206 Radiology MRI UE Joint w/ + w/o Cont Lt 73223 610 "$4,584.00 " $770.00 $480.51 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $480.51 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $480.51 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092206 Radiology MRI UE Joint w/ + w/o Cont Rt 73223 610 "$4,584.00 " $770.00 $480.51 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $480.51 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $480.51 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092206 Radiology MRI UE Non Joint w/ + w/o Cont Bil 73220 610 "$4,584.00 " $770.00 $509.64 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $509.64 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $509.64 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092206 Radiology MRI UE Non Joint w/ + w/o Cont Lt 73220 610 "$4,584.00 " $770.00 $509.64 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $509.64 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $509.64 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092206 Radiology MRI UE Non Joint w/ + w/o Cont Rt 73220 610 "$4,584.00 " $770.00 $509.64 $- "$1,227.27 " "$3,667.20 " $- N/A "$1,191.84 " N/A $650 per service date $650 per service date N/A N/A "$2,750.40 " N/A N/A "$2,292.00 " N/A N/A $509.64 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,787.76 " N/A N/A $618 per service date N/A N/A "$3,667.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,535.64 " N/A N/A $509.64 N/A N/A "$2,750.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,375.20 " N/A N/A "$2,750.40 " N/A "$1,227.27 " N/A N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A N/A "$1,375.20 " N/A "$4,584.00 " "$4,584.00 " N/A 4092214 Radiology MRI UE Joint w/o Cont Bil 73221 610 "$3,482.00 " $770.00 $252.82 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $252.82 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $252.82 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4092214 Radiology MRI UE Joint w/o Cont Lt 73221 610 "$3,482.00 " $770.00 $252.82 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $252.82 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $252.82 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4092214 Radiology MRI UE Joint w/o Cont Rt 73221 610 "$3,482.00 " $770.00 $252.82 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $252.82 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $252.82 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4092214 Radiology MRI UE Non Joint w/o Cont Bil 73218 610 "$3,482.00 " $770.00 $365.73 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $365.73 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $365.73 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4092214 Radiology MRI UE Non Joint w/o Cont Lt 73218 610 "$3,482.00 " $770.00 $365.73 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $365.73 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $365.73 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4092214 Radiology MRI UE Non Joint w/o Cont Rt 73218 610 "$3,482.00 " $770.00 $365.73 $- "$1,227.27 " "$2,785.60 " $- N/A $905.32 N/A $650 per service date $650 per service date N/A N/A "$2,089.20 " N/A N/A "$1,741.00 " N/A N/A $365.73 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,357.98 " N/A N/A $618 per service date N/A N/A "$2,785.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,166.47 " N/A N/A $365.73 N/A N/A "$2,089.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,044.60 " N/A N/A "$2,089.20 " N/A "$1,227.27 " N/A N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A N/A "$1,044.60 " N/A "$3,482.00 " "$3,482.00 " N/A 4095508 Radiology MRI Chest w/o Cont 71550 610 "$4,139.00 " $770.00 $414.23 $- "$1,227.27 " "$3,311.20 " $- N/A "$1,076.14 " N/A $650 per service date $650 per service date N/A N/A "$2,483.40 " N/A N/A "$2,069.50 " N/A N/A $414.23 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,614.21 " N/A N/A $618 per service date N/A N/A "$3,311.20 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,386.57 " N/A N/A $414.23 N/A N/A "$2,483.40 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,241.70 " N/A N/A "$2,483.40 " N/A "$1,227.27 " N/A N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A N/A "$1,241.70 " N/A "$4,139.00 " "$4,139.00 " N/A 4095509 Radiology MRI Chest w/ Cont 71551 610 "$4,762.00 " $770.00 $468.47 $- "$1,227.27 " "$3,809.60 " $- N/A "$1,238.12 " N/A $650 per service date $650 per service date N/A N/A "$2,857.20 " N/A N/A "$2,381.00 " N/A N/A $468.47 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,857.18 " N/A N/A $618 per service date N/A N/A "$3,809.60 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,595.27 " N/A N/A $468.47 N/A N/A "$2,857.20 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,428.60 " N/A N/A "$2,857.20 " N/A "$1,227.27 " N/A N/A N/A "$1,428.60 " N/A N/A "$1,428.60 " N/A N/A "$1,428.60 " N/A N/A "$1,428.60 " N/A N/A "$1,428.60 " N/A N/A "$1,428.60 " N/A "$4,762.00 " "$4,762.00 " N/A 4095510 Radiology MRI Chest w/ + w/o Cont 71552 610 "$4,688.00 " $770.00 $589.38 $- "$1,227.27 " "$3,750.40 " $- N/A "$1,218.88 " N/A $650 per service date $650 per service date N/A N/A "$2,812.80 " N/A N/A "$2,344.00 " N/A N/A $589.38 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,828.32 " N/A N/A $618 per service date N/A N/A "$3,750.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,570.48 " N/A N/A $589.38 N/A N/A "$2,812.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,406.40 " N/A N/A "$2,812.80 " N/A "$1,227.27 " N/A N/A N/A "$1,406.40 " N/A N/A "$1,406.40 " N/A N/A "$1,406.40 " N/A N/A "$1,406.40 " N/A N/A "$1,406.40 " N/A N/A "$1,406.40 " N/A "$4,688.00 " "$4,688.00 " N/A 4095513 Radiology MRI Abdomen w/ Cont 74182 610 "$4,623.00 " $770.00 $462.08 $- "$1,227.27 " "$3,698.40 " $- N/A "$1,201.98 " N/A $650 per service date $650 per service date N/A N/A "$2,773.80 " N/A N/A "$2,311.50 " N/A N/A $462.08 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,802.97 " N/A N/A $618 per service date N/A N/A "$3,698.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,548.71 " N/A N/A $462.08 N/A N/A "$2,773.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,386.90 " N/A N/A "$2,773.80 " N/A "$1,227.27 " N/A N/A N/A "$1,386.90 " N/A N/A "$1,386.90 " N/A N/A "$1,386.90 " N/A N/A "$1,386.90 " N/A N/A "$1,386.90 " N/A N/A "$1,386.90 " N/A "$4,623.00 " "$4,623.00 " N/A 4095514 Radiology MRI Abdomen w/ + w/o Cont 74183 610 "$5,670.00 " $770.00 $516.55 $- "$1,227.27 " "$4,536.00 " $- N/A "$1,474.20 " N/A $650 per service date $650 per service date N/A N/A "$3,402.00 " N/A N/A "$2,835.00 " N/A N/A $516.55 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,211.30 " N/A N/A $618 per service date N/A N/A "$4,536.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,899.45 " N/A N/A $516.55 N/A N/A "$3,402.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,701.00 " N/A N/A "$3,402.00 " N/A "$1,227.27 " N/A N/A N/A "$1,701.00 " N/A N/A "$1,701.00 " N/A N/A "$1,701.00 " N/A N/A "$1,701.00 " N/A N/A "$1,701.00 " N/A N/A "$1,701.00 " N/A "$5,670.00 " "$5,670.00 " N/A 4095516 Radiology MRI Pelvis w/ + w/o Cont 72197 610 "$5,576.00 " $770.00 $514.78 $- "$1,227.27 " "$4,460.80 " $- N/A "$1,449.76 " N/A $650 per service date $650 per service date N/A N/A "$3,345.60 " N/A N/A "$2,788.00 " N/A N/A $514.78 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$2,174.64 " N/A N/A $618 per service date N/A N/A "$4,460.80 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,867.96 " N/A N/A $514.78 N/A N/A "$3,345.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,672.80 " N/A N/A "$3,345.60 " N/A "$1,227.27 " N/A N/A N/A "$1,672.80 " N/A N/A "$1,672.80 " N/A N/A "$1,672.80 " N/A N/A "$1,672.80 " N/A N/A "$1,672.80 " N/A N/A "$1,672.80 " N/A "$5,576.00 " "$5,576.00 " N/A 4095517 Radiology MRI Brain w/o Cont 70551 611 "$4,178.00 " $770.00 $242.95 $- "$1,227.27 " "$3,342.40 " $- N/A "$1,086.28 " N/A $650 per service date $650 per service date N/A N/A "$2,506.80 " N/A N/A "$2,089.00 " N/A N/A $242.95 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,629.42 " N/A N/A $618 per service date N/A N/A "$3,342.40 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,399.63 " N/A N/A $242.95 N/A N/A "$2,506.80 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,253.40 " N/A N/A "$2,506.80 " N/A "$1,227.27 " N/A N/A N/A "$1,253.40 " N/A N/A "$1,253.40 " N/A N/A "$1,253.40 " N/A N/A "$1,253.40 " N/A N/A "$1,253.40 " N/A N/A "$1,253.40 " N/A "$4,178.00 " "$4,178.00 " N/A 4097001 Radiology MA Diag Breast Addl Views 2D w/Cad Bil. 77066 401 $565.00 $740.00 $146.90 $- "$1,197.27 " "$1,266.00 " $- N/A $146.90 N/A $650 per service date $650 per service date N/A N/A $339.00 N/A N/A $282.50 N/A N/A $164.99 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $220.35 N/A N/A $618 per service date N/A N/A $452.00 N/A N/A $912.00 N/A $740.00 N/A N/A N/A $189.28 N/A N/A $164.99 N/A N/A $339.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $169.50 N/A N/A $339.00 N/A "$1,197.27 " N/A N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4097003 Radiology MA Diag Breast Addl Views 2D w/Cad Lt. 77065 401 $448.00 $741.00 $116.48 $- "$1,198.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $741.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,198.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097004 Radiology MA Diag Breast Addl Views 2D w/Cad Rt. 77065 401 $448.00 $742.00 $116.48 $- "$1,199.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $742.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,199.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097037 Radiology MA Diag Breast 2D w/ Cad Bil. 77066 401 $565.00 $743.00 $146.90 $- "$1,200.27 " "$1,266.00 " $- N/A $146.90 N/A $650 per service date $650 per service date N/A N/A $339.00 N/A N/A $282.50 N/A N/A $164.99 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $220.35 N/A N/A $618 per service date N/A N/A $452.00 N/A N/A $912.00 N/A $743.00 N/A N/A N/A $189.28 N/A N/A $164.99 N/A N/A $339.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $169.50 N/A N/A $339.00 N/A "$1,200.27 " N/A N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4097045 Radiology MA Diag Breast 3DTomo Bil. 77062 614 $292.00 $744.00 $75.92 $- "$1,201.27 " "$1,266.00 " $- N/A $75.92 N/A $650 per service date $650 per service date N/A N/A $175.20 N/A N/A $146.00 N/A N/A N/A N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $113.88 N/A N/A $618 per service date N/A N/A $233.60 N/A N/A $912.00 N/A $744.00 N/A N/A N/A $97.82 N/A N/A N/A N/A N/A $175.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $87.60 N/A N/A $175.20 N/A "$1,201.27 " N/A N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4097052 Radiology MA Diag Breast 3DTomo Lt. 77061 614 $210.00 $745.00 $54.60 $- "$1,202.27 " "$1,266.00 " $- N/A $54.60 N/A $650 per service date $650 per service date N/A N/A $126.00 N/A N/A $105.00 N/A N/A N/A N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $81.90 N/A N/A $618 per service date N/A N/A $168.00 N/A N/A $912.00 N/A $745.00 N/A N/A N/A $70.35 N/A N/A N/A N/A N/A $126.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $63.00 N/A N/A $126.00 N/A "$1,202.27 " N/A N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A $210.00 $210.00 N/A 4097059 Radiology MA Diag Breast 3DTomo Rt. 77061 614 $210.00 $746.00 $54.60 $- "$1,203.27 " "$1,266.00 " $- N/A $54.60 N/A $650 per service date $650 per service date N/A N/A $126.00 N/A N/A $105.00 N/A N/A N/A N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $81.90 N/A N/A $618 per service date N/A N/A $168.00 N/A N/A $912.00 N/A $746.00 N/A N/A N/A $70.35 N/A N/A N/A N/A N/A $126.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $63.00 N/A N/A $126.00 N/A "$1,203.27 " N/A N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A $210.00 $210.00 N/A 4097075 Radiology MA Diag Implant 2D w/Cad Bil. 77066 401 $565.00 $747.00 $146.90 $- "$1,204.27 " "$1,266.00 " $- N/A $146.90 N/A $650 per service date $650 per service date N/A N/A $339.00 N/A N/A $282.50 N/A N/A $164.99 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $220.35 N/A N/A $618 per service date N/A N/A $452.00 N/A N/A $912.00 N/A $747.00 N/A N/A N/A $189.28 N/A N/A $164.99 N/A N/A $339.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $169.50 N/A N/A $339.00 N/A "$1,204.27 " N/A N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4097079 Radiology MA Diag Implant 2D w/Cad Lt. 77065 401 $448.00 $748.00 $116.48 $- "$1,205.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $748.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,205.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097083 Radiology MA Diag Implant 2D w/Cad Rt. 77065 401 $448.00 $749.00 $116.48 $- "$1,206.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $749.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,206.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097091 Radiology MA Diag Breast 2D w/Cad Lt. 77065 401 $448.00 $750.00 $116.48 $- "$1,207.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $750.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,207.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097095 Radiology MA Diag Ltd Marker Place 2D w/Cad Lt. 77065 401 $448.00 $751.00 $116.48 $- "$1,208.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $751.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,208.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097097 Radiology MA Diag Ltd Marker Place 2D w/Cad Rt. 77065 401 $448.00 $752.00 $116.48 $- "$1,209.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $752.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,209.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097106 Radiology MA Diag Breast 2D w/Cad Rt. 77065 401 $448.00 $753.00 $116.48 $- "$1,210.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $753.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,210.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097109 Radiology MA Diag Implant 3DTomo Bil. 77062 614 $292.00 $754.00 $75.92 $- "$1,211.27 " "$1,266.00 " $- N/A $75.92 N/A $650 per service date $650 per service date N/A N/A $175.20 N/A N/A $146.00 N/A N/A N/A N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $113.88 N/A N/A $618 per service date N/A N/A $233.60 N/A N/A $912.00 N/A $754.00 N/A N/A N/A $97.82 N/A N/A N/A N/A N/A $175.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $87.60 N/A N/A $175.20 N/A "$1,211.27 " N/A N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4097112 Radiology MA Ductogram or Galactogram Inj 19030 320 $571.00 $755.00 $68.68 $- "$1,212.27 " "$1,266.00 " $- N/A $148.46 N/A $650 per service date $650 per service date N/A N/A $342.60 N/A N/A $285.50 N/A N/A $68.68 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $222.69 N/A N/A $618 per service date N/A N/A $456.80 N/A N/A $912.00 N/A $755.00 N/A N/A N/A $191.29 N/A N/A $68.68 N/A N/A $342.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $171.30 N/A N/A $342.60 N/A "$1,212.27 " N/A N/A N/A $171.30 N/A N/A $171.30 N/A N/A $171.30 N/A N/A $171.30 N/A N/A $171.30 N/A N/A $171.30 N/A $571.00 $571.00 N/A 4097113 Radiology MA Ductogram or Galactogram Mult Bil 77054 320 $298.00 $756.00 $77.48 $- "$1,213.27 " "$1,266.00 " $- N/A $77.48 N/A $650 per service date $650 per service date N/A N/A $178.80 N/A N/A $149.00 N/A N/A $79.90 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $116.22 N/A N/A $618 per service date N/A N/A $238.40 N/A N/A $912.00 N/A $756.00 N/A N/A N/A $99.83 N/A N/A $79.90 N/A N/A $178.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $89.40 N/A N/A $178.80 N/A "$1,213.27 " N/A N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A $298.00 $298.00 N/A 4097115 Radiology MA Ductogram or Galactogram Mult Lt 77054 320 $490.00 $757.00 $79.90 $- "$1,214.27 " "$1,266.00 " $- N/A $127.40 N/A $650 per service date $650 per service date N/A N/A $294.00 N/A N/A $245.00 N/A N/A $79.90 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $191.10 N/A N/A $618 per service date N/A N/A $392.00 N/A N/A $912.00 N/A $757.00 N/A N/A N/A $164.15 N/A N/A $79.90 N/A N/A $294.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $147.00 N/A N/A $294.00 N/A "$1,214.27 " N/A N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A $490.00 $490.00 N/A 4097117 Radiology MA Ductogram or Galactogram Mult Rt 77054 320 $490.00 $758.00 $79.90 $- "$1,215.27 " "$1,266.00 " $- N/A $127.40 N/A $650 per service date $650 per service date N/A N/A $294.00 N/A N/A $245.00 N/A N/A $79.90 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $191.10 N/A N/A $618 per service date N/A N/A $392.00 N/A N/A $912.00 N/A $758.00 N/A N/A N/A $164.15 N/A N/A $79.90 N/A N/A $294.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $147.00 N/A N/A $294.00 N/A "$1,215.27 " N/A N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A N/A $147.00 N/A $490.00 $490.00 N/A 4097119 Radiology MA Ductogram or Galactogram Single Bil 77053 320 $231.00 $759.00 $59.07 $- "$1,216.27 " "$1,266.00 " $- N/A $60.06 N/A $650 per service date $650 per service date N/A N/A $138.60 N/A N/A $115.50 N/A N/A $59.07 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $90.09 N/A N/A $618 per service date N/A N/A $184.80 N/A N/A $912.00 N/A $759.00 N/A N/A N/A $77.39 N/A N/A $59.07 N/A N/A $138.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $69.30 N/A N/A $138.60 N/A "$1,216.27 " N/A N/A N/A $69.30 N/A N/A $69.30 N/A N/A $69.30 N/A N/A $69.30 N/A N/A $69.30 N/A N/A $69.30 N/A $231.00 $231.00 N/A 4097122 Radiology MA Ductogram or Galactogram Single Lt 77053 320 $762.00 $760.00 $59.07 $- "$1,217.27 " "$1,266.00 " $- N/A $198.12 N/A $650 per service date $650 per service date N/A N/A $457.20 N/A N/A $381.00 N/A N/A $59.07 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $297.18 N/A N/A $618 per service date N/A N/A $609.60 N/A N/A $912.00 N/A $760.00 N/A N/A N/A $255.27 N/A N/A $59.07 N/A N/A $457.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $228.60 N/A N/A $457.20 N/A "$1,217.27 " N/A N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A $762.00 $762.00 N/A 4097124 Radiology MA Ductogram or Galactogram Single Rt 77053 320 $762.00 $761.00 $59.07 $- "$1,218.27 " "$1,266.00 " $- N/A $198.12 N/A $650 per service date $650 per service date N/A N/A $457.20 N/A N/A $381.00 N/A N/A $59.07 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $297.18 N/A N/A $618 per service date N/A N/A $609.60 N/A N/A $912.00 N/A $761.00 N/A N/A N/A $255.27 N/A N/A $59.07 N/A N/A $457.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $228.60 N/A N/A $457.20 N/A "$1,218.27 " N/A N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A N/A $228.60 N/A $762.00 $762.00 N/A 4097137 Radiology MA Diag Breast Post Proc 2D w/CAD Bil 77066 401 $565.00 $762.00 $146.90 $- "$1,219.27 " "$1,266.00 " $- N/A $146.90 N/A $650 per service date $650 per service date N/A N/A $339.00 N/A N/A $282.50 N/A N/A $164.99 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $220.35 N/A N/A $618 per service date N/A N/A $452.00 N/A N/A $912.00 N/A $762.00 N/A N/A N/A $189.28 N/A N/A $164.99 N/A N/A $339.00 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $169.50 N/A N/A $339.00 N/A "$1,219.27 " N/A N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A N/A $169.50 N/A $565.00 $565.00 N/A 4097138 Radiology MA Diag Breast Post Proc 2D w/Cad Lt 77065 401 $448.00 $763.00 $116.48 $- "$1,220.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $763.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,220.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097141 Radiology MA Diag Breast Post Proc 2D w/Cad Rt 77065 401 $448.00 $764.00 $116.48 $- "$1,221.27 " "$1,266.00 " $- N/A $116.48 N/A $650 per service date $650 per service date N/A N/A $268.80 N/A N/A $224.00 N/A N/A $130.53 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $174.72 N/A N/A $618 per service date N/A N/A $358.40 N/A N/A $912.00 N/A $764.00 N/A N/A N/A $150.08 N/A N/A $130.53 N/A N/A $268.80 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $134.40 N/A N/A $268.80 N/A "$1,221.27 " N/A N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A N/A $134.40 N/A $448.00 $448.00 N/A 4097147 Radiology MA Screen Breast 2D w/Cad Bil. 77067 403 $456.00 $765.00 $118.56 $- "$1,222.27 " "$1,266.00 " $- N/A $118.56 N/A $650 per service date $650 per service date N/A N/A $273.60 N/A N/A $228.00 N/A N/A $133.00 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $177.84 N/A N/A $618 per service date N/A N/A $364.80 N/A N/A $912.00 N/A $765.00 N/A N/A N/A $152.76 N/A N/A $133.00 N/A N/A $273.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $136.80 N/A N/A $273.60 N/A "$1,222.27 " N/A N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A $456.00 $456.00 N/A 4097149 Radiology MA Screen Breast 3DTomo Bil. 77063 403 $456.00 $766.00 $54.84 $- "$1,223.27 " "$1,266.00 " $- N/A $118.56 N/A $650 per service date $650 per service date N/A N/A $273.60 N/A N/A $228.00 N/A N/A $54.84 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $177.84 N/A N/A $618 per service date N/A N/A $364.80 N/A N/A $912.00 N/A $766.00 N/A N/A N/A $152.76 N/A N/A $54.84 N/A N/A $273.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $136.80 N/A N/A $273.60 N/A "$1,223.27 " N/A N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A $456.00 $456.00 N/A 4097157 Radiology MA Screen Implant 2D w/Cad Bil. 77067 403 $456.00 $767.00 $118.56 $- "$1,224.27 " "$1,266.00 " $- N/A $118.56 N/A $650 per service date $650 per service date N/A N/A $273.60 N/A N/A $228.00 N/A N/A $133.00 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $177.84 N/A N/A $618 per service date N/A N/A $364.80 N/A N/A $912.00 N/A $767.00 N/A N/A N/A $152.76 N/A N/A $133.00 N/A N/A $273.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $136.80 N/A N/A $273.60 N/A "$1,224.27 " N/A N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A $456.00 $456.00 N/A 4097161 Radiology MA Screen Implant 3DTomo Bil. 77063 403 $456.00 $768.00 $54.84 $- "$1,225.27 " "$1,266.00 " $- N/A $118.56 N/A $650 per service date $650 per service date N/A N/A $273.60 N/A N/A $228.00 N/A N/A $54.84 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $177.84 N/A N/A $618 per service date N/A N/A $364.80 N/A N/A $912.00 N/A $768.00 N/A N/A N/A $152.76 N/A N/A $54.84 N/A N/A $273.60 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $136.80 N/A N/A $273.60 N/A "$1,225.27 " N/A N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A N/A $136.80 N/A $456.00 $456.00 N/A 4097168 Radiology MA Screen Breast 2D Promo Bil. 77067 403 $0.01 $769.00 $0.00 $- "$1,226.27 " "$1,266.00 " $- N/A $0.00 N/A $650 per service date $650 per service date N/A N/A $0.01 N/A N/A $0.01 N/A N/A $133.00 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $0.00 N/A N/A $618 per service date N/A N/A $0.01 N/A N/A $912.00 N/A $769.00 N/A N/A N/A $0.00 N/A N/A $133.00 N/A N/A $0.01 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $0.00 N/A N/A $0.01 N/A "$1,226.27 " N/A N/A N/A $0.00 N/A N/A $0.00 N/A N/A $0.00 N/A N/A $0.00 N/A N/A $0.00 N/A N/A $0.00 N/A $0.01 $0.01 N/A 4097213 Radiology MRI LE Joint w/ + w/o Cont Lt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097213 Radiology MRI LE Joint w/ + w/o Cont Rt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097213 Radiology MRI LE Joint w/o Cont Lt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097213 Radiology MRI LE Joint w/o Cont Rt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097213 Radiology MRI LE Joint w/ Cont Lt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097213 Radiology MRI LE Joint w/ Cont Rt 73721 610 "$3,990.00 " $770.00 $253.18 $- "$1,227.27 " "$3,192.00 " $- N/A "$1,037.40 " N/A $650 per service date $650 per service date N/A N/A "$2,394.00 " N/A N/A "$1,995.00 " N/A N/A $253.18 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A "$1,556.10 " N/A N/A $618 per service date N/A N/A "$3,192.00 " N/A N/A $912.00 N/A $770.00 N/A N/A N/A "$1,336.65 " N/A N/A $253.18 N/A N/A "$2,394.00 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A "$1,197.00 " N/A N/A "$2,394.00 " N/A "$1,227.27 " N/A N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A N/A "$1,197.00 " N/A "$3,990.00 " "$3,990.00 " N/A 4097237 Radiology MRI Breast w/ + w/o Cont Bil. 77049 614 "$2,316.00 " $771.00 $388.36 $- "$1,228.27 " "$1,852.80 " $- N/A $602.16 N/A $650 per service date $650 per service date N/A N/A "$1,389.60 " N/A N/A "$1,158.00 " N/A N/A $388.36 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $903.24 N/A N/A $618 per service date N/A N/A "$1,852.80 " N/A N/A $912.00 N/A $771.00 N/A N/A N/A $775.86 N/A N/A $388.36 N/A N/A "$1,389.60 " N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $694.80 N/A N/A "$1,389.60 " N/A "$1,228.27 " N/A N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A N/A $694.80 N/A "$2,316.00 " "$2,316.00 " N/A 4097242 Radiology MRI Breast w/ + w/o Cont Lt. 77048 614 "$1,157.00 " $772.00 $300.82 $- "$1,229.27 " "$1,266.00 " $- N/A $300.82 N/A $650 per service date $650 per service date N/A N/A $694.20 N/A N/A $578.50 N/A N/A $380.27 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $451.23 N/A N/A $618 per service date N/A N/A $925.60 N/A N/A $912.00 N/A $772.00 N/A N/A N/A $387.60 N/A N/A $380.27 N/A N/A $694.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $347.10 N/A N/A $694.20 N/A "$1,229.27 " N/A N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A "$1,157.00 " "$1,157.00 " N/A 4097247 Radiology MRI Breast w/ + w/o Cont Rt. 77048 614 "$1,157.00 " $773.00 $300.82 $- "$1,230.27 " "$1,266.00 " $- N/A $300.82 N/A $650 per service date $650 per service date N/A N/A $694.20 N/A N/A $578.50 N/A N/A $380.27 N/A N/A $827.70 N/A N/A "$1,266.00 " N/A N/A $451.23 N/A N/A $618 per service date N/A N/A $925.60 N/A N/A $912.00 N/A $773.00 N/A N/A N/A $387.60 N/A N/A $380.27 N/A N/A $694.20 N/A N/A $978.09 N/A N/A "$1,038.00 " N/A N/A $347.10 N/A N/A $694.20 N/A "$1,230.27 " N/A N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A N/A $347.10 N/A "$1,157.00 " "$1,157.00 " N/A 4097292 Radiology US Breast Comp Bil. 76641 402 $454.00 $- $105.62 $- $- $363.20 $- N/A $118.04 N/A N/A $126.83 N/A N/A $272.40 N/A N/A $227.00 N/A N/A $105.62 N/A N/A $308.72 N/A N/A $258.78 N/A N/A $177.06 N/A N/A $317.80 N/A N/A $363.20 N/A N/A $249.70 N/A N/A $317.80 N/A N/A $152.09 N/A N/A $105.62 N/A N/A $272.40 N/A N/A $158.90 N/A N/A $295.10 N/A N/A $136.20 N/A N/A $272.40 N/A N/A $317.80 N/A N/A $136.20 N/A N/A $136.20 N/A N/A $136.20 N/A N/A $136.20 N/A N/A $136.20 N/A N/A $136.20 N/A $454.00 $454.00 N/A 4097294 Radiology US Breast Comp Lt. 76641 402 $686.00 $- $105.62 $- $- $548.80 $- N/A $178.36 N/A N/A $126.83 N/A N/A $411.60 N/A N/A $343.00 N/A N/A $105.62 N/A N/A $466.48 N/A N/A $391.02 N/A N/A $267.54 N/A N/A $480.20 N/A N/A $548.80 N/A N/A $377.30 N/A N/A $480.20 N/A N/A $229.81 N/A N/A $105.62 N/A N/A $411.60 N/A N/A $240.10 N/A N/A $445.90 N/A N/A $205.80 N/A N/A $411.60 N/A N/A $480.20 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A $686.00 $686.00 N/A 4097296 Radiology US Breast Comp Rt. 76641 402 $686.00 $- $105.62 $- $- $548.80 $- N/A $178.36 N/A N/A $126.83 N/A N/A $411.60 N/A N/A $343.00 N/A N/A $105.62 N/A N/A $466.48 N/A N/A $391.02 N/A N/A $267.54 N/A N/A $480.20 N/A N/A $548.80 N/A N/A $377.30 N/A N/A $480.20 N/A N/A $229.81 N/A N/A $105.62 N/A N/A $411.60 N/A N/A $240.10 N/A N/A $445.90 N/A N/A $205.80 N/A N/A $411.60 N/A N/A $480.20 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A N/A $205.80 N/A $686.00 $686.00 N/A 4097314 Radiology US Breast Ltd Bil. 76642 402 $359.00 $- $86.60 $- $- $287.20 $- N/A $93.34 N/A N/A $104.27 N/A N/A $215.40 N/A N/A $179.50 N/A N/A $86.60 N/A N/A $244.12 N/A N/A $204.63 N/A N/A $140.01 N/A N/A $251.30 N/A N/A $287.20 N/A N/A $197.45 N/A N/A $251.30 N/A N/A $120.27 N/A N/A $86.60 N/A N/A $215.40 N/A N/A $125.65 N/A N/A $233.35 N/A N/A $107.70 N/A N/A $215.40 N/A N/A $251.30 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A $359.00 $359.00 N/A 4097316 Radiology US Breast Ltd Lt. 76642 402 $518.00 $- $86.60 $- $- $414.40 $- N/A $134.68 N/A N/A $104.27 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $86.60 N/A N/A $352.24 N/A N/A $295.26 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $86.60 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 4097318 Radiology US Breast Ltd Rt. 76642 402 $518.00 $- $86.60 $- $- $414.40 $- N/A $134.68 N/A N/A $104.27 N/A N/A $310.80 N/A N/A $259.00 N/A N/A $86.60 N/A N/A $352.24 N/A N/A $295.26 N/A N/A $202.02 N/A N/A $362.60 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $362.60 N/A N/A $173.53 N/A N/A $86.60 N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $362.60 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 49045391 Respiratory Therapy "Noninvasive ear or pulse oximetry for oxygen saturation, sin" 93005 730 $725.00 $- $6.96 $- $- $580.00 $- N/A $188.50 N/A N/A $274.05 N/A N/A $435.00 N/A N/A $362.50 N/A N/A $6.96 N/A N/A $493.00 N/A N/A $427.75 N/A N/A $282.75 N/A N/A $507.50 N/A N/A $580.00 N/A N/A $398.75 N/A N/A $507.50 N/A N/A $242.88 N/A N/A $6.96 N/A N/A $435.00 N/A N/A $253.75 N/A N/A $471.25 N/A N/A $217.50 N/A N/A $435.00 N/A N/A $507.50 N/A N/A $217.50 N/A N/A $217.50 N/A N/A $217.50 N/A N/A $217.50 N/A N/A $217.50 N/A N/A $217.50 N/A $725.00 $725.00 N/A 4167002 Respiratory Therapy Charges ABG ANALYSIS 82803 301 "$1,190.00 " $- $12.41 $- $- $952.00 $- N/A $309.40 N/A N/A $449.82 N/A N/A $714.00 N/A N/A $595.00 N/A N/A $12.41 N/A N/A $809.20 N/A N/A $702.10 N/A N/A $464.10 N/A N/A $833.00 N/A N/A $952.00 N/A N/A $654.50 N/A N/A $833.00 N/A N/A $398.65 N/A N/A $12.41 N/A N/A $714.00 N/A N/A $416.50 N/A N/A $773.50 N/A N/A $357.00 N/A N/A $714.00 N/A N/A $833.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A "$1,190.00 " "$1,190.00 " N/A 4170001 Respiratory Therapy Charges CPAP INT AND MGT 94660 410 "$2,962.00 " $- $31.21 $- $- "$2,369.60 " $- N/A $770.12 N/A N/A "$1,119.64 " N/A N/A "$1,777.20 " N/A N/A "$1,481.00 " N/A N/A $31.21 N/A N/A "$2,014.16 " N/A N/A "$1,747.58 " N/A N/A "$1,155.18 " N/A N/A "$2,073.40 " N/A N/A "$2,369.60 " N/A N/A "$1,629.10 " N/A N/A "$2,073.40 " N/A N/A $992.27 N/A N/A $31.21 N/A N/A "$1,777.20 " N/A N/A "$1,036.70 " N/A N/A "$1,925.30 " N/A N/A $888.60 N/A N/A "$1,777.20 " N/A N/A "$2,073.40 " N/A N/A $888.60 N/A N/A $888.60 N/A N/A $888.60 N/A N/A $888.60 N/A N/A $888.60 N/A N/A $888.60 N/A "$2,962.00 " "$2,962.00 " N/A 4170002 Respiratory Therapy Charges HI FLOW NASAL CANNULA 271 $51.00 $- $13.26 $- $- $40.80 $- N/A $13.26 N/A N/A $19.28 N/A N/A $30.60 N/A N/A $25.50 N/A N/A N/A N/A N/A $34.68 N/A N/A $30.09 N/A N/A $19.89 N/A N/A $35.70 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $35.70 N/A N/A $17.09 N/A N/A N/A N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $35.70 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 4170044 Respiratory Therapy Charges AEROSOL HOURLY 271 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A $15.34 N/A N/A $10.14 N/A N/A $18.20 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $18.20 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $18.20 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 4170051 Respiratory Therapy Charges AEROSOL OR TRACH MAS 272 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A $21.24 N/A N/A $14.04 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $25.20 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 4170150 Respiratory Therapy Charges INCENTIVE SPIROMETRY 270 $156.00 $- $40.56 $- $- $124.80 $- N/A $40.56 N/A N/A $58.97 N/A N/A $93.60 N/A N/A $78.00 N/A N/A N/A N/A N/A $106.08 N/A N/A $92.04 N/A N/A $60.84 N/A N/A $109.20 N/A N/A $124.80 N/A N/A $85.80 N/A N/A $109.20 N/A N/A $52.26 N/A N/A N/A N/A N/A $93.60 N/A N/A $54.60 N/A N/A $101.40 N/A N/A $46.80 N/A N/A $93.60 N/A N/A $109.20 N/A N/A $46.80 N/A N/A $46.80 N/A N/A $46.80 N/A N/A $46.80 N/A N/A $46.80 N/A N/A $46.80 N/A $156.00 $156.00 N/A 4170473 Respiratory Therapy Charges SVN DISPOSABLE 272 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A $21.24 N/A N/A $14.04 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $25.20 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 4170474 Respiratory Therapy Charges O2 PER HOUR LTC 271 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A $15.34 N/A N/A $10.14 N/A N/A $18.20 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $18.20 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $18.20 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 4170515 Respiratory Therapy Charges ED OXYGEN PER HOUR. 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A $12.39 N/A N/A $8.19 N/A N/A $14.70 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $14.70 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $14.70 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 4170515 Respiratory Therapy Charges ED OXYGEN PER HOUR. (RT) 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A $12.39 N/A N/A $8.19 N/A N/A $14.70 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $14.70 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $14.70 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 4170515 Respiratory Therapy Charges ER OXYGEN PER HOUR. 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A $12.39 N/A N/A $8.19 N/A N/A $14.70 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $14.70 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $14.70 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 4170549 Respiratory Therapy Charges OXYGEN SETUP (RT) 270 STAT $- #VALUE! $- $- #VALUE! $- N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A N/A N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A N/A N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A N/A #VALUE! N/A STAT STAT N/A 4170556 Respiratory Therapy Charges OXYGEN HUMIDIFIER 271 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $18.90 N/A N/A $30.00 N/A N/A $25.00 N/A N/A N/A N/A N/A $34.00 N/A N/A $29.50 N/A N/A $19.50 N/A N/A $35.00 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $35.00 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $35.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 4170564 Respiratory Therapy Charges OXYGEN CONNECT TUBIN 271 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A $17.11 N/A N/A $11.31 N/A N/A $20.30 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $20.30 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $20.30 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 4170572 Respiratory Therapy Charges OXYGEN CANNULA 272 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A $17.11 N/A N/A $11.31 N/A N/A $20.30 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $20.30 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $20.30 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 4170580 Respiratory Therapy Charges OXYGEN MASK 271 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A $17.11 N/A N/A $11.31 N/A N/A $20.30 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $20.30 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $20.30 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 4170599 Respiratory Therapy Charges IP Daily Oxygen 271 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A $5.31 N/A N/A $3.51 N/A N/A $6.30 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $6.30 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $6.30 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 4170796 Respiratory Therapy Charges COOL MIST SETUP 270 $403.00 $- $104.78 $- $- $322.40 $- N/A $104.78 N/A N/A $152.33 N/A N/A $241.80 N/A N/A $201.50 N/A N/A N/A N/A N/A $274.04 N/A N/A $237.77 N/A N/A $157.17 N/A N/A $282.10 N/A N/A $322.40 N/A N/A $221.65 N/A N/A $282.10 N/A N/A $135.01 N/A N/A N/A N/A N/A $241.80 N/A N/A $141.05 N/A N/A $261.95 N/A N/A $120.90 N/A N/A $241.80 N/A N/A $282.10 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A N/A $120.90 N/A $403.00 $403.00 N/A 4170812 Respiratory Therapy Charges COOL MIST/24 HOURS SUBSEQ 272 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A $60.77 N/A N/A $40.17 N/A N/A $72.10 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $72.10 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $72.10 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 4170879 Respiratory Therapy Charges NT SUCTION 270 $120.00 $- $31.20 $- $- $96.00 $- N/A $31.20 N/A N/A $45.36 N/A N/A $72.00 N/A N/A $60.00 N/A N/A N/A N/A N/A $81.60 N/A N/A $70.80 N/A N/A $46.80 N/A N/A $84.00 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $84.00 N/A N/A $40.20 N/A N/A N/A N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $84.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 4170952 Respiratory Therapy Charges TRACH CARE SUPPLY 270 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A $59.00 N/A N/A $39.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $70.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 4171026 Respiratory Therapy Charges CPT SUBSEQUENT 94668 410 $467.00 $- $24.78 $- $- $373.60 $- N/A $121.42 N/A N/A $176.53 N/A N/A $280.20 N/A N/A $233.50 N/A N/A $24.78 N/A N/A $317.56 N/A N/A $275.53 N/A N/A $182.13 N/A N/A $326.90 N/A N/A $373.60 N/A N/A $256.85 N/A N/A $326.90 N/A N/A $156.45 N/A N/A $24.78 N/A N/A $280.20 N/A N/A $163.45 N/A N/A $303.55 N/A N/A $140.10 N/A N/A $280.20 N/A N/A $326.90 N/A N/A $140.10 N/A N/A $140.10 N/A N/A $140.10 N/A N/A $140.10 N/A N/A $140.10 N/A N/A $140.10 N/A $467.00 $467.00 N/A 4171059 Respiratory Therapy Charges OXYGEN VENTIMASK 271 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A $23.01 N/A N/A $15.21 N/A N/A $27.30 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $27.30 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $27.30 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 4171828 Respiratory Therapy Charges NON-REBREATHING MASK 271 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A $27.73 N/A N/A $18.33 N/A N/A $32.90 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $32.90 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $32.90 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 4171836 Respiratory Therapy Charges DISP AMBU BAG 271 $113.00 $- $29.38 $- $- $90.40 $- N/A $29.38 N/A N/A $42.71 N/A N/A $67.80 N/A N/A $56.50 N/A N/A N/A N/A N/A $76.84 N/A N/A $66.67 N/A N/A $44.07 N/A N/A $79.10 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $79.10 N/A N/A $37.86 N/A N/A N/A N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $79.10 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 4172016 Respiratory Therapy Charges MDI SPACER ADULT 271 $98.00 $- $25.48 $- $- $78.40 $- N/A $25.48 N/A N/A $37.04 N/A N/A $58.80 N/A N/A $49.00 N/A N/A N/A N/A N/A $66.64 N/A N/A $57.82 N/A N/A $38.22 N/A N/A $68.60 N/A N/A $78.40 N/A N/A $53.90 N/A N/A $68.60 N/A N/A $32.83 N/A N/A N/A N/A N/A $58.80 N/A N/A $34.30 N/A N/A $63.70 N/A N/A $29.40 N/A N/A $58.80 N/A N/A $68.60 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A $98.00 $98.00 N/A 4172024 Respiratory Therapy Charges MDI INSTRUCT/XX 94664 410 $410.00 $- $14.52 $- $- $328.00 $- N/A $106.60 N/A N/A $154.98 N/A N/A $246.00 N/A N/A $205.00 N/A N/A $14.52 N/A N/A $278.80 N/A N/A $241.90 N/A N/A $159.90 N/A N/A $287.00 N/A N/A $328.00 N/A N/A $225.50 N/A N/A $287.00 N/A N/A $137.35 N/A N/A $14.52 N/A N/A $246.00 N/A N/A $143.50 N/A N/A $266.50 N/A N/A $123.00 N/A N/A $246.00 N/A N/A $287.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A $410.00 $410.00 N/A 4173503 Respiratory Therapy Charges SPUTUM INDUCED INITI 94664 410 $320.00 $- $14.52 $- $- $256.00 $- N/A $83.20 N/A N/A $120.96 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $14.52 N/A N/A $217.60 N/A N/A $188.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $14.52 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4176400 Respiratory Therapy Charges INHALATION TREATMENT. 94640 410 $105.00 $- $15.42 $- $- $84.00 $- N/A $27.30 N/A N/A $39.69 N/A N/A $63.00 N/A N/A $52.50 N/A N/A $15.42 N/A N/A $71.40 N/A N/A $61.95 N/A N/A $40.95 N/A N/A $73.50 N/A N/A $84.00 N/A N/A $57.75 N/A N/A $73.50 N/A N/A $35.18 N/A N/A $15.42 N/A N/A $63.00 N/A N/A $36.75 N/A N/A $68.25 N/A N/A $31.50 N/A N/A $63.00 N/A N/A $73.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A $105.00 $105.00 N/A 4176405 Respiratory Therapy Charges "CONT.INHAL TX, FIRST HR." 94644 410 $617.00 $- $37.16 $- $- $493.60 $- N/A $160.42 N/A N/A $233.23 N/A N/A $370.20 N/A N/A $308.50 N/A N/A $37.16 N/A N/A $419.56 N/A N/A $364.03 N/A N/A $240.63 N/A N/A $431.90 N/A N/A $493.60 N/A N/A $339.35 N/A N/A $431.90 N/A N/A $206.70 N/A N/A $37.16 N/A N/A $370.20 N/A N/A $215.95 N/A N/A $401.05 N/A N/A $185.10 N/A N/A $370.20 N/A N/A $431.90 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A N/A $185.10 N/A $617.00 $617.00 N/A 4176407 Respiratory Therapy Charges "CONT.INHAL.TX,EA.ADDL.HR." 94645 410 $653.00 $- $12.10 $- $- $522.40 $- N/A $169.78 N/A N/A $246.83 N/A N/A $391.80 N/A N/A $326.50 N/A N/A $12.10 N/A N/A $444.04 N/A N/A $385.27 N/A N/A $254.67 N/A N/A $457.10 N/A N/A $522.40 N/A N/A $359.15 N/A N/A $457.10 N/A N/A $218.76 N/A N/A $12.10 N/A N/A $391.80 N/A N/A $228.55 N/A N/A $424.45 N/A N/A $195.90 N/A N/A $391.80 N/A N/A $457.10 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A N/A $195.90 N/A $653.00 $653.00 N/A 4176517 Respiratory Therapy Charges IPPB TREATMENT 94640 410 $203.00 $- $15.42 $- $- $162.40 $- N/A $52.78 N/A N/A $76.73 N/A N/A $121.80 N/A N/A $101.50 N/A N/A $15.42 N/A N/A $138.04 N/A N/A $119.77 N/A N/A $79.17 N/A N/A $142.10 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $142.10 N/A N/A $68.01 N/A N/A $15.42 N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $142.10 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 4176525 Respiratory Therapy Charges IPPB DISPOSABLE 271 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A $31.27 N/A N/A $20.67 N/A N/A $37.10 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $37.10 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $37.10 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 4176558 Respiratory Therapy Charges VENTILATOR INLINE TX 94640 410 $410.00 $- $15.42 $- $- $328.00 $- N/A $106.60 N/A N/A $154.98 N/A N/A $246.00 N/A N/A $205.00 N/A N/A $15.42 N/A N/A $278.80 N/A N/A $241.90 N/A N/A $159.90 N/A N/A $287.00 N/A N/A $328.00 N/A N/A $225.50 N/A N/A $287.00 N/A N/A $137.35 N/A N/A $15.42 N/A N/A $246.00 N/A N/A $143.50 N/A N/A $266.50 N/A N/A $123.00 N/A N/A $246.00 N/A N/A $287.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A N/A $123.00 N/A $410.00 $410.00 N/A 4176566 Respiratory Therapy Charges VENT SET UP 94002 410 "$6,417.00 " $- "$1,668.42 " $- $- "$5,133.60 " $- N/A "$1,668.42 " N/A N/A "$2,425.63 " N/A N/A "$3,850.20 " N/A N/A "$3,208.50 " N/A N/A N/A N/A N/A "$4,363.56 " N/A N/A "$3,786.03 " N/A N/A "$2,502.63 " N/A N/A "$4,491.90 " N/A N/A "$5,133.60 " N/A N/A "$3,529.35 " N/A N/A "$4,491.90 " N/A N/A "$2,149.70 " N/A N/A N/A N/A N/A "$3,850.20 " N/A N/A "$2,245.95 " N/A N/A "$4,171.05 " N/A N/A "$1,925.10 " N/A N/A "$3,850.20 " N/A N/A "$4,491.90 " N/A N/A "$1,925.10 " N/A N/A "$1,925.10 " N/A N/A "$1,925.10 " N/A N/A "$1,925.10 " N/A N/A "$1,925.10 " N/A N/A "$1,925.10 " N/A "$6,417.00 " "$6,417.00 " N/A 4176574 Respiratory Therapy Charges VENT SUBSEQUENT DAYS 94003 410 "$5,922.00 " $- "$1,539.72 " $- $- "$4,737.60 " $- N/A "$1,539.72 " N/A N/A "$2,238.52 " N/A N/A "$3,553.20 " N/A N/A "$2,961.00 " N/A N/A N/A N/A N/A "$4,026.96 " N/A N/A "$3,493.98 " N/A N/A "$2,309.58 " N/A N/A "$4,145.40 " N/A N/A "$4,737.60 " N/A N/A "$3,257.10 " N/A N/A "$4,145.40 " N/A N/A "$1,983.87 " N/A N/A N/A N/A N/A "$3,553.20 " N/A N/A "$2,072.70 " N/A N/A "$3,849.30 " N/A N/A "$1,776.60 " N/A N/A "$3,553.20 " N/A N/A "$4,145.40 " N/A N/A "$1,776.60 " N/A N/A "$1,776.60 " N/A N/A "$1,776.60 " N/A N/A "$1,776.60 " N/A N/A "$1,776.60 " N/A N/A "$1,776.60 " N/A "$5,922.00 " "$5,922.00 " N/A 4176640 Respiratory Therapy Charges AEROSOL SETUP 272 $130.00 $- $33.80 $- $- $104.00 $- N/A $33.80 N/A N/A $49.14 N/A N/A $78.00 N/A N/A $65.00 N/A N/A N/A N/A N/A $88.40 N/A N/A $76.70 N/A N/A $50.70 N/A N/A $91.00 N/A N/A $104.00 N/A N/A $71.50 N/A N/A $91.00 N/A N/A $43.55 N/A N/A N/A N/A N/A $78.00 N/A N/A $45.50 N/A N/A $84.50 N/A N/A $39.00 N/A N/A $78.00 N/A N/A $91.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A N/A $39.00 N/A $130.00 $130.00 N/A 4176665 Respiratory Therapy Charges DEMO NEBULIZER/INHALER 94664 410 $320.00 $- $14.52 $- $- $256.00 $- N/A $83.20 N/A N/A $120.96 N/A N/A $192.00 N/A N/A $160.00 N/A N/A $14.52 N/A N/A $217.60 N/A N/A $188.80 N/A N/A $124.80 N/A N/A $224.00 N/A N/A $256.00 N/A N/A $176.00 N/A N/A $224.00 N/A N/A $107.20 N/A N/A $14.52 N/A N/A $192.00 N/A N/A $112.00 N/A N/A $208.00 N/A N/A $96.00 N/A N/A $192.00 N/A N/A $224.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A N/A $96.00 N/A $320.00 $320.00 N/A 4176681 Respiratory Therapy Charges CPT INITIAL 94667 410 $427.00 $- $21.46 $- $- $341.60 $- N/A $111.02 N/A N/A $161.41 N/A N/A $256.20 N/A N/A $213.50 N/A N/A $21.46 N/A N/A $290.36 N/A N/A $251.93 N/A N/A $166.53 N/A N/A $298.90 N/A N/A $341.60 N/A N/A $234.85 N/A N/A $298.90 N/A N/A $143.05 N/A N/A $21.46 N/A N/A $256.20 N/A N/A $149.45 N/A N/A $277.55 N/A N/A $128.10 N/A N/A $256.20 N/A N/A $298.90 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A $427.00 $427.00 N/A 4176945 Respiratory Therapy Charges AEROSOL DISPOSABLE 271 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A $24.78 N/A N/A $16.38 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $29.40 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 4177935 Respiratory Therapy Charges TRACH SUCTION SYSTEM 271 $150.00 $- $39.00 $- $- $120.00 $- N/A $39.00 N/A N/A $56.70 N/A N/A $90.00 N/A N/A $75.00 N/A N/A N/A N/A N/A $102.00 N/A N/A $88.50 N/A N/A $58.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A N/A N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $105.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 4512210 SLP Tx/Procedures "SLP Cog Ther Intervent,First 15Min Units" 97129 440 $99.00 $- $23.95 $- $- $111.00 $- N/A $25.74 N/A N/A $23.95 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4512220 SLP Tx/Procedures "SLP Cog Ther Intervent, Addl 15Min Units" 97130 440 $99.00 $- $23.24 $- $- $111.00 $- N/A $25.74 N/A N/A $23.24 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 2161211 Speech/Audiology Charges Standard Cognitive Eval charge 96125 444 $292.00 $- $75.92 $- $- $233.60 $- N/A $75.92 N/A N/A $126.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $94.11 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $94.11 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 2161211 Speech/Audiology Charges Yes 96125 444 $292.00 $- $75.92 $- $- $233.60 $- N/A $75.92 N/A N/A $126.73 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $94.11 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $94.11 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4513711 Speech/Audiology Charges Video Swallow Eval Charge (Motion) 92611 444 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $102.98 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $75.66 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $75.66 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4513715 Speech/Audiology Charges Treatment of Swallowing Dysfunction Charge 92526 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $90.61 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $72.02 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $72.02 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4513715 Speech/Audiology Charges TREATMENT SWALLOW DYSFUNCTION 92526 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $90.61 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $72.02 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $72.02 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4513717 Speech/Audiology Charges Speech Generating Device Evaluation Charge 92607 444 $387.00 $- $100.62 $- $- $309.60 $- N/A $100.62 N/A N/A $140.54 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $106.91 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $106.91 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4513719 Speech/Audiology Charges Speech Generating Device Eval Additional 30 Min 92608 444 $195.00 $- $44.28 $- $- $156.00 $- N/A $50.70 N/A N/A $56.56 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $44.28 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $44.28 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4513721 Speech/Audiology Charges ST Eval of Auditory Rehab Status Charge 92626 471 $387.00 $- $63.47 $- $- $309.60 $- N/A $100.62 N/A N/A $88.43 N/A N/A $232.20 N/A N/A $193.50 N/A N/A $63.47 N/A N/A $263.16 N/A N/A $111.00 N/A N/A $150.93 N/A N/A $270.90 N/A N/A $309.60 N/A N/A $200 per visit N/A N/A $270.90 N/A N/A $129.65 N/A N/A $63.47 N/A N/A $232.20 N/A N/A $135.45 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $116.10 N/A N/A $232.20 N/A N/A $270.90 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 4514050 Speech/Audiology Charges Speech Sound Prod w/ Language Charge 92523 444 $195.00 $- $50.70 $- $- $201.61 $- N/A $50.70 N/A N/A $201.61 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $157.93 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $157.93 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4514052 Speech/Audiology Charges Speech Fluency Eval Charge 92521 444 $292.00 $- $75.92 $- $- $233.60 $- N/A $75.92 N/A N/A $119.59 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $93.69 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $93.69 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4514054 Speech/Audiology Charges Speech Sound Production Eval Charge 92522 444 $292.00 $- $75.92 $- $- $233.60 $- N/A $75.92 N/A N/A $96.94 N/A N/A $175.20 N/A N/A $146.00 N/A N/A $75.94 N/A N/A $198.56 N/A N/A $111.00 N/A N/A $113.88 N/A N/A $204.40 N/A N/A $233.60 N/A N/A $200 per visit N/A N/A $204.40 N/A N/A $97.82 N/A N/A $75.94 N/A N/A $175.20 N/A N/A $102.20 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $87.60 N/A N/A $175.20 N/A N/A $204.40 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A N/A $87.60 N/A $292.00 $292.00 N/A 4514070 Speech/Audiology Charges Cognitive Skills Development Charges 97127 G0515 440 $99.00 $- $25.74 $- $- $111.00 $- N/A $25.74 N/A N/A N/A N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A $111.00 N/A N/A $38.61 N/A N/A $69.30 N/A N/A $79.20 N/A N/A $200 per visit N/A N/A $69.30 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $29.70 N/A N/A $59.40 N/A N/A $69.30 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 4514072 Speech/Audiology Charges Swallow Evaluation Charge 92610 444 $561.00 $- $60.31 $- $- $448.80 $- N/A $145.86 N/A N/A $78.38 N/A N/A $336.60 N/A N/A $280.50 N/A N/A $60.31 N/A N/A $381.48 N/A N/A $111.00 N/A N/A $218.79 N/A N/A $392.70 N/A N/A $448.80 N/A N/A $200 per visit N/A N/A $392.70 N/A N/A $187.94 N/A N/A $60.31 N/A N/A $336.60 N/A N/A $196.35 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $168.30 N/A N/A $336.60 N/A N/A $392.70 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A N/A $168.30 N/A $561.00 $561.00 N/A 4515014 Speech/Audiology Charges Speech/Language/Voice/Auditory Charge 92507 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $74.54 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $66.04 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $66.04 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4515014 Speech/Audiology Charges Tx of Speech/Lang/Voice/Comm/Auditory Chg Medicaid 92507 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $74.54 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $66.04 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $66.04 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4515014 Speech/Audiology Charges Tx of Speech/Lang/Voice/Comm/Auditory Chg 92507 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $74.54 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $66.04 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $66.04 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 4517094 Speech/Audiology Charges STBU: ST TX Swallow Dysfunction 92526 440 $195.00 $- $50.70 $- $- $156.00 $- N/A $50.70 N/A N/A $90.61 N/A N/A $117.00 N/A N/A $97.50 N/A N/A $72.02 N/A N/A $132.60 N/A N/A $111.00 N/A N/A $76.05 N/A N/A $136.50 N/A N/A $156.00 N/A N/A $200 per visit N/A N/A $136.50 N/A N/A $65.33 N/A N/A $72.02 N/A N/A $117.00 N/A N/A $68.25 N/A N/A $103.00/treatment; $163.00 max/day N/A N/A $58.50 N/A N/A $117.00 N/A N/A $136.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A N/A $58.50 N/A $195.00 $195.00 N/A 1500000 Supplies 2X2 2PK STERILE 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500001 Supplies 4X4 10PK STERILE 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500002 Supplies 4X4 2PK DRAIN SPONGE 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500003 Supplies 4X4 2PK STERILE 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500004 Supplies ABD DRESSING 8X10 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500005 Supplies "ABDOMINAL BINDER, LARGE" 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500006 Supplies "ABDOMINAL BINDER, MEDIUM" 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500007 Supplies "ABDOMINAL BINDER, SMALL" 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500008 Supplies "ABDOMINAL BINDER, XL" 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500009 Supplies ACE BANDAGE 2 IN 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500010 Supplies ACE BANDAGE 3 IN A6449 A6449 623 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500011 Supplies ACE BANDAGE 4 IN 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500012 Supplies ACE BANDAGE 6 IN 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500013 Supplies ADAPTER XMAS TREE 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500014 Supplies ADAPTIC GAUZE 3X3 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500015 Supplies ADAPTIC GAUZE 3X8 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500016 Supplies ADD-A-FOLEY TRAY 272 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500017 Supplies AIRWAY LARGE ADULT 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500018 Supplies AIRWAY MEDIUM ADULT 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500019 Supplies ANTI REFLUX VALVE 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 1500020 Supplies AQUACEL 2 X 2 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500021 Supplies AQUACEL Rope DRESSING 270 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $18.90 N/A N/A $30.00 N/A N/A $25.00 N/A N/A N/A N/A N/A $34.00 N/A N/A N/A N/A N/A $19.50 N/A N/A $22.75 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $32.50 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 1500022 Supplies ARM SLING (CHILD) SM A4565 A4565 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500023 Supplies ARM SLING UNIVERSAL A4565 A4565 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500024 Supplies BENZOIN TINC. SWAB 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500025 Supplies BETADINE SWAB 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500027 Supplies BIOPATCH DISK 1'''' 4MM. 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500028 Supplies "BIPOLAR PACING CATH, FEM." 270 $593.00 $- $154.18 $- $- $474.40 $- N/A $154.18 N/A N/A $224.15 N/A N/A $355.80 N/A N/A $296.50 N/A N/A N/A N/A N/A $403.24 N/A N/A N/A N/A N/A $231.27 N/A N/A $269.82 N/A N/A $474.40 N/A N/A $326.15 N/A N/A $385.45 N/A N/A $198.66 N/A N/A N/A N/A N/A $355.80 N/A N/A $207.55 N/A N/A $385.45 N/A N/A $177.90 N/A N/A $355.80 N/A N/A $385.45 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A $593.00 $593.00 N/A 1500029 Supplies "BIPOLAR PACING CATH, V.C." 270 $593.00 $- $154.18 $- $- $474.40 $- N/A $154.18 N/A N/A $224.15 N/A N/A $355.80 N/A N/A $296.50 N/A N/A N/A N/A N/A $403.24 N/A N/A N/A N/A N/A $231.27 N/A N/A $269.82 N/A N/A $474.40 N/A N/A $326.15 N/A N/A $385.45 N/A N/A $198.66 N/A N/A N/A N/A N/A $355.80 N/A N/A $207.55 N/A N/A $385.45 N/A N/A $177.90 N/A N/A $355.80 N/A N/A $385.45 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A N/A $177.90 N/A $593.00 $593.00 N/A 1500030 Supplies BLOOD Y SET W/CLAMP 270 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1500031 Supplies BLOOD Y SET W/PUMP 82 270 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1500032 Supplies "BODY BAG, XL" 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1500033 Supplies BONE MARROW TRAY 270 $289.00 $- $75.14 $- $- $231.20 $- N/A $75.14 N/A N/A $109.24 N/A N/A $173.40 N/A N/A $144.50 N/A N/A N/A N/A N/A $196.52 N/A N/A N/A N/A N/A $112.71 N/A N/A $131.50 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $187.85 N/A N/A $96.82 N/A N/A N/A N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 1500034 Supplies "BOOT, HEELMEDIX W/WEDGE" 270 $453.00 $- $117.78 $- $- $362.40 $- N/A $117.78 N/A N/A $171.23 N/A N/A $271.80 N/A N/A $226.50 N/A N/A N/A N/A N/A $308.04 N/A N/A N/A N/A N/A $176.67 N/A N/A $206.12 N/A N/A $362.40 N/A N/A $249.15 N/A N/A $294.45 N/A N/A $151.76 N/A N/A N/A N/A N/A $271.80 N/A N/A $158.55 N/A N/A $294.45 N/A N/A $135.90 N/A N/A $271.80 N/A N/A $294.45 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A N/A $135.90 N/A $453.00 $453.00 N/A 1500036 Supplies BOWL 32 OZ. (STERILE) 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500038 Supplies BULB SYRINGE 2 OZ. 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500039 Supplies BULB SYRINGE 3 OZ 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500040 Supplies CAST SHOE - MED 270 $124.00 $- $32.24 $- $- $99.20 $- N/A $32.24 N/A N/A $46.87 N/A N/A $74.40 N/A N/A $62.00 N/A N/A N/A N/A N/A $84.32 N/A N/A N/A N/A N/A $48.36 N/A N/A $56.42 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $80.60 N/A N/A $41.54 N/A N/A N/A N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 1500041 Supplies CAST SHOE LARGE 270 $124.00 $- $32.24 $- $- $99.20 $- N/A $32.24 N/A N/A $46.87 N/A N/A $74.40 N/A N/A $62.00 N/A N/A N/A N/A N/A $84.32 N/A N/A N/A N/A N/A $48.36 N/A N/A $56.42 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $80.60 N/A N/A $41.54 N/A N/A N/A N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 1500042 Supplies CAST SHOE SMALL 270 $124.00 $- $32.24 $- $- $99.20 $- N/A $32.24 N/A N/A $46.87 N/A N/A $74.40 N/A N/A $62.00 N/A N/A N/A N/A N/A $84.32 N/A N/A N/A N/A N/A $48.36 N/A N/A $56.42 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $80.60 N/A N/A $41.54 N/A N/A N/A N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 1500043 Supplies "CATH, FOLEY 10FR 3CC" 272 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500044 Supplies CATH FOLEY 12FR 5CC 272 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500045 Supplies "CATH, FOLEY 14FR 5CC" 272 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500046 Supplies CATH FOLEY 16FR 30CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500047 Supplies CATH FOLEY 16FR 5CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500048 Supplies CATH FOLEY 16FR 5CC SILIC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500049 Supplies "CATH, FOLEY 18FR 30CC" 272 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500050 Supplies CATH FOLEY 18FR 5CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500051 Supplies CATH FOLEY 18fr.30cc.SIL. 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500052 Supplies CATH FOLEY 18FR.5CC. SIL. 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500053 Supplies CATH FOLEY 20FR 30CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500054 Supplies CATH FOLEY 20FR. 5CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500055 Supplies "CATH, FOLEY 22FR 30CC" 272 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500056 Supplies "CATH, FOLEY 22FR 5CC" 272 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500057 Supplies CATH FOLEY 24F 5CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500059 Supplies CATH FOLEY 30FR 30CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500060 Supplies "CATH, FOLEY 8FR 3CC" 272 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500061 Supplies CATH KIT (FEMALE) 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500062 Supplies CATH KIT (MALE) 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500063 Supplies "CATH KIT, INFANT" 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500064 Supplies "CATH, FOLEY 3-WAY 16fr." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500065 Supplies "CATH, FOLEY 3-WAY 20fr." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500066 Supplies "CATH, FOLEY COUDE 14FR." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500067 Supplies "CATH, FOLEY COUDE 16FR." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500068 Supplies "CATH, FOLEY COUDE 18FR." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500069 Supplies "CATH, FOLEY COUDE 20fr." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500070 Supplies "CATH, RED ROBINSON 16FR." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500071 Supplies CATHETER PLUG 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500072 Supplies "CATHETER, SILICONE 20FR." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500073 Supplies CERVICAL COLLAR FOAM LG L0120 L0120 274 $113.00 $- $29.38 $- $- $90.40 $- N/A $29.38 N/A N/A $42.71 N/A N/A $67.80 N/A N/A $56.50 N/A N/A N/A N/A N/A $76.84 N/A N/A N/A N/A N/A $44.07 N/A N/A $51.42 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $73.45 N/A N/A $37.86 N/A N/A N/A N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 1500074 Supplies CERVICAL COLLAR FOAM MED L0120 L0120 274 $113.00 $- $29.38 $- $- $90.40 $- N/A $29.38 N/A N/A $42.71 N/A N/A $67.80 N/A N/A $56.50 N/A N/A N/A N/A N/A $76.84 N/A N/A N/A N/A N/A $44.07 N/A N/A $51.42 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $73.45 N/A N/A $37.86 N/A N/A N/A N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 1500075 Supplies CERVICAL COLLAR FOAM SMAL L0120 L0120 274 $113.00 $- $29.38 $- $- $90.40 $- N/A $29.38 N/A N/A $42.71 N/A N/A $67.80 N/A N/A $56.50 N/A N/A N/A N/A N/A $76.84 N/A N/A N/A N/A N/A $44.07 N/A N/A $51.42 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $73.45 N/A N/A $37.86 N/A N/A N/A N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 1500076 Supplies CHEST TUBE 12FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500077 Supplies CHEST TUBE 16FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500078 Supplies CHEST TUBE 20FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500079 Supplies CHEST TUBE 24FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500080 Supplies CHEST TUBE 28FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500081 Supplies CHEST TUBE 32FR. TROCAR 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500082 Supplies CHEST TUBE 36FR. 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500083 Supplies CHEST TUBE 40FR. 270 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500084 Supplies CHEST TUBE TRAY 272 $391.00 $- $101.66 $- $- $312.80 $- N/A $101.66 N/A N/A $147.80 N/A N/A $234.60 N/A N/A $195.50 N/A N/A N/A N/A N/A $265.88 N/A N/A N/A N/A N/A $152.49 N/A N/A $177.91 N/A N/A $312.80 N/A N/A $215.05 N/A N/A $254.15 N/A N/A $130.99 N/A N/A N/A N/A N/A $234.60 N/A N/A $136.85 N/A N/A $254.15 N/A N/A $117.30 N/A N/A $234.60 N/A N/A $254.15 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A N/A $117.30 N/A $391.00 $391.00 N/A 1500085 Supplies CLAVE CAP 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500086 Supplies CLAVE CONNECTOR 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500087 Supplies CLAVICAL SPLINT LG L3650 L3650 274 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $64.85 N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A $64.85 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500088 Supplies CLAVICAL SPLINT MED L3650 L3650 274 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $64.85 N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A $64.85 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500089 Supplies CLAVICAL SPLINT SML L3650 L3650 274 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A $64.85 N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A $64.85 N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500090 Supplies COCKUP SPLINT LT LG L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500091 Supplies COCKUP SPLINT LT. MED. L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500092 Supplies COCKUP SPLINT LT. SML. L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500093 Supplies COCKUP SPLINT RT MED L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500094 Supplies COCKUP SPLINT RT. LG. L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500095 Supplies COCKUP SPLINT SM. RIGHT L3809 L3809 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A N/A N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A N/A N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500096 Supplies COLD PACK INSTANT 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500097 Supplies CONNECTING TUBING 20 INCH 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500098 Supplies CONNECTOR 5 IN 1 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500099 Supplies COVADERM 6x6 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500100 Supplies COVADERM DRESSING 2X2 A6203 A6203 623 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500101 Supplies COVADERM DRESSING 4x14 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500102 Supplies COVADERM PLUS 4X4 A6203 A6203 623 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500103 Supplies "CRUTCH, ADULT REGULAR" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500104 Supplies "CRUTCH, PEDIATRIC" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500105 Supplies "CRUTCH, TALL ADULT" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500106 Supplies DIAL-A-FLOW SET 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500107 Supplies DIAPER ADULT LARGE 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500108 Supplies "DIAPER, ADULT X-LARGE" 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500109 Supplies "DIAPER, BARIATRIC" 270 $81.00 $- $21.06 $- $- $64.80 $- N/A $21.06 N/A N/A $30.62 N/A N/A $48.60 N/A N/A $40.50 N/A N/A N/A N/A N/A $55.08 N/A N/A N/A N/A N/A $31.59 N/A N/A $36.86 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $52.65 N/A N/A $27.14 N/A N/A N/A N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 1500110 Supplies DIAPERS ADULT MED. 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500111 Supplies DISP. INNER CANNULA #10 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500112 Supplies DISP. INNER CANNULA #4 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500113 Supplies DISP. INNER CANNULA #6 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500114 Supplies DRAIN BAG 2000CC 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500115 Supplies DRESSING CHANGE TRAY 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500116 Supplies EASI-LAV LAVAGE 34FR. 270 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A N/A N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A N/A N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500118 Supplies ELECTRODE ECG DISP. 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500119 Supplies "ELECTRODE, PEDIATRIC" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500120 Supplies ENEMA BUCKET 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500121 Supplies EPISTAT NASAL CATHETER 270 $576.00 $- $149.76 $- $- $460.80 $- N/A $149.76 N/A N/A $217.73 N/A N/A $345.60 N/A N/A $288.00 N/A N/A N/A N/A N/A $391.68 N/A N/A N/A N/A N/A $224.64 N/A N/A $262.08 N/A N/A $460.80 N/A N/A $316.80 N/A N/A $374.40 N/A N/A $192.96 N/A N/A N/A N/A N/A $345.60 N/A N/A $201.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $345.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A $576.00 $576.00 N/A 1500122 Supplies "EXTENSION SET, MICROBORE" 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500123 Supplies EYE PAD OVAL (STERILE) 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500126 Supplies FEMORAL ARTERIAL CATH. 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500127 Supplies FILTERSET IVEX-2 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500128 Supplies "FOLEY CATH TRAY, SILICONE" 270 $122.00 $- $31.72 $- $- $97.60 $- N/A $31.72 N/A N/A $46.12 N/A N/A $73.20 N/A N/A $61.00 N/A N/A N/A N/A N/A $82.96 N/A N/A N/A N/A N/A $47.58 N/A N/A $55.51 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $79.30 N/A N/A $40.87 N/A N/A N/A N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 1500129 Supplies GRADUATE (DISP.) 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500130 Supplies "GRIPPER NEEDLE, 20gX1" 270 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500131 Supplies "GRIPPER NEEDLE, 20gX3/4" 270 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500132 Supplies "GRIPPER NEEDLE, 22gX1" 270 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500133 Supplies "HEEL PROTECTOR, FUR LG." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500134 Supplies "HEEL PROTECTOR, FUR REG." 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500135 Supplies "HEEL PROTECTORS, LARGE" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500136 Supplies "HEEL PROTECTORS, MEDIUM" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500137 Supplies HIGH-FLOW FLUID ADMIN SET 270 $189.00 $- $49.14 $- $- $151.20 $- N/A $49.14 N/A N/A $71.44 N/A N/A $113.40 N/A N/A $94.50 N/A N/A N/A N/A N/A $128.52 N/A N/A N/A N/A N/A $73.71 N/A N/A $86.00 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $122.85 N/A N/A $63.32 N/A N/A N/A N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 1500138 Supplies "HINGED KNEE BRACE, LONG" L1810 L1810 274 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A $132.30 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $108.87 N/A N/A $238.00 N/A N/A N/A N/A N/A $136.50 N/A N/A $159.25 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $227.50 N/A N/A $117.25 N/A N/A $108.87 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 1500139 Supplies "HINGED KNEE BRACE, MEDIUM" L1810 L1810 274 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A $132.30 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $108.87 N/A N/A $238.00 N/A N/A N/A N/A N/A $136.50 N/A N/A $159.25 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $227.50 N/A N/A $117.25 N/A N/A $108.87 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 1500140 Supplies "HINGED KNEE BRACE, SHORT" L1810 L1810 274 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A $132.30 N/A N/A $210.00 N/A N/A $175.00 N/A N/A $108.87 N/A N/A $238.00 N/A N/A N/A N/A N/A $136.50 N/A N/A $159.25 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $227.50 N/A N/A $117.25 N/A N/A $108.87 N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 1500141 Supplies HOT PACK INSTANT 270 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $18.90 N/A N/A $30.00 N/A N/A $25.00 N/A N/A N/A N/A N/A $34.00 N/A N/A N/A N/A N/A $19.50 N/A N/A $22.75 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $32.50 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 1500142 Supplies HOTLINE SET 270 $99.00 $- $25.74 $- $- $79.20 $- N/A $25.74 N/A N/A $37.42 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A N/A N/A N/A $38.61 N/A N/A $45.05 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $64.35 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 1500143 Supplies HYDROCOLLOID DRESSING 4X4 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500144 Supplies HYDROFERA BLUE 4x4 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500145 Supplies I.V. START KIT 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500146 Supplies "IMMOBILIZER, DELUXE SHOUL" L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500147 Supplies "IMMOBILIZER, DELUXE X-SM" L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500148 Supplies INTRODUCER KIR 8.5FR. 270 $242.00 $- $62.92 $- $- $193.60 $- N/A $62.92 N/A N/A $91.48 N/A N/A $145.20 N/A N/A $121.00 N/A N/A N/A N/A N/A $164.56 N/A N/A N/A N/A N/A $94.38 N/A N/A $110.11 N/A N/A $193.60 N/A N/A $133.10 N/A N/A $157.30 N/A N/A $81.07 N/A N/A N/A N/A N/A $145.20 N/A N/A $84.70 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $145.20 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A $242.00 $242.00 N/A 1500149 Supplies INTRODUCER KIT 6FR. 270 $242.00 $- $62.92 $- $- $193.60 $- N/A $62.92 N/A N/A $91.48 N/A N/A $145.20 N/A N/A $121.00 N/A N/A N/A N/A N/A $164.56 N/A N/A N/A N/A N/A $94.38 N/A N/A $110.11 N/A N/A $193.60 N/A N/A $133.10 N/A N/A $157.30 N/A N/A $81.07 N/A N/A N/A N/A N/A $145.20 N/A N/A $84.70 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $145.20 N/A N/A $157.30 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A N/A $72.60 N/A $242.00 $242.00 N/A 1500150 Supplies IODOFORM PACKING 1 INCH 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500151 Supplies IODOFORM PACKING 1/2 INCH 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500152 Supplies IODOFORM PACKING 1/4 INCH 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500153 Supplies "IODOSORB GEL, 40 GRAM" 270 $281.00 $- $73.06 $- $- $224.80 $- N/A $73.06 N/A N/A $106.22 N/A N/A $168.60 N/A N/A $140.50 N/A N/A N/A N/A N/A $191.08 N/A N/A N/A N/A N/A $109.59 N/A N/A $127.86 N/A N/A $224.80 N/A N/A $154.55 N/A N/A $182.65 N/A N/A $94.14 N/A N/A N/A N/A N/A $168.60 N/A N/A $98.35 N/A N/A $182.65 N/A N/A $84.30 N/A N/A $168.60 N/A N/A $182.65 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A N/A $84.30 N/A $281.00 $281.00 N/A 1500154 Supplies IRRIG. 0.9 SOD. CL. 1000M 272 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1500155 Supplies IRRIG. STERILE WATER 1000 272 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1500156 Supplies IRRIGATION TRAY (STERILE) 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500157 Supplies I.V. CATHETER 14GA 1 3/4 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500158 Supplies I.V. CATHETER 16GX1 1/4 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500159 Supplies JELCO 18GA 1X1/4 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500160 Supplies JELCO 20GA 1 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500161 Supplies JELCO 22GA 1 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500162 Supplies JELCO 24G.X3/4 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500163 Supplies KERLIX FLUFF 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500164 Supplies KERLIX ROLL (STERILE PK.) 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500165 Supplies KLING 2 IN STERILE 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500166 Supplies KLING 3 IN STERILE 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500167 Supplies KLING 4 STERILE 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500168 Supplies KLING 6 STERILE 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500169 Supplies KNEE IMMOBILIZER 20 inch L1830 L1830 274 $330.00 $- $85.80 $- $- $264.00 $- N/A $85.80 N/A N/A $124.74 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $97.75 N/A N/A $224.40 N/A N/A N/A N/A N/A $128.70 N/A N/A $150.15 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $214.50 N/A N/A $110.55 N/A N/A $97.75 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 1500170 Supplies KNEE IMMOBILIZER 24 INCH L1830 L1830 274 $330.00 $- $85.80 $- $- $264.00 $- N/A $85.80 N/A N/A $124.74 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $97.75 N/A N/A $224.40 N/A N/A N/A N/A N/A $128.70 N/A N/A $150.15 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $214.50 N/A N/A $110.55 N/A N/A $97.75 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 1500171 Supplies KNEE IMMOBILIZER 16 INCH L1830 L1830 274 $330.00 $- $85.80 $- $- $264.00 $- N/A $85.80 N/A N/A $124.74 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $97.75 N/A N/A $224.40 N/A N/A N/A N/A N/A $128.70 N/A N/A $150.15 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $214.50 N/A N/A $110.55 N/A N/A $97.75 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 1500172 Supplies KNEE SPLINT 20 INCH L1830 L1830 274 $330.00 $- $85.80 $- $- $264.00 $- N/A $85.80 N/A N/A $124.74 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $97.75 N/A N/A $224.40 N/A N/A N/A N/A N/A $128.70 N/A N/A $150.15 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $214.50 N/A N/A $110.55 N/A N/A $97.75 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 1500173 Supplies KNEE SPLINT 24 INCH L1830 L1830 274 $330.00 $- $85.80 $- $- $264.00 $- N/A $85.80 N/A N/A $124.74 N/A N/A $198.00 N/A N/A $165.00 N/A N/A $97.75 N/A N/A $224.40 N/A N/A N/A N/A N/A $128.70 N/A N/A $150.15 N/A N/A $264.00 N/A N/A $181.50 N/A N/A $214.50 N/A N/A $110.55 N/A N/A $97.75 N/A N/A $198.00 N/A N/A $115.50 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $198.00 N/A N/A $214.50 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A N/A $99.00 N/A $330.00 $330.00 N/A 1500174 Supplies K-PAD 18X26'''' DISP. 270 $102.00 $- $26.52 $- $- $81.60 $- N/A $26.52 N/A N/A $38.56 N/A N/A $61.20 N/A N/A $51.00 N/A N/A N/A N/A N/A $69.36 N/A N/A N/A N/A N/A $39.78 N/A N/A $46.41 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $66.30 N/A N/A $34.17 N/A N/A N/A N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 1500175 Supplies K-THERMIA BLANKET 24X60 270 $251.00 $- $65.26 $- $- $200.80 $- N/A $65.26 N/A N/A $94.88 N/A N/A $150.60 N/A N/A $125.50 N/A N/A N/A N/A N/A $170.68 N/A N/A N/A N/A N/A $97.89 N/A N/A $114.21 N/A N/A $200.80 N/A N/A $138.05 N/A N/A $163.15 N/A N/A $84.09 N/A N/A N/A N/A N/A $150.60 N/A N/A $87.85 N/A N/A $163.15 N/A N/A $75.30 N/A N/A $150.60 N/A N/A $163.15 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A N/A $75.30 N/A $251.00 $251.00 N/A 1500176 Supplies LACERATION TRAY CUST. 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500177 Supplies LEG BAG (URINARY) 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500178 Supplies LEG BAG W/EXT. TUBING 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500179 Supplies LEG STRAP (CATH) 270 $70.00 $- $18.20 $- $- $56.00 $- N/A $18.20 N/A N/A $26.46 N/A N/A $42.00 N/A N/A $35.00 N/A N/A N/A N/A N/A $47.60 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $45.50 N/A N/A $23.45 N/A N/A N/A N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 1500180 Supplies LEMON GLYCERINE SWAB 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500181 Supplies LEVINE TUBE 10FR 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500182 Supplies LEVINE TUBE 12FR 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500183 Supplies LEVINE TUBE 14FR 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500184 Supplies LEVINE TUBE 16FR 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500185 Supplies LEVINE TUBE 18FR 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500186 Supplies LIMB HOLDER DISP. 270 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500187 Supplies LOPEZ VALVE 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500188 Supplies LUMBAR PUNCTURE (ADULT) 270 $127.00 $- $33.02 $- $- $101.60 $- N/A $33.02 N/A N/A $48.01 N/A N/A $76.20 N/A N/A $63.50 N/A N/A N/A N/A N/A $86.36 N/A N/A N/A N/A N/A $49.53 N/A N/A $57.79 N/A N/A $101.60 N/A N/A $69.85 N/A N/A $82.55 N/A N/A $42.55 N/A N/A N/A N/A N/A $76.20 N/A N/A $44.45 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $76.20 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A $127.00 $127.00 N/A 1500189 Supplies LUMBAR PUNCTURE (PED.) 270 $127.00 $- $33.02 $- $- $101.60 $- N/A $33.02 N/A N/A $48.01 N/A N/A $76.20 N/A N/A $63.50 N/A N/A N/A N/A N/A $86.36 N/A N/A N/A N/A N/A $49.53 N/A N/A $57.79 N/A N/A $101.60 N/A N/A $69.85 N/A N/A $82.55 N/A N/A $42.55 N/A N/A N/A N/A N/A $76.20 N/A N/A $44.45 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $76.20 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A $127.00 $127.00 N/A 1500190 Supplies LYOFOAM DRESSING 4X4 IN 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500191 Supplies MAXSORB AG DRESSING 270 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A $36.29 N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A N/A N/A N/A $37.44 N/A N/A $43.68 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $62.40 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 1500192 Supplies MAXSORB CAL. ALG. 4x4 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500193 Supplies MEDLINE ENTERAL FEED SET 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500194 Supplies MEPILEX BORDER 9x9 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500195 Supplies MEPILEX BORDER LITE 1.5x2 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500196 Supplies MEPILEX BORDER LITE 6x6 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500197 Supplies MEPILEX SACRUM 7x7 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500198 Supplies "MEPILEX, LIGHT BORDER 4x4" 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500199 Supplies MID STREAM CLEAN CATCH KI 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500201 Supplies MUCOUS SPEC. TRAP 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500202 Supplies MULTIDEX GEL 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500203 Supplies MULTIDEX POWDER 6gm. 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500204 Supplies "MULTIDEX POWDER, 12 GRAM" 270 $77.00 $- $20.02 $- $- $61.60 $- N/A $20.02 N/A N/A $29.11 N/A N/A $46.20 N/A N/A $38.50 N/A N/A N/A N/A N/A $52.36 N/A N/A N/A N/A N/A $30.03 N/A N/A $35.04 N/A N/A $61.60 N/A N/A $42.35 N/A N/A $50.05 N/A N/A $25.80 N/A N/A N/A N/A N/A $46.20 N/A N/A $26.95 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $46.20 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A $77.00 $77.00 N/A 1500205 Supplies OPSITE DRESSING 2X3 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500206 Supplies "OPSITE, LARGE 4x5" 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500207 Supplies "OSTOMY FLANGE, 2 1/4" 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500208 Supplies OSTOMY ONE-PIECE SYSTEM 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500209 Supplies OSTOMY POUCH 2.75 CLEAR 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500210 Supplies "OSTOMY POUCH, 2 1/4" 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500211 Supplies OSTOMY POUCH 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500212 Supplies "OSTOMY POUCH, CUT TO FIT" 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500213 Supplies OSTOMY WAFER 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500214 Supplies "OXISENSOR, ADULT" 270 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500215 Supplies "OXISENSOR, INFANT" 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500216 Supplies "OXISENSOR, PEDIATRIC" 270 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500217 Supplies "PATRIOT COLLAR, ADULT" 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500218 Supplies "PATRIOT COLLAR, PEDIATRIC" 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500220 Supplies PERI WASH 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500221 Supplies PERICARDIOCENTESIS KIT 270 $603.00 $- $156.78 $- $- $482.40 $- N/A $156.78 N/A N/A $227.93 N/A N/A $361.80 N/A N/A $301.50 N/A N/A N/A N/A N/A $410.04 N/A N/A N/A N/A N/A $235.17 N/A N/A $274.37 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $391.95 N/A N/A $202.01 N/A N/A N/A N/A N/A $361.80 N/A N/A $211.05 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 1500222 Supplies PERITONEAL LAVAGE TRAY 270 $235.00 $- $61.10 $- $- $188.00 $- N/A $61.10 N/A N/A $88.83 N/A N/A $141.00 N/A N/A $117.50 N/A N/A N/A N/A N/A $159.80 N/A N/A N/A N/A N/A $91.65 N/A N/A $106.93 N/A N/A $188.00 N/A N/A $129.25 N/A N/A $152.75 N/A N/A $78.73 N/A N/A N/A N/A N/A $141.00 N/A N/A $82.25 N/A N/A $152.75 N/A N/A $70.50 N/A N/A $141.00 N/A N/A $152.75 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A N/A $70.50 N/A $235.00 $235.00 N/A 1500223 Supplies PIGGYBACK SET NONVENT 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500224 Supplies PLAIN PACKING 1 INCH 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500225 Supplies PLAIN PACKING 1/2 INCH 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500226 Supplies PLAIN PACKING 1/4 INCH 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500227 Supplies PLEUR EVAC 270 $573.00 $- $148.98 $- $- $458.40 $- N/A $148.98 N/A N/A $216.59 N/A N/A $343.80 N/A N/A $286.50 N/A N/A N/A N/A N/A $389.64 N/A N/A N/A N/A N/A $223.47 N/A N/A $260.72 N/A N/A $458.40 N/A N/A $315.15 N/A N/A $372.45 N/A N/A $191.96 N/A N/A N/A N/A N/A $343.80 N/A N/A $200.55 N/A N/A $372.45 N/A N/A $171.90 N/A N/A $343.80 N/A N/A $372.45 N/A N/A $171.90 N/A N/A $171.90 N/A N/A $171.90 N/A N/A $171.90 N/A N/A $171.90 N/A N/A $171.90 N/A $573.00 $573.00 N/A 1500228 Supplies PLUM BLOOD SET 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1500229 Supplies PLUM EXTENSION SET 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500230 Supplies PLUM NITRO SET 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1500231 Supplies PLUM PRIMARY TUBING 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500232 Supplies PLUM SECONDARY IV TUBING 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500233 Supplies PNEUMOTHORAX SET 270 $485.00 $- $126.10 $- $- $388.00 $- N/A $126.10 N/A N/A $183.33 N/A N/A $291.00 N/A N/A $242.50 N/A N/A N/A N/A N/A $329.80 N/A N/A N/A N/A N/A $189.15 N/A N/A $220.68 N/A N/A $388.00 N/A N/A $266.75 N/A N/A $315.25 N/A N/A $162.48 N/A N/A N/A N/A N/A $291.00 N/A N/A $169.75 N/A N/A $315.25 N/A N/A $145.50 N/A N/A $291.00 N/A N/A $315.25 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A $485.00 $485.00 N/A 1500234 Supplies POLYMEM DRESSING 4X4 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500235 Supplies POLYMEM SILVER 4x4 270 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500236 Supplies POLYMEM STRIP 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500237 Supplies POLYWIC DRESSING 270 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500238 Supplies "POSEY VEST, LARGE" 270 $119.00 $- $30.94 $- $- $95.20 $- N/A $30.94 N/A N/A $44.98 N/A N/A $71.40 N/A N/A $59.50 N/A N/A N/A N/A N/A $80.92 N/A N/A N/A N/A N/A $46.41 N/A N/A $54.15 N/A N/A $95.20 N/A N/A $65.45 N/A N/A $77.35 N/A N/A $39.87 N/A N/A N/A N/A N/A $71.40 N/A N/A $41.65 N/A N/A $77.35 N/A N/A $35.70 N/A N/A $71.40 N/A N/A $77.35 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A $119.00 $119.00 N/A 1500239 Supplies "POSEY VEST, MEDIUM" 270 $119.00 $- $30.94 $- $- $95.20 $- N/A $30.94 N/A N/A $44.98 N/A N/A $71.40 N/A N/A $59.50 N/A N/A N/A N/A N/A $80.92 N/A N/A N/A N/A N/A $46.41 N/A N/A $54.15 N/A N/A $95.20 N/A N/A $65.45 N/A N/A $77.35 N/A N/A $39.87 N/A N/A N/A N/A N/A $71.40 N/A N/A $41.65 N/A N/A $77.35 N/A N/A $35.70 N/A N/A $71.40 N/A N/A $77.35 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A N/A $35.70 N/A $119.00 $119.00 N/A 1500240 Supplies "POST OP SHOE, FEMALE LG." 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500241 Supplies "POST OP SHOE, FEMALE MED." 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500242 Supplies "POST OP SHOE, FEMALE SM." 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500243 Supplies "POST OP SHOE, MALE LARGE" 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500244 Supplies "POST OP SHOE, MALE MED." 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500245 Supplies "POST OP SHOE, MALE SMALL" 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500246 Supplies PRIMARY IV SET A4223 A4223 264 $81.00 $- $21.06 $- $- $64.80 $- N/A $21.06 N/A N/A $30.62 N/A N/A $48.60 N/A N/A $40.50 N/A N/A N/A N/A N/A $55.08 N/A N/A N/A N/A N/A $31.59 N/A N/A $36.86 N/A N/A $64.80 N/A N/A $44.55 N/A N/A $52.65 N/A N/A $27.14 N/A N/A N/A N/A N/A $48.60 N/A N/A $28.35 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $48.60 N/A N/A $52.65 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A N/A $24.30 N/A $81.00 $81.00 N/A 1500247 Supplies "PULL UPS, LARGE" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500248 Supplies "PULL UPS, MEDIUM" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500249 Supplies "PULL UPS, SMALL" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500250 Supplies "PULL UPS, X-LARGE" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500251 Supplies RADIAL ART CATH. KIT 20G 270 $151.00 $- $39.26 $- $- $120.80 $- N/A $39.26 N/A N/A $57.08 N/A N/A $90.60 N/A N/A $75.50 N/A N/A N/A N/A N/A $102.68 N/A N/A N/A N/A N/A $58.89 N/A N/A $68.71 N/A N/A $120.80 N/A N/A $83.05 N/A N/A $98.15 N/A N/A $50.59 N/A N/A N/A N/A N/A $90.60 N/A N/A $52.85 N/A N/A $98.15 N/A N/A $45.30 N/A N/A $90.60 N/A N/A $98.15 N/A N/A $45.30 N/A N/A $45.30 N/A N/A $45.30 N/A N/A $45.30 N/A N/A $45.30 N/A N/A $45.30 N/A $151.00 $151.00 N/A 1500252 Supplies RECTAL TUBE 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500253 Supplies RIB BELT MEN 6 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500254 Supplies RIB BELT WOMEN 6 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500255 Supplies SANITARY NAPKIN (O.B. PAD 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500256 Supplies SCALPEL STERILE #10 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500257 Supplies SCALPEL STERILE #11 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500258 Supplies SCALPEL STERILE #15 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500259 Supplies SETOPRESS DRESSING 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A $29.48 N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A N/A N/A N/A $30.42 N/A N/A $35.49 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $50.70 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 1500260 Supplies SHOULDER/ARM IMM LG FEM. L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500261 Supplies SHOULDER/ARM IMM LG.MALE L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500262 Supplies SHOULDER/ARM IMM MD FEM. L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500263 Supplies SHOULDER/ARM IMM XLG FEM. L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500264 Supplies SHOULDER/ARM IMM XLG MALE L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500265 Supplies SHOULDER/ARM IMM. MD.MALE L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500266 Supplies SHOULDER/ARM IMM. XXL FEM L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500267 Supplies SHOULDER/ARM IMM.XXL MALE L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500268 Supplies SHOULDER/ARM IMMOB SM L3650 L3650 274 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A $64.85 N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A $64.85 N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500269 Supplies SHUR CLENS 20ML 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500271 Supplies "SKIN SLEEVE, ARM REG." 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500272 Supplies "SKIN SLEEVE, LARGE ARM" 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500275 Supplies "SKIN STAPLER, REGULAR" 270 $58.00 $- $15.08 $- $- $46.40 $- N/A $15.08 N/A N/A $21.92 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A N/A N/A N/A $22.62 N/A N/A $26.39 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $37.70 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 1500276 Supplies "SKIN STAPLER, WIDE" 270 $58.00 $- $15.08 $- $- $46.40 $- N/A $15.08 N/A N/A $21.92 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A N/A N/A N/A $22.62 N/A N/A $26.39 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $37.70 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 1500277 Supplies SKINTEGRITY HYDROGEL 270 $125.00 $- $32.50 $- $- $100.00 $- N/A $32.50 N/A N/A $47.25 N/A N/A $75.00 N/A N/A $62.50 N/A N/A N/A N/A N/A $85.00 N/A N/A N/A N/A N/A $48.75 N/A N/A $56.88 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $81.25 N/A N/A $41.88 N/A N/A N/A N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 1500278 Supplies SPINAL NEEDLE 18X3 1/2 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500279 Supplies SPINAL NEEDLE 20X3 1/2 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500280 Supplies SPINAL NEEDLE 22X3 1/2 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500281 Supplies SPINAL NEEDLE 25X3 1/2 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500282 Supplies SPLASH SHIELD 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500283 Supplies "STAT LOCK, PICC LINE" 272 $51.00 $- $13.26 $- $- $40.80 $- N/A $13.26 N/A N/A $19.28 N/A N/A $30.60 N/A N/A $25.50 N/A N/A N/A N/A N/A $34.68 N/A N/A N/A N/A N/A $19.89 N/A N/A $23.21 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $33.15 N/A N/A $17.09 N/A N/A N/A N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 1500284 Supplies STERI STRIP 1/2 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500285 Supplies STERI STRIP 1/4 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500286 Supplies STERI STRIP 1/8 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500287 Supplies STETHOSCOPE DISP. 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500288 Supplies "STOMAHESIVE PASTE, 1/2 oz" 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A $29.48 N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A N/A N/A N/A $30.42 N/A N/A $35.49 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $50.70 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 1500289 Supplies STRAIGHT CATH TRAY 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500290 Supplies SUCTION CATH 8FR 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500291 Supplies SUCTION CATH KIT 14FR W/G 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500292 Supplies SUCTION CATHETER 10fr. 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500293 Supplies SUCTION CATHETER 12fr. 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500294 Supplies SUCTION CATHETER 14fr. 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500295 Supplies SUCTION CATHETER 18 FR 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500296 Supplies SUCTION CONN. TUBE 1/4X10 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500297 Supplies SUCTION LINER 1500CC. 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500298 Supplies SUCTION TUBE ATT. DEVICE 272 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500299 Supplies SUPPORTER LARGE 270 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.15 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A N/A N/A N/A $36.27 N/A N/A $42.32 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $60.45 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 1500300 Supplies SUPPORTER MEDIUM 270 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.15 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A N/A N/A N/A $36.27 N/A N/A $42.32 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $60.45 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 1500301 Supplies SUPPORTER SMALL 270 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.15 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A N/A N/A N/A $36.27 N/A N/A $42.32 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $60.45 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 1500303 Supplies "SUTURE REMOVAL TRAY, PT" 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500304 Supplies SYRINGE 20CC L.L. 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500305 Supplies SYRINGE 30CC L.L. 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500306 Supplies SYRINGE 60CC CATH TIP 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500307 Supplies SYRINGE 60CC L.L. 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500308 Supplies TED KNEE LARGE LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500309 Supplies TED KNEE LARGE REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500310 Supplies TED KNEE MEDIUM LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500311 Supplies TED KNEE MEDIUM REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500312 Supplies TED KNEE SMALL LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500313 Supplies TED KNEE X-LARGE LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500314 Supplies TED KNEE X-LARGE REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500315 Supplies TED KNEE XXL-REG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500316 Supplies "TED KNEE, SMALL REGULAR" 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500317 Supplies TED THIGH LARGE LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500318 Supplies TED THIGH LARGE REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500319 Supplies TED THIGH LARGE SHORT 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500320 Supplies TED THIGH MEDIUM LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500321 Supplies TED THIGH MEDIUM REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500322 Supplies TED THIGH MEDIUM SHORT 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500323 Supplies TED THIGH SMALL LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500324 Supplies TED THIGH SMALL REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500325 Supplies TED THIGH SMALL SHORT 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500326 Supplies TED THIGH X-LARGE LONG 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500327 Supplies TED THIGH X-LARGE REGULAR 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500328 Supplies "TEGO, DIALYSIS CONNECTOR" 270 $77.00 $- $20.02 $- $- $61.60 $- N/A $20.02 N/A N/A $29.11 N/A N/A $46.20 N/A N/A $38.50 N/A N/A N/A N/A N/A $52.36 N/A N/A N/A N/A N/A $30.03 N/A N/A $35.04 N/A N/A $61.60 N/A N/A $42.35 N/A N/A $50.05 N/A N/A $25.80 N/A N/A N/A N/A N/A $46.20 N/A N/A $26.95 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $46.20 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A $77.00 $77.00 N/A 1500330 Supplies TELFA 3X4 (STERILE) 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500331 Supplies TELFA 3X8 (STERILE) 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500332 Supplies TEXAS CATHETER 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1500333 Supplies "THERAHONEY GEL, 1.5 oz." 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500334 Supplies THORA/PARACENTESIS TRAY 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500335 Supplies TOOTHETTE 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500337 Supplies TRACH ENDO TUBE 2.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500338 Supplies TRACH SHILEY #10 DCT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500339 Supplies TRACH SHILEY #10 FENESTRA 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500340 Supplies TRACH SHILEY #4 DCT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500341 Supplies TRACH SHILEY #4 FENESTRAT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500342 Supplies TRACH SHILEY #6 DCT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500343 Supplies TRACH SHILEY #6 FENESTRAT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500344 Supplies TRACH SHILEY #8 DCT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500345 Supplies TRACH SHILEY #8 FENESTRAT 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500346 Supplies TRACH TUBE 6.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500347 Supplies TRACH TUBE ENDO 10.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500348 Supplies TRACH TUBE ENDO 2.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500349 Supplies TRACH TUBE ENDO 3.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500350 Supplies TRACH TUBE ENDO 3.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500351 Supplies TRACH TUBE ENDO 4.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500352 Supplies TRACH TUBE ENDO 4.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500353 Supplies TRACH TUBE ENDO 5.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500354 Supplies TRACH TUBE ENDO 5.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500355 Supplies TRACH TUBE ENDO 6.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500356 Supplies TRACH TUBE ENDO 7.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500357 Supplies TRACH TUBE ENDO 7.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500358 Supplies TRACH TUBE ENDO 8.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500359 Supplies TRACH TUBE ENDO 8.5 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500360 Supplies TRACH TUBE ENDO 9.0 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500361 Supplies "TRACH, SHILEY 5.0 PED" 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500362 Supplies "TRACH, SHILEY NEO 4.0" 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500363 Supplies "TRACH, SHILEY PED 4.0" 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 1500364 Supplies "TRANSDUCER, SMALL" 270 $414.00 $- $107.64 $- $- $331.20 $- N/A $107.64 N/A N/A $156.49 N/A N/A $248.40 N/A N/A $207.00 N/A N/A N/A N/A N/A $281.52 N/A N/A N/A N/A N/A $161.46 N/A N/A $188.37 N/A N/A $331.20 N/A N/A $227.70 N/A N/A $269.10 N/A N/A $138.69 N/A N/A N/A N/A N/A $248.40 N/A N/A $144.90 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $248.40 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A $414.00 $414.00 N/A 1500365 Supplies TRIPLE LUMEN CATHETER 270 $894.00 $- $232.44 $- $- $715.20 $- N/A $232.44 N/A N/A $337.93 N/A N/A $536.40 N/A N/A $447.00 N/A N/A N/A N/A N/A $607.92 N/A N/A N/A N/A N/A $348.66 N/A N/A $406.77 N/A N/A $715.20 N/A N/A $491.70 N/A N/A $581.10 N/A N/A $299.49 N/A N/A N/A N/A N/A $536.40 N/A N/A $312.90 N/A N/A $581.10 N/A N/A $268.20 N/A N/A $536.40 N/A N/A $581.10 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A N/A $268.20 N/A $894.00 $894.00 N/A 1500366 Supplies "TUBE, BLAKEMORE 16fr." 272 "$2,544.00 " $- $661.44 $- $- "$2,035.20 " $- N/A $661.44 N/A N/A $961.63 N/A N/A "$1,526.40 " N/A N/A "$1,272.00 " N/A N/A N/A N/A N/A "$1,729.92 " N/A N/A N/A N/A N/A $992.16 N/A N/A "$1,157.52 " N/A N/A "$2,035.20 " N/A N/A "$1,399.20 " N/A N/A "$1,653.60 " N/A N/A $852.24 N/A N/A N/A N/A N/A "$1,526.40 " N/A N/A $890.40 N/A N/A "$1,653.60 " N/A N/A $763.20 N/A N/A "$1,526.40 " N/A N/A "$1,653.60 " N/A N/A $763.20 N/A N/A $763.20 N/A N/A $763.20 N/A N/A $763.20 N/A N/A $763.20 N/A N/A $763.20 N/A "$2,544.00 " "$2,544.00 " N/A 1500367 Supplies URINE COLLECTION BAG PEDS 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500368 Supplies URINE METER FOLEY TRAY W/ 270 $179.00 $- $46.54 $- $- $143.20 $- N/A $46.54 N/A N/A $67.66 N/A N/A $107.40 N/A N/A $89.50 N/A N/A N/A N/A N/A $121.72 N/A N/A N/A N/A N/A $69.81 N/A N/A $81.45 N/A N/A $143.20 N/A N/A $98.45 N/A N/A $116.35 N/A N/A $59.97 N/A N/A N/A N/A N/A $107.40 N/A N/A $62.65 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $107.40 N/A N/A $116.35 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A N/A $53.70 N/A $179.00 $179.00 N/A 1500369 Supplies URINE STRAINER 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500370 Supplies VASELINE GAUZE 3X9 (STERI 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500371 Supplies "VENAFLOW CUFF, CALF" 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500372 Supplies "VENAFLOW CUFF, FOOT" 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500373 Supplies "VENAFLOW CUFF, THIGH" 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500374 Supplies V-LINK 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500375 Supplies "WRIST SPLINT, LARGE LEFT" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500376 Supplies "WRIST SPLINT, LARGE RIGHT" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500377 Supplies "WRIST SPLINT, MEDIUM LEFT" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500378 Supplies "WRIST SPLINT, MEDIUM RIGH" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500379 Supplies "WRIST SPLINT, SMALL LEFT" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500380 Supplies "WRIST SPLINT, SMALL RIGHT" L3908 L3908 274 $221.00 $- $57.46 $- $- $176.80 $- N/A $57.46 N/A N/A $83.54 N/A N/A $132.60 N/A N/A $110.50 N/A N/A $65.50 N/A N/A $150.28 N/A N/A N/A N/A N/A $86.19 N/A N/A $100.56 N/A N/A $176.80 N/A N/A $121.55 N/A N/A $143.65 N/A N/A $74.04 N/A N/A $65.50 N/A N/A $132.60 N/A N/A $77.35 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $132.60 N/A N/A $143.65 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A N/A $66.30 N/A $221.00 $221.00 N/A 1500381 Supplies XEROFORM GAUZE 2X2 (STERI 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500382 Supplies XEROFORM GAUZE 4X4 (STERI 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500383 Supplies YANKAUER SUCTION TIP (STE 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500384 Supplies AIRWAY INFANT 40MM 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500385 Supplies AIRWAY CHILD 60MM 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500386 Supplies AIRWAY SM. ADULT 80MM 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500387 Supplies AIRWAY XLG ADULT 110M 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500388 Supplies FLOSEAL 270 "$1,141.00 " $- $296.66 $- $- $912.80 $- N/A $296.66 N/A N/A $431.30 N/A N/A $684.60 N/A N/A $570.50 N/A N/A N/A N/A N/A $775.88 N/A N/A N/A N/A N/A $444.99 N/A N/A $519.16 N/A N/A $912.80 N/A N/A $627.55 N/A N/A $741.65 N/A N/A $382.24 N/A N/A N/A N/A N/A $684.60 N/A N/A $399.35 N/A N/A $741.65 N/A N/A $342.30 N/A N/A $684.60 N/A N/A $741.65 N/A N/A $342.30 N/A N/A $342.30 N/A N/A $342.30 N/A N/A $342.30 N/A N/A $342.30 N/A N/A $342.30 N/A "$1,141.00 " "$1,141.00 " N/A 1500389 Supplies "ABDUCTION PILLOW, HIP" 270 $238.00 $- $61.88 $- $- $190.40 $- N/A $61.88 N/A N/A $89.96 N/A N/A $142.80 N/A N/A $119.00 N/A N/A N/A N/A N/A $161.84 N/A N/A N/A N/A N/A $92.82 N/A N/A $108.29 N/A N/A $190.40 N/A N/A $130.90 N/A N/A $154.70 N/A N/A $79.73 N/A N/A N/A N/A N/A $142.80 N/A N/A $83.30 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $142.80 N/A N/A $154.70 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A N/A $71.40 N/A $238.00 $238.00 N/A 1500390 Supplies "ABD. PILLOW, SLING STYLE" 270 $293.00 $- $76.18 $- $- $234.40 $- N/A $76.18 N/A N/A $110.75 N/A N/A $175.80 N/A N/A $146.50 N/A N/A N/A N/A N/A $199.24 N/A N/A N/A N/A N/A $114.27 N/A N/A $133.32 N/A N/A $234.40 N/A N/A $161.15 N/A N/A $190.45 N/A N/A $98.16 N/A N/A N/A N/A N/A $175.80 N/A N/A $102.55 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $175.80 N/A N/A $190.45 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A N/A $87.90 N/A $293.00 $293.00 N/A 1500391 Supplies "ABD.PILLOW, SHOULDER" 270 $259.00 $- $67.34 $- $- $207.20 $- N/A $67.34 N/A N/A $97.90 N/A N/A $155.40 N/A N/A $129.50 N/A N/A N/A N/A N/A $176.12 N/A N/A N/A N/A N/A $101.01 N/A N/A $117.85 N/A N/A $207.20 N/A N/A $142.45 N/A N/A $168.35 N/A N/A $86.77 N/A N/A N/A N/A N/A $155.40 N/A N/A $90.65 N/A N/A $168.35 N/A N/A $77.70 N/A N/A $155.40 N/A N/A $168.35 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A N/A $77.70 N/A $259.00 $259.00 N/A 1500392 Supplies TROCAR 5MM XCEL 270 $990.00 $- $257.40 $- $- $792.00 $- N/A $257.40 N/A N/A $374.22 N/A N/A $594.00 N/A N/A $495.00 N/A N/A N/A N/A N/A $673.20 N/A N/A N/A N/A N/A $386.10 N/A N/A $450.45 N/A N/A $792.00 N/A N/A $544.50 N/A N/A $643.50 N/A N/A $331.65 N/A N/A N/A N/A N/A $594.00 N/A N/A $346.50 N/A N/A $643.50 N/A N/A $297.00 N/A N/A $594.00 N/A N/A $643.50 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A N/A $297.00 N/A $990.00 $990.00 N/A 1500393 Supplies ENDO BABCOCK 5MM. 270 $345.00 $- $89.70 $- $- $276.00 $- N/A $89.70 N/A N/A $130.41 N/A N/A $207.00 N/A N/A $172.50 N/A N/A N/A N/A N/A $234.60 N/A N/A N/A N/A N/A $134.55 N/A N/A $156.98 N/A N/A $276.00 N/A N/A $189.75 N/A N/A $224.25 N/A N/A $115.58 N/A N/A N/A N/A N/A $207.00 N/A N/A $120.75 N/A N/A $224.25 N/A N/A $103.50 N/A N/A $207.00 N/A N/A $224.25 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A $345.00 $345.00 N/A 1500394 Supplies TROCAR 5MM. BLADELESS 270 $995.00 $- $258.70 $- $- $796.00 $- N/A $258.70 N/A N/A $376.11 N/A N/A $597.00 N/A N/A $497.50 N/A N/A N/A N/A N/A $676.60 N/A N/A N/A N/A N/A $388.05 N/A N/A $452.73 N/A N/A $796.00 N/A N/A $547.25 N/A N/A $646.75 N/A N/A $333.33 N/A N/A N/A N/A N/A $597.00 N/A N/A $348.25 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $597.00 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A $995.00 $995.00 N/A 1500396 Supplies COBAN STERILE 6 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500397 Supplies ESMARK STERILE 4 INCH 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500398 Supplies ESMARK STERILE 6 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500399 Supplies ENDOSCOPIC SHEARS DISP. 270 $630.00 $- $163.80 $- $- $504.00 $- N/A $163.80 N/A N/A $238.14 N/A N/A $378.00 N/A N/A $315.00 N/A N/A N/A N/A N/A $428.40 N/A N/A N/A N/A N/A $245.70 N/A N/A $286.65 N/A N/A $504.00 N/A N/A $346.50 N/A N/A $409.50 N/A N/A $211.05 N/A N/A N/A N/A N/A $378.00 N/A N/A $220.50 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $378.00 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A $630.00 $630.00 N/A 1500400 Supplies DRAIN JP SUCTION RESER. 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500401 Supplies ENDOSCOPIC KITTNER 270 $648.00 $- $168.48 $- $- $518.40 $- N/A $168.48 N/A N/A $244.94 N/A N/A $388.80 N/A N/A $324.00 N/A N/A N/A N/A N/A $440.64 N/A N/A N/A N/A N/A $252.72 N/A N/A $294.84 N/A N/A $518.40 N/A N/A $356.40 N/A N/A $421.20 N/A N/A $217.08 N/A N/A N/A N/A N/A $388.80 N/A N/A $226.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $388.80 N/A N/A $421.20 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A N/A $194.40 N/A $648.00 $648.00 N/A 1500402 Supplies DRAPE SHEET LAP CHOLE 270 $120.00 $- $31.20 $- $- $96.00 $- N/A $31.20 N/A N/A $45.36 N/A N/A $72.00 N/A N/A $60.00 N/A N/A N/A N/A N/A $81.60 N/A N/A N/A N/A N/A $46.80 N/A N/A $54.60 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $78.00 N/A N/A $40.20 N/A N/A N/A N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 1500403 Supplies BAG DECANTER I.V. 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500404 Supplies DRAPE ARTHROSCOPY KNEE 270 $414.00 $- $107.64 $- $- $331.20 $- N/A $107.64 N/A N/A $156.49 N/A N/A $248.40 N/A N/A $207.00 N/A N/A N/A N/A N/A $281.52 N/A N/A N/A N/A N/A $161.46 N/A N/A $188.37 N/A N/A $331.20 N/A N/A $227.70 N/A N/A $269.10 N/A N/A $138.69 N/A N/A N/A N/A N/A $248.40 N/A N/A $144.90 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $248.40 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A $414.00 $414.00 N/A 1500405 Supplies SPONGE NEURO 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500406 Supplies GLOVE BIOGEL-6 1/2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500407 Supplies GLOVE BIOGEL 6 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500408 Supplies GLOVE BIOGEL-7 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500409 Supplies GLOVE BIOGEL SKINSENSE 7 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500410 Supplies GLOVE BIOGEL 7 1/2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500411 Supplies GLOVE BIOGEL SKINSENSE 75 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500412 Supplies GLOVE BIOGEL 8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500413 Supplies GLOVE BIOGEL 8 1/2 270 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.15 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A N/A N/A N/A $36.27 N/A N/A $42.32 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $60.45 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 1500414 Supplies SPONGE TONSIL MEDIUM 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500415 Supplies EENT PACK 270 $333.00 $- $86.58 $- $- $266.40 $- N/A $86.58 N/A N/A $125.87 N/A N/A $199.80 N/A N/A $166.50 N/A N/A N/A N/A N/A $226.44 N/A N/A N/A N/A N/A $129.87 N/A N/A $151.52 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $216.45 N/A N/A $111.56 N/A N/A N/A N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 1500416 Supplies MESH MARLEX PLUG MEDIUM C1781 C1781 278 "$2,789.00 " $- $725.14 $- $- "$2,231.20 " $- N/A $725.14 N/A N/A "$1,054.24 " N/A N/A "$1,673.40 " N/A N/A "$1,394.50 " N/A N/A N/A N/A N/A "$1,896.52 " N/A N/A N/A N/A N/A "$1,087.71 " N/A N/A "$1,269.00 " N/A N/A "$2,231.20 " N/A N/A "$1,533.95 " N/A N/A "$1,812.85 " N/A N/A $934.32 N/A N/A N/A N/A N/A "$1,673.40 " N/A N/A $976.15 N/A N/A "$1,812.85 " N/A N/A $836.70 N/A N/A "$1,673.40 " N/A N/A "$1,812.85 " N/A N/A $836.70 N/A N/A $836.70 N/A N/A $836.70 N/A N/A $836.70 N/A N/A $836.70 N/A N/A $836.70 N/A "$2,789.00 " "$2,789.00 " N/A 1500417 Supplies MESH MARLEX W/PLUG LARGE C1781 C1781 278 "$2,816.00 " $- $732.16 $- $- "$2,252.80 " $- N/A $732.16 N/A N/A "$1,064.45 " N/A N/A "$1,689.60 " N/A N/A "$1,408.00 " N/A N/A N/A N/A N/A "$1,914.88 " N/A N/A N/A N/A N/A "$1,098.24 " N/A N/A "$1,281.28 " N/A N/A "$2,252.80 " N/A N/A "$1,548.80 " N/A N/A "$1,830.40 " N/A N/A $943.36 N/A N/A N/A N/A N/A "$1,689.60 " N/A N/A $985.60 N/A N/A "$1,830.40 " N/A N/A $844.80 N/A N/A "$1,689.60 " N/A N/A "$1,830.40 " N/A N/A $844.80 N/A N/A $844.80 N/A N/A $844.80 N/A N/A $844.80 N/A N/A $844.80 N/A N/A $844.80 N/A "$2,816.00 " "$2,816.00 " N/A 1500418 Supplies "MARLEX MESH PLUG, SMALL" C1781 C1781 278 "$2,764.00 " $- $718.64 $- $- "$2,211.20 " $- N/A $718.64 N/A N/A "$1,044.79 " N/A N/A "$1,658.40 " N/A N/A "$1,382.00 " N/A N/A N/A N/A N/A "$1,879.52 " N/A N/A N/A N/A N/A "$1,077.96 " N/A N/A "$1,257.62 " N/A N/A "$2,211.20 " N/A N/A "$1,520.20 " N/A N/A "$1,796.60 " N/A N/A $925.94 N/A N/A N/A N/A N/A "$1,658.40 " N/A N/A $967.40 N/A N/A "$1,796.60 " N/A N/A $829.20 N/A N/A "$1,658.40 " N/A N/A "$1,796.60 " N/A N/A $829.20 N/A N/A $829.20 N/A N/A $829.20 N/A N/A $829.20 N/A N/A $829.20 N/A N/A $829.20 N/A "$2,764.00 " "$2,764.00 " N/A 1500419 Supplies ENDO CATCH 270 "$1,510.00 " $- $392.60 $- $- "$1,208.00 " $- N/A $392.60 N/A N/A $570.78 N/A N/A $906.00 N/A N/A $755.00 N/A N/A N/A N/A N/A "$1,026.80 " N/A N/A N/A N/A N/A $588.90 N/A N/A $687.05 N/A N/A "$1,208.00 " N/A N/A $830.50 N/A N/A $981.50 N/A N/A $505.85 N/A N/A N/A N/A N/A $906.00 N/A N/A $528.50 N/A N/A $981.50 N/A N/A $453.00 N/A N/A $906.00 N/A N/A $981.50 N/A N/A $453.00 N/A N/A $453.00 N/A N/A $453.00 N/A N/A $453.00 N/A N/A $453.00 N/A N/A $453.00 N/A "$1,510.00 " "$1,510.00 " N/A 1500420 Supplies DRAIN BLAKE 10MM FLAT FLU 270 $264.00 $- $68.64 $- $- $211.20 $- N/A $68.64 N/A N/A $99.79 N/A N/A $158.40 N/A N/A $132.00 N/A N/A N/A N/A N/A $179.52 N/A N/A N/A N/A N/A $102.96 N/A N/A $120.12 N/A N/A $211.20 N/A N/A $145.20 N/A N/A $171.60 N/A N/A $88.44 N/A N/A N/A N/A N/A $158.40 N/A N/A $92.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $158.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A $264.00 $264.00 N/A 1500421 Supplies DRAIN BLAKE 15FR ROUND 270 $264.00 $- $68.64 $- $- $211.20 $- N/A $68.64 N/A N/A $99.79 N/A N/A $158.40 N/A N/A $132.00 N/A N/A N/A N/A N/A $179.52 N/A N/A N/A N/A N/A $102.96 N/A N/A $120.12 N/A N/A $211.20 N/A N/A $145.20 N/A N/A $171.60 N/A N/A $88.44 N/A N/A N/A N/A N/A $158.40 N/A N/A $92.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $158.40 N/A N/A $171.60 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A N/A $79.20 N/A $264.00 $264.00 N/A 1500422 Supplies DRAIN BLAKE 7MM FLAT FLUT 270 $421.00 $- $109.46 $- $- $336.80 $- N/A $109.46 N/A N/A $159.14 N/A N/A $252.60 N/A N/A $210.50 N/A N/A N/A N/A N/A $286.28 N/A N/A N/A N/A N/A $164.19 N/A N/A $191.56 N/A N/A $336.80 N/A N/A $231.55 N/A N/A $273.65 N/A N/A $141.04 N/A N/A N/A N/A N/A $252.60 N/A N/A $147.35 N/A N/A $273.65 N/A N/A $126.30 N/A N/A $252.60 N/A N/A $273.65 N/A N/A $126.30 N/A N/A $126.30 N/A N/A $126.30 N/A N/A $126.30 N/A N/A $126.30 N/A N/A $126.30 N/A $421.00 $421.00 N/A 1500423 Supplies NOVASURE SYSTEM 270 "$7,201.00 " $- "$1,872.26 " $- $- "$5,760.80 " $- N/A "$1,872.26 " N/A N/A "$2,721.98 " N/A N/A "$4,320.60 " N/A N/A "$3,600.50 " N/A N/A N/A N/A N/A "$4,896.68 " N/A N/A N/A N/A N/A "$2,808.39 " N/A N/A "$3,276.46 " N/A N/A "$5,760.80 " N/A N/A "$3,960.55 " N/A N/A "$4,680.65 " N/A N/A "$2,412.34 " N/A N/A N/A N/A N/A "$4,320.60 " N/A N/A "$2,520.35 " N/A N/A "$4,680.65 " N/A N/A "$2,160.30 " N/A N/A "$4,320.60 " N/A N/A "$4,680.65 " N/A N/A "$2,160.30 " N/A N/A "$2,160.30 " N/A N/A "$2,160.30 " N/A N/A "$2,160.30 " N/A N/A "$2,160.30 " N/A N/A "$2,160.30 " N/A "$7,201.00 " "$7,201.00 " N/A 1500424 Supplies ADIANA 270 "$4,451.00 " $- "$1,157.26 " $- $- "$3,560.80 " $- N/A "$1,157.26 " N/A N/A "$1,682.48 " N/A N/A "$2,670.60 " N/A N/A "$2,225.50 " N/A N/A N/A N/A N/A "$3,026.68 " N/A N/A N/A N/A N/A "$1,735.89 " N/A N/A "$2,025.21 " N/A N/A "$3,560.80 " N/A N/A "$2,448.05 " N/A N/A "$2,893.15 " N/A N/A "$1,491.09 " N/A N/A N/A N/A N/A "$2,670.60 " N/A N/A "$1,557.85 " N/A N/A "$2,893.15 " N/A N/A "$1,335.30 " N/A N/A "$2,670.60 " N/A N/A "$2,893.15 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A N/A "$1,335.30 " N/A "$4,451.00 " "$4,451.00 " N/A 1500425 Supplies ELECT. LOOP 26FR CUTT 270 $576.00 $- $149.76 $- $- $460.80 $- N/A $149.76 N/A N/A $217.73 N/A N/A $345.60 N/A N/A $288.00 N/A N/A N/A N/A N/A $391.68 N/A N/A N/A N/A N/A $224.64 N/A N/A $262.08 N/A N/A $460.80 N/A N/A $316.80 N/A N/A $374.40 N/A N/A $192.96 N/A N/A N/A N/A N/A $345.60 N/A N/A $201.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $345.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A $576.00 $576.00 N/A 1500426 Supplies GLOVE DURAPRENE SZ. 8.5 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500427 Supplies GLOVE DURAPRENE SZ. 8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500428 Supplies GLOVE ORTHOPEDIC 71/2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500429 Supplies GLOVE ORTHO SZ. 7 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500430 Supplies GLOVE ORTHOPEDIC 8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500431 Supplies GLOVE ORTHOPEDIC 8 1/2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500432 Supplies LITHOTOMY PACK 270 $77.00 $- $20.02 $- $- $61.60 $- N/A $20.02 N/A N/A $29.11 N/A N/A $46.20 N/A N/A $38.50 N/A N/A N/A N/A N/A $52.36 N/A N/A N/A N/A N/A $30.03 N/A N/A $35.04 N/A N/A $61.60 N/A N/A $42.35 N/A N/A $50.05 N/A N/A $25.80 N/A N/A N/A N/A N/A $46.20 N/A N/A $26.95 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $46.20 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A $77.00 $77.00 N/A 1500433 Supplies GLOVE STERILE 8 PROTEGRI 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500434 Supplies SPINAL NEEDLE 22gX5 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500435 Supplies SPINAL NEEDLE 22gX7 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500436 Supplies BEAVER BLADE #6400 270 $59.00 $- $15.34 $- $- $47.20 $- N/A $15.34 N/A N/A $22.30 N/A N/A $35.40 N/A N/A $29.50 N/A N/A N/A N/A N/A $40.12 N/A N/A N/A N/A N/A $23.01 N/A N/A $26.85 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $38.35 N/A N/A $19.77 N/A N/A N/A N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 1500437 Supplies WECK-CEL SURGICAL SPEARS 270 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 1500438 Supplies SUTURE VICRYL 1 CT-1 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500439 Supplies SUTURE VICRYL 1 CTX J977H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500440 Supplies SUTURE VICRYL 0 CT-2 J270 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500441 Supplies SUTURE VICRYL 0 CP-2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500442 Supplies SUTURE VICRYL 0 CT-1 CR/8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500443 Supplies SUTURE VICRYL 0 CT-1 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500444 Supplies SUTURE VICRYL 2-0 CT-2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500445 Supplies SUTURE VICRYL 2-0 CT-1 J2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500446 Supplies SUTURE VICRYL 2-0 CP-2 J8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500447 Supplies SUTURE VICRYL 2-0 CP-2 270 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A $36.29 N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A N/A N/A N/A $37.44 N/A N/A $43.68 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $62.40 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 1500448 Supplies SUTURE VICRYL 2-0 CP-1 J2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500449 Supplies SUTURE VICRYL 2-0 SH J417 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500450 Supplies SUTURE VICRYL 2-0 J911T 270 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $18.90 N/A N/A $30.00 N/A N/A $25.00 N/A N/A N/A N/A N/A $34.00 N/A N/A N/A N/A N/A $19.50 N/A N/A $22.75 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $32.50 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 1500451 Supplies SUTURE VICRYL 2-0 CT-2 PO 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500452 Supplies SUTURE VICRYL 3-0 CT-1 J2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500453 Supplies SUTURE VICRYL 3-0 SH J416 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500454 Supplies SUTURE VICRYL 3-0 PS-2 18 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500455 Supplies SUTURE VICRYL 3-0 FS-2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500456 Supplies SUTURE VICRYL 3-0 CP-2 J8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500457 Supplies SUTURE VICRYL 3-0 SH P/O 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500458 Supplies SUTURE VICRYL 4-0 FS-2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500459 Supplies SUTURE VICRYL 4-0 SH J415 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500460 Supplies SUTURE VICRYL 4-0 P3 J494 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500461 Supplies SUTURE TIES VICRYL 0 18''J 270 $50.00 $- $13.00 $- $- $40.00 $- N/A $13.00 N/A N/A $18.90 N/A N/A $30.00 N/A N/A $25.00 N/A N/A N/A N/A N/A $34.00 N/A N/A N/A N/A N/A $19.50 N/A N/A $22.75 N/A N/A $40.00 N/A N/A $27.50 N/A N/A $32.50 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.00 N/A N/A $17.50 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $30.00 N/A N/A $32.50 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A N/A $15.00 N/A $50.00 $50.00 N/A 1500462 Supplies SUTURE VICRYL 5-0 P-2 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500463 Supplies SUTURE TIES VICRYL 3-0 J9 270 $49.00 $- $12.74 $- $- $39.20 $- N/A $12.74 N/A N/A $18.52 N/A N/A $29.40 N/A N/A $24.50 N/A N/A N/A N/A N/A $33.32 N/A N/A N/A N/A N/A $19.11 N/A N/A $22.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $31.85 N/A N/A $16.42 N/A N/A N/A N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 1500464 Supplies SUTURE TIES VICRYL 4-0 18 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 1500465 Supplies SUTURE PROLENE 1 CT-1 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500466 Supplies SUTURE PROLENE 2-0 SH 883 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500467 Supplies SUTURE PROLENE 2-0 FS 868 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500468 Supplies SUTURE PROLENE 3-0 FS-2 8 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500469 Supplies SUTURE PROLENE 4-0 P-3 86 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500470 Supplies SUTURE PROLENE 3-0 FSL 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500471 Supplies SUTURE PROLENE 4-0 PS-2 8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500472 Supplies SUTURE PROLENE 4-0 FS-2 8683G 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500473 Supplies SUTURE PROLENE 4-0 FS-1 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 1500474 Supplies SUTURE PROLENE 5-0 P-3 86 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500475 Supplies SUTURE PROLENE 6-0 P-3 86 270 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500476 Supplies SUTURE PROLENE 7-0 BV-1 270 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1500477 Supplies SUTURE PROLENE 6-0 BV-1 270 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1500478 Supplies SUTURE CHROMIC 0 CT-1 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500479 Supplies SUTURE CHROMIC 1 CT-1 925 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500480 Supplies SUTURE CHROMIC 2-0 CT-1 8 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500481 Supplies SUTURE CHROMIC 3-0 SH 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500482 Supplies SUTURE CHROMIC 4-0 PS-2 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500483 Supplies SUTURE CHROMIC 3-0 RB-1 U 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500484 Supplies SUTURE CHROMIC 4-0 PS4C 2 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500485 Supplies SUTURE CHROMIC 4-0 SH-1 G 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500486 Supplies SUTURE CHROMIC 0 CTX 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500487 Supplies SUTURE CHROMIC 4-0 RB-1 U 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500488 Supplies SUTURE CHROMIC 6-0 PS-3 1 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500489 Supplies SUTURE TIES SILK 0 24''SA- 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500490 Supplies SUTURE SILK 0 SH K834H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500491 Supplies SUTURE SILK 0 CT-1 424H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500492 Supplies SUTURE SILK 2-0 SH K833H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500493 Supplies SUTURE SILK 4-0 SH K831H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500494 Supplies SUTURE ETHILON 3-0 PS-1 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500495 Supplies SUTURE ETHILON 5-0 PS-3 1 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500496 Supplies SUTURE NYLON 5-0 P-3 690G 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500497 Supplies SUTURE ETHILON 6-0 P-1 69 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500498 Supplies SUTURE FIBERWIRE 2 TAPER 270 $120.00 $- $31.20 $- $- $96.00 $- N/A $31.20 N/A N/A $45.36 N/A N/A $72.00 N/A N/A $60.00 N/A N/A N/A N/A N/A $81.60 N/A N/A N/A N/A N/A $46.80 N/A N/A $54.60 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $78.00 N/A N/A $40.20 N/A N/A N/A N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 1500499 Supplies SUTURE FIBERWIRE #5 270 $226.00 $- $58.76 $- $- $180.80 $- N/A $58.76 N/A N/A $85.43 N/A N/A $135.60 N/A N/A $113.00 N/A N/A N/A N/A N/A $153.68 N/A N/A N/A N/A N/A $88.14 N/A N/A $102.83 N/A N/A $180.80 N/A N/A $124.30 N/A N/A $146.90 N/A N/A $75.71 N/A N/A N/A N/A N/A $135.60 N/A N/A $79.10 N/A N/A $146.90 N/A N/A $67.80 N/A N/A $135.60 N/A N/A $146.90 N/A N/A $67.80 N/A N/A $67.80 N/A N/A $67.80 N/A N/A $67.80 N/A N/A $67.80 N/A N/A $67.80 N/A $226.00 $226.00 N/A 1500500 Supplies SUTURE ETHIBOND 0 CX45D 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500501 Supplies SUTURE ETHIBOND 1 (CTX) 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500502 Supplies SUTURE ETHIBOND 2 MO-7 MS 270 $202.00 $- $52.52 $- $- $161.60 $- N/A $52.52 N/A N/A $76.36 N/A N/A $121.20 N/A N/A $101.00 N/A N/A N/A N/A N/A $137.36 N/A N/A N/A N/A N/A $78.78 N/A N/A $91.91 N/A N/A $161.60 N/A N/A $111.10 N/A N/A $131.30 N/A N/A $67.67 N/A N/A N/A N/A N/A $121.20 N/A N/A $70.70 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $121.20 N/A N/A $131.30 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A N/A $60.60 N/A $202.00 $202.00 N/A 1500503 Supplies SUTURE ETHIBOND 1 CT-1 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500504 Supplies LIGACLIP APPLIER 270 $285.00 $- $74.10 $- $- $228.00 $- N/A $74.10 N/A N/A $107.73 N/A N/A $171.00 N/A N/A $142.50 N/A N/A N/A N/A N/A $193.80 N/A N/A N/A N/A N/A $111.15 N/A N/A $129.68 N/A N/A $228.00 N/A N/A $156.75 N/A N/A $185.25 N/A N/A $95.48 N/A N/A N/A N/A N/A $171.00 N/A N/A $99.75 N/A N/A $185.25 N/A N/A $85.50 N/A N/A $171.00 N/A N/A $185.25 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A N/A $85.50 N/A $285.00 $285.00 N/A 1500505 Supplies LIGACLIP LARGE LC-400 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500506 Supplies LIGASURE XTD 270 "$1,864.00 " $- $484.64 $- $- "$1,491.20 " $- N/A $484.64 N/A N/A $704.59 N/A N/A "$1,118.40 " N/A N/A $932.00 N/A N/A N/A N/A N/A "$1,267.52 " N/A N/A N/A N/A N/A $726.96 N/A N/A $848.12 N/A N/A "$1,491.20 " N/A N/A "$1,025.20 " N/A N/A "$1,211.60 " N/A N/A $624.44 N/A N/A N/A N/A N/A "$1,118.40 " N/A N/A $652.40 N/A N/A "$1,211.60 " N/A N/A $559.20 N/A N/A "$1,118.40 " N/A N/A "$1,211.60 " N/A N/A $559.20 N/A N/A $559.20 N/A N/A $559.20 N/A N/A $559.20 N/A N/A $559.20 N/A N/A $559.20 N/A "$1,864.00 " "$1,864.00 " N/A 1500507 Supplies LIGACLIP MEDIUM LC200 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500508 Supplies "LIGACLIP, SMALL MCS20" 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500509 Supplies HEMOCLIP MEDIUM 523600 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500510 Supplies STAPLER RELOAD TLC 75 270 $916.00 $- $238.16 $- $- $732.80 $- N/A $238.16 N/A N/A $346.25 N/A N/A $549.60 N/A N/A $458.00 N/A N/A N/A N/A N/A $622.88 N/A N/A N/A N/A N/A $357.24 N/A N/A $416.78 N/A N/A $732.80 N/A N/A $503.80 N/A N/A $595.40 N/A N/A $306.86 N/A N/A N/A N/A N/A $549.60 N/A N/A $320.60 N/A N/A $595.40 N/A N/A $274.80 N/A N/A $549.60 N/A N/A $595.40 N/A N/A $274.80 N/A N/A $274.80 N/A N/A $274.80 N/A N/A $274.80 N/A N/A $274.80 N/A N/A $274.80 N/A $916.00 $916.00 N/A 1500511 Supplies "STAPLER RELOAD, TCR75" 270 $575.00 $- $149.50 $- $- $460.00 $- N/A $149.50 N/A N/A $217.35 N/A N/A $345.00 N/A N/A $287.50 N/A N/A N/A N/A N/A $391.00 N/A N/A N/A N/A N/A $224.25 N/A N/A $261.63 N/A N/A $460.00 N/A N/A $316.25 N/A N/A $373.75 N/A N/A $192.63 N/A N/A N/A N/A N/A $345.00 N/A N/A $201.25 N/A N/A $373.75 N/A N/A $172.50 N/A N/A $345.00 N/A N/A $373.75 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A N/A $172.50 N/A $575.00 $575.00 N/A 1500512 Supplies "STAPLER RELOAD, TRT75" 270 $500.00 $- $130.00 $- $- $400.00 $- N/A $130.00 N/A N/A $189.00 N/A N/A $300.00 N/A N/A $250.00 N/A N/A N/A N/A N/A $340.00 N/A N/A N/A N/A N/A $195.00 N/A N/A $227.50 N/A N/A $400.00 N/A N/A $275.00 N/A N/A $325.00 N/A N/A $167.50 N/A N/A N/A N/A N/A $300.00 N/A N/A $175.00 N/A N/A $325.00 N/A N/A $150.00 N/A N/A $300.00 N/A N/A $325.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A N/A $150.00 N/A $500.00 $500.00 N/A 1500513 Supplies "STAPLER RELOAD, TR35W" 270 "$1,078.00 " $- $280.28 $- $- $862.40 $- N/A $280.28 N/A N/A $407.48 N/A N/A $646.80 N/A N/A $539.00 N/A N/A N/A N/A N/A $733.04 N/A N/A N/A N/A N/A $420.42 N/A N/A $490.49 N/A N/A $862.40 N/A N/A $592.90 N/A N/A $700.70 N/A N/A $361.13 N/A N/A N/A N/A N/A $646.80 N/A N/A $377.30 N/A N/A $700.70 N/A N/A $323.40 N/A N/A $646.80 N/A N/A $700.70 N/A N/A $323.40 N/A N/A $323.40 N/A N/A $323.40 N/A N/A $323.40 N/A N/A $323.40 N/A N/A $323.40 N/A "$1,078.00 " "$1,078.00 " N/A 1500514 Supplies STAPER RELOAD TR35B 270 $706.00 $- $183.56 $- $- $564.80 $- N/A $183.56 N/A N/A $266.87 N/A N/A $423.60 N/A N/A $353.00 N/A N/A N/A N/A N/A $480.08 N/A N/A N/A N/A N/A $275.34 N/A N/A $321.23 N/A N/A $564.80 N/A N/A $388.30 N/A N/A $458.90 N/A N/A $236.51 N/A N/A N/A N/A N/A $423.60 N/A N/A $247.10 N/A N/A $458.90 N/A N/A $211.80 N/A N/A $423.60 N/A N/A $458.90 N/A N/A $211.80 N/A N/A $211.80 N/A N/A $211.80 N/A N/A $211.80 N/A N/A $211.80 N/A N/A $211.80 N/A $706.00 $706.00 N/A 1500515 Supplies STAPLER ATS-45 270 "$1,705.00 " $- $443.30 $- $- "$1,364.00 " $- N/A $443.30 N/A N/A $644.49 N/A N/A "$1,023.00 " N/A N/A $852.50 N/A N/A N/A N/A N/A "$1,159.40 " N/A N/A N/A N/A N/A $664.95 N/A N/A $775.78 N/A N/A "$1,364.00 " N/A N/A $937.75 N/A N/A "$1,108.25 " N/A N/A $571.18 N/A N/A N/A N/A N/A "$1,023.00 " N/A N/A $596.75 N/A N/A "$1,108.25 " N/A N/A $511.50 N/A N/A "$1,023.00 " N/A N/A "$1,108.25 " N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A N/A $511.50 N/A "$1,705.00 " "$1,705.00 " N/A 1500516 Supplies TROCAR XCEL 12mm. 270 "$1,311.00 " $- $340.86 $- $- "$1,048.80 " $- N/A $340.86 N/A N/A $495.56 N/A N/A $786.60 N/A N/A $655.50 N/A N/A N/A N/A N/A $891.48 N/A N/A N/A N/A N/A $511.29 N/A N/A $596.51 N/A N/A "$1,048.80 " N/A N/A $721.05 N/A N/A $852.15 N/A N/A $439.19 N/A N/A N/A N/A N/A $786.60 N/A N/A $458.85 N/A N/A $852.15 N/A N/A $393.30 N/A N/A $786.60 N/A N/A $852.15 N/A N/A $393.30 N/A N/A $393.30 N/A N/A $393.30 N/A N/A $393.30 N/A N/A $393.30 N/A N/A $393.30 N/A "$1,311.00 " "$1,311.00 " N/A 1500517 Supplies TROCAR 11MM ETHICON D11LT 270 "$1,273.00 " $- $330.98 $- $- "$1,018.40 " $- N/A $330.98 N/A N/A $481.19 N/A N/A $763.80 N/A N/A $636.50 N/A N/A N/A N/A N/A $865.64 N/A N/A N/A N/A N/A $496.47 N/A N/A $579.22 N/A N/A "$1,018.40 " N/A N/A $700.15 N/A N/A $827.45 N/A N/A $426.46 N/A N/A N/A N/A N/A $763.80 N/A N/A $445.55 N/A N/A $827.45 N/A N/A $381.90 N/A N/A $763.80 N/A N/A $827.45 N/A N/A $381.90 N/A N/A $381.90 N/A N/A $381.90 N/A N/A $381.90 N/A N/A $381.90 N/A N/A $381.90 N/A "$1,273.00 " "$1,273.00 " N/A 1500518 Supplies TROCAR 11MM. NON-BLADED 270 "$1,278.00 " $- $332.28 $- $- "$1,022.40 " $- N/A $332.28 N/A N/A $483.08 N/A N/A $766.80 N/A N/A $639.00 N/A N/A N/A N/A N/A $869.04 N/A N/A N/A N/A N/A $498.42 N/A N/A $581.49 N/A N/A "$1,022.40 " N/A N/A $702.90 N/A N/A $830.70 N/A N/A $428.13 N/A N/A N/A N/A N/A $766.80 N/A N/A $447.30 N/A N/A $830.70 N/A N/A $383.40 N/A N/A $766.80 N/A N/A $830.70 N/A N/A $383.40 N/A N/A $383.40 N/A N/A $383.40 N/A N/A $383.40 N/A N/A $383.40 N/A N/A $383.40 N/A "$1,278.00 " "$1,278.00 " N/A 1500519 Supplies VARIES NEEDLE 270 $344.00 $- $89.44 $- $- $275.20 $- N/A $89.44 N/A N/A $130.03 N/A N/A $206.40 N/A N/A $172.00 N/A N/A N/A N/A N/A $233.92 N/A N/A N/A N/A N/A $134.16 N/A N/A $156.52 N/A N/A $275.20 N/A N/A $189.20 N/A N/A $223.60 N/A N/A $115.24 N/A N/A N/A N/A N/A $206.40 N/A N/A $120.40 N/A N/A $223.60 N/A N/A $103.20 N/A N/A $206.40 N/A N/A $223.60 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A N/A $103.20 N/A $344.00 $344.00 N/A 1500520 Supplies REDUCER CAP 270 $98.00 $- $25.48 $- $- $78.40 $- N/A $25.48 N/A N/A $37.04 N/A N/A $58.80 N/A N/A $49.00 N/A N/A N/A N/A N/A $66.64 N/A N/A N/A N/A N/A $38.22 N/A N/A $44.59 N/A N/A $78.40 N/A N/A $53.90 N/A N/A $63.70 N/A N/A $32.83 N/A N/A N/A N/A N/A $58.80 N/A N/A $34.30 N/A N/A $63.70 N/A N/A $29.40 N/A N/A $58.80 N/A N/A $63.70 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A N/A $29.40 N/A $98.00 $98.00 N/A 1500521 Supplies TROCAR BLUNT PORT 270 $866.00 $- $225.16 $- $- $692.80 $- N/A $225.16 N/A N/A $327.35 N/A N/A $519.60 N/A N/A $433.00 N/A N/A N/A N/A N/A $588.88 N/A N/A N/A N/A N/A $337.74 N/A N/A $394.03 N/A N/A $692.80 N/A N/A $476.30 N/A N/A $562.90 N/A N/A $290.11 N/A N/A N/A N/A N/A $519.60 N/A N/A $303.10 N/A N/A $562.90 N/A N/A $259.80 N/A N/A $519.60 N/A N/A $562.90 N/A N/A $259.80 N/A N/A $259.80 N/A N/A $259.80 N/A N/A $259.80 N/A N/A $259.80 N/A N/A $259.80 N/A $866.00 $866.00 N/A 1500522 Supplies SUTURE MONOCRYL 3-0 SH 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500523 Supplies SUTURE MONOCRYL 4-0 PS2 Y496G 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500524 Supplies TAPE UNBILICAL -U11T 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500525 Supplies SUTURE GORE-TEX THX-36 270 $132.00 $- $34.32 $- $- $105.60 $- N/A $34.32 N/A N/A $49.90 N/A N/A $79.20 N/A N/A $66.00 N/A N/A N/A N/A N/A $89.76 N/A N/A N/A N/A N/A $51.48 N/A N/A $60.06 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $85.80 N/A N/A $44.22 N/A N/A N/A N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $79.20 N/A N/A $85.80 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A N/A $39.60 N/A $132.00 $132.00 N/A 1500526 Supplies NEEDLE KEITH STR 2 C1713 C1713 278 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500527 Supplies SUTURE PDS II 3-0 PS-2 270 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 1500528 Supplies SUTURE PDS II #1 CT-1 270 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 1500529 Supplies SUTURE PDS 0 CT-X 270 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 1500530 Supplies SUTURE PDS II 1 TP-1 270 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 1500531 Supplies SUTURE VICRYL 0 UR-6 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500532 Supplies "BUR SHAVER, UNHOODED 4.0" 270 $517.00 $- $134.42 $- $- $413.60 $- N/A $134.42 N/A N/A $195.43 N/A N/A $310.20 N/A N/A $258.50 N/A N/A N/A N/A N/A $351.56 N/A N/A N/A N/A N/A $201.63 N/A N/A $235.24 N/A N/A $413.60 N/A N/A $284.35 N/A N/A $336.05 N/A N/A $173.20 N/A N/A N/A N/A N/A $310.20 N/A N/A $180.95 N/A N/A $336.05 N/A N/A $155.10 N/A N/A $310.20 N/A N/A $336.05 N/A N/A $155.10 N/A N/A $155.10 N/A N/A $155.10 N/A N/A $155.10 N/A N/A $155.10 N/A N/A $155.10 N/A $517.00 $517.00 N/A 1500533 Supplies SHOULDER SUSP KITS 270 $445.00 $- $115.70 $- $- $356.00 $- N/A $115.70 N/A N/A $168.21 N/A N/A $267.00 N/A N/A $222.50 N/A N/A N/A N/A N/A $302.60 N/A N/A N/A N/A N/A $173.55 N/A N/A $202.48 N/A N/A $356.00 N/A N/A $244.75 N/A N/A $289.25 N/A N/A $149.08 N/A N/A N/A N/A N/A $267.00 N/A N/A $155.75 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $267.00 N/A N/A $289.25 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A N/A $133.50 N/A $445.00 $445.00 N/A 1500534 Supplies BURS TPS MICRO-ROUND 3.0 270 $324.00 $- $84.24 $- $- $259.20 $- N/A $84.24 N/A N/A $122.47 N/A N/A $194.40 N/A N/A $162.00 N/A N/A N/A N/A N/A $220.32 N/A N/A N/A N/A N/A $126.36 N/A N/A $147.42 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $210.60 N/A N/A $108.54 N/A N/A N/A N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 1500535 Supplies BURS TPS MICRO ROUND 4.0 270 $324.00 $- $84.24 $- $- $259.20 $- N/A $84.24 N/A N/A $122.47 N/A N/A $194.40 N/A N/A $162.00 N/A N/A N/A N/A N/A $220.32 N/A N/A N/A N/A N/A $126.36 N/A N/A $147.42 N/A N/A $259.20 N/A N/A $178.20 N/A N/A $210.60 N/A N/A $108.54 N/A N/A N/A N/A N/A $194.40 N/A N/A $113.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $194.40 N/A N/A $210.60 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A N/A $97.20 N/A $324.00 $324.00 N/A 1500536 Supplies "SAW BLADE TPS, #111" 270 $630.00 $- $163.80 $- $- $504.00 $- N/A $163.80 N/A N/A $238.14 N/A N/A $378.00 N/A N/A $315.00 N/A N/A N/A N/A N/A $428.40 N/A N/A N/A N/A N/A $245.70 N/A N/A $286.65 N/A N/A $504.00 N/A N/A $346.50 N/A N/A $409.50 N/A N/A $211.05 N/A N/A N/A N/A N/A $378.00 N/A N/A $220.50 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $378.00 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A $630.00 $630.00 N/A 1500537 Supplies "SAW BLADE, TPS #225" 270 $368.00 $- $95.68 $- $- $294.40 $- N/A $95.68 N/A N/A $139.10 N/A N/A $220.80 N/A N/A $184.00 N/A N/A N/A N/A N/A $250.24 N/A N/A N/A N/A N/A $143.52 N/A N/A $167.44 N/A N/A $294.40 N/A N/A $202.40 N/A N/A $239.20 N/A N/A $123.28 N/A N/A N/A N/A N/A $220.80 N/A N/A $128.80 N/A N/A $239.20 N/A N/A $110.40 N/A N/A $220.80 N/A N/A $239.20 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A N/A $110.40 N/A $368.00 $368.00 N/A 1500538 Supplies SAW BLADE TPS 414 270 $347.00 $- $90.22 $- $- $277.60 $- N/A $90.22 N/A N/A $131.17 N/A N/A $208.20 N/A N/A $173.50 N/A N/A N/A N/A N/A $235.96 N/A N/A N/A N/A N/A $135.33 N/A N/A $157.89 N/A N/A $277.60 N/A N/A $190.85 N/A N/A $225.55 N/A N/A $116.25 N/A N/A N/A N/A N/A $208.20 N/A N/A $121.45 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $208.20 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A $347.00 $347.00 N/A 1500539 Supplies "SAW BLADE SAG (MED,WIDE)" 270 $449.00 $- $116.74 $- $- $359.20 $- N/A $116.74 N/A N/A $169.72 N/A N/A $269.40 N/A N/A $224.50 N/A N/A N/A N/A N/A $305.32 N/A N/A N/A N/A N/A $175.11 N/A N/A $204.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $291.85 N/A N/A $150.42 N/A N/A N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 1500540 Supplies "SAW BLADE SAG (WIDE,THIN)" 270 $449.00 $- $116.74 $- $- $359.20 $- N/A $116.74 N/A N/A $169.72 N/A N/A $269.40 N/A N/A $224.50 N/A N/A N/A N/A N/A $305.32 N/A N/A N/A N/A N/A $175.11 N/A N/A $204.30 N/A N/A $359.20 N/A N/A $246.95 N/A N/A $291.85 N/A N/A $150.42 N/A N/A N/A N/A N/A $269.40 N/A N/A $157.15 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $269.40 N/A N/A $291.85 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A N/A $134.70 N/A $449.00 $449.00 N/A 1500541 Supplies SAW BLADE TPS 105 270 $347.00 $- $90.22 $- $- $277.60 $- N/A $90.22 N/A N/A $131.17 N/A N/A $208.20 N/A N/A $173.50 N/A N/A N/A N/A N/A $235.96 N/A N/A N/A N/A N/A $135.33 N/A N/A $157.89 N/A N/A $277.60 N/A N/A $190.85 N/A N/A $225.55 N/A N/A $116.25 N/A N/A N/A N/A N/A $208.20 N/A N/A $121.45 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $208.20 N/A N/A $225.55 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A N/A $104.10 N/A $347.00 $347.00 N/A 1500542 Supplies BURS MICRO EGG 4.0 270 $586.00 $- $152.36 $- $- $468.80 $- N/A $152.36 N/A N/A $221.51 N/A N/A $351.60 N/A N/A $293.00 N/A N/A N/A N/A N/A $398.48 N/A N/A N/A N/A N/A $228.54 N/A N/A $266.63 N/A N/A $468.80 N/A N/A $322.30 N/A N/A $380.90 N/A N/A $196.31 N/A N/A N/A N/A N/A $351.60 N/A N/A $205.10 N/A N/A $380.90 N/A N/A $175.80 N/A N/A $351.60 N/A N/A $380.90 N/A N/A $175.80 N/A N/A $175.80 N/A N/A $175.80 N/A N/A $175.80 N/A N/A $175.80 N/A N/A $175.80 N/A $586.00 $586.00 N/A 1500543 Supplies LARGE STOCKINETTE 270 $55.00 $- $14.30 $- $- $44.00 $- N/A $14.30 N/A N/A $20.79 N/A N/A $33.00 N/A N/A $27.50 N/A N/A N/A N/A N/A $37.40 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.03 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $35.75 N/A N/A $18.43 N/A N/A N/A N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 1500544 Supplies ANCHOR CORKSCREW 5.0 AR-1 C1713 C1713 278 "$1,491.00 " $- $387.66 $- $- "$1,192.80 " $- N/A $387.66 N/A N/A $563.60 N/A N/A $894.60 N/A N/A $745.50 N/A N/A N/A N/A N/A "$1,013.88 " N/A N/A N/A N/A N/A $581.49 N/A N/A $678.41 N/A N/A "$1,192.80 " N/A N/A $820.05 N/A N/A $969.15 N/A N/A $499.49 N/A N/A N/A N/A N/A $894.60 N/A N/A $521.85 N/A N/A $969.15 N/A N/A $447.30 N/A N/A $894.60 N/A N/A $969.15 N/A N/A $447.30 N/A N/A $447.30 N/A N/A $447.30 N/A N/A $447.30 N/A N/A $447.30 N/A N/A $447.30 N/A "$1,491.00 " "$1,491.00 " N/A 1500545 Supplies BOVIE NEEDLE TIP 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500546 Supplies BLANKET HALF TC-2052 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500547 Supplies THERMACARE QUILTS TC-1050 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500548 Supplies DRAIN BLAKE 7MM TROCAR 270 $485.00 $- $126.10 $- $- $388.00 $- N/A $126.10 N/A N/A $183.33 N/A N/A $291.00 N/A N/A $242.50 N/A N/A N/A N/A N/A $329.80 N/A N/A N/A N/A N/A $189.15 N/A N/A $220.68 N/A N/A $388.00 N/A N/A $266.75 N/A N/A $315.25 N/A N/A $162.48 N/A N/A N/A N/A N/A $291.00 N/A N/A $169.75 N/A N/A $315.25 N/A N/A $145.50 N/A N/A $291.00 N/A N/A $315.25 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A N/A $145.50 N/A $485.00 $485.00 N/A 1500549 Supplies HEMOCLIP SMALL 523635 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500550 Supplies INSUFF. TUBING HIGH FLOW 270 $68.00 $- $17.68 $- $- $54.40 $- N/A $17.68 N/A N/A $25.70 N/A N/A $40.80 N/A N/A $34.00 N/A N/A N/A N/A N/A $46.24 N/A N/A N/A N/A N/A $26.52 N/A N/A $30.94 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $44.20 N/A N/A $22.78 N/A N/A N/A N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 1500551 Supplies MARKING PEN W/RULER 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500552 Supplies "BITE BLOCK, CHEKMED BLUE" 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500553 Supplies SNARE SPIRAL 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500554 Supplies SNARE DISPOSABLE (ALL) 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500555 Supplies SNARE OVAL LARGE 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500556 Supplies SNARE SMALL 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500557 Supplies "SNARE, OVAL STANDARD" 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500558 Supplies SNARE HEXAGONAL 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500559 Supplies SUCTION TIP POOLE 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500560 Supplies TROCAR OPTIVIEW 10-12MM 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500561 Supplies "DRAIN, PENROSE 1" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500562 Supplies "DRAIN, PENROSE 3/4" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500563 Supplies DRAIN PENROSE 1/4 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500564 Supplies DRAPE GOWN COOL ZONE LG. 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500565 Supplies DRAPE GOWN COOL ZONE XL 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500566 Supplies DRAPE GOWN COOL ZONE XXL 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500567 Supplies SUTURE VICRYL 0 CP-1 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500568 Supplies SERFAS WAND 4.0 90-S MAX 270 "$1,190.00 " $- $309.40 $- $- $952.00 $- N/A $309.40 N/A N/A $449.82 N/A N/A $714.00 N/A N/A $595.00 N/A N/A N/A N/A N/A $809.20 N/A N/A N/A N/A N/A $464.10 N/A N/A $541.45 N/A N/A $952.00 N/A N/A $654.50 N/A N/A $773.50 N/A N/A $398.65 N/A N/A N/A N/A N/A $714.00 N/A N/A $416.50 N/A N/A $773.50 N/A N/A $357.00 N/A N/A $714.00 N/A N/A $773.50 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A N/A $357.00 N/A "$1,190.00 " "$1,190.00 " N/A 1500569 Supplies STRYKER SURGILAV 270 $296.00 $- $76.96 $- $- $236.80 $- N/A $76.96 N/A N/A $111.89 N/A N/A $177.60 N/A N/A $148.00 N/A N/A N/A N/A N/A $201.28 N/A N/A N/A N/A N/A $115.44 N/A N/A $134.68 N/A N/A $236.80 N/A N/A $162.80 N/A N/A $192.40 N/A N/A $99.16 N/A N/A N/A N/A N/A $177.60 N/A N/A $103.60 N/A N/A $192.40 N/A N/A $88.80 N/A N/A $177.60 N/A N/A $192.40 N/A N/A $88.80 N/A N/A $88.80 N/A N/A $88.80 N/A N/A $88.80 N/A N/A $88.80 N/A N/A $88.80 N/A $296.00 $296.00 N/A 1500570 Supplies STRYKER TOMCAT SHAVER 4.0 270 $518.00 $- $134.68 $- $- $414.40 $- N/A $134.68 N/A N/A $195.80 N/A N/A $310.80 N/A N/A $259.00 N/A N/A N/A N/A N/A $352.24 N/A N/A N/A N/A N/A $202.02 N/A N/A $235.69 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $336.70 N/A N/A $173.53 N/A N/A N/A N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 1500571 Supplies STRYKER PUMP TUBING 270 $477.00 $- $124.02 $- $- $381.60 $- N/A $124.02 N/A N/A $180.31 N/A N/A $286.20 N/A N/A $238.50 N/A N/A N/A N/A N/A $324.36 N/A N/A N/A N/A N/A $186.03 N/A N/A $217.04 N/A N/A $381.60 N/A N/A $262.35 N/A N/A $310.05 N/A N/A $159.80 N/A N/A N/A N/A N/A $286.20 N/A N/A $166.95 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $286.20 N/A N/A $310.05 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A N/A $143.10 N/A $477.00 $477.00 N/A 1500572 Supplies RESECTOR 4.0mm. STRYKER 270 $518.00 $- $134.68 $- $- $414.40 $- N/A $134.68 N/A N/A $195.80 N/A N/A $310.80 N/A N/A $259.00 N/A N/A N/A N/A N/A $352.24 N/A N/A N/A N/A N/A $202.02 N/A N/A $235.69 N/A N/A $414.40 N/A N/A $284.90 N/A N/A $336.70 N/A N/A $173.53 N/A N/A N/A N/A N/A $310.80 N/A N/A $181.30 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $310.80 N/A N/A $336.70 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A N/A $155.40 N/A $518.00 $518.00 N/A 1500573 Supplies BURS BARREL4.0mm. 270 $546.00 $- $141.96 $- $- $436.80 $- N/A $141.96 N/A N/A $206.39 N/A N/A $327.60 N/A N/A $273.00 N/A N/A N/A N/A N/A $371.28 N/A N/A N/A N/A N/A $212.94 N/A N/A $248.43 N/A N/A $436.80 N/A N/A $300.30 N/A N/A $354.90 N/A N/A $182.91 N/A N/A N/A N/A N/A $327.60 N/A N/A $191.10 N/A N/A $354.90 N/A N/A $163.80 N/A N/A $327.60 N/A N/A $354.90 N/A N/A $163.80 N/A N/A $163.80 N/A N/A $163.80 N/A N/A $163.80 N/A N/A $163.80 N/A N/A $163.80 N/A $546.00 $546.00 N/A 1500574 Supplies ANGLED TOMCAT 4.0mm. 270 $576.00 $- $149.76 $- $- $460.80 $- N/A $149.76 N/A N/A $217.73 N/A N/A $345.60 N/A N/A $288.00 N/A N/A N/A N/A N/A $391.68 N/A N/A N/A N/A N/A $224.64 N/A N/A $262.08 N/A N/A $460.80 N/A N/A $316.80 N/A N/A $374.40 N/A N/A $192.96 N/A N/A N/A N/A N/A $345.60 N/A N/A $201.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $345.60 N/A N/A $374.40 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A N/A $172.80 N/A $576.00 $576.00 N/A 1500575 Supplies ANGLED AGRESS. PLUS 4.0mm 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500576 Supplies "CAST PADDING, 3'' STERILE" 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500577 Supplies DYNACAST CASTING 2 270 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1500578 Supplies DYNACAST CASTING 3 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500579 Supplies DYNACAST CASTING 5 270 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1500580 Supplies ARTHROSCOPY SHOULDER PACK 270 $184.00 $- $47.84 $- $- $147.20 $- N/A $47.84 N/A N/A $69.55 N/A N/A $110.40 N/A N/A $92.00 N/A N/A N/A N/A N/A $125.12 N/A N/A N/A N/A N/A $71.76 N/A N/A $83.72 N/A N/A $147.20 N/A N/A $101.20 N/A N/A $119.60 N/A N/A $61.64 N/A N/A N/A N/A N/A $110.40 N/A N/A $64.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $110.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A $184.00 $184.00 N/A 1500581 Supplies "DENVER SPLINT, MEDLARGE" 270 $306.00 $- $79.56 $- $- $244.80 $- N/A $79.56 N/A N/A $115.67 N/A N/A $183.60 N/A N/A $153.00 N/A N/A N/A N/A N/A $208.08 N/A N/A N/A N/A N/A $119.34 N/A N/A $139.23 N/A N/A $244.80 N/A N/A $168.30 N/A N/A $198.90 N/A N/A $102.51 N/A N/A N/A N/A N/A $183.60 N/A N/A $107.10 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $183.60 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A $306.00 $306.00 N/A 1500582 Supplies DENVER SPLINT PETITE 270 $306.00 $- $79.56 $- $- $244.80 $- N/A $79.56 N/A N/A $115.67 N/A N/A $183.60 N/A N/A $153.00 N/A N/A N/A N/A N/A $208.08 N/A N/A N/A N/A N/A $119.34 N/A N/A $139.23 N/A N/A $244.80 N/A N/A $168.30 N/A N/A $198.90 N/A N/A $102.51 N/A N/A N/A N/A N/A $183.60 N/A N/A $107.10 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $183.60 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A $306.00 $306.00 N/A 1500583 Supplies SUCTION/COAGULATOR 8 FR 270 $97.00 $- $25.22 $- $- $77.60 $- N/A $25.22 N/A N/A $36.67 N/A N/A $58.20 N/A N/A $48.50 N/A N/A N/A N/A N/A $65.96 N/A N/A N/A N/A N/A $37.83 N/A N/A $44.14 N/A N/A $77.60 N/A N/A $53.35 N/A N/A $63.05 N/A N/A $32.50 N/A N/A N/A N/A N/A $58.20 N/A N/A $33.95 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $58.20 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A $97.00 $97.00 N/A 1500584 Supplies T-TUBE MODIFIED SILICONE 270 $198.00 $- $51.48 $- $- $158.40 $- N/A $51.48 N/A N/A $74.84 N/A N/A $118.80 N/A N/A $99.00 N/A N/A N/A N/A N/A $134.64 N/A N/A N/A N/A N/A $77.22 N/A N/A $90.09 N/A N/A $158.40 N/A N/A $108.90 N/A N/A $128.70 N/A N/A $66.33 N/A N/A N/A N/A N/A $118.80 N/A N/A $69.30 N/A N/A $128.70 N/A N/A $59.40 N/A N/A $118.80 N/A N/A $128.70 N/A N/A $59.40 N/A N/A $59.40 N/A N/A $59.40 N/A N/A $59.40 N/A N/A $59.40 N/A N/A $59.40 N/A $198.00 $198.00 N/A 1500585 Supplies "REUTER BIVALVE, STANDARD" 270 $214.00 $- $55.64 $- $- $171.20 $- N/A $55.64 N/A N/A $80.89 N/A N/A $128.40 N/A N/A $107.00 N/A N/A N/A N/A N/A $145.52 N/A N/A N/A N/A N/A $83.46 N/A N/A $97.37 N/A N/A $171.20 N/A N/A $117.70 N/A N/A $139.10 N/A N/A $71.69 N/A N/A N/A N/A N/A $128.40 N/A N/A $74.90 N/A N/A $139.10 N/A N/A $64.20 N/A N/A $128.40 N/A N/A $139.10 N/A N/A $64.20 N/A N/A $64.20 N/A N/A $64.20 N/A N/A $64.20 N/A N/A $64.20 N/A N/A $64.20 N/A $214.00 $214.00 N/A 1500586 Supplies "REUTER BIVALVE, LARGE" 270 $270.00 $- $70.20 $- $- $216.00 $- N/A $70.20 N/A N/A $102.06 N/A N/A $162.00 N/A N/A $135.00 N/A N/A N/A N/A N/A $183.60 N/A N/A N/A N/A N/A $105.30 N/A N/A $122.85 N/A N/A $216.00 N/A N/A $148.50 N/A N/A $175.50 N/A N/A $90.45 N/A N/A N/A N/A N/A $162.00 N/A N/A $94.50 N/A N/A $175.50 N/A N/A $81.00 N/A N/A $162.00 N/A N/A $175.50 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A N/A $81.00 N/A $270.00 $270.00 N/A 1500587 Supplies RASP TPS LG.TEAR CROSS C 270 "$1,117.00 " $- $290.42 $- $- $893.60 $- N/A $290.42 N/A N/A $422.23 N/A N/A $670.20 N/A N/A $558.50 N/A N/A N/A N/A N/A $759.56 N/A N/A N/A N/A N/A $435.63 N/A N/A $508.24 N/A N/A $893.60 N/A N/A $614.35 N/A N/A $726.05 N/A N/A $374.20 N/A N/A N/A N/A N/A $670.20 N/A N/A $390.95 N/A N/A $726.05 N/A N/A $335.10 N/A N/A $670.20 N/A N/A $726.05 N/A N/A $335.10 N/A N/A $335.10 N/A N/A $335.10 N/A N/A $335.10 N/A N/A $335.10 N/A N/A $335.10 N/A "$1,117.00 " "$1,117.00 " N/A 1500588 Supplies "RASP, CUT SMALL" 270 "$1,053.00 " $- $273.78 $- $- $842.40 $- N/A $273.78 N/A N/A $398.03 N/A N/A $631.80 N/A N/A $526.50 N/A N/A N/A N/A N/A $716.04 N/A N/A N/A N/A N/A $410.67 N/A N/A $479.12 N/A N/A $842.40 N/A N/A $579.15 N/A N/A $684.45 N/A N/A $352.76 N/A N/A N/A N/A N/A $631.80 N/A N/A $368.55 N/A N/A $684.45 N/A N/A $315.90 N/A N/A $631.80 N/A N/A $684.45 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A N/A $315.90 N/A "$1,053.00 " "$1,053.00 " N/A 1500589 Supplies JURGAN REFILL RACK CREAM 270 $41.00 $- $10.66 $- $- $32.80 $- N/A $10.66 N/A N/A $15.50 N/A N/A $24.60 N/A N/A $20.50 N/A N/A N/A N/A N/A $27.88 N/A N/A N/A N/A N/A $15.99 N/A N/A $18.66 N/A N/A $32.80 N/A N/A $22.55 N/A N/A $26.65 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.60 N/A N/A $14.35 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $24.60 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A $41.00 $41.00 N/A 1500590 Supplies JURGAN REFILL RACK GREEN 270 $41.00 $- $10.66 $- $- $32.80 $- N/A $10.66 N/A N/A $15.50 N/A N/A $24.60 N/A N/A $20.50 N/A N/A N/A N/A N/A $27.88 N/A N/A N/A N/A N/A $15.99 N/A N/A $18.66 N/A N/A $32.80 N/A N/A $22.55 N/A N/A $26.65 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.60 N/A N/A $14.35 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $24.60 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A $41.00 $41.00 N/A 1500591 Supplies JURGAN REFILL RACK YELLOW 270 $41.00 $- $10.66 $- $- $32.80 $- N/A $10.66 N/A N/A $15.50 N/A N/A $24.60 N/A N/A $20.50 N/A N/A N/A N/A N/A $27.88 N/A N/A N/A N/A N/A $15.99 N/A N/A $18.66 N/A N/A $32.80 N/A N/A $22.55 N/A N/A $26.65 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.60 N/A N/A $14.35 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $24.60 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A $41.00 $41.00 N/A 1500592 Supplies MESH OVAL SMALL KUGEL C1781 C1781 278 "$3,195.00 " $- $830.70 $- $- "$2,556.00 " $- N/A $830.70 N/A N/A "$1,207.71 " N/A N/A "$1,917.00 " N/A N/A "$1,597.50 " N/A N/A N/A N/A N/A "$2,172.60 " N/A N/A N/A N/A N/A "$1,246.05 " N/A N/A "$1,453.73 " N/A N/A "$2,556.00 " N/A N/A "$1,757.25 " N/A N/A "$2,076.75 " N/A N/A "$1,070.33 " N/A N/A N/A N/A N/A "$1,917.00 " N/A N/A "$1,118.25 " N/A N/A "$2,076.75 " N/A N/A $958.50 N/A N/A "$1,917.00 " N/A N/A "$2,076.75 " N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A "$3,195.00 " "$3,195.00 " N/A 1500593 Supplies "MESH, SM. ROUND KUGEL" C1781 C1781 278 "$3,499.00 " $- $909.74 $- $- "$2,799.20 " $- N/A $909.74 N/A N/A "$1,322.62 " N/A N/A "$2,099.40 " N/A N/A "$1,749.50 " N/A N/A N/A N/A N/A "$2,379.32 " N/A N/A N/A N/A N/A "$1,364.61 " N/A N/A "$1,592.05 " N/A N/A "$2,799.20 " N/A N/A "$1,924.45 " N/A N/A "$2,274.35 " N/A N/A "$1,172.17 " N/A N/A N/A N/A N/A "$2,099.40 " N/A N/A "$1,224.65 " N/A N/A "$2,274.35 " N/A N/A "$1,049.70 " N/A N/A "$2,099.40 " N/A N/A "$2,274.35 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A "$3,499.00 " "$3,499.00 " N/A 1500594 Supplies MESH OVAL MEDIUM KUGEL C1781 C1781 278 "$3,905.00 " $- "$1,015.30 " $- $- "$3,124.00 " $- N/A "$1,015.30 " N/A N/A "$1,476.09 " N/A N/A "$2,343.00 " N/A N/A "$1,952.50 " N/A N/A N/A N/A N/A "$2,655.40 " N/A N/A N/A N/A N/A "$1,522.95 " N/A N/A "$1,776.78 " N/A N/A "$3,124.00 " N/A N/A "$2,147.75 " N/A N/A "$2,538.25 " N/A N/A "$1,308.18 " N/A N/A N/A N/A N/A "$2,343.00 " N/A N/A "$1,366.75 " N/A N/A "$2,538.25 " N/A N/A "$1,171.50 " N/A N/A "$2,343.00 " N/A N/A "$2,538.25 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A "$3,905.00 " "$3,905.00 " N/A 1500595 Supplies SPECIMEN CONTAINER 4oz 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500596 Supplies SYRINGE ASEPTO 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500597 Supplies FALOPE-RING APPLICATOR 270 "$2,265.00 " $- $588.90 $- $- "$1,812.00 " $- N/A $588.90 N/A N/A $856.17 N/A N/A "$1,359.00 " N/A N/A "$1,132.50 " N/A N/A N/A N/A N/A "$1,540.20 " N/A N/A N/A N/A N/A $883.35 N/A N/A "$1,030.58 " N/A N/A "$1,812.00 " N/A N/A "$1,245.75 " N/A N/A "$1,472.25 " N/A N/A $758.78 N/A N/A N/A N/A N/A "$1,359.00 " N/A N/A $792.75 N/A N/A "$1,472.25 " N/A N/A $679.50 N/A N/A "$1,359.00 " N/A N/A "$1,472.25 " N/A N/A $679.50 N/A N/A $679.50 N/A N/A $679.50 N/A N/A $679.50 N/A N/A $679.50 N/A N/A $679.50 N/A "$2,265.00 " "$2,265.00 " N/A 1500598 Supplies FRED DEFOGGER 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A $29.48 N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A N/A N/A N/A $30.42 N/A N/A $35.49 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $50.70 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 1500599 Supplies MESH SURGIPRO 6X6 278 $300.00 $- $78.00 $- $- $240.00 $- N/A $78.00 N/A N/A $113.40 N/A N/A $180.00 N/A N/A $150.00 N/A N/A N/A N/A N/A $204.00 N/A N/A N/A N/A N/A $117.00 N/A N/A $136.50 N/A N/A $240.00 N/A N/A $165.00 N/A N/A $195.00 N/A N/A $100.50 N/A N/A N/A N/A N/A $180.00 N/A N/A $105.00 N/A N/A $195.00 N/A N/A $90.00 N/A N/A $180.00 N/A N/A $195.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A N/A $90.00 N/A $300.00 $300.00 N/A 1500600 Supplies DRAPE SHEET LARGE ORTHO-U 270 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.00 N/A N/A $20.00 N/A N/A N/A N/A N/A $27.20 N/A N/A N/A N/A N/A $15.60 N/A N/A $18.20 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $26.00 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 1500601 Supplies SPONGE LAP 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500602 Supplies SPONGE RAYTEC 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500603 Supplies "DRAIN, PENROSE 1/2 18" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500604 Supplies SPONGE PEANUT 270 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500605 Supplies STAPLER SKIN 270 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A $36.29 N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A N/A N/A N/A $37.44 N/A N/A $43.68 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $62.40 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 1500606 Supplies CHOLANGIOGRAM CATH OPERAT 270 $208.00 $- $54.08 $- $- $166.40 $- N/A $54.08 N/A N/A $78.62 N/A N/A $124.80 N/A N/A $104.00 N/A N/A N/A N/A N/A $141.44 N/A N/A N/A N/A N/A $81.12 N/A N/A $94.64 N/A N/A $166.40 N/A N/A $114.40 N/A N/A $135.20 N/A N/A $69.68 N/A N/A N/A N/A N/A $124.80 N/A N/A $72.80 N/A N/A $135.20 N/A N/A $62.40 N/A N/A $124.80 N/A N/A $135.20 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A N/A $62.40 N/A $208.00 $208.00 N/A 1500607 Supplies LAP CHOLE CATHETER 270 $248.00 $- $64.48 $- $- $198.40 $- N/A $64.48 N/A N/A $93.74 N/A N/A $148.80 N/A N/A $124.00 N/A N/A N/A N/A N/A $168.64 N/A N/A N/A N/A N/A $96.72 N/A N/A $112.84 N/A N/A $198.40 N/A N/A $136.40 N/A N/A $161.20 N/A N/A $83.08 N/A N/A N/A N/A N/A $148.80 N/A N/A $86.80 N/A N/A $161.20 N/A N/A $74.40 N/A N/A $148.80 N/A N/A $161.20 N/A N/A $74.40 N/A N/A $74.40 N/A N/A $74.40 N/A N/A $74.40 N/A N/A $74.40 N/A N/A $74.40 N/A $248.00 $248.00 N/A 1500608 Supplies SURGICEL 4X8 270 $600.00 $- $156.00 $- $- $480.00 $- N/A $156.00 N/A N/A $226.80 N/A N/A $360.00 N/A N/A $300.00 N/A N/A N/A N/A N/A $408.00 N/A N/A N/A N/A N/A $234.00 N/A N/A $273.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $390.00 N/A N/A $201.00 N/A N/A N/A N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $360.00 N/A N/A $390.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A N/A $180.00 N/A $600.00 $600.00 N/A 1500609 Supplies JUMBO JUG 270 $185.00 $- $48.10 $- $- $148.00 $- N/A $48.10 N/A N/A $69.93 N/A N/A $111.00 N/A N/A $92.50 N/A N/A N/A N/A N/A $125.80 N/A N/A N/A N/A N/A $72.15 N/A N/A $84.18 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $120.25 N/A N/A $61.98 N/A N/A N/A N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 1500610 Supplies DRAPE HAND 270 $106.00 $- $27.56 $- $- $84.80 $- N/A $27.56 N/A N/A $40.07 N/A N/A $63.60 N/A N/A $53.00 N/A N/A N/A N/A N/A $72.08 N/A N/A N/A N/A N/A $41.34 N/A N/A $48.23 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $68.90 N/A N/A $35.51 N/A N/A N/A N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 1500611 Supplies DRAPE C-ARM 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500612 Supplies DRAPE MAYO STAND 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500613 Supplies DRAPE TRANSVERSE LAP 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500614 Supplies DRAPE SHEET LARGE 3/4 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500615 Supplies LTA ANESTHESIA KIT 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500616 Supplies DRAPE STOCKINETTE IMP MED 270 $55.00 $- $14.30 $- $- $44.00 $- N/A $14.30 N/A N/A $20.79 N/A N/A $33.00 N/A N/A $27.50 N/A N/A N/A N/A N/A $37.40 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.03 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $35.75 N/A N/A $18.43 N/A N/A N/A N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 1500617 Supplies SUCTION TIP FRAZIER 270 $108.00 $- $28.08 $- $- $86.40 $- N/A $28.08 N/A N/A $40.82 N/A N/A $64.80 N/A N/A $54.00 N/A N/A N/A N/A N/A $73.44 N/A N/A N/A N/A N/A $42.12 N/A N/A $49.14 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $70.20 N/A N/A $36.18 N/A N/A N/A N/A N/A $64.80 N/A N/A $37.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $64.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A $108.00 $108.00 N/A 1500618 Supplies BOVIE TIP EXT. TEFLON 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500619 Supplies DRAPE SHEET EXTREMITY 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500620 Supplies DRAPE EXTREMITY BILATERA 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500621 Supplies BOVIE PENCIL PACK 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500622 Supplies MAJOR PACK 270 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500623 Supplies DRAPE SHEET LAPAROTOMY 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500624 Supplies LAPAROSCOPY PACK 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500625 Supplies DRAPE UNDERBUTTOCKS 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500626 Supplies BASIN SINGLE 270 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1500627 Supplies DRAPE IOBAN 3M (6650) 270 $70.00 $- $18.20 $- $- $56.00 $- N/A $18.20 N/A N/A $26.46 N/A N/A $42.00 N/A N/A $35.00 N/A N/A N/A N/A N/A $47.60 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $45.50 N/A N/A $23.45 N/A N/A N/A N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 1500628 Supplies DRAPE IOBAN 3M (6651) 270 $70.00 $- $18.20 $- $- $56.00 $- N/A $18.20 N/A N/A $26.46 N/A N/A $42.00 N/A N/A $35.00 N/A N/A N/A N/A N/A $47.60 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $45.50 N/A N/A $23.45 N/A N/A N/A N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 1500629 Supplies DRAPE LEGGINGS STERILE 270 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500630 Supplies PREP DURA 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500631 Supplies DRAPE SHOULDER 270 $124.00 $- $32.24 $- $- $99.20 $- N/A $32.24 N/A N/A $46.87 N/A N/A $74.40 N/A N/A $62.00 N/A N/A N/A N/A N/A $84.32 N/A N/A N/A N/A N/A $48.36 N/A N/A $56.42 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $80.60 N/A N/A $41.54 N/A N/A N/A N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 1500632 Supplies DRAPE PED LAP 270 $97.00 $- $25.22 $- $- $77.60 $- N/A $25.22 N/A N/A $36.67 N/A N/A $58.20 N/A N/A $48.50 N/A N/A N/A N/A N/A $65.96 N/A N/A N/A N/A N/A $37.83 N/A N/A $44.14 N/A N/A $77.60 N/A N/A $53.35 N/A N/A $63.05 N/A N/A $32.50 N/A N/A N/A N/A N/A $58.20 N/A N/A $33.95 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $58.20 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A $97.00 $97.00 N/A 1500633 Supplies DRESSING XEROFORM 5X9 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500634 Supplies DRAPE UNDERBUTTOCK W/FP 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500635 Supplies DRAPE LITHOTOMY W/POUCH 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1500636 Supplies BEAVER BLADE-ORTHO 270 $127.00 $- $33.02 $- $- $101.60 $- N/A $33.02 N/A N/A $48.01 N/A N/A $76.20 N/A N/A $63.50 N/A N/A N/A N/A N/A $86.36 N/A N/A N/A N/A N/A $49.53 N/A N/A $57.79 N/A N/A $101.60 N/A N/A $69.85 N/A N/A $82.55 N/A N/A $42.55 N/A N/A N/A N/A N/A $76.20 N/A N/A $44.45 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $76.20 N/A N/A $82.55 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A N/A $38.10 N/A $127.00 $127.00 N/A 1500637 Supplies TROCAR SPIKE (DISP) 270 $101.00 $- $26.26 $- $- $80.80 $- N/A $26.26 N/A N/A $38.18 N/A N/A $60.60 N/A N/A $50.50 N/A N/A N/A N/A N/A $68.68 N/A N/A N/A N/A N/A $39.39 N/A N/A $45.96 N/A N/A $80.80 N/A N/A $55.55 N/A N/A $65.65 N/A N/A $33.84 N/A N/A N/A N/A N/A $60.60 N/A N/A $35.35 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $60.60 N/A N/A $65.65 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A N/A $30.30 N/A $101.00 $101.00 N/A 1500638 Supplies "KUGEL PATCH, MED. OVAL" C1781 C1781 278 "$3,905.00 " $- "$1,015.30 " $- $- "$3,124.00 " $- N/A "$1,015.30 " N/A N/A "$1,476.09 " N/A N/A "$2,343.00 " N/A N/A "$1,952.50 " N/A N/A N/A N/A N/A "$2,655.40 " N/A N/A N/A N/A N/A "$1,522.95 " N/A N/A "$1,776.78 " N/A N/A "$3,124.00 " N/A N/A "$2,147.75 " N/A N/A "$2,538.25 " N/A N/A "$1,308.18 " N/A N/A N/A N/A N/A "$2,343.00 " N/A N/A "$1,366.75 " N/A N/A "$2,538.25 " N/A N/A "$1,171.50 " N/A N/A "$2,343.00 " N/A N/A "$2,538.25 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A N/A "$1,171.50 " N/A "$3,905.00 " "$3,905.00 " N/A 1500639 Supplies "KUGEL PATCH, SMALL OVAL" C1781 C1781 278 "$3,195.00 " $- $830.70 $- $- "$2,556.00 " $- N/A $830.70 N/A N/A "$1,207.71 " N/A N/A "$1,917.00 " N/A N/A "$1,597.50 " N/A N/A N/A N/A N/A "$2,172.60 " N/A N/A N/A N/A N/A "$1,246.05 " N/A N/A "$1,453.73 " N/A N/A "$2,556.00 " N/A N/A "$1,757.25 " N/A N/A "$2,076.75 " N/A N/A "$1,070.33 " N/A N/A N/A N/A N/A "$1,917.00 " N/A N/A "$1,118.25 " N/A N/A "$2,076.75 " N/A N/A $958.50 N/A N/A "$1,917.00 " N/A N/A "$2,076.75 " N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A N/A $958.50 N/A "$3,195.00 " "$3,195.00 " N/A 1500640 Supplies "MESH PATCH, LG OVAL KUGEL" C1781 C1781 278 "$4,487.00 " $- "$1,166.62 " $- $- "$3,589.60 " $- N/A "$1,166.62 " N/A N/A "$1,696.09 " N/A N/A "$2,692.20 " N/A N/A "$2,243.50 " N/A N/A N/A N/A N/A "$3,051.16 " N/A N/A N/A N/A N/A "$1,749.93 " N/A N/A "$2,041.59 " N/A N/A "$3,589.60 " N/A N/A "$2,467.85 " N/A N/A "$2,916.55 " N/A N/A "$1,503.15 " N/A N/A N/A N/A N/A "$2,692.20 " N/A N/A "$1,570.45 " N/A N/A "$2,916.55 " N/A N/A "$1,346.10 " N/A N/A "$2,692.20 " N/A N/A "$2,916.55 " N/A N/A "$1,346.10 " N/A N/A "$1,346.10 " N/A N/A "$1,346.10 " N/A N/A "$1,346.10 " N/A N/A "$1,346.10 " N/A N/A "$1,346.10 " N/A "$4,487.00 " "$4,487.00 " N/A 1500641 Supplies "MESH, KUGEL COMP. SMALL" C1781 C1781 278 "$3,499.00 " $- $909.74 $- $- "$2,799.20 " $- N/A $909.74 N/A N/A "$1,322.62 " N/A N/A "$2,099.40 " N/A N/A "$1,749.50 " N/A N/A N/A N/A N/A "$2,379.32 " N/A N/A N/A N/A N/A "$1,364.61 " N/A N/A "$1,592.05 " N/A N/A "$2,799.20 " N/A N/A "$1,924.45 " N/A N/A "$2,274.35 " N/A N/A "$1,172.17 " N/A N/A N/A N/A N/A "$2,099.40 " N/A N/A "$1,224.65 " N/A N/A "$2,274.35 " N/A N/A "$1,049.70 " N/A N/A "$2,099.40 " N/A N/A "$2,274.35 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A N/A "$1,049.70 " N/A "$3,499.00 " "$3,499.00 " N/A 1500642 Supplies MESH LG CIRCLE KUGEL C1781 C1781 278 "$3,932.00 " $- "$1,022.32 " $- $- "$3,145.60 " $- N/A "$1,022.32 " N/A N/A "$1,486.30 " N/A N/A "$2,359.20 " N/A N/A "$1,966.00 " N/A N/A N/A N/A N/A "$2,673.76 " N/A N/A N/A N/A N/A "$1,533.48 " N/A N/A "$1,789.06 " N/A N/A "$3,145.60 " N/A N/A "$2,162.60 " N/A N/A "$2,555.80 " N/A N/A "$1,317.22 " N/A N/A N/A N/A N/A "$2,359.20 " N/A N/A "$1,376.20 " N/A N/A "$2,555.80 " N/A N/A "$1,179.60 " N/A N/A "$2,359.20 " N/A N/A "$2,555.80 " N/A N/A "$1,179.60 " N/A N/A "$1,179.60 " N/A N/A "$1,179.60 " N/A N/A "$1,179.60 " N/A N/A "$1,179.60 " N/A N/A "$1,179.60 " N/A "$3,932.00 " "$3,932.00 " N/A 1500643 Supplies MICROLINE M/L CLIP CARTRIDGE 270 $489.00 $- $127.14 $- $- $391.20 $- N/A $127.14 N/A N/A $184.84 N/A N/A $293.40 N/A N/A $244.50 N/A N/A N/A N/A N/A $332.52 N/A N/A N/A N/A N/A $190.71 N/A N/A $222.50 N/A N/A $391.20 N/A N/A $268.95 N/A N/A $317.85 N/A N/A $163.82 N/A N/A N/A N/A N/A $293.40 N/A N/A $171.15 N/A N/A $317.85 N/A N/A $146.70 N/A N/A $293.40 N/A N/A $317.85 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A N/A $146.70 N/A $489.00 $489.00 N/A 1500644 Supplies "LAPAROSCOPIC HOOK, 5MM" 270 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A N/A N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A N/A N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500645 Supplies NEEDLE WHITACRE 22gX3.5 270 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500646 Supplies "LMA, SIZE 3 DISPOSABLE" 270 $169.00 $- $43.94 $- $- $135.20 $- N/A $43.94 N/A N/A $63.88 N/A N/A $101.40 N/A N/A $84.50 N/A N/A N/A N/A N/A $114.92 N/A N/A N/A N/A N/A $65.91 N/A N/A $76.90 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $109.85 N/A N/A $56.62 N/A N/A N/A N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 1500647 Supplies LMA SIZE 4 (DISPOSABLE) 270 $169.00 $- $43.94 $- $- $135.20 $- N/A $43.94 N/A N/A $63.88 N/A N/A $101.40 N/A N/A $84.50 N/A N/A N/A N/A N/A $114.92 N/A N/A N/A N/A N/A $65.91 N/A N/A $76.90 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $109.85 N/A N/A $56.62 N/A N/A N/A N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 1500648 Supplies LMA SIZE 5 (DISPOSABLE) 270 $169.00 $- $43.94 $- $- $135.20 $- N/A $43.94 N/A N/A $63.88 N/A N/A $101.40 N/A N/A $84.50 N/A N/A N/A N/A N/A $114.92 N/A N/A N/A N/A N/A $65.91 N/A N/A $76.90 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $109.85 N/A N/A $56.62 N/A N/A N/A N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 1500649 Supplies DRAPE POLY U CLEAR D1015 270 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.00 N/A N/A $20.00 N/A N/A N/A N/A N/A $27.20 N/A N/A N/A N/A N/A $15.60 N/A N/A $18.20 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $26.00 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 1500650 Supplies DRAPE IMPERVIOUS U- BLUE 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500651 Supplies DRAIN BLAKE 10FR ROUND 270 $333.00 $- $86.58 $- $- $266.40 $- N/A $86.58 N/A N/A $125.87 N/A N/A $199.80 N/A N/A $166.50 N/A N/A N/A N/A N/A $226.44 N/A N/A N/A N/A N/A $129.87 N/A N/A $151.52 N/A N/A $266.40 N/A N/A $183.15 N/A N/A $216.45 N/A N/A $111.56 N/A N/A N/A N/A N/A $199.80 N/A N/A $116.55 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $199.80 N/A N/A $216.45 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A N/A $99.90 N/A $333.00 $333.00 N/A 1500652 Supplies NASAL PACKING POPE POSTER 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500653 Supplies NASAL MEROGEL DRSG STENT 270 $417.00 $- $108.42 $- $- $333.60 $- N/A $108.42 N/A N/A $157.63 N/A N/A $250.20 N/A N/A $208.50 N/A N/A N/A N/A N/A $283.56 N/A N/A N/A N/A N/A $162.63 N/A N/A $189.74 N/A N/A $333.60 N/A N/A $229.35 N/A N/A $271.05 N/A N/A $139.70 N/A N/A N/A N/A N/A $250.20 N/A N/A $145.95 N/A N/A $271.05 N/A N/A $125.10 N/A N/A $250.20 N/A N/A $271.05 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A N/A $125.10 N/A $417.00 $417.00 N/A 1500654 Supplies NASAL MEROPACK DSG STENT 270 $519.00 $- $134.94 $- $- $415.20 $- N/A $134.94 N/A N/A $196.18 N/A N/A $311.40 N/A N/A $259.50 N/A N/A N/A N/A N/A $352.92 N/A N/A N/A N/A N/A $202.41 N/A N/A $236.15 N/A N/A $415.20 N/A N/A $285.45 N/A N/A $337.35 N/A N/A $173.87 N/A N/A N/A N/A N/A $311.40 N/A N/A $181.65 N/A N/A $337.35 N/A N/A $155.70 N/A N/A $311.40 N/A N/A $337.35 N/A N/A $155.70 N/A N/A $155.70 N/A N/A $155.70 N/A N/A $155.70 N/A N/A $155.70 N/A N/A $155.70 N/A $519.00 $519.00 N/A 1500655 Supplies RAINS FRONT.SINUS STENT 270 $318.00 $- $82.68 $- $- $254.40 $- N/A $82.68 N/A N/A $120.20 N/A N/A $190.80 N/A N/A $159.00 N/A N/A N/A N/A N/A $216.24 N/A N/A N/A N/A N/A $124.02 N/A N/A $144.69 N/A N/A $254.40 N/A N/A $174.90 N/A N/A $206.70 N/A N/A $106.53 N/A N/A N/A N/A N/A $190.80 N/A N/A $111.30 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $190.80 N/A N/A $206.70 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A N/A $95.40 N/A $318.00 $318.00 N/A 1500656 Supplies ACE STERILE 4 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500657 Supplies ACE STERILE 6 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500658 Supplies PROBE PLUS HAND CONTROL 270 $345.00 $- $89.70 $- $- $276.00 $- N/A $89.70 N/A N/A $130.41 N/A N/A $207.00 N/A N/A $172.50 N/A N/A N/A N/A N/A $234.60 N/A N/A N/A N/A N/A $134.55 N/A N/A $156.98 N/A N/A $276.00 N/A N/A $189.75 N/A N/A $224.25 N/A N/A $115.58 N/A N/A N/A N/A N/A $207.00 N/A N/A $120.75 N/A N/A $224.25 N/A N/A $103.50 N/A N/A $207.00 N/A N/A $224.25 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A N/A $103.50 N/A $345.00 $345.00 N/A 1500659 Supplies CHOLANGIOGRAPHY KIT 270 $468.00 $- $121.68 $- $- $374.40 $- N/A $121.68 N/A N/A $176.90 N/A N/A $280.80 N/A N/A $234.00 N/A N/A N/A N/A N/A $318.24 N/A N/A N/A N/A N/A $182.52 N/A N/A $212.94 N/A N/A $374.40 N/A N/A $257.40 N/A N/A $304.20 N/A N/A $156.78 N/A N/A N/A N/A N/A $280.80 N/A N/A $163.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $280.80 N/A N/A $304.20 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A N/A $140.40 N/A $468.00 $468.00 N/A 1500660 Supplies VAG. PACKING GAUZE 270 $58.00 $- $15.08 $- $- $46.40 $- N/A $15.08 N/A N/A $21.92 N/A N/A $34.80 N/A N/A $29.00 N/A N/A N/A N/A N/A $39.44 N/A N/A N/A N/A N/A $22.62 N/A N/A $26.39 N/A N/A $46.40 N/A N/A $31.90 N/A N/A $37.70 N/A N/A $19.43 N/A N/A N/A N/A N/A $34.80 N/A N/A $20.30 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $34.80 N/A N/A $37.70 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A N/A $17.40 N/A $58.00 $58.00 N/A 1500661 Supplies STRAIGHT SHOT BLADE CURVE 270 "$1,007.00 " $- $261.82 $- $- $805.60 $- N/A $261.82 N/A N/A $380.65 N/A N/A $604.20 N/A N/A $503.50 N/A N/A N/A N/A N/A $684.76 N/A N/A N/A N/A N/A $392.73 N/A N/A $458.19 N/A N/A $805.60 N/A N/A $553.85 N/A N/A $654.55 N/A N/A $337.35 N/A N/A N/A N/A N/A $604.20 N/A N/A $352.45 N/A N/A $654.55 N/A N/A $302.10 N/A N/A $604.20 N/A N/A $654.55 N/A N/A $302.10 N/A N/A $302.10 N/A N/A $302.10 N/A N/A $302.10 N/A N/A $302.10 N/A N/A $302.10 N/A "$1,007.00 " "$1,007.00 " N/A 1500662 Supplies STRAIGHT SHOT TUBING 270 $213.00 $- $55.38 $- $- $170.40 $- N/A $55.38 N/A N/A $80.51 N/A N/A $127.80 N/A N/A $106.50 N/A N/A N/A N/A N/A $144.84 N/A N/A N/A N/A N/A $83.07 N/A N/A $96.92 N/A N/A $170.40 N/A N/A $117.15 N/A N/A $138.45 N/A N/A $71.36 N/A N/A N/A N/A N/A $127.80 N/A N/A $74.55 N/A N/A $138.45 N/A N/A $63.90 N/A N/A $127.80 N/A N/A $138.45 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A $213.00 $213.00 N/A 1500663 Supplies ESSURE DEVICE 278 "$8,537.00 " $- "$2,219.62 " $- $- "$6,829.60 " $- N/A "$2,219.62 " N/A N/A "$3,226.99 " N/A N/A "$5,122.20 " N/A N/A "$4,268.50 " N/A N/A N/A N/A N/A "$5,805.16 " N/A N/A N/A N/A N/A "$3,329.43 " N/A N/A "$3,884.34 " N/A N/A "$6,829.60 " N/A N/A "$4,695.35 " N/A N/A "$5,549.05 " N/A N/A "$2,859.90 " N/A N/A N/A N/A N/A "$5,122.20 " N/A N/A "$2,987.95 " N/A N/A "$5,549.05 " N/A N/A "$2,561.10 " N/A N/A "$5,122.20 " N/A N/A "$5,549.05 " N/A N/A "$2,561.10 " N/A N/A "$2,561.10 " N/A N/A "$2,561.10 " N/A N/A "$2,561.10 " N/A N/A "$2,561.10 " N/A N/A "$2,561.10 " N/A "$8,537.00 " "$8,537.00 " N/A 1500664 Supplies EVAC 70 COBLATOR WAND 270 "$1,307.00 " $- $339.82 $- $- "$1,045.60 " $- N/A $339.82 N/A N/A $494.05 N/A N/A $784.20 N/A N/A $653.50 N/A N/A N/A N/A N/A $888.76 N/A N/A N/A N/A N/A $509.73 N/A N/A $594.69 N/A N/A "$1,045.60 " N/A N/A $718.85 N/A N/A $849.55 N/A N/A $437.85 N/A N/A N/A N/A N/A $784.20 N/A N/A $457.45 N/A N/A $849.55 N/A N/A $392.10 N/A N/A $784.20 N/A N/A $849.55 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A N/A $392.10 N/A "$1,307.00 " "$1,307.00 " N/A 1500665 Supplies BONE WAX 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500666 Supplies MIC. ENDOCUT SCISSOR TIP 270 $630.00 $- $163.80 $- $- $504.00 $- N/A $163.80 N/A N/A $238.14 N/A N/A $378.00 N/A N/A $315.00 N/A N/A N/A N/A N/A $428.40 N/A N/A N/A N/A N/A $245.70 N/A N/A $286.65 N/A N/A $504.00 N/A N/A $346.50 N/A N/A $409.50 N/A N/A $211.05 N/A N/A N/A N/A N/A $378.00 N/A N/A $220.50 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $378.00 N/A N/A $409.50 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A N/A $189.00 N/A $630.00 $630.00 N/A 1500667 Supplies EAR WICK 9x15mm. 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500668 Supplies ORTHO-GLASS PRE-CUT 3 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500669 Supplies ORTHO GLASS PRE-CUT 5 270 $142.00 $- $36.92 $- $- $113.60 $- N/A $36.92 N/A N/A $53.68 N/A N/A $85.20 N/A N/A $71.00 N/A N/A N/A N/A N/A $96.56 N/A N/A N/A N/A N/A $55.38 N/A N/A $64.61 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $92.30 N/A N/A $47.57 N/A N/A N/A N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 1500670 Supplies OTO. VENT TUBE SHEPHERD 270 $91.00 $- $23.66 $- $- $72.80 $- N/A $23.66 N/A N/A $34.40 N/A N/A $54.60 N/A N/A $45.50 N/A N/A N/A N/A N/A $61.88 N/A N/A N/A N/A N/A $35.49 N/A N/A $41.41 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $59.15 N/A N/A $30.49 N/A N/A N/A N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 1500671 Supplies SUTURE CHROMIC 4-0 1643G 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500672 Supplies SUTURE CHROMIC 1 48G 270 $69.00 $- $17.94 $- $- $55.20 $- N/A $17.94 N/A N/A $26.08 N/A N/A $41.40 N/A N/A $34.50 N/A N/A N/A N/A N/A $46.92 N/A N/A N/A N/A N/A $26.91 N/A N/A $31.40 N/A N/A $55.20 N/A N/A $37.95 N/A N/A $44.85 N/A N/A $23.12 N/A N/A N/A N/A N/A $41.40 N/A N/A $24.15 N/A N/A $44.85 N/A N/A $20.70 N/A N/A $41.40 N/A N/A $44.85 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A N/A $20.70 N/A $69.00 $69.00 N/A 1500673 Supplies SUTURE NYLON 8-0 1716G 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 1500674 Supplies SUTURE CHROMIC 4-0 1793G 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500675 Supplies SUTURE CHROMIC 5-0 1766G 270 $113.00 $- $29.38 $- $- $90.40 $- N/A $29.38 N/A N/A $42.71 N/A N/A $67.80 N/A N/A $56.50 N/A N/A N/A N/A N/A $76.84 N/A N/A N/A N/A N/A $44.07 N/A N/A $51.42 N/A N/A $90.40 N/A N/A $62.15 N/A N/A $73.45 N/A N/A $37.86 N/A N/A N/A N/A N/A $67.80 N/A N/A $39.55 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $67.80 N/A N/A $73.45 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A N/A $33.90 N/A $113.00 $113.00 N/A 1500676 Supplies SUTURE SILK 0 M834G 270 $51.00 $- $13.26 $- $- $40.80 $- N/A $13.26 N/A N/A $19.28 N/A N/A $30.60 N/A N/A $25.50 N/A N/A N/A N/A N/A $34.68 N/A N/A N/A N/A N/A $19.89 N/A N/A $23.21 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $33.15 N/A N/A $17.09 N/A N/A N/A N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 1500677 Supplies SUTURE ETHILON 5-0 1855G 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500678 Supplies SUTURE MONOCRYL 4-0 Y845G 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500679 Supplies SUTURE PLAIN GUT 5-0 686G 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500680 Supplies SUTURE MONOCRYL 2-0 Y227H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500681 Supplies SUTURE ETHIBOND 4-0 X204H 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500682 Supplies SUTURE SURG.STEEL 4-0540G 270 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500683 Supplies SUTURE TICRON 3-0 3109-43 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A $29.48 N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A N/A N/A N/A $30.42 N/A N/A $35.49 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $50.70 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 1500684 Supplies SUTURE TICRON 4-0 2862-34 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500685 Supplies SUTURE ETHIBOND 1 X518H 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500686 Supplies SUTURE ETHIBOND 2-0 CX26D 270 $74.00 $- $19.24 $- $- $59.20 $- N/A $19.24 N/A N/A $27.97 N/A N/A $44.40 N/A N/A $37.00 N/A N/A N/A N/A N/A $50.32 N/A N/A N/A N/A N/A $28.86 N/A N/A $33.67 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $48.10 N/A N/A $24.79 N/A N/A N/A N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 1500687 Supplies SUTURE MONOCRYL 3-0 Y936H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500688 Supplies SUTURE PLAIN GUT 2-0 843H 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500689 Supplies SUTURE PLAIN GUT 4-0 H821 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500690 Supplies SUTURE PLAIN GUT 6-0 1916 270 $49.00 $- $12.74 $- $- $39.20 $- N/A $12.74 N/A N/A $18.52 N/A N/A $29.40 N/A N/A $24.50 N/A N/A N/A N/A N/A $33.32 N/A N/A N/A N/A N/A $19.11 N/A N/A $22.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $31.85 N/A N/A $16.42 N/A N/A N/A N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $29.40 N/A N/A $31.85 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A N/A $14.70 N/A $49.00 $49.00 N/A 1500691 Supplies SUTURE VICRYL 0 J381H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500692 Supplies SUTURE PROLENE 2-0 8533H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500693 Supplies SUTURE PLAIN GUT 2-0 N863 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500694 Supplies SUTURE PROLENE 1 D6958 270 $184.00 $- $47.84 $- $- $147.20 $- N/A $47.84 N/A N/A $69.55 N/A N/A $110.40 N/A N/A $92.00 N/A N/A N/A N/A N/A $125.12 N/A N/A N/A N/A N/A $71.76 N/A N/A $83.72 N/A N/A $147.20 N/A N/A $101.20 N/A N/A $119.60 N/A N/A $61.64 N/A N/A N/A N/A N/A $110.40 N/A N/A $64.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $110.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A $184.00 $184.00 N/A 1500695 Supplies "CAUTERY, FINETIP/HIGH TIP" 270 $55.00 $- $14.30 $- $- $44.00 $- N/A $14.30 N/A N/A $20.79 N/A N/A $33.00 N/A N/A $27.50 N/A N/A N/A N/A N/A $37.40 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.03 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $35.75 N/A N/A $18.43 N/A N/A N/A N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 1500696 Supplies "SPONGE, LAP" 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500697 Supplies "GLOVES, SENSICARE ALOE9.0" 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500698 Supplies K-WIRE .062 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500699 Supplies SUTURE VICRYL CT-1 J946H 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500700 Supplies SUTURE CHROMIC 2-0 SH G123H 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500701 Supplies SUTURE PROLENE SH 8832H 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500702 Supplies SUTURE ETHILON 5-0 PS-2 1666H 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500703 Supplies SUTURE MONOCRYL 4-0 PC3 Y845G 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500704 Supplies "SUTURE VICRYL 2-0, FS-1 J443H" 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500705 Supplies "SUTURE ETHILON 4-0, PS-2 CLEAR 1611G" 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500706 Supplies "SUTURE ETHILON 3-0, PS-2 1669H" 272 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500707 Supplies "SUTURE ETHIBOND, 2-0, OS-4 X519H" 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500708 Supplies "SUTURE ETHIBOND, 2-0, CT-2 X411H" 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500709 Supplies "SUTURE VICRYL 3-0, CT-2, J232H" 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500710 Supplies "QUICKTRACH, ADULT" 272 "$1,094.00 " $- $284.44 $- $- $875.20 $- N/A $284.44 N/A N/A $413.53 N/A N/A $656.40 N/A N/A $547.00 N/A N/A N/A N/A N/A $743.92 N/A N/A N/A N/A N/A $426.66 N/A N/A $497.77 N/A N/A $875.20 N/A N/A $601.70 N/A N/A $711.10 N/A N/A $366.49 N/A N/A N/A N/A N/A $656.40 N/A N/A $382.90 N/A N/A $711.10 N/A N/A $328.20 N/A N/A $656.40 N/A N/A $711.10 N/A N/A $328.20 N/A N/A $328.20 N/A N/A $328.20 N/A N/A $328.20 N/A N/A $328.20 N/A N/A $328.20 N/A "$1,094.00 " "$1,094.00 " N/A 1500711 Supplies SUTURE ETHILON 4-0 P-3 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500712 Supplies SUTURE VICRYL 5-0 PC-3 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500713 Supplies DRAPE TABLE COVER 270 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500714 Supplies SUTURE ETHILON 3-0 1673H 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500715 Supplies SUTURE ETHILON 6-0 P-3 16 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500716 Supplies SUTURE ETHILON 4-0 FS-2 6 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500717 Supplies SUTURE ETHILON 3-0 FS-1 6 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500718 Supplies SUTURE ETHILON 5-0 P3 270 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500719 Supplies SUTURE PROLENE 6-0 P-1 86 270 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500720 Supplies DERMABOND PROPEN 270 $162.00 $- $42.12 $- $- $129.60 $- N/A $42.12 N/A N/A $61.24 N/A N/A $97.20 N/A N/A $81.00 N/A N/A N/A N/A N/A $110.16 N/A N/A N/A N/A N/A $63.18 N/A N/A $73.71 N/A N/A $129.60 N/A N/A $89.10 N/A N/A $105.30 N/A N/A $54.27 N/A N/A N/A N/A N/A $97.20 N/A N/A $56.70 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $97.20 N/A N/A $105.30 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A N/A $48.60 N/A $162.00 $162.00 N/A 1500721 Supplies SUTURE VICRYL 5-0 P-3 J49 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500722 Supplies SUTURE VICRYL 1 CT-1 CR/8 270 $77.00 $- $20.02 $- $- $61.60 $- N/A $20.02 N/A N/A $29.11 N/A N/A $46.20 N/A N/A $38.50 N/A N/A N/A N/A N/A $52.36 N/A N/A N/A N/A N/A $30.03 N/A N/A $35.04 N/A N/A $61.60 N/A N/A $42.35 N/A N/A $50.05 N/A N/A $25.80 N/A N/A N/A N/A N/A $46.20 N/A N/A $26.95 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $46.20 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A $77.00 $77.00 N/A 1500723 Supplies COBAN STERILE 4 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500724 Supplies GLOVE SENSICARE 8 270 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500725 Supplies "TOWEL, OR (6/PK)" 270 $41.00 $- $10.66 $- $- $32.80 $- N/A $10.66 N/A N/A $15.50 N/A N/A $24.60 N/A N/A $20.50 N/A N/A N/A N/A N/A $27.88 N/A N/A N/A N/A N/A $15.99 N/A N/A $18.66 N/A N/A $32.80 N/A N/A $22.55 N/A N/A $26.65 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.60 N/A N/A $14.35 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $24.60 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A $41.00 $41.00 N/A 1500726 Supplies STYLET 14 FR INTUBATION 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500727 Supplies "CAST PADDING, 6" 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500728 Supplies "CAST PADDING, 6'' STERILE" 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500729 Supplies S.C. IRRIGATION 3000ml. 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500730 Supplies TUR TUBING 2-LEAD 270 $59.00 $- $15.34 $- $- $47.20 $- N/A $15.34 N/A N/A $22.30 N/A N/A $35.40 N/A N/A $29.50 N/A N/A N/A N/A N/A $40.12 N/A N/A N/A N/A N/A $23.01 N/A N/A $26.85 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $38.35 N/A N/A $19.77 N/A N/A N/A N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 1500731 Supplies GOWN IMPERVIOUS 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1500732 Supplies BLADE SURGICAL #10 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500733 Supplies BLADE SURGICAL #11 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500734 Supplies BLADE SURGICAL #15 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500735 Supplies "SYRINGE, 10cc. CONTROL" 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500736 Supplies ORTHO GLASS PRE-CUT 4x15 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500737 Supplies ORTHO GLASS PRE-CUT 5x30 270 $102.00 $- $26.52 $- $- $81.60 $- N/A $26.52 N/A N/A $38.56 N/A N/A $61.20 N/A N/A $51.00 N/A N/A N/A N/A N/A $69.36 N/A N/A N/A N/A N/A $39.78 N/A N/A $46.41 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $66.30 N/A N/A $34.17 N/A N/A N/A N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 1500738 Supplies ORTHO GLASS PRE-CUT 6x30 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1500739 Supplies "CATH, FOLEY 3-WAY 18fr." 272 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500740 Supplies ANKLE BRACE 270 $102.00 $- $26.52 $- $- $81.60 $- N/A $26.52 N/A N/A $38.56 N/A N/A $61.20 N/A N/A $51.00 N/A N/A N/A N/A N/A $69.36 N/A N/A N/A N/A N/A $39.78 N/A N/A $46.41 N/A N/A $81.60 N/A N/A $56.10 N/A N/A $66.30 N/A N/A $34.17 N/A N/A N/A N/A N/A $61.20 N/A N/A $35.70 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $61.20 N/A N/A $66.30 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A N/A $30.60 N/A $102.00 $102.00 N/A 1500741 Supplies Z-GUARD PASTE 4oz 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500742 Supplies "HYDRAGUARD PASTE, 4oz." 270 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500743 Supplies "SUTURE, VICRYL 4-0 PS" 272 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 1500747 Supplies "THUMB SPICA, SHORT" 270 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A N/A N/A N/A $39.00 N/A N/A $45.50 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $65.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 1500748 Supplies "THUMB SPICA, LONG" 270 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A N/A N/A N/A $39.00 N/A N/A $45.50 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $65.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 1500749 Supplies GLIDESCOPE STYLET 272 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A N/A N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A N/A N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500750 Supplies GLIDESCOPE BLADE #3 272 $116.00 $- $30.16 $- $- $92.80 $- N/A $30.16 N/A N/A $43.85 N/A N/A $69.60 N/A N/A $58.00 N/A N/A N/A N/A N/A $78.88 N/A N/A N/A N/A N/A $45.24 N/A N/A $52.78 N/A N/A $92.80 N/A N/A $63.80 N/A N/A $75.40 N/A N/A $38.86 N/A N/A N/A N/A N/A $69.60 N/A N/A $40.60 N/A N/A $75.40 N/A N/A $34.80 N/A N/A $69.60 N/A N/A $75.40 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A $116.00 $116.00 N/A 1500751 Supplies 272 $116.00 $- $30.16 $- $- $92.80 $- N/A $30.16 N/A N/A $43.85 N/A N/A $69.60 N/A N/A $58.00 N/A N/A N/A N/A N/A $78.88 N/A N/A N/A N/A N/A $45.24 N/A N/A $52.78 N/A N/A $92.80 N/A N/A $63.80 N/A N/A $75.40 N/A N/A $38.86 N/A N/A N/A N/A N/A $69.60 N/A N/A $40.60 N/A N/A $75.40 N/A N/A $34.80 N/A N/A $69.60 N/A N/A $75.40 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A N/A $34.80 N/A $116.00 $116.00 N/A 1500752 Supplies SILVASORB GEL 1.5oz. 272 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.15 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A N/A N/A N/A $36.27 N/A N/A $42.32 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $60.45 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $55.80 N/A N/A $60.45 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A N/A $27.90 N/A $93.00 $93.00 N/A 1500753 Supplies OPTIFOAM DRESSING 6x6 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1500754 Supplies OPTIFOAM DRESSING 4X4 270 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A $14.36 N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.84 N/A N/A N/A N/A N/A $14.82 N/A N/A $17.29 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $24.70 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 1500755 Supplies GASTROSTOMY TUBE 16FR. 272 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1500756 Supplies GASTROSTOMY TUBE 20FR. 272 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1500757 Supplies 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500757 Supplies PROSHIELD OINTMENT 4 oz. 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500758 Supplies "DEFIB PAD, ADULT LIFEPAK 20" 270 $176.00 $- $45.76 $- $- $140.80 $- N/A $45.76 N/A N/A $66.53 N/A N/A $105.60 N/A N/A $88.00 N/A N/A N/A N/A N/A $119.68 N/A N/A N/A N/A N/A $68.64 N/A N/A $80.08 N/A N/A $140.80 N/A N/A $96.80 N/A N/A $114.40 N/A N/A $58.96 N/A N/A N/A N/A N/A $105.60 N/A N/A $61.60 N/A N/A $114.40 N/A N/A $52.80 N/A N/A $105.60 N/A N/A $114.40 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A $176.00 $176.00 N/A 1500759 Supplies "DEFIB PADS, PEDIATRIC LIFEPAK 20" 270 $250.00 $- $65.00 $- $- $200.00 $- N/A $65.00 N/A N/A $94.50 N/A N/A $150.00 N/A N/A $125.00 N/A N/A N/A N/A N/A $170.00 N/A N/A N/A N/A N/A $97.50 N/A N/A $113.75 N/A N/A $200.00 N/A N/A $137.50 N/A N/A $162.50 N/A N/A $83.75 N/A N/A N/A N/A N/A $150.00 N/A N/A $87.50 N/A N/A $162.50 N/A N/A $75.00 N/A N/A $150.00 N/A N/A $162.50 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A N/A $75.00 N/A $250.00 $250.00 N/A 1500760 Supplies SPANDAGE (PER FOOT) 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500761 Supplies "PELVIC EXAM DEVICE, REGULAR" 272 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500762 Supplies "PELVIC EXAM DEVICE, SMALL" 272 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 1500764 Supplies "FINGER SPLINT, CURVED 3" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500765 Supplies "FINGER SPLINT, CURVED 4" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500766 Supplies "FINGER SPLINT, CURVED 6" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500767 Supplies FINGER SPLINT 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500768 Supplies "FINGER SPLINT, ALUM. 3/4" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500769 Supplies "FINGER SPLINT, ALUM 1/2" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500770 Supplies CPM PADS 270 $120.00 $- $31.20 $- $- $96.00 $- N/A $31.20 N/A N/A $45.36 N/A N/A $72.00 N/A N/A $60.00 N/A N/A N/A N/A N/A $81.60 N/A N/A N/A N/A N/A $46.80 N/A N/A $54.60 N/A N/A $96.00 N/A N/A $66.00 N/A N/A $78.00 N/A N/A $40.20 N/A N/A N/A N/A N/A $72.00 N/A N/A $42.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $72.00 N/A N/A $78.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A N/A $36.00 N/A $120.00 $120.00 N/A 1500771 Supplies "DRAPE, MINOR PROCEDURE" 272 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500772 Supplies EMPTY EVAC CONTAINER 1000ML. 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500773 Supplies HELISTAT 272 "$1,030.00 " $- $267.80 $- $- $824.00 $- N/A $267.80 N/A N/A $389.34 N/A N/A $618.00 N/A N/A $515.00 N/A N/A N/A N/A N/A $700.40 N/A N/A N/A N/A N/A $401.70 N/A N/A $468.65 N/A N/A $824.00 N/A N/A $566.50 N/A N/A $669.50 N/A N/A $345.05 N/A N/A N/A N/A N/A $618.00 N/A N/A $360.50 N/A N/A $669.50 N/A N/A $309.00 N/A N/A $618.00 N/A N/A $669.50 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A N/A $309.00 N/A "$1,030.00 " "$1,030.00 " N/A 1500774 Supplies MORGAN LENS 272 $124.00 $- $32.24 $- $- $99.20 $- N/A $32.24 N/A N/A $46.87 N/A N/A $74.40 N/A N/A $62.00 N/A N/A N/A N/A N/A $84.32 N/A N/A N/A N/A N/A $48.36 N/A N/A $56.42 N/A N/A $99.20 N/A N/A $68.20 N/A N/A $80.60 N/A N/A $41.54 N/A N/A N/A N/A N/A $74.40 N/A N/A $43.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $74.40 N/A N/A $80.60 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A N/A $37.20 N/A $124.00 $124.00 N/A 1500775 Supplies RAPID RHINO 5.5cm. ANT. 272 $225.00 $- $58.50 $- $- $180.00 $- N/A $58.50 N/A N/A $85.05 N/A N/A $135.00 N/A N/A $112.50 N/A N/A N/A N/A N/A $153.00 N/A N/A N/A N/A N/A $87.75 N/A N/A $102.38 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $146.25 N/A N/A $75.38 N/A N/A N/A N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 1500776 Supplies RAPID RHINO 7.5cm. 272 $225.00 $- $58.50 $- $- $180.00 $- N/A $58.50 N/A N/A $85.05 N/A N/A $135.00 N/A N/A $112.50 N/A N/A N/A N/A N/A $153.00 N/A N/A N/A N/A N/A $87.75 N/A N/A $102.38 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $146.25 N/A N/A $75.38 N/A N/A N/A N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 1500777 Supplies RAPID RHINO 7.5cm. POS/AN 272 $225.00 $- $58.50 $- $- $180.00 $- N/A $58.50 N/A N/A $85.05 N/A N/A $135.00 N/A N/A $112.50 N/A N/A N/A N/A N/A $153.00 N/A N/A N/A N/A N/A $87.75 N/A N/A $102.38 N/A N/A $180.00 N/A N/A $123.75 N/A N/A $146.25 N/A N/A $75.38 N/A N/A N/A N/A N/A $135.00 N/A N/A $78.75 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $135.00 N/A N/A $146.25 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A N/A $67.50 N/A $225.00 $225.00 N/A 1500778 Supplies RAPID RHINO 900 272 $427.00 $- $111.02 $- $- $341.60 $- N/A $111.02 N/A N/A $161.41 N/A N/A $256.20 N/A N/A $213.50 N/A N/A N/A N/A N/A $290.36 N/A N/A N/A N/A N/A $166.53 N/A N/A $194.29 N/A N/A $341.60 N/A N/A $234.85 N/A N/A $277.55 N/A N/A $143.05 N/A N/A N/A N/A N/A $256.20 N/A N/A $149.45 N/A N/A $277.55 N/A N/A $128.10 N/A N/A $256.20 N/A N/A $277.55 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A N/A $128.10 N/A $427.00 $427.00 N/A 1500779 Supplies ESOPHOGEAL PROBE 272 $160.00 $- $41.60 $- $- $128.00 $- N/A $41.60 N/A N/A $60.48 N/A N/A $96.00 N/A N/A $80.00 N/A N/A N/A N/A N/A $108.80 N/A N/A N/A N/A N/A $62.40 N/A N/A $72.80 N/A N/A $128.00 N/A N/A $88.00 N/A N/A $104.00 N/A N/A $53.60 N/A N/A N/A N/A N/A $96.00 N/A N/A $56.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $96.00 N/A N/A $104.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A N/A $48.00 N/A $160.00 $160.00 N/A 1500780 Supplies UNNA BOOT 271 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500781 Supplies SUTURE: MERSILENE 5-0 P-3 272 $41.00 $- $10.66 $- $- $32.80 $- N/A $10.66 N/A N/A $15.50 N/A N/A $24.60 N/A N/A $20.50 N/A N/A N/A N/A N/A $27.88 N/A N/A N/A N/A N/A $15.99 N/A N/A $18.66 N/A N/A $32.80 N/A N/A $22.55 N/A N/A $26.65 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.60 N/A N/A $14.35 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $24.60 N/A N/A $26.65 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A N/A $12.30 N/A $41.00 $41.00 N/A 1500782 Supplies "AIR WALKER BOOT, SMALL" L4361 L4361 274 $384.00 $- $99.84 $- $- $307.20 $- N/A $99.84 N/A N/A $145.15 N/A N/A $230.40 N/A N/A $192.00 N/A N/A N/A N/A N/A $261.12 N/A N/A N/A N/A N/A $149.76 N/A N/A $174.72 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $249.60 N/A N/A $128.64 N/A N/A N/A N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 1500783 Supplies "AIR WALKER BOOT, MEDIUM" 270 $384.00 $- $99.84 $- $- $307.20 $- N/A $99.84 N/A N/A $145.15 N/A N/A $230.40 N/A N/A $192.00 N/A N/A N/A N/A N/A $261.12 N/A N/A N/A N/A N/A $149.76 N/A N/A $174.72 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $249.60 N/A N/A $128.64 N/A N/A N/A N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 1500784 Supplies "AIR WALKER BOOT, LARGE" 270 $384.00 $- $99.84 $- $- $307.20 $- N/A $99.84 N/A N/A $145.15 N/A N/A $230.40 N/A N/A $192.00 N/A N/A N/A N/A N/A $261.12 N/A N/A N/A N/A N/A $149.76 N/A N/A $174.72 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $249.60 N/A N/A $128.64 N/A N/A N/A N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 1500785 Supplies "AIR WALKER BOOT, X-LARGE" 270 $384.00 $- $99.84 $- $- $307.20 $- N/A $99.84 N/A N/A $145.15 N/A N/A $230.40 N/A N/A $192.00 N/A N/A N/A N/A N/A $261.12 N/A N/A N/A N/A N/A $149.76 N/A N/A $174.72 N/A N/A $307.20 N/A N/A $211.20 N/A N/A $249.60 N/A N/A $128.64 N/A N/A N/A N/A N/A $230.40 N/A N/A $134.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $230.40 N/A N/A $249.60 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A N/A $115.20 N/A $384.00 $384.00 N/A 1500786 Supplies "CAUTERY, SINGLE USE" 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500787 Supplies "CO2 DETECTOR, ADULT" 270 $125.00 $- $32.50 $- $- $100.00 $- N/A $32.50 N/A N/A $47.25 N/A N/A $75.00 N/A N/A $62.50 N/A N/A N/A N/A N/A $85.00 N/A N/A N/A N/A N/A $48.75 N/A N/A $56.88 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $81.25 N/A N/A $41.88 N/A N/A N/A N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 1500788 Supplies "CO2 DETECTOR, PEDIATRIC" 270 $125.00 $- $32.50 $- $- $100.00 $- N/A $32.50 N/A N/A $47.25 N/A N/A $75.00 N/A N/A $62.50 N/A N/A N/A N/A N/A $85.00 N/A N/A N/A N/A N/A $48.75 N/A N/A $56.88 N/A N/A $100.00 N/A N/A $68.75 N/A N/A $81.25 N/A N/A $41.88 N/A N/A N/A N/A N/A $75.00 N/A N/A $43.75 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $75.00 N/A N/A $81.25 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A N/A $37.50 N/A $125.00 $125.00 N/A 1500789 Supplies NOSEBLEED TRAY 272 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A N/A N/A N/A $39.00 N/A N/A $45.50 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $65.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $60.00 N/A N/A $65.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A N/A $30.00 N/A $100.00 $100.00 N/A 1500790 Supplies SUTURE: PLAIN GUT 4-0 P3 272 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500791 Supplies SUTURE: ETHILON 3-0 PS-1 272 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500792 Supplies SUTURE CHROMIC GUT 5-0 272 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500793 Supplies NOSE CLIPS 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500794 Supplies "PODOUS BOOT, UNIVERSAL" 270 $243.00 $- $63.18 $- $- $194.40 $- N/A $63.18 N/A N/A $91.85 N/A N/A $145.80 N/A N/A $121.50 N/A N/A N/A N/A N/A $165.24 N/A N/A N/A N/A N/A $94.77 N/A N/A $110.57 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $157.95 N/A N/A $81.41 N/A N/A N/A N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 1500795 Supplies BSS IRRIG. SOLUTION 15ml. 272 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500796 Supplies ORTHO GLASS SPLINT 3 INCH 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500797 Supplies ORTHO GLASS SPLINT 4 INCH 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500798 Supplies ORTHO GLASS SPLINT 5 INCH 270 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1500799 Supplies SUTURE VICRYL 4-0 PS-2 272 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500800 Supplies "BUTTON AID, WEIGHTED" 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1500801 Supplies "FORCEP, WITH TEETH" 272 $55.00 $- $14.30 $- $- $44.00 $- N/A $14.30 N/A N/A $20.79 N/A N/A $33.00 N/A N/A $27.50 N/A N/A N/A N/A N/A $37.40 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.03 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $35.75 N/A N/A $18.43 N/A N/A N/A N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 1500802 Supplies NEEDLE TIP ELECTRODE 272 $261.00 $- $67.86 $- $- $208.80 $- N/A $67.86 N/A N/A $98.66 N/A N/A $156.60 N/A N/A $130.50 N/A N/A N/A N/A N/A $177.48 N/A N/A N/A N/A N/A $101.79 N/A N/A $118.76 N/A N/A $208.80 N/A N/A $143.55 N/A N/A $169.65 N/A N/A $87.44 N/A N/A N/A N/A N/A $156.60 N/A N/A $91.35 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $156.60 N/A N/A $169.65 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A N/A $78.30 N/A $261.00 $261.00 N/A 1500803 Supplies "XEROFORM DRESSING, 1x8 INCH" 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500804 Supplies "SKIN HOOK, DOUBLE 2mm." 272 $275.00 $- $71.50 $- $- $220.00 $- N/A $71.50 N/A N/A $103.95 N/A N/A $165.00 N/A N/A $137.50 N/A N/A N/A N/A N/A $187.00 N/A N/A N/A N/A N/A $107.25 N/A N/A $125.13 N/A N/A $220.00 N/A N/A $151.25 N/A N/A $178.75 N/A N/A $92.13 N/A N/A N/A N/A N/A $165.00 N/A N/A $96.25 N/A N/A $178.75 N/A N/A $82.50 N/A N/A $165.00 N/A N/A $178.75 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A N/A $82.50 N/A $275.00 $275.00 N/A 1500805 Supplies "SKIN HOOK, DOUBLE 5mm." 272 $223.00 $- $57.98 $- $- $178.40 $- N/A $57.98 N/A N/A $84.29 N/A N/A $133.80 N/A N/A $111.50 N/A N/A N/A N/A N/A $151.64 N/A N/A N/A N/A N/A $86.97 N/A N/A $101.47 N/A N/A $178.40 N/A N/A $122.65 N/A N/A $144.95 N/A N/A $74.71 N/A N/A N/A N/A N/A $133.80 N/A N/A $78.05 N/A N/A $144.95 N/A N/A $66.90 N/A N/A $133.80 N/A N/A $144.95 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A N/A $66.90 N/A $223.00 $223.00 N/A 1500806 Supplies "SKIN HOOK, SINGLE SIZE 1" 272 $213.00 $- $55.38 $- $- $170.40 $- N/A $55.38 N/A N/A $80.51 N/A N/A $127.80 N/A N/A $106.50 N/A N/A N/A N/A N/A $144.84 N/A N/A N/A N/A N/A $83.07 N/A N/A $96.92 N/A N/A $170.40 N/A N/A $117.15 N/A N/A $138.45 N/A N/A $71.36 N/A N/A N/A N/A N/A $127.80 N/A N/A $74.55 N/A N/A $138.45 N/A N/A $63.90 N/A N/A $127.80 N/A N/A $138.45 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A N/A $63.90 N/A $213.00 $213.00 N/A 1500807 Supplies "SKIN HOOK, SINGLE SIZE 2" 272 $212.00 $- $55.12 $- $- $169.60 $- N/A $55.12 N/A N/A $80.14 N/A N/A $127.20 N/A N/A $106.00 N/A N/A N/A N/A N/A $144.16 N/A N/A N/A N/A N/A $82.68 N/A N/A $96.46 N/A N/A $169.60 N/A N/A $116.60 N/A N/A $137.80 N/A N/A $71.02 N/A N/A N/A N/A N/A $127.20 N/A N/A $74.20 N/A N/A $137.80 N/A N/A $63.60 N/A N/A $127.20 N/A N/A $137.80 N/A N/A $63.60 N/A N/A $63.60 N/A N/A $63.60 N/A N/A $63.60 N/A N/A $63.60 N/A N/A $63.60 N/A $212.00 $212.00 N/A 1500808 Supplies COBAN 2 INCH STERILE TAN 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500809 Supplies "COBAN, 2 INCH NON-STERILE TAN" 271 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500810 Supplies COBAN 3 INCH STERILE TAN 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500811 Supplies "COBAN, 3 INCH NON-STERILE TAN" 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500812 Supplies COBAN 4 INCH NON-STERILE 271 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500813 Supplies COBAN 6 INCH NON-STERILE 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500814 Supplies AIRWAY NASAL 26FR 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500815 Supplies AIRWAY NASAL 28FR 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500816 Supplies AIRWAY NASAL 30FR 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500817 Supplies AIRWAY NASAL 32FR 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500818 Supplies AIRWAY NASAL 34FR 271 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500819 Supplies "FORCEP, HOT BIOPSY" 272 $122.00 $- $31.72 $- $- $97.60 $- N/A $31.72 N/A N/A $46.12 N/A N/A $73.20 N/A N/A $61.00 N/A N/A N/A N/A N/A $82.96 N/A N/A N/A N/A N/A $47.58 N/A N/A $55.51 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $79.30 N/A N/A $40.87 N/A N/A N/A N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 1500820 Supplies "FORCEP, GRASPING" 272 $529.00 $- $137.54 $- $- $423.20 $- N/A $137.54 N/A N/A $199.96 N/A N/A $317.40 N/A N/A $264.50 N/A N/A N/A N/A N/A $359.72 N/A N/A N/A N/A N/A $206.31 N/A N/A $240.70 N/A N/A $423.20 N/A N/A $290.95 N/A N/A $343.85 N/A N/A $177.22 N/A N/A N/A N/A N/A $317.40 N/A N/A $185.15 N/A N/A $343.85 N/A N/A $158.70 N/A N/A $317.40 N/A N/A $343.85 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A N/A $158.70 N/A $529.00 $529.00 N/A 1500821 Supplies "SNARE, POLYPECTOMY" 272 $91.00 $- $23.66 $- $- $72.80 $- N/A $23.66 N/A N/A $34.40 N/A N/A $54.60 N/A N/A $45.50 N/A N/A N/A N/A N/A $61.88 N/A N/A N/A N/A N/A $35.49 N/A N/A $41.41 N/A N/A $72.80 N/A N/A $50.05 N/A N/A $59.15 N/A N/A $30.49 N/A N/A N/A N/A N/A $54.60 N/A N/A $31.85 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $54.60 N/A N/A $59.15 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A N/A $27.30 N/A $91.00 $91.00 N/A 1500822 Supplies TRAPEASE SINGLE CHAMBER 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500823 Supplies "BULB SYRINGE, 3 OZ. SURGERY" 272 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500824 Supplies "CAST PADDING, STERILE 2 INCH" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500825 Supplies "GLOVE, SURGICAL TRIUMPH 7.5" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500826 Supplies "GLOVE, SURGICAL TRIUMPH 8.0" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500827 Supplies K-WIRE .028 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500828 Supplies K-WIRE .035 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500829 Supplies K-WIRE .045 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500830 Supplies "DRESSING, TEGADERM 4x4.75" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500831 Supplies "DRESSING, TEGADERM 6X8" 272 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 1500832 Supplies "GLOVE, SURGICAL 6.5 SIGNATURE TOUCH" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500833 Supplies "GLOVE, SURGICAL 7.0 SIGNATURE TOUCH" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500834 Supplies "GLOVE, SURGICAL 8.5 SIGNATURE TOUCH" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500835 Supplies "GLOVE, SURGICAL 6.5 LF SENSICARE MICRO" 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500836 Supplies "GLOVE, SURGICAL 7.0 LF SENSICARE MICRO" 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500837 Supplies "GLOVE, SURGICAL 7.5 LF SENSICARE MICRO" 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500838 Supplies "GLOVE, SURGICAL 8.0 LF SENSICARE MICRO" 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500839 Supplies "GLOVE, SURGICAL 8.5 LF SENSICARE MICRO" 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500840 Supplies SCRUB BRUSH (NO SOAP) 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500842 Supplies "OPTIFOAM AG, POST-OP STRIP 3.5x10" 272 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500843 Supplies "CANNULA, 7mmX7cm" 272 $150.00 $- $39.00 $- $- $120.00 $- N/A $39.00 N/A N/A $56.70 N/A N/A $90.00 N/A N/A $75.00 N/A N/A N/A N/A N/A $102.00 N/A N/A N/A N/A N/A $58.50 N/A N/A $68.25 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $97.50 N/A N/A $50.25 N/A N/A N/A N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $90.00 N/A N/A $97.50 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A N/A $45.00 N/A $150.00 $150.00 N/A 1500844 Supplies "CANNULA, THREADED 5mm X 75mm" 272 $153.00 $- $39.78 $- $- $122.40 $- N/A $39.78 N/A N/A $57.83 N/A N/A $91.80 N/A N/A $76.50 N/A N/A N/A N/A N/A $104.04 N/A N/A N/A N/A N/A $59.67 N/A N/A $69.62 N/A N/A $122.40 N/A N/A $84.15 N/A N/A $99.45 N/A N/A $51.26 N/A N/A N/A N/A N/A $91.80 N/A N/A $53.55 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $91.80 N/A N/A $99.45 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A N/A $45.90 N/A $153.00 $153.00 N/A 1500845 Supplies STIMUPLEX NEEDLE 24gX1 272 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500846 Supplies SUTURE: ETHIBOND EXCEL 2 272 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1500847 Supplies SUTURE: VICRYL PLUS 1 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500848 Supplies SUTURE: VICRYL PLUS 3-0 272 $77.00 $- $20.02 $- $- $61.60 $- N/A $20.02 N/A N/A $29.11 N/A N/A $46.20 N/A N/A $38.50 N/A N/A N/A N/A N/A $52.36 N/A N/A N/A N/A N/A $30.03 N/A N/A $35.04 N/A N/A $61.60 N/A N/A $42.35 N/A N/A $50.05 N/A N/A $25.80 N/A N/A N/A N/A N/A $46.20 N/A N/A $26.95 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $46.20 N/A N/A $50.05 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A N/A $23.10 N/A $77.00 $77.00 N/A 1500849 Supplies "CHLORAPREP APPLICATOR, ORANGE 26ml." 272 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.00 N/A N/A $20.00 N/A N/A N/A N/A N/A $27.20 N/A N/A N/A N/A N/A $15.60 N/A N/A $18.20 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $26.00 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 1500850 Supplies OMNI JUG 272 $185.00 $- $48.10 $- $- $148.00 $- N/A $48.10 N/A N/A $69.93 N/A N/A $111.00 N/A N/A $92.50 N/A N/A N/A N/A N/A $125.80 N/A N/A N/A N/A N/A $72.15 N/A N/A $84.18 N/A N/A $148.00 N/A N/A $101.75 N/A N/A $120.25 N/A N/A $61.98 N/A N/A N/A N/A N/A $111.00 N/A N/A $64.75 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $111.00 N/A N/A $120.25 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A N/A $55.50 N/A $185.00 $185.00 N/A 1500851 Supplies "CANNULA, THREADED 8.0x75mm." 272 $306.00 $- $79.56 $- $- $244.80 $- N/A $79.56 N/A N/A $115.67 N/A N/A $183.60 N/A N/A $153.00 N/A N/A N/A N/A N/A $208.08 N/A N/A N/A N/A N/A $119.34 N/A N/A $139.23 N/A N/A $244.80 N/A N/A $168.30 N/A N/A $198.90 N/A N/A $102.51 N/A N/A N/A N/A N/A $183.60 N/A N/A $107.10 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $183.60 N/A N/A $198.90 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A N/A $91.80 N/A $306.00 $306.00 N/A 1500852 Supplies "GLOVE, SURGICAL SENSICARE ALOE 6.5" 272 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 1500853 Supplies "GLOVE, SURGICAL SENSICARE LT 6.5" 272 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500854 Supplies "GLOVE, SURGICAL SENSICARE LT 8.0" 272 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500855 Supplies "GLOVE, SURGICAL SENSICARE LT 8.5" 272 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500856 Supplies SUTURE: PROLENE 0 CT-1 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500857 Supplies SUTURE: PDS II 0 TP-1 272 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500858 Supplies RESTON FOAM 1X8X12 270 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1500859 Supplies "DRAPE, STERI U-DRAPE 1015" 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500860 Supplies "NEEDLE INJECTION, GI LAB 25G.x4MM." 272 $361.00 $- $93.86 $- $- $288.80 $- N/A $93.86 N/A N/A $136.46 N/A N/A $216.60 N/A N/A $180.50 N/A N/A N/A N/A N/A $245.48 N/A N/A N/A N/A N/A $140.79 N/A N/A $164.26 N/A N/A $288.80 N/A N/A $198.55 N/A N/A $234.65 N/A N/A $120.94 N/A N/A N/A N/A N/A $216.60 N/A N/A $126.35 N/A N/A $234.65 N/A N/A $108.30 N/A N/A $216.60 N/A N/A $234.65 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A N/A $108.30 N/A $361.00 $361.00 N/A 1500861 Supplies "SCRUB BRUSH, CHG 4%" 272 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1500862 Supplies "SCRUB BRUSH, ULTRADEX 3%" 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500863 Supplies "SCRUB BRUSH, POVIDONE IODINE WET" 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500864 Supplies "MESH, OVAL LARGE" 272 "$2,461.00 " $- $639.86 $- $- "$1,968.80 " $- N/A $639.86 N/A N/A $930.26 N/A N/A "$1,476.60 " N/A N/A "$1,230.50 " N/A N/A N/A N/A N/A "$1,673.48 " N/A N/A N/A N/A N/A $959.79 N/A N/A "$1,119.76 " N/A N/A "$1,968.80 " N/A N/A "$1,353.55 " N/A N/A "$1,599.65 " N/A N/A $824.44 N/A N/A N/A N/A N/A "$1,476.60 " N/A N/A $861.35 N/A N/A "$1,599.65 " N/A N/A $738.30 N/A N/A "$1,476.60 " N/A N/A "$1,599.65 " N/A N/A $738.30 N/A N/A $738.30 N/A N/A $738.30 N/A N/A $738.30 N/A N/A $738.30 N/A N/A $738.30 N/A "$2,461.00 " "$2,461.00 " N/A 1500865 Supplies "MESH, SMALL OVAL VENTRIO" 272 "$1,793.00 " $- $466.18 $- $- "$1,434.40 " $- N/A $466.18 N/A N/A $677.75 N/A N/A "$1,075.80 " N/A N/A $896.50 N/A N/A N/A N/A N/A "$1,219.24 " N/A N/A N/A N/A N/A $699.27 N/A N/A $815.82 N/A N/A "$1,434.40 " N/A N/A $986.15 N/A N/A "$1,165.45 " N/A N/A $600.66 N/A N/A N/A N/A N/A "$1,075.80 " N/A N/A $627.55 N/A N/A "$1,165.45 " N/A N/A $537.90 N/A N/A "$1,075.80 " N/A N/A "$1,165.45 " N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A "$1,793.00 " "$1,793.00 " N/A 1500866 Supplies "MESH, MEDIUM OVAL W/SORBAFLEX" 272 "$2,644.00 " $- $687.44 $- $- "$2,115.20 " $- N/A $687.44 N/A N/A $999.43 N/A N/A "$1,586.40 " N/A N/A "$1,322.00 " N/A N/A N/A N/A N/A "$1,797.92 " N/A N/A N/A N/A N/A "$1,031.16 " N/A N/A "$1,203.02 " N/A N/A "$2,115.20 " N/A N/A "$1,454.20 " N/A N/A "$1,718.60 " N/A N/A $885.74 N/A N/A N/A N/A N/A "$1,586.40 " N/A N/A $925.40 N/A N/A "$1,718.60 " N/A N/A $793.20 N/A N/A "$1,586.40 " N/A N/A "$1,718.60 " N/A N/A $793.20 N/A N/A $793.20 N/A N/A $793.20 N/A N/A $793.20 N/A N/A $793.20 N/A N/A $793.20 N/A "$2,644.00 " "$2,644.00 " N/A 1500867 Supplies "MESH, CIRCLE 4.5'' VENTRIO" 272 "$2,022.00 " $- $525.72 $- $- "$1,617.60 " $- N/A $525.72 N/A N/A $764.32 N/A N/A "$1,213.20 " N/A N/A "$1,011.00 " N/A N/A N/A N/A N/A "$1,374.96 " N/A N/A N/A N/A N/A $788.58 N/A N/A $920.01 N/A N/A "$1,617.60 " N/A N/A "$1,112.10 " N/A N/A "$1,314.30 " N/A N/A $677.37 N/A N/A N/A N/A N/A "$1,213.20 " N/A N/A $707.70 N/A N/A "$1,314.30 " N/A N/A $606.60 N/A N/A "$1,213.20 " N/A N/A "$1,314.30 " N/A N/A $606.60 N/A N/A $606.60 N/A N/A $606.60 N/A N/A $606.60 N/A N/A $606.60 N/A N/A $606.60 N/A "$2,022.00 " "$2,022.00 " N/A 1500868 Supplies "BURR SHAVER, HOODED 4.0" 272 $350.00 $- $91.00 $- $- $280.00 $- N/A $91.00 N/A N/A $132.30 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A $238.00 N/A N/A N/A N/A N/A $136.50 N/A N/A $159.25 N/A N/A $280.00 N/A N/A $192.50 N/A N/A $227.50 N/A N/A $117.25 N/A N/A N/A N/A N/A $210.00 N/A N/A $122.50 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $210.00 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 1500869 Supplies "TUBING, ARTHROSCOPY" 272 $622.00 $- $161.72 $- $- $497.60 $- N/A $161.72 N/A N/A $235.12 N/A N/A $373.20 N/A N/A $311.00 N/A N/A N/A N/A N/A $422.96 N/A N/A N/A N/A N/A $242.58 N/A N/A $283.01 N/A N/A $497.60 N/A N/A $342.10 N/A N/A $404.30 N/A N/A $208.37 N/A N/A N/A N/A N/A $373.20 N/A N/A $217.70 N/A N/A $404.30 N/A N/A $186.60 N/A N/A $373.20 N/A N/A $404.30 N/A N/A $186.60 N/A N/A $186.60 N/A N/A $186.60 N/A N/A $186.60 N/A N/A $186.60 N/A N/A $186.60 N/A $622.00 $622.00 N/A 1500870 Supplies SERFAS WAND 90 ACCELERATOR 272 "$1,163.00 " $- $302.38 $- $- $930.40 $- N/A $302.38 N/A N/A $439.61 N/A N/A $697.80 N/A N/A $581.50 N/A N/A N/A N/A N/A $790.84 N/A N/A N/A N/A N/A $453.57 N/A N/A $529.17 N/A N/A $930.40 N/A N/A $639.65 N/A N/A $755.95 N/A N/A $389.61 N/A N/A N/A N/A N/A $697.80 N/A N/A $407.05 N/A N/A $755.95 N/A N/A $348.90 N/A N/A $697.80 N/A N/A $755.95 N/A N/A $348.90 N/A N/A $348.90 N/A N/A $348.90 N/A N/A $348.90 N/A N/A $348.90 N/A N/A $348.90 N/A "$1,163.00 " "$1,163.00 " N/A 1500871 Supplies SHOULDER/ARM IMMOBILIZER SMALL FEMALE 270 $219.00 $- $56.94 $- $- $175.20 $- N/A $56.94 N/A N/A $82.78 N/A N/A $131.40 N/A N/A $109.50 N/A N/A N/A N/A N/A $148.92 N/A N/A N/A N/A N/A $85.41 N/A N/A $99.65 N/A N/A $175.20 N/A N/A $120.45 N/A N/A $142.35 N/A N/A $73.37 N/A N/A N/A N/A N/A $131.40 N/A N/A $76.65 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $131.40 N/A N/A $142.35 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A N/A $65.70 N/A $219.00 $219.00 N/A 1500872 Supplies ENDOTRACHEAL TUBE 6.0 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500873 Supplies ENDOTRACHEAL TUBE 6.5 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500874 Supplies ENDOTRACHEAL TUBE 7.0 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500875 Supplies ENDOTRACHEAL TUBE 7.5 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500876 Supplies ENDOTRACHEAL TUBE 8.0 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500877 Supplies ENDOTRACHEAL TUBE 8.5 SURGERY 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500878 Supplies "PACK, MINOR SINGLE BASIN" 272 $184.00 $- $47.84 $- $- $147.20 $- N/A $47.84 N/A N/A $69.55 N/A N/A $110.40 N/A N/A $92.00 N/A N/A N/A N/A N/A $125.12 N/A N/A N/A N/A N/A $71.76 N/A N/A $83.72 N/A N/A $147.20 N/A N/A $101.20 N/A N/A $119.60 N/A N/A $61.64 N/A N/A N/A N/A N/A $110.40 N/A N/A $64.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $110.40 N/A N/A $119.60 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A N/A $55.20 N/A $184.00 $184.00 N/A 1500879 Supplies "IMMOBILIZER, SHOULDER W/ABDUCTION MEDIUM" 270 $236.00 $- $61.36 $- $- $188.80 $- N/A $61.36 N/A N/A $89.21 N/A N/A $141.60 N/A N/A $118.00 N/A N/A N/A N/A N/A $160.48 N/A N/A N/A N/A N/A $92.04 N/A N/A $107.38 N/A N/A $188.80 N/A N/A $129.80 N/A N/A $153.40 N/A N/A $79.06 N/A N/A N/A N/A N/A $141.60 N/A N/A $82.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $141.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A $236.00 $236.00 N/A 1500880 Supplies "IMMOBILIZER, SHOULDER W/ABDUCTION LARGE" 272 $236.00 $- $61.36 $- $- $188.80 $- N/A $61.36 N/A N/A $89.21 N/A N/A $141.60 N/A N/A $118.00 N/A N/A N/A N/A N/A $160.48 N/A N/A N/A N/A N/A $92.04 N/A N/A $107.38 N/A N/A $188.80 N/A N/A $129.80 N/A N/A $153.40 N/A N/A $79.06 N/A N/A N/A N/A N/A $141.60 N/A N/A $82.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $141.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A $236.00 $236.00 N/A 1500881 Supplies "IMMOBILIZER, SHOULDER W/ABDUCTION X-LARGE" 270 $236.00 $- $61.36 $- $- $188.80 $- N/A $61.36 N/A N/A $89.21 N/A N/A $141.60 N/A N/A $118.00 N/A N/A N/A N/A N/A $160.48 N/A N/A N/A N/A N/A $92.04 N/A N/A $107.38 N/A N/A $188.80 N/A N/A $129.80 N/A N/A $153.40 N/A N/A $79.06 N/A N/A N/A N/A N/A $141.60 N/A N/A $82.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $141.60 N/A N/A $153.40 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A N/A $70.80 N/A $236.00 $236.00 N/A 1500882 Supplies GELFOAM SPONGE #100 272 $365.00 $- $94.90 $- $- $292.00 $- N/A $94.90 N/A N/A $137.97 N/A N/A $219.00 N/A N/A $182.50 N/A N/A N/A N/A N/A $248.20 N/A N/A N/A N/A N/A $142.35 N/A N/A $166.08 N/A N/A $292.00 N/A N/A $200.75 N/A N/A $237.25 N/A N/A $122.28 N/A N/A N/A N/A N/A $219.00 N/A N/A $127.75 N/A N/A $237.25 N/A N/A $109.50 N/A N/A $219.00 N/A N/A $237.25 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A N/A $109.50 N/A $365.00 $365.00 N/A 1500883 Supplies GELFOAM SPONGE #50 272 $247.00 $- $64.22 $- $- $197.60 $- N/A $64.22 N/A N/A $93.37 N/A N/A $148.20 N/A N/A $123.50 N/A N/A N/A N/A N/A $167.96 N/A N/A N/A N/A N/A $96.33 N/A N/A $112.39 N/A N/A $197.60 N/A N/A $135.85 N/A N/A $160.55 N/A N/A $82.75 N/A N/A N/A N/A N/A $148.20 N/A N/A $86.45 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $148.20 N/A N/A $160.55 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A N/A $74.10 N/A $247.00 $247.00 N/A 1500884 Supplies SUTURE: PROLENE 3-0 PS-2 272 $32.00 $- $8.32 $- $- $25.60 $- N/A $8.32 N/A N/A $12.10 N/A N/A $19.20 N/A N/A $16.00 N/A N/A N/A N/A N/A $21.76 N/A N/A N/A N/A N/A $12.48 N/A N/A $14.56 N/A N/A $25.60 N/A N/A $17.60 N/A N/A $20.80 N/A N/A $10.72 N/A N/A N/A N/A N/A $19.20 N/A N/A $11.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $19.20 N/A N/A $20.80 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A N/A $9.60 N/A $32.00 $32.00 N/A 1500885 Supplies SUTURE: SILK 0 MO-6 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500886 Supplies SUTURE: SILK TIES 2-0 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500887 Supplies SUTURE: SILK TIES 3-0 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500888 Supplies FASTRESPONDER STERNAL IO 270 $884.00 $- $229.84 $- $- $707.20 $- N/A $229.84 N/A N/A $334.15 N/A N/A $530.40 N/A N/A $442.00 N/A N/A N/A N/A N/A $601.12 N/A N/A N/A N/A N/A $344.76 N/A N/A $402.22 N/A N/A $707.20 N/A N/A $486.20 N/A N/A $574.60 N/A N/A $296.14 N/A N/A N/A N/A N/A $530.40 N/A N/A $309.40 N/A N/A $574.60 N/A N/A $265.20 N/A N/A $530.40 N/A N/A $574.60 N/A N/A $265.20 N/A N/A $265.20 N/A N/A $265.20 N/A N/A $265.20 N/A N/A $265.20 N/A N/A $265.20 N/A $884.00 $884.00 N/A 1500889 Supplies SUTURE: SILK 3-0 SH 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500890 Supplies SUTURE: ETHILON 4-0 PS 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500891 Supplies SUTURE: ETHIBOND EXCEL 0 CT-1 272 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500892 Supplies SUTURE: PLAIN GUT 4-0 SH 272 $21.00 $- $5.46 $- $- $16.80 $- N/A $5.46 N/A N/A $7.94 N/A N/A $12.60 N/A N/A $10.50 N/A N/A N/A N/A N/A $14.28 N/A N/A N/A N/A N/A $8.19 N/A N/A $9.56 N/A N/A $16.80 N/A N/A $11.55 N/A N/A $13.65 N/A N/A $7.04 N/A N/A N/A N/A N/A $12.60 N/A N/A $7.35 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $12.60 N/A N/A $13.65 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A N/A $6.30 N/A $21.00 $21.00 N/A 1500893 Supplies SUTURE: MONOCRYL 3-0 PS-2 272 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500894 Supplies SUTURE: MONOCRYL 4-0 SH 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500895 Supplies SUTURE: VICRYL TIES 2-0 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500896 Supplies SUTURE: VICRYL TIES 3-0 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500897 Supplies SUTURE: ETHIBOND EXCEL 2-0 MO-7 272 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1500898 Supplies SUTURE: PLAIN GUT 3-0 SH 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500899 Supplies OPUS SPEEDSCREW IMPLANT 270 $917.00 $- $238.42 $- $- $733.60 $- N/A $238.42 N/A N/A $346.63 N/A N/A $550.20 N/A N/A $458.50 N/A N/A N/A N/A N/A $623.56 N/A N/A N/A N/A N/A $357.63 N/A N/A $417.24 N/A N/A $733.60 N/A N/A $504.35 N/A N/A $596.05 N/A N/A $307.20 N/A N/A N/A N/A N/A $550.20 N/A N/A $320.95 N/A N/A $596.05 N/A N/A $275.10 N/A N/A $550.20 N/A N/A $596.05 N/A N/A $275.10 N/A N/A $275.10 N/A N/A $275.10 N/A N/A $275.10 N/A N/A $275.10 N/A N/A $275.10 N/A $917.00 $917.00 N/A 1500900 Supplies SMARTSTITCH PP MW BLACK COBRAID 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500901 Supplies SPEEDSCREW PLUS W/MC MGW COBRAID 270 "$2,218.00 " $- $576.68 $- $- "$1,774.40 " $- N/A $576.68 N/A N/A $838.40 N/A N/A "$1,330.80 " N/A N/A "$1,109.00 " N/A N/A N/A N/A N/A "$1,508.24 " N/A N/A N/A N/A N/A $865.02 N/A N/A "$1,009.19 " N/A N/A "$1,774.40 " N/A N/A "$1,219.90 " N/A N/A "$1,441.70 " N/A N/A $743.03 N/A N/A N/A N/A N/A "$1,330.80 " N/A N/A $776.30 N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A "$1,330.80 " N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A "$2,218.00 " "$2,218.00 " N/A 1500902 Supplies SMARTSTITCH PP CONNECTOR 270 $429.00 $- $111.54 $- $- $343.20 $- N/A $111.54 N/A N/A $162.16 N/A N/A $257.40 N/A N/A $214.50 N/A N/A N/A N/A N/A $291.72 N/A N/A N/A N/A N/A $167.31 N/A N/A $195.20 N/A N/A $343.20 N/A N/A $235.95 N/A N/A $278.85 N/A N/A $143.72 N/A N/A N/A N/A N/A $257.40 N/A N/A $150.15 N/A N/A $278.85 N/A N/A $128.70 N/A N/A $257.40 N/A N/A $278.85 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A N/A $128.70 N/A $429.00 $429.00 N/A 1500903 Supplies SMARTSTITCH PERFECTPASSER SUTURE CARTRIDGE 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1500904 Supplies CANNULA CLEARTRAC THREADED 8.5x90MM. 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500905 Supplies SPEEDSCREW PLUS W/PP MGW COBRAID 270 "$2,218.00 " $- $576.68 $- $- "$1,774.40 " $- N/A $576.68 N/A N/A $838.40 N/A N/A "$1,330.80 " N/A N/A "$1,109.00 " N/A N/A N/A N/A N/A "$1,508.24 " N/A N/A N/A N/A N/A $865.02 N/A N/A "$1,009.19 " N/A N/A "$1,774.40 " N/A N/A "$1,219.90 " N/A N/A "$1,441.70 " N/A N/A $743.03 N/A N/A N/A N/A N/A "$1,330.80 " N/A N/A $776.30 N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A "$1,330.80 " N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A "$2,218.00 " "$2,218.00 " N/A 1500906 Supplies SPEEDSCREW 5.5MM. PLUS W/PP MW BLACK COBRAID 270 "$2,218.00 " $- $576.68 $- $- "$1,774.40 " $- N/A $576.68 N/A N/A $838.40 N/A N/A "$1,330.80 " N/A N/A "$1,109.00 " N/A N/A N/A N/A N/A "$1,508.24 " N/A N/A N/A N/A N/A $865.02 N/A N/A "$1,009.19 " N/A N/A "$1,774.40 " N/A N/A "$1,219.90 " N/A N/A "$1,441.70 " N/A N/A $743.03 N/A N/A N/A N/A N/A "$1,330.80 " N/A N/A $776.30 N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A "$1,330.80 " N/A N/A "$1,441.70 " N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A N/A $665.40 N/A "$2,218.00 " "$2,218.00 " N/A 1500907 Supplies TUBEGAUZE # 3 272 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500908 Supplies TUBE GAUZE #2 272 $6.00 $- $1.56 $- $- $4.80 $- N/A $1.56 N/A N/A $2.27 N/A N/A $3.60 N/A N/A $3.00 N/A N/A N/A N/A N/A $4.08 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.73 N/A N/A $4.80 N/A N/A $3.30 N/A N/A $3.90 N/A N/A $2.01 N/A N/A N/A N/A N/A $3.60 N/A N/A $2.10 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $3.60 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A $6.00 $6.00 N/A 1500910 Supplies INTRAOSSEOUS KIT 45MM. 270 "$1,006.00 " $- $261.56 $- $- $804.80 $- N/A $261.56 N/A N/A $380.27 N/A N/A $603.60 N/A N/A $503.00 N/A N/A N/A N/A N/A $684.08 N/A N/A N/A N/A N/A $392.34 N/A N/A $457.73 N/A N/A $804.80 N/A N/A $553.30 N/A N/A $653.90 N/A N/A $337.01 N/A N/A N/A N/A N/A $603.60 N/A N/A $352.10 N/A N/A $653.90 N/A N/A $301.80 N/A N/A $603.60 N/A N/A $653.90 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A N/A $301.80 N/A "$1,006.00 " "$1,006.00 " N/A 1500911 Supplies KLING 1 INCH 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500912 Supplies SUTURE: PROLENE 5-0 PS-2 272 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500913 Supplies "BANDAGE, COFLEX 1 INCH" 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500914 Supplies ACE BANDAGE 2 INCH SELF CLOSE 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500915 Supplies SUTURE: PROLENE 5-0 PS-3 272 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1500916 Supplies "KNEE BRACE, SMALL REDDIE" 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500917 Supplies "KNEE BRACE, MEDIUM REDDIE" 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500918 Supplies "KNEE BRACE, LARGE REDDIE" 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500919 Supplies "KNEE BRACE, X-LARGE REDDIE" 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 1500920 Supplies "DRAIN, FLAT 7MM. FULL FLUTED" 272 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500921 Supplies SUTURE ETHILON 5-0 FS-2 272 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1500922 Supplies COVADERM DRESSING 4X10 272 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 1500923 Supplies "TEMP. PROBE, RECTAL PHILIPS SURGERY" 272 $66.00 $- $17.16 $- $- $52.80 $- N/A $17.16 N/A N/A $24.95 N/A N/A $39.60 N/A N/A $33.00 N/A N/A N/A N/A N/A $44.88 N/A N/A N/A N/A N/A $25.74 N/A N/A $30.03 N/A N/A $52.80 N/A N/A $36.30 N/A N/A $42.90 N/A N/A $22.11 N/A N/A N/A N/A N/A $39.60 N/A N/A $23.10 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $39.60 N/A N/A $42.90 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A N/A $19.80 N/A $66.00 $66.00 N/A 1500924 Supplies SAW BLADE TPS #103 270 $216.00 $- $56.16 $- $- $172.80 $- N/A $56.16 N/A N/A $81.65 N/A N/A $129.60 N/A N/A $108.00 N/A N/A N/A N/A N/A $146.88 N/A N/A N/A N/A N/A $84.24 N/A N/A $98.28 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $140.40 N/A N/A $72.36 N/A N/A N/A N/A N/A $129.60 N/A N/A $75.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $129.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A $216.00 $216.00 N/A 1500925 Supplies SAW BLADE TPS #114 270 $216.00 $- $56.16 $- $- $172.80 $- N/A $56.16 N/A N/A $81.65 N/A N/A $129.60 N/A N/A $108.00 N/A N/A N/A N/A N/A $146.88 N/A N/A N/A N/A N/A $84.24 N/A N/A $98.28 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $140.40 N/A N/A $72.36 N/A N/A N/A N/A N/A $129.60 N/A N/A $75.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $129.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A $216.00 $216.00 N/A 1500926 Supplies "FINGER SPLINT, STAXX SET" 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500927 Supplies SAW BLADE TPS #412 270 $216.00 $- $56.16 $- $- $172.80 $- N/A $56.16 N/A N/A $81.65 N/A N/A $129.60 N/A N/A $108.00 N/A N/A N/A N/A N/A $146.88 N/A N/A N/A N/A N/A $84.24 N/A N/A $98.28 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $140.40 N/A N/A $72.36 N/A N/A N/A N/A N/A $129.60 N/A N/A $75.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $129.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A $216.00 $216.00 N/A 1500928 Supplies SAW BLADE TPS #511 270 $216.00 $- $56.16 $- $- $172.80 $- N/A $56.16 N/A N/A $81.65 N/A N/A $129.60 N/A N/A $108.00 N/A N/A N/A N/A N/A $146.88 N/A N/A N/A N/A N/A $84.24 N/A N/A $98.28 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $140.40 N/A N/A $72.36 N/A N/A N/A N/A N/A $129.60 N/A N/A $75.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $129.60 N/A N/A $140.40 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A N/A $64.80 N/A $216.00 $216.00 N/A 1500930 Supplies "DRAPE, MAYO STAND X-LARGE" 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1500931 Supplies "CAST TAPE, 4 INCH DELTA LITE" 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 1500932 Supplies "CAST TAPE, 5 INCH DELTA LITE" 270 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1500933 Supplies K-WIRE 1.1 272 $239.00 $- $62.14 $- $- $191.20 $- N/A $62.14 N/A N/A $90.34 N/A N/A $143.40 N/A N/A $119.50 N/A N/A N/A N/A N/A $162.52 N/A N/A N/A N/A N/A $93.21 N/A N/A $108.75 N/A N/A $191.20 N/A N/A $131.45 N/A N/A $155.35 N/A N/A $80.07 N/A N/A N/A N/A N/A $143.40 N/A N/A $83.65 N/A N/A $155.35 N/A N/A $71.70 N/A N/A $143.40 N/A N/A $155.35 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A N/A $71.70 N/A $239.00 $239.00 N/A 1500934 Supplies SCREW 3.0 X 16 272 "$1,191.00 " $- $309.66 $- $- $952.80 $- N/A $309.66 N/A N/A $450.20 N/A N/A $714.60 N/A N/A $595.50 N/A N/A N/A N/A N/A $809.88 N/A N/A N/A N/A N/A $464.49 N/A N/A $541.91 N/A N/A $952.80 N/A N/A $655.05 N/A N/A $774.15 N/A N/A $398.99 N/A N/A N/A N/A N/A $714.60 N/A N/A $416.85 N/A N/A $774.15 N/A N/A $357.30 N/A N/A $714.60 N/A N/A $774.15 N/A N/A $357.30 N/A N/A $357.30 N/A N/A $357.30 N/A N/A $357.30 N/A N/A $357.30 N/A N/A $357.30 N/A "$1,191.00 " "$1,191.00 " N/A 1500940 Supplies STYLET 6FR. INTUBATION 272 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500941 Supplies "PULL UPS, XX-LARGE" 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500942 Supplies "NASAL PACKING, MEROCEL 2000 4.5" 272 $99.00 $- $25.74 $- $- $79.20 $- N/A $25.74 N/A N/A $37.42 N/A N/A $59.40 N/A N/A $49.50 N/A N/A N/A N/A N/A $67.32 N/A N/A N/A N/A N/A $38.61 N/A N/A $45.05 N/A N/A $79.20 N/A N/A $54.45 N/A N/A $64.35 N/A N/A $33.17 N/A N/A N/A N/A N/A $59.40 N/A N/A $34.65 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $59.40 N/A N/A $64.35 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A N/A $29.70 N/A $99.00 $99.00 N/A 1500943 Supplies "NASAL PACKING, MEROCEL 2000 8.0" 272 $114.00 $- $29.64 $- $- $91.20 $- N/A $29.64 N/A N/A $43.09 N/A N/A $68.40 N/A N/A $57.00 N/A N/A N/A N/A N/A $77.52 N/A N/A N/A N/A N/A $44.46 N/A N/A $51.87 N/A N/A $91.20 N/A N/A $62.70 N/A N/A $74.10 N/A N/A $38.19 N/A N/A N/A N/A N/A $68.40 N/A N/A $39.90 N/A N/A $74.10 N/A N/A $34.20 N/A N/A $68.40 N/A N/A $74.10 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A N/A $34.20 N/A $114.00 $114.00 N/A 1500944 Supplies FULLER SHIELD 272 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 1500945 Supplies SUTURE: VICRYL PLUS 2-0 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500946 Supplies "DRAPE, LAPAROTOMY PEDS" 272 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500947 Supplies "AIRWAY, SUPRAGLOTTIC #4" 272 $303.00 $- $78.78 $- $- $242.40 $- N/A $78.78 N/A N/A $114.53 N/A N/A $181.80 N/A N/A $151.50 N/A N/A N/A N/A N/A $206.04 N/A N/A N/A N/A N/A $118.17 N/A N/A $137.87 N/A N/A $242.40 N/A N/A $166.65 N/A N/A $196.95 N/A N/A $101.51 N/A N/A N/A N/A N/A $181.80 N/A N/A $106.05 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $181.80 N/A N/A $196.95 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A N/A $90.90 N/A $303.00 $303.00 N/A 1500948 Supplies ACTICOAT FLEX 3 DRESSING 4X4 272 $51.00 $- $13.26 $- $- $40.80 $- N/A $13.26 N/A N/A $19.28 N/A N/A $30.60 N/A N/A $25.50 N/A N/A N/A N/A N/A $34.68 N/A N/A N/A N/A N/A $19.89 N/A N/A $23.21 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $33.15 N/A N/A $17.09 N/A N/A N/A N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 1500951 Supplies "FILTERLINE SET, NASAL O2 CO2" 272 $74.00 $- $19.24 $- $- $59.20 $- N/A $19.24 N/A N/A $27.97 N/A N/A $44.40 N/A N/A $37.00 N/A N/A N/A N/A N/A $50.32 N/A N/A N/A N/A N/A $28.86 N/A N/A $33.67 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $48.10 N/A N/A $24.79 N/A N/A N/A N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 1500952 Supplies "DRAIN, FLAT 10mm. FULL" 272 $53.00 $- $13.78 $- $- $42.40 $- N/A $13.78 N/A N/A $20.03 N/A N/A $31.80 N/A N/A $26.50 N/A N/A N/A N/A N/A $36.04 N/A N/A N/A N/A N/A $20.67 N/A N/A $24.12 N/A N/A $42.40 N/A N/A $29.15 N/A N/A $34.45 N/A N/A $17.76 N/A N/A N/A N/A N/A $31.80 N/A N/A $18.55 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $31.80 N/A N/A $34.45 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A N/A $15.90 N/A $53.00 $53.00 N/A 1500953 Supplies "PILLOW, HEADREST RT. INTUBATION SLOT" 272 $74.00 $- $19.24 $- $- $59.20 $- N/A $19.24 N/A N/A $27.97 N/A N/A $44.40 N/A N/A $37.00 N/A N/A N/A N/A N/A $50.32 N/A N/A N/A N/A N/A $28.86 N/A N/A $33.67 N/A N/A $59.20 N/A N/A $40.70 N/A N/A $48.10 N/A N/A $24.79 N/A N/A N/A N/A N/A $44.40 N/A N/A $25.90 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $44.40 N/A N/A $48.10 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A N/A $22.20 N/A $74.00 $74.00 N/A 1500954 Supplies "VENAFLOW CUFF, CALF X-LARGE" 270 $168.00 $- $43.68 $- $- $134.40 $- N/A $43.68 N/A N/A $63.50 N/A N/A $100.80 N/A N/A $84.00 N/A N/A N/A N/A N/A $114.24 N/A N/A N/A N/A N/A $65.52 N/A N/A $76.44 N/A N/A $134.40 N/A N/A $92.40 N/A N/A $109.20 N/A N/A $56.28 N/A N/A N/A N/A N/A $100.80 N/A N/A $58.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $100.80 N/A N/A $109.20 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A N/A $50.40 N/A $168.00 $168.00 N/A 1500955 Supplies "VENAFLOW CUFF, CALF BARIATRIC" 270 $174.00 $- $45.24 $- $- $139.20 $- N/A $45.24 N/A N/A $65.77 N/A N/A $104.40 N/A N/A $87.00 N/A N/A N/A N/A N/A $118.32 N/A N/A N/A N/A N/A $67.86 N/A N/A $79.17 N/A N/A $139.20 N/A N/A $95.70 N/A N/A $113.10 N/A N/A $58.29 N/A N/A N/A N/A N/A $104.40 N/A N/A $60.90 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $104.40 N/A N/A $113.10 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A N/A $52.20 N/A $174.00 $174.00 N/A 1500956 Supplies DOYLE SLIM LINE DRESSING 8.0 272 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500957 Supplies MEPILEX HEEL DRESSING 272 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1500958 Supplies OPTIFOAM SACRUM 7X7 272 $39.00 $- $10.14 $- $- $31.20 $- N/A $10.14 N/A N/A $14.74 N/A N/A $23.40 N/A N/A $19.50 N/A N/A N/A N/A N/A $26.52 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.75 N/A N/A $31.20 N/A N/A $21.45 N/A N/A $25.35 N/A N/A $13.07 N/A N/A N/A N/A N/A $23.40 N/A N/A $13.65 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $23.40 N/A N/A $25.35 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A N/A $11.70 N/A $39.00 $39.00 N/A 1500959 Supplies OPTIFOAM SACRUM 9X9 272 $59.00 $- $15.34 $- $- $47.20 $- N/A $15.34 N/A N/A $22.30 N/A N/A $35.40 N/A N/A $29.50 N/A N/A N/A N/A N/A $40.12 N/A N/A N/A N/A N/A $23.01 N/A N/A $26.85 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $38.35 N/A N/A $19.77 N/A N/A N/A N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 1500960 Supplies SUTURE: PROLENE 5-0 FS-2 272 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1500961 Supplies SIGMOIDOSCOPIC SUCTION 18FR. 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1500962 Supplies SUTURE: CHROMIC 7-0 272 $169.00 $- $43.94 $- $- $135.20 $- N/A $43.94 N/A N/A $63.88 N/A N/A $101.40 N/A N/A $84.50 N/A N/A N/A N/A N/A $114.92 N/A N/A N/A N/A N/A $65.91 N/A N/A $76.90 N/A N/A $135.20 N/A N/A $92.95 N/A N/A $109.85 N/A N/A $56.62 N/A N/A N/A N/A N/A $101.40 N/A N/A $59.15 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $101.40 N/A N/A $109.85 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A N/A $50.70 N/A $169.00 $169.00 N/A 1500963 Supplies SUTURE: SILK 6-0 P-1 272 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1500964 Supplies SUTURE: SILK 4-0 C-3 272 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500965 Supplies BULB SYRINGE 1 OZ. 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1500966 Supplies URO-CATCHER BAG 270 $108.00 $- $28.08 $- $- $86.40 $- N/A $28.08 N/A N/A $40.82 N/A N/A $64.80 N/A N/A $54.00 N/A N/A N/A N/A N/A $73.44 N/A N/A N/A N/A N/A $42.12 N/A N/A $49.14 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $70.20 N/A N/A $36.18 N/A N/A N/A N/A N/A $64.80 N/A N/A $37.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $64.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A $108.00 $108.00 N/A 1500967 Supplies NEPHROSTOMY BAG 500ML. 270 $189.00 $- $49.14 $- $- $151.20 $- N/A $49.14 N/A N/A $71.44 N/A N/A $113.40 N/A N/A $94.50 N/A N/A N/A N/A N/A $128.52 N/A N/A N/A N/A N/A $73.71 N/A N/A $86.00 N/A N/A $151.20 N/A N/A $103.95 N/A N/A $122.85 N/A N/A $63.32 N/A N/A N/A N/A N/A $113.40 N/A N/A $66.15 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $113.40 N/A N/A $122.85 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A N/A $56.70 N/A $189.00 $189.00 N/A 1500968 Supplies "E.T. TUBE INTRODUCER, BOU" 270 $87.00 $- $22.62 $- $- $69.60 $- N/A $22.62 N/A N/A $32.89 N/A N/A $52.20 N/A N/A $43.50 N/A N/A N/A N/A N/A $59.16 N/A N/A N/A N/A N/A $33.93 N/A N/A $39.59 N/A N/A $69.60 N/A N/A $47.85 N/A N/A $56.55 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.20 N/A N/A $30.45 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $52.20 N/A N/A $56.55 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A N/A $26.10 N/A $87.00 $87.00 N/A 1500970 Supplies SUTURE: ETHILON 6-0 PS-3 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1500971 Supplies "HEEL PROTECTOR, X-LARGE" 270 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A N/A N/A N/A $14.04 N/A N/A $16.38 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $23.40 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $21.60 N/A N/A $23.40 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A N/A $10.80 N/A $36.00 $36.00 N/A 1500972 Supplies "AIR STIRRUP, LEFT SMALL" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500973 Supplies "AIR STIRRUP, RIGHT SMALL" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500974 Supplies "AIR STIRRUP, LEFT MEDIUM" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500975 Supplies "AIR STIRRUP, RIGHT MEDIUM" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500976 Supplies "AIR STIRRUP, LEFT LARGE" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500977 Supplies "AIR STIRRUP, RIGHT LARGE" 270 $121.00 $- $31.46 $- $- $96.80 $- N/A $31.46 N/A N/A $45.74 N/A N/A $72.60 N/A N/A $60.50 N/A N/A N/A N/A N/A $82.28 N/A N/A N/A N/A N/A $47.19 N/A N/A $55.06 N/A N/A $96.80 N/A N/A $66.55 N/A N/A $78.65 N/A N/A $40.54 N/A N/A N/A N/A N/A $72.60 N/A N/A $42.35 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $72.60 N/A N/A $78.65 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A N/A $36.30 N/A $121.00 $121.00 N/A 1500978 Supplies G-TUBE 20FR. 272 $106.00 $- $27.56 $- $- $84.80 $- N/A $27.56 N/A N/A $40.07 N/A N/A $63.60 N/A N/A $53.00 N/A N/A N/A N/A N/A $72.08 N/A N/A N/A N/A N/A $41.34 N/A N/A $48.23 N/A N/A $84.80 N/A N/A $58.30 N/A N/A $68.90 N/A N/A $35.51 N/A N/A N/A N/A N/A $63.60 N/A N/A $37.10 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $63.60 N/A N/A $68.90 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A N/A $31.80 N/A $106.00 $106.00 N/A 1500979 Supplies "UNDERWEAR, MESH MEDIUM" 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500980 Supplies "TROCAR, BLADED 5MMX150MM" 272 $108.00 $- $28.08 $- $- $86.40 $- N/A $28.08 N/A N/A $40.82 N/A N/A $64.80 N/A N/A $54.00 N/A N/A N/A N/A N/A $73.44 N/A N/A N/A N/A N/A $42.12 N/A N/A $49.14 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $70.20 N/A N/A $36.18 N/A N/A N/A N/A N/A $64.80 N/A N/A $37.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $64.80 N/A N/A $70.20 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A N/A $32.40 N/A $108.00 $108.00 N/A 1500981 Supplies "TROCAR, BLADED 11MMX150MM" 272 $167.00 $- $43.42 $- $- $133.60 $- N/A $43.42 N/A N/A $63.13 N/A N/A $100.20 N/A N/A $83.50 N/A N/A N/A N/A N/A $113.56 N/A N/A N/A N/A N/A $65.13 N/A N/A $75.99 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $108.55 N/A N/A $55.95 N/A N/A N/A N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 1500982 Supplies "CATHETER, CONDOM LARGE" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500983 Supplies "CATHETER, CONDOM SMALL" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1500984 Supplies "CATH, FOLEY SECUREMENT DEVICE" 272 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500985 Supplies ARGLAES POWDER 5 GM. 270 $149.00 $- $38.74 $- $- $119.20 $- N/A $38.74 N/A N/A $56.32 N/A N/A $89.40 N/A N/A $74.50 N/A N/A N/A N/A N/A $101.32 N/A N/A N/A N/A N/A $58.11 N/A N/A $67.80 N/A N/A $119.20 N/A N/A $81.95 N/A N/A $96.85 N/A N/A $49.92 N/A N/A N/A N/A N/A $89.40 N/A N/A $52.15 N/A N/A $96.85 N/A N/A $44.70 N/A N/A $89.40 N/A N/A $96.85 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A N/A $44.70 N/A $149.00 $149.00 N/A 1500986 Supplies SUTURE: FAST GUT 5-0 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1500987 Supplies CATH FOLEY 14FR. 5CC. SILICONE 272 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500988 Supplies CATH FOLEY 20FR 5CC SILICONE 272 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1500989 Supplies CATH FOLEY 16FR 30CC SILICONE 272 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1500990 Supplies "SCISSORS, IRIS STERILE" 272 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1500991 Supplies EZ-IO NEEDLE KIT 25MM. BLUE 272 $770.00 $- $200.20 $- $- $616.00 $- N/A $200.20 N/A N/A $291.06 N/A N/A $462.00 N/A N/A $385.00 N/A N/A N/A N/A N/A $523.60 N/A N/A N/A N/A N/A $300.30 N/A N/A $350.35 N/A N/A $616.00 N/A N/A $423.50 N/A N/A $500.50 N/A N/A $257.95 N/A N/A N/A N/A N/A $462.00 N/A N/A $269.50 N/A N/A $500.50 N/A N/A $231.00 N/A N/A $462.00 N/A N/A $500.50 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A $770.00 $770.00 N/A 1500992 Supplies EZ-IO NEEDLE KIT 15MM. PINK 272 $770.00 $- $200.20 $- $- $616.00 $- N/A $200.20 N/A N/A $291.06 N/A N/A $462.00 N/A N/A $385.00 N/A N/A N/A N/A N/A $523.60 N/A N/A N/A N/A N/A $300.30 N/A N/A $350.35 N/A N/A $616.00 N/A N/A $423.50 N/A N/A $500.50 N/A N/A $257.95 N/A N/A N/A N/A N/A $462.00 N/A N/A $269.50 N/A N/A $500.50 N/A N/A $231.00 N/A N/A $462.00 N/A N/A $500.50 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A N/A $231.00 N/A $770.00 $770.00 N/A 1500993 Supplies "OSTOMY POUCH, 4 INCH" 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1500994 Supplies "OSTOMY FLANGE, 4 INCH" 272 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1500995 Supplies CATHETER BAG COVER 270 $68.00 $- $17.68 $- $- $54.40 $- N/A $17.68 N/A N/A $25.70 N/A N/A $40.80 N/A N/A $34.00 N/A N/A N/A N/A N/A $46.24 N/A N/A N/A N/A N/A $26.52 N/A N/A $30.94 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $44.20 N/A N/A $22.78 N/A N/A N/A N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $40.80 N/A N/A $44.20 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A N/A $20.40 N/A $68.00 $68.00 N/A 1500996 Supplies RAPID RHINO 7.5cm. POS/AN W/AIRWAY 272 $215.00 $- $55.90 $- $- $172.00 $- N/A $55.90 N/A N/A $81.27 N/A N/A $129.00 N/A N/A $107.50 N/A N/A N/A N/A N/A $146.20 N/A N/A N/A N/A N/A $83.85 N/A N/A $97.83 N/A N/A $172.00 N/A N/A $118.25 N/A N/A $139.75 N/A N/A $72.03 N/A N/A N/A N/A N/A $129.00 N/A N/A $75.25 N/A N/A $139.75 N/A N/A $64.50 N/A N/A $129.00 N/A N/A $139.75 N/A N/A $64.50 N/A N/A $64.50 N/A N/A $64.50 N/A N/A $64.50 N/A N/A $64.50 N/A N/A $64.50 N/A $215.00 $215.00 N/A 1500997 Supplies SUTURE VICRYL 5-0 PS-2 J495G 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1500998 Supplies SUTURE VICRYL 6-0 PS-3 J499G 272 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1500999 Supplies SUTURE PROLENE 4-0 P-3 8604G? 272 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 1501000 Supplies SUTURE PROLENE 5-0 P-3 8605G 272 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1501001 Supplies MAXSORG AG FLAT ROPE 1X12 272 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1501002 Supplies LARYNG MAC #1 DISP 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501003 Supplies LARYNG MAC. #2 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501004 Supplies LARYNG. MAC #3 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501005 Supplies LARYNG. MAC #4 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501006 Supplies LARYNG. MILLER #1 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501007 Supplies LARYNG. MILLER #2 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501008 Supplies LARYNG. MILLER #3 DISP. 272 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501009 Supplies "LARYNGOSCOPE BLADE, MILLER 4 DISPOSABLE" 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1501010 Supplies ULTRASOUND PROBE COVER W/GEL 272 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $15.60 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $14.40 N/A N/A $15.60 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A N/A $7.20 N/A $24.00 $24.00 N/A 1501011 Supplies GROUNDING PADS 272 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A $6.43 N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A N/A N/A N/A $6.63 N/A N/A $7.74 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.05 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $10.20 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A $17.00 $17.00 N/A 1501012 Supplies MASK SIMPLE ADULT 270 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1501013 Supplies SEPP BENZOIN TINCTURE 272 $7.00 $- $1.82 $- $- $5.60 $- N/A $1.82 N/A N/A $2.65 N/A N/A $4.20 N/A N/A $3.50 N/A N/A N/A N/A N/A $4.76 N/A N/A N/A N/A N/A $2.73 N/A N/A $3.19 N/A N/A $5.60 N/A N/A $3.85 N/A N/A $4.55 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.20 N/A N/A $2.45 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $4.20 N/A N/A $4.55 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A N/A $2.10 N/A $7.00 $7.00 N/A 1501014 Supplies IV SPIKE ADAPTER VENTED 272 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 1501015 Supplies DRAIN FULL FLUTED 19FR. 272 $80.00 $- $20.80 $- $- $64.00 $- N/A $20.80 N/A N/A $30.24 N/A N/A $48.00 N/A N/A $40.00 N/A N/A N/A N/A N/A $54.40 N/A N/A N/A N/A N/A $31.20 N/A N/A $36.40 N/A N/A $64.00 N/A N/A $44.00 N/A N/A $52.00 N/A N/A $26.80 N/A N/A N/A N/A N/A $48.00 N/A N/A $28.00 N/A N/A $52.00 N/A N/A $24.00 N/A N/A $48.00 N/A N/A $52.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A N/A $24.00 N/A $80.00 $80.00 N/A 1501016 Supplies I.V. CATHETER 20GX1.88 270 $65.00 $- $16.90 $- $- $52.00 $- N/A $16.90 N/A N/A $24.57 N/A N/A $39.00 N/A N/A $32.50 N/A N/A N/A N/A N/A $44.20 N/A N/A N/A N/A N/A $25.35 N/A N/A $29.58 N/A N/A $52.00 N/A N/A $35.75 N/A N/A $42.25 N/A N/A $21.78 N/A N/A N/A N/A N/A $39.00 N/A N/A $22.75 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $39.00 N/A N/A $42.25 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A N/A $19.50 N/A $65.00 $65.00 N/A 1501017 Supplies "WRIST SPLINT, PEDIATRIC LEFT" 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1501018 Supplies "WRIST SPLINT, PEDIATRIC RIGHT" 270 $72.00 $- $18.72 $- $- $57.60 $- N/A $18.72 N/A N/A $27.22 N/A N/A $43.20 N/A N/A $36.00 N/A N/A N/A N/A N/A $48.96 N/A N/A N/A N/A N/A $28.08 N/A N/A $32.76 N/A N/A $57.60 N/A N/A $39.60 N/A N/A $46.80 N/A N/A $24.12 N/A N/A N/A N/A N/A $43.20 N/A N/A $25.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $43.20 N/A N/A $46.80 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A N/A $21.60 N/A $72.00 $72.00 N/A 1501019 Supplies "ARTHROSCOPY PACK, KNEE" 272 $446.00 $- $115.96 $- $- $356.80 $- N/A $115.96 N/A N/A $168.59 N/A N/A $267.60 N/A N/A $223.00 N/A N/A N/A N/A N/A $303.28 N/A N/A N/A N/A N/A $173.94 N/A N/A $202.93 N/A N/A $356.80 N/A N/A $245.30 N/A N/A $289.90 N/A N/A $149.41 N/A N/A N/A N/A N/A $267.60 N/A N/A $156.10 N/A N/A $289.90 N/A N/A $133.80 N/A N/A $267.60 N/A N/A $289.90 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A N/A $133.80 N/A $446.00 $446.00 N/A 1501020 Supplies "GLOVE, POLYISOPRENE MICRO 8.0" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501021 Supplies "GLOVE, POLYISOPRENE ESTEEM 8.5" 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501022 Supplies BURETTE MICRODRIP SET 272 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1501023 Supplies LAP CHOLE PACK 272 $289.00 $- $75.14 $- $- $231.20 $- N/A $75.14 N/A N/A $109.24 N/A N/A $173.40 N/A N/A $144.50 N/A N/A N/A N/A N/A $196.52 N/A N/A N/A N/A N/A $112.71 N/A N/A $131.50 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $187.85 N/A N/A $96.82 N/A N/A N/A N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 1501024 Supplies TROCAR 5MM. STABILITY SLEEVE 272 "$1,940.00 " $- $504.40 $- $- "$1,552.00 " $- N/A $504.40 N/A N/A $733.32 N/A N/A "$1,164.00 " N/A N/A $970.00 N/A N/A N/A N/A N/A "$1,319.20 " N/A N/A N/A N/A N/A $756.60 N/A N/A $882.70 N/A N/A "$1,552.00 " N/A N/A "$1,067.00 " N/A N/A "$1,261.00 " N/A N/A $649.90 N/A N/A N/A N/A N/A "$1,164.00 " N/A N/A $679.00 N/A N/A "$1,261.00 " N/A N/A $582.00 N/A N/A "$1,164.00 " N/A N/A "$1,261.00 " N/A N/A $582.00 N/A N/A $582.00 N/A N/A $582.00 N/A N/A $582.00 N/A N/A $582.00 N/A N/A $582.00 N/A "$1,940.00 " "$1,940.00 " N/A 1501025 Supplies SUTURE PROLENE 2-0 CT-1 272 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A N/A N/A N/A $6.24 N/A N/A $7.28 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $10.40 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $9.60 N/A N/A $10.40 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A N/A $4.80 N/A $16.00 $16.00 N/A 1501026 Supplies "LAPAROSCOPIC SCISSOR, DISPOSABLE" 272 "$1,432.00 " $- $372.32 $- $- "$1,145.60 " $- N/A $372.32 N/A N/A $541.30 N/A N/A $859.20 N/A N/A $716.00 N/A N/A N/A N/A N/A $973.76 N/A N/A N/A N/A N/A $558.48 N/A N/A $651.56 N/A N/A "$1,145.60 " N/A N/A $787.60 N/A N/A $930.80 N/A N/A $479.72 N/A N/A N/A N/A N/A $859.20 N/A N/A $501.20 N/A N/A $930.80 N/A N/A $429.60 N/A N/A $859.20 N/A N/A $930.80 N/A N/A $429.60 N/A N/A $429.60 N/A N/A $429.60 N/A N/A $429.60 N/A N/A $429.60 N/A N/A $429.60 N/A "$1,432.00 " "$1,432.00 " N/A 1501027 Supplies CARTER THOMASON CLOSURE SYSTEM 272 "$1,468.00 " $- $381.68 $- $- "$1,174.40 " $- N/A $381.68 N/A N/A $554.90 N/A N/A $880.80 N/A N/A $734.00 N/A N/A N/A N/A N/A $998.24 N/A N/A N/A N/A N/A $572.52 N/A N/A $667.94 N/A N/A "$1,174.40 " N/A N/A $807.40 N/A N/A $954.20 N/A N/A $491.78 N/A N/A N/A N/A N/A $880.80 N/A N/A $513.80 N/A N/A $954.20 N/A N/A $440.40 N/A N/A $880.80 N/A N/A $954.20 N/A N/A $440.40 N/A N/A $440.40 N/A N/A $440.40 N/A N/A $440.40 N/A N/A $440.40 N/A N/A $440.40 N/A "$1,468.00 " "$1,468.00 " N/A 1501028 Supplies SURGICEL 2X14 272 $665.00 $- $172.90 $- $- $532.00 $- N/A $172.90 N/A N/A $251.37 N/A N/A $399.00 N/A N/A $332.50 N/A N/A N/A N/A N/A $452.20 N/A N/A N/A N/A N/A $259.35 N/A N/A $302.58 N/A N/A $532.00 N/A N/A $365.75 N/A N/A $432.25 N/A N/A $222.78 N/A N/A N/A N/A N/A $399.00 N/A N/A $232.75 N/A N/A $432.25 N/A N/A $199.50 N/A N/A $399.00 N/A N/A $432.25 N/A N/A $199.50 N/A N/A $199.50 N/A N/A $199.50 N/A N/A $199.50 N/A N/A $199.50 N/A N/A $199.50 N/A $665.00 $665.00 N/A 1501029 Supplies "GLOVE, PROTEXIS PI CLASSIC 7.5" 272 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1501030 Supplies "GLOVE, PROTEXIS PI BLUE 7.5" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1501031 Supplies TROCAR 15MMX100MM 272 $715.00 $- $185.90 $- $- $572.00 $- N/A $185.90 N/A N/A $270.27 N/A N/A $429.00 N/A N/A $357.50 N/A N/A N/A N/A N/A $486.20 N/A N/A N/A N/A N/A $278.85 N/A N/A $325.33 N/A N/A $572.00 N/A N/A $393.25 N/A N/A $464.75 N/A N/A $239.53 N/A N/A N/A N/A N/A $429.00 N/A N/A $250.25 N/A N/A $464.75 N/A N/A $214.50 N/A N/A $429.00 N/A N/A $464.75 N/A N/A $214.50 N/A N/A $214.50 N/A N/A $214.50 N/A N/A $214.50 N/A N/A $214.50 N/A N/A $214.50 N/A $715.00 $715.00 N/A 1501032 Supplies "GLOVE, BIOGEL SKINSENSE 8.5" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1501033 Supplies "COMPLIANCE KIT, BEDSIDE" 270 $62.00 $- $16.12 $- $- $49.60 $- N/A $16.12 N/A N/A $23.44 N/A N/A $37.20 N/A N/A $31.00 N/A N/A N/A N/A N/A $42.16 N/A N/A N/A N/A N/A $24.18 N/A N/A $28.21 N/A N/A $49.60 N/A N/A $34.10 N/A N/A $40.30 N/A N/A $20.77 N/A N/A N/A N/A N/A $37.20 N/A N/A $21.70 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $37.20 N/A N/A $40.30 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A N/A $18.60 N/A $62.00 $62.00 N/A 1501034 Supplies "ARM SLING, TODDLER" 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1501035 Supplies "CLIP APPLIER, ENDO MED/LG" 272 $660.00 $- $171.60 $- $- $528.00 $- N/A $171.60 N/A N/A $249.48 N/A N/A $396.00 N/A N/A $330.00 N/A N/A N/A N/A N/A $448.80 N/A N/A N/A N/A N/A $257.40 N/A N/A $300.30 N/A N/A $528.00 N/A N/A $363.00 N/A N/A $429.00 N/A N/A $221.10 N/A N/A N/A N/A N/A $396.00 N/A N/A $231.00 N/A N/A $429.00 N/A N/A $198.00 N/A N/A $396.00 N/A N/A $429.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A N/A $198.00 N/A $660.00 $660.00 N/A 1501036 Supplies BLADE ELECTRODE INSULATED 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1501037 Supplies SUTURE: VICRYL 0 CT-1 272 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1501038 Supplies MESH 3D MAX LARGE RIGHT 4X6 272 "$1,265.00 " $- $328.90 $- $- "$1,012.00 " $- N/A $328.90 N/A N/A $478.17 N/A N/A $759.00 N/A N/A $632.50 N/A N/A N/A N/A N/A $860.20 N/A N/A N/A N/A N/A $493.35 N/A N/A $575.58 N/A N/A "$1,012.00 " N/A N/A $695.75 N/A N/A $822.25 N/A N/A $423.78 N/A N/A N/A N/A N/A $759.00 N/A N/A $442.75 N/A N/A $822.25 N/A N/A $379.50 N/A N/A $759.00 N/A N/A $822.25 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A "$1,265.00 " "$1,265.00 " N/A 1501039 Supplies MESH 3D MAX LARGE LEFT 4X6 272 "$1,265.00 " $- $328.90 $- $- "$1,012.00 " $- N/A $328.90 N/A N/A $478.17 N/A N/A $759.00 N/A N/A $632.50 N/A N/A N/A N/A N/A $860.20 N/A N/A N/A N/A N/A $493.35 N/A N/A $575.58 N/A N/A "$1,012.00 " N/A N/A $695.75 N/A N/A $822.25 N/A N/A $423.78 N/A N/A N/A N/A N/A $759.00 N/A N/A $442.75 N/A N/A $822.25 N/A N/A $379.50 N/A N/A $759.00 N/A N/A $822.25 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A N/A $379.50 N/A "$1,265.00 " "$1,265.00 " N/A 1501040 Supplies SPACEMAKER PRO DISSECTION KIT 270 "$3,648.00 " $- $948.48 $- $- "$2,918.40 " $- N/A $948.48 N/A N/A "$1,378.94 " N/A N/A "$2,188.80 " N/A N/A "$1,824.00 " N/A N/A N/A N/A N/A "$2,480.64 " N/A N/A N/A N/A N/A "$1,422.72 " N/A N/A "$1,659.84 " N/A N/A "$2,918.40 " N/A N/A "$2,006.40 " N/A N/A "$2,371.20 " N/A N/A "$1,222.08 " N/A N/A N/A N/A N/A "$2,188.80 " N/A N/A "$1,276.80 " N/A N/A "$2,371.20 " N/A N/A "$1,094.40 " N/A N/A "$2,188.80 " N/A N/A "$2,371.20 " N/A N/A "$1,094.40 " N/A N/A "$1,094.40 " N/A N/A "$1,094.40 " N/A N/A "$1,094.40 " N/A N/A "$1,094.40 " N/A N/A "$1,094.40 " N/A "$3,648.00 " "$3,648.00 " N/A 1501041 Supplies MESH HERNIA TACKER DEVICE ABSTACK 30 270 "$2,840.00 " $- $738.40 $- $- "$2,272.00 " $- N/A $738.40 N/A N/A "$1,073.52 " N/A N/A "$1,704.00 " N/A N/A "$1,420.00 " N/A N/A N/A N/A N/A "$1,931.20 " N/A N/A N/A N/A N/A "$1,107.60 " N/A N/A "$1,292.20 " N/A N/A "$2,272.00 " N/A N/A "$1,562.00 " N/A N/A "$1,846.00 " N/A N/A $951.40 N/A N/A N/A N/A N/A "$1,704.00 " N/A N/A $994.00 N/A N/A "$1,846.00 " N/A N/A $852.00 N/A N/A "$1,704.00 " N/A N/A "$1,846.00 " N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A "$2,840.00 " "$2,840.00 " N/A 1501042 Supplies MESH HERNIA TACKER DEVICE ABSTACK 15 270 "$2,840.00 " $- $738.40 $- $- "$2,272.00 " $- N/A $738.40 N/A N/A "$1,073.52 " N/A N/A "$1,704.00 " N/A N/A "$1,420.00 " N/A N/A N/A N/A N/A "$1,931.20 " N/A N/A N/A N/A N/A "$1,107.60 " N/A N/A "$1,292.20 " N/A N/A "$2,272.00 " N/A N/A "$1,562.00 " N/A N/A "$1,846.00 " N/A N/A $951.40 N/A N/A N/A N/A N/A "$1,704.00 " N/A N/A $994.00 N/A N/A "$1,846.00 " N/A N/A $852.00 N/A N/A "$1,704.00 " N/A N/A "$1,846.00 " N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A N/A $852.00 N/A "$2,840.00 " "$2,840.00 " N/A 1501043 Supplies ANTIFUNGAL OINTMENT 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 1501044 Supplies "GRASPER, LAPAROSCOPIC 35CM." 270 "$5,831.00 " $- "$1,516.06 " $- $- "$4,664.80 " $- N/A "$1,516.06 " N/A N/A "$2,204.12 " N/A N/A "$3,498.60 " N/A N/A "$2,915.50 " N/A N/A N/A N/A N/A "$3,965.08 " N/A N/A N/A N/A N/A "$2,274.09 " N/A N/A "$2,653.11 " N/A N/A "$4,664.80 " N/A N/A "$3,207.05 " N/A N/A "$3,790.15 " N/A N/A "$1,953.39 " N/A N/A N/A N/A N/A "$3,498.60 " N/A N/A "$2,040.85 " N/A N/A "$3,790.15 " N/A N/A "$1,749.30 " N/A N/A "$3,498.60 " N/A N/A "$3,790.15 " N/A N/A "$1,749.30 " N/A N/A "$1,749.30 " N/A N/A "$1,749.30 " N/A N/A "$1,749.30 " N/A N/A "$1,749.30 " N/A N/A "$1,749.30 " N/A "$5,831.00 " "$5,831.00 " N/A 1501045 Supplies PREP TRAY WET 270 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A $6.43 N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A N/A N/A N/A $6.63 N/A N/A $7.74 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.05 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $10.20 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A $17.00 $17.00 N/A 1501046 Supplies SUTURE: SILK 4-0 PS-2 272 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A $6.43 N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A N/A N/A N/A $6.63 N/A N/A $7.74 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.05 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $10.20 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A $17.00 $17.00 N/A 1501047 Supplies ATOMIZER NASAL W/SYRINGE 270 $82.00 $- $21.32 $- $- $65.60 $- N/A $21.32 N/A N/A $31.00 N/A N/A $49.20 N/A N/A $41.00 N/A N/A N/A N/A N/A $55.76 N/A N/A N/A N/A N/A $31.98 N/A N/A $37.31 N/A N/A $65.60 N/A N/A $45.10 N/A N/A $53.30 N/A N/A $27.47 N/A N/A N/A N/A N/A $49.20 N/A N/A $28.70 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $49.20 N/A N/A $53.30 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A N/A $24.60 N/A $82.00 $82.00 N/A 1501048 Supplies "FORCEP, SPLINTER FINE" 272 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1501049 Supplies SUTURE: SILK TIES 0 SA66G 272 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501050 Supplies "CLIP APPLIER, ENDO 10MM." 272 "$3,875.00 " $- "$1,007.50 " $- $- "$3,100.00 " $- N/A "$1,007.50 " N/A N/A "$1,464.75 " N/A N/A "$2,325.00 " N/A N/A "$1,937.50 " N/A N/A N/A N/A N/A "$2,635.00 " N/A N/A N/A N/A N/A "$1,511.25 " N/A N/A "$1,763.13 " N/A N/A "$3,100.00 " N/A N/A "$2,131.25 " N/A N/A "$2,518.75 " N/A N/A "$1,298.13 " N/A N/A N/A N/A N/A "$2,325.00 " N/A N/A "$1,356.25 " N/A N/A "$2,518.75 " N/A N/A "$1,162.50 " N/A N/A "$2,325.00 " N/A N/A "$2,518.75 " N/A N/A "$1,162.50 " N/A N/A "$1,162.50 " N/A N/A "$1,162.50 " N/A N/A "$1,162.50 " N/A N/A "$1,162.50 " N/A N/A "$1,162.50 " N/A "$3,875.00 " "$3,875.00 " N/A 1501051 Supplies "ENDOPATH TIP ELECTRODE, PROBE PLUS II" 270 $107.00 $- $27.82 $- $- $85.60 $- N/A $27.82 N/A N/A $40.45 N/A N/A $64.20 N/A N/A $53.50 N/A N/A N/A N/A N/A $72.76 N/A N/A N/A N/A N/A $41.73 N/A N/A $48.69 N/A N/A $85.60 N/A N/A $58.85 N/A N/A $69.55 N/A N/A $35.85 N/A N/A N/A N/A N/A $64.20 N/A N/A $37.45 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $64.20 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A $107.00 $107.00 N/A 1501052 Supplies "GLOVE, POLYISOPRENE MICRO 7.0" 270 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A N/A N/A N/A $4.29 N/A N/A $5.01 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1501053 Supplies SURGIFOAM SPONGE 2X6 270 $86.00 $- $22.36 $- $- $68.80 $- N/A $22.36 N/A N/A $32.51 N/A N/A $51.60 N/A N/A $43.00 N/A N/A N/A N/A N/A $58.48 N/A N/A N/A N/A N/A $33.54 N/A N/A $39.13 N/A N/A $68.80 N/A N/A $47.30 N/A N/A $55.90 N/A N/A $28.81 N/A N/A N/A N/A N/A $51.60 N/A N/A $30.10 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $51.60 N/A N/A $55.90 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A N/A $25.80 N/A $86.00 $86.00 N/A 1501055 Supplies SUTURE: SILK 2-0 CT-1 272 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.00 N/A N/A $20.00 N/A N/A N/A N/A N/A $27.20 N/A N/A N/A N/A N/A $15.60 N/A N/A $18.20 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $26.00 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 1501056 Supplies SCOPE WARMER 270 $78.00 $- $20.28 $- $- $62.40 $- N/A $20.28 N/A N/A $29.48 N/A N/A $46.80 N/A N/A $39.00 N/A N/A N/A N/A N/A $53.04 N/A N/A N/A N/A N/A $30.42 N/A N/A $35.49 N/A N/A $62.40 N/A N/A $42.90 N/A N/A $50.70 N/A N/A $26.13 N/A N/A N/A N/A N/A $46.80 N/A N/A $27.30 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $46.80 N/A N/A $50.70 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A N/A $23.40 N/A $78.00 $78.00 N/A 1501057 Supplies CAUTERY TIP POLISHER 270 $6.00 $- $1.56 $- $- $4.80 $- N/A $1.56 N/A N/A $2.27 N/A N/A $3.60 N/A N/A $3.00 N/A N/A N/A N/A N/A $4.08 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.73 N/A N/A $4.80 N/A N/A $3.30 N/A N/A $3.90 N/A N/A $2.01 N/A N/A N/A N/A N/A $3.60 N/A N/A $2.10 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $3.60 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A $6.00 $6.00 N/A 1501060 Supplies TWIN SITE EXTENSION 270 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A $14.36 N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.84 N/A N/A N/A N/A N/A $14.82 N/A N/A $17.29 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $24.70 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 1501061 Supplies "TED HOSE, KNEE XXXL REGULAR" 270 $42.00 $- $10.92 $- $- $33.60 $- N/A $10.92 N/A N/A $15.88 N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A N/A N/A N/A $16.38 N/A N/A $19.11 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $27.30 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $25.20 N/A N/A $27.30 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A N/A $12.60 N/A $42.00 $42.00 N/A 1501062 Supplies "BOUGIE, FLEX TIP" 272 $107.00 $- $27.82 $- $- $85.60 $- N/A $27.82 N/A N/A $40.45 N/A N/A $64.20 N/A N/A $53.50 N/A N/A N/A N/A N/A $72.76 N/A N/A N/A N/A N/A $41.73 N/A N/A $48.69 N/A N/A $85.60 N/A N/A $58.85 N/A N/A $69.55 N/A N/A $35.85 N/A N/A N/A N/A N/A $64.20 N/A N/A $37.45 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $64.20 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A $107.00 $107.00 N/A 1501064 Supplies CHEST TUBE 8 FR. TROCAR 272 $182.00 $- $47.32 $- $- $145.60 $- N/A $47.32 N/A N/A $68.80 N/A N/A $109.20 N/A N/A $91.00 N/A N/A N/A N/A N/A $123.76 N/A N/A N/A N/A N/A $70.98 N/A N/A $82.81 N/A N/A $145.60 N/A N/A $100.10 N/A N/A $118.30 N/A N/A $60.97 N/A N/A N/A N/A N/A $109.20 N/A N/A $63.70 N/A N/A $118.30 N/A N/A $54.60 N/A N/A $109.20 N/A N/A $118.30 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A N/A $54.60 N/A $182.00 $182.00 N/A 1501065 Supplies "TROCAR, 5MM, BLADELESS OPTIVIEW" 272 $821.00 $- $213.46 $- $- $656.80 $- N/A $213.46 N/A N/A $310.34 N/A N/A $492.60 N/A N/A $410.50 N/A N/A N/A N/A N/A $558.28 N/A N/A N/A N/A N/A $320.19 N/A N/A $373.56 N/A N/A $656.80 N/A N/A $451.55 N/A N/A $533.65 N/A N/A $275.04 N/A N/A N/A N/A N/A $492.60 N/A N/A $287.35 N/A N/A $533.65 N/A N/A $246.30 N/A N/A $492.60 N/A N/A $533.65 N/A N/A $246.30 N/A N/A $246.30 N/A N/A $246.30 N/A N/A $246.30 N/A N/A $246.30 N/A N/A $246.30 N/A $821.00 $821.00 N/A 1501066 Supplies "MESH, SYMBOTEX RECTANGLE 10X15 CM." 272 "$2,521.00 " $- $655.46 $- $- "$2,016.80 " $- N/A $655.46 N/A N/A $952.94 N/A N/A "$1,512.60 " N/A N/A "$1,260.50 " N/A N/A N/A N/A N/A "$1,714.28 " N/A N/A N/A N/A N/A $983.19 N/A N/A "$1,147.06 " N/A N/A "$2,016.80 " N/A N/A "$1,386.55 " N/A N/A "$1,638.65 " N/A N/A $844.54 N/A N/A N/A N/A N/A "$1,512.60 " N/A N/A $882.35 N/A N/A "$1,638.65 " N/A N/A $756.30 N/A N/A "$1,512.60 " N/A N/A "$1,638.65 " N/A N/A $756.30 N/A N/A $756.30 N/A N/A $756.30 N/A N/A $756.30 N/A N/A $756.30 N/A N/A $756.30 N/A "$2,521.00 " "$2,521.00 " N/A 1501068 Supplies MONOPOLAR CORD 270 $76.00 $- $19.76 $- $- $60.80 $- N/A $19.76 N/A N/A $28.73 N/A N/A $45.60 N/A N/A $38.00 N/A N/A N/A N/A N/A $51.68 N/A N/A N/A N/A N/A $29.64 N/A N/A $34.58 N/A N/A $60.80 N/A N/A $41.80 N/A N/A $49.40 N/A N/A $25.46 N/A N/A N/A N/A N/A $45.60 N/A N/A $26.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $45.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A $76.00 $76.00 N/A 1501069 Supplies OB PACK 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 1501070 Supplies "GRIPPER NEEDLE, POWERLOC 19GX1 INCH" 270 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 1501071 Supplies SUTURE: ETHILON 4-0 PS-2 272 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A $6.43 N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A N/A N/A N/A $6.63 N/A N/A $7.74 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.05 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $10.20 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A $17.00 $17.00 N/A 1501072 Supplies SUTURE ANCHOR MINI 272 "$1,581.00 " $- $411.06 $- $- "$1,264.80 " $- N/A $411.06 N/A N/A $597.62 N/A N/A $948.60 N/A N/A $790.50 N/A N/A N/A N/A N/A "$1,075.08 " N/A N/A N/A N/A N/A $616.59 N/A N/A $719.36 N/A N/A "$1,264.80 " N/A N/A $869.55 N/A N/A "$1,027.65 " N/A N/A $529.64 N/A N/A N/A N/A N/A $948.60 N/A N/A $553.35 N/A N/A "$1,027.65 " N/A N/A $474.30 N/A N/A $948.60 N/A N/A "$1,027.65 " N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A N/A $474.30 N/A "$1,581.00 " "$1,581.00 " N/A 1501073 Supplies MINI S-TAK INSTRUMENT KIT 270 $852.00 $- $221.52 $- $- $681.60 $- N/A $221.52 N/A N/A $322.06 N/A N/A $511.20 N/A N/A $426.00 N/A N/A N/A N/A N/A $579.36 N/A N/A N/A N/A N/A $332.28 N/A N/A $387.66 N/A N/A $681.60 N/A N/A $468.60 N/A N/A $553.80 N/A N/A $285.42 N/A N/A N/A N/A N/A $511.20 N/A N/A $298.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $511.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A $852.00 $852.00 N/A 1501074 Supplies STAPLE DYNANITE W/INSTRUMENTS 270 "$7,269.00 " $- "$1,889.94 " $- $- "$5,815.20 " $- N/A "$1,889.94 " N/A N/A "$2,747.68 " N/A N/A "$4,361.40 " N/A N/A "$3,634.50 " N/A N/A N/A N/A N/A "$4,942.92 " N/A N/A N/A N/A N/A "$2,834.91 " N/A N/A "$3,307.40 " N/A N/A "$5,815.20 " N/A N/A "$3,997.95 " N/A N/A "$4,724.85 " N/A N/A "$2,435.12 " N/A N/A N/A N/A N/A "$4,361.40 " N/A N/A "$2,544.15 " N/A N/A "$4,724.85 " N/A N/A "$2,180.70 " N/A N/A "$4,361.40 " N/A N/A "$4,724.85 " N/A N/A "$2,180.70 " N/A N/A "$2,180.70 " N/A N/A "$2,180.70 " N/A N/A "$2,180.70 " N/A N/A "$2,180.70 " N/A N/A "$2,180.70 " N/A "$7,269.00 " "$7,269.00 " N/A 1501075 Supplies GUIDE WIRE W/TROCAR TIP 1.35MM. 272 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A N/A N/A N/A $29.25 N/A N/A $34.13 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $48.75 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $45.00 N/A N/A $48.75 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A N/A $22.50 N/A $75.00 $75.00 N/A 1501076 Supplies "DRILL BIT, 2.5MM CANNULATED" 272 $852.00 $- $221.52 $- $- $681.60 $- N/A $221.52 N/A N/A $322.06 N/A N/A $511.20 N/A N/A $426.00 N/A N/A N/A N/A N/A $579.36 N/A N/A N/A N/A N/A $332.28 N/A N/A $387.66 N/A N/A $681.60 N/A N/A $468.60 N/A N/A $553.80 N/A N/A $285.42 N/A N/A N/A N/A N/A $511.20 N/A N/A $298.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $511.20 N/A N/A $553.80 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A N/A $255.60 N/A $852.00 $852.00 N/A 1501077 Supplies "SCREW, QUICKFIX CANNULATED 46MM." 272 $803.00 $- $208.78 $- $- $642.40 $- N/A $208.78 N/A N/A $303.53 N/A N/A $481.80 N/A N/A $401.50 N/A N/A N/A N/A N/A $546.04 N/A N/A N/A N/A N/A $313.17 N/A N/A $365.37 N/A N/A $642.40 N/A N/A $441.65 N/A N/A $521.95 N/A N/A $269.01 N/A N/A N/A N/A N/A $481.80 N/A N/A $281.05 N/A N/A $521.95 N/A N/A $240.90 N/A N/A $481.80 N/A N/A $521.95 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A N/A $240.90 N/A $803.00 $803.00 N/A 1501078 Supplies CAPNOGRAPHY SAMPLE LINE 270 $181.00 $- $47.06 $- $- $144.80 $- N/A $47.06 N/A N/A $68.42 N/A N/A $108.60 N/A N/A $90.50 N/A N/A N/A N/A N/A $123.08 N/A N/A N/A N/A N/A $70.59 N/A N/A $82.36 N/A N/A $144.80 N/A N/A $99.55 N/A N/A $117.65 N/A N/A $60.64 N/A N/A N/A N/A N/A $108.60 N/A N/A $63.35 N/A N/A $117.65 N/A N/A $54.30 N/A N/A $108.60 N/A N/A $117.65 N/A N/A $54.30 N/A N/A $54.30 N/A N/A $54.30 N/A N/A $54.30 N/A N/A $54.30 N/A N/A $54.30 N/A $181.00 $181.00 N/A 1501079 Supplies CAPNOGRAPHY OXYGEN TUBING 270 $96.00 $- $24.96 $- $- $76.80 $- N/A $24.96 N/A N/A $36.29 N/A N/A $57.60 N/A N/A $48.00 N/A N/A N/A N/A N/A $65.28 N/A N/A N/A N/A N/A $37.44 N/A N/A $43.68 N/A N/A $76.80 N/A N/A $52.80 N/A N/A $62.40 N/A N/A $32.16 N/A N/A N/A N/A N/A $57.60 N/A N/A $33.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $57.60 N/A N/A $62.40 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A N/A $28.80 N/A $96.00 $96.00 N/A 1501080 Supplies MICROLINE CAUTERY L-TIP 270 $79.00 $- $20.54 $- $- $63.20 $- N/A $20.54 N/A N/A $29.86 N/A N/A $47.40 N/A N/A $39.50 N/A N/A N/A N/A N/A $53.72 N/A N/A N/A N/A N/A $30.81 N/A N/A $35.95 N/A N/A $63.20 N/A N/A $43.45 N/A N/A $51.35 N/A N/A $26.47 N/A N/A N/A N/A N/A $47.40 N/A N/A $27.65 N/A N/A $51.35 N/A N/A $23.70 N/A N/A $47.40 N/A N/A $51.35 N/A N/A $23.70 N/A N/A $23.70 N/A N/A $23.70 N/A N/A $23.70 N/A N/A $23.70 N/A N/A $23.70 N/A $79.00 $79.00 N/A 1501081 Supplies ETS VASCULAR RELOAD 270 $548.00 $- $142.48 $- $- $438.40 $- N/A $142.48 N/A N/A $207.14 N/A N/A $328.80 N/A N/A $274.00 N/A N/A N/A N/A N/A $372.64 N/A N/A N/A N/A N/A $213.72 N/A N/A $249.34 N/A N/A $438.40 N/A N/A $301.40 N/A N/A $356.20 N/A N/A $183.58 N/A N/A N/A N/A N/A $328.80 N/A N/A $191.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $328.80 N/A N/A $356.20 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A N/A $164.40 N/A $548.00 $548.00 N/A 1501082 Supplies MICROLINE GRASPER TIP RENEW LAPCLINCH 270 $298.00 $- $77.48 $- $- $238.40 $- N/A $77.48 N/A N/A $112.64 N/A N/A $178.80 N/A N/A $149.00 N/A N/A N/A N/A N/A $202.64 N/A N/A N/A N/A N/A $116.22 N/A N/A $135.59 N/A N/A $238.40 N/A N/A $163.90 N/A N/A $193.70 N/A N/A $99.83 N/A N/A N/A N/A N/A $178.80 N/A N/A $104.30 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $178.80 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A $298.00 $298.00 N/A 1501083 Supplies MICROLINE FORCEP TRADITIONAL MARYLAND 270 $298.00 $- $77.48 $- $- $238.40 $- N/A $77.48 N/A N/A $112.64 N/A N/A $178.80 N/A N/A $149.00 N/A N/A N/A N/A N/A $202.64 N/A N/A N/A N/A N/A $116.22 N/A N/A $135.59 N/A N/A $238.40 N/A N/A $163.90 N/A N/A $193.70 N/A N/A $99.83 N/A N/A N/A N/A N/A $178.80 N/A N/A $104.30 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $178.80 N/A N/A $193.70 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A N/A $89.40 N/A $298.00 $298.00 N/A 1501084 Supplies "VAGINAL SPECULUM, LIGHTED SMALL" 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1501085 Supplies "VAGINAL SPECULUM, LIGHTED MEDIUM" 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1501086 Supplies "VAGINAL SPECULUM, LIGHTED LARGE" 270 $44.00 $- $11.44 $- $- $35.20 $- N/A $11.44 N/A N/A $16.63 N/A N/A $26.40 N/A N/A $22.00 N/A N/A N/A N/A N/A $29.92 N/A N/A N/A N/A N/A $17.16 N/A N/A $20.02 N/A N/A $35.20 N/A N/A $24.20 N/A N/A $28.60 N/A N/A $14.74 N/A N/A N/A N/A N/A $26.40 N/A N/A $15.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $26.40 N/A N/A $28.60 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A N/A $13.20 N/A $44.00 $44.00 N/A 1501087 Supplies "BUR, SHANNON CORTA 2.0x8MM" 270 "$1,504.00 " $- $391.04 $- $- "$1,203.20 " $- N/A $391.04 N/A N/A $568.51 N/A N/A $902.40 N/A N/A $752.00 N/A N/A N/A N/A N/A "$1,022.72 " N/A N/A N/A N/A N/A $586.56 N/A N/A $684.32 N/A N/A "$1,203.20 " N/A N/A $827.20 N/A N/A $977.60 N/A N/A $503.84 N/A N/A N/A N/A N/A $902.40 N/A N/A $526.40 N/A N/A $977.60 N/A N/A $451.20 N/A N/A $902.40 N/A N/A $977.60 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A "$1,504.00 " "$1,504.00 " N/A 1501088 Supplies BUR SHANNON RECTA 2.0x12MM 270 "$1,504.00 " $- $391.04 $- $- "$1,203.20 " $- N/A $391.04 N/A N/A $568.51 N/A N/A $902.40 N/A N/A $752.00 N/A N/A N/A N/A N/A "$1,022.72 " N/A N/A N/A N/A N/A $586.56 N/A N/A $684.32 N/A N/A "$1,203.20 " N/A N/A $827.20 N/A N/A $977.60 N/A N/A $503.84 N/A N/A N/A N/A N/A $902.40 N/A N/A $526.40 N/A N/A $977.60 N/A N/A $451.20 N/A N/A $902.40 N/A N/A $977.60 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A N/A $451.20 N/A "$1,504.00 " "$1,504.00 " N/A 1501089 Supplies BUR SHANNON 44 SIDE CUTTING 270 $297.00 $- $77.22 $- $- $237.60 $- N/A $77.22 N/A N/A $112.27 N/A N/A $178.20 N/A N/A $148.50 N/A N/A N/A N/A N/A $201.96 N/A N/A N/A N/A N/A $115.83 N/A N/A $135.14 N/A N/A $237.60 N/A N/A $163.35 N/A N/A $193.05 N/A N/A $99.50 N/A N/A N/A N/A N/A $178.20 N/A N/A $103.95 N/A N/A $193.05 N/A N/A $89.10 N/A N/A $178.20 N/A N/A $193.05 N/A N/A $89.10 N/A N/A $89.10 N/A N/A $89.10 N/A N/A $89.10 N/A N/A $89.10 N/A N/A $89.10 N/A $297.00 $297.00 N/A 1501090 Supplies BB-TAK MTP 270 $232.00 $- $60.32 $- $- $185.60 $- N/A $60.32 N/A N/A $87.70 N/A N/A $139.20 N/A N/A $116.00 N/A N/A N/A N/A N/A $157.76 N/A N/A N/A N/A N/A $90.48 N/A N/A $105.56 N/A N/A $185.60 N/A N/A $127.60 N/A N/A $150.80 N/A N/A $77.72 N/A N/A N/A N/A N/A $139.20 N/A N/A $81.20 N/A N/A $150.80 N/A N/A $69.60 N/A N/A $139.20 N/A N/A $150.80 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A $232.00 $232.00 N/A 1501091 Supplies DYNANITE G-WIRE 270 $645.00 $- $167.70 $- $- $516.00 $- N/A $167.70 N/A N/A $243.81 N/A N/A $387.00 N/A N/A $322.50 N/A N/A N/A N/A N/A $438.60 N/A N/A N/A N/A N/A $251.55 N/A N/A $293.48 N/A N/A $516.00 N/A N/A $354.75 N/A N/A $419.25 N/A N/A $216.08 N/A N/A N/A N/A N/A $387.00 N/A N/A $225.75 N/A N/A $419.25 N/A N/A $193.50 N/A N/A $387.00 N/A N/A $419.25 N/A N/A $193.50 N/A N/A $193.50 N/A N/A $193.50 N/A N/A $193.50 N/A N/A $193.50 N/A N/A $193.50 N/A $645.00 $645.00 N/A 1501092 Supplies SCREW QUICKFIX CANC. 3.0X30MM 270 $695.00 $- $180.70 $- $- $556.00 $- N/A $180.70 N/A N/A $262.71 N/A N/A $417.00 N/A N/A $347.50 N/A N/A N/A N/A N/A $472.60 N/A N/A N/A N/A N/A $271.05 N/A N/A $316.23 N/A N/A $556.00 N/A N/A $382.25 N/A N/A $451.75 N/A N/A $232.83 N/A N/A N/A N/A N/A $417.00 N/A N/A $243.25 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $417.00 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A $695.00 $695.00 N/A 1501093 Supplies G-WIRE W/TROCAR TIP 270 $70.00 $- $18.20 $- $- $56.00 $- N/A $18.20 N/A N/A $26.46 N/A N/A $42.00 N/A N/A $35.00 N/A N/A N/A N/A N/A $47.60 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $45.50 N/A N/A $23.45 N/A N/A N/A N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 1501094 Supplies DRILL BIT CANNULATED 2.0MM 270 $811.00 $- $210.86 $- $- $648.80 $- N/A $210.86 N/A N/A $306.56 N/A N/A $486.60 N/A N/A $405.50 N/A N/A N/A N/A N/A $551.48 N/A N/A N/A N/A N/A $316.29 N/A N/A $369.01 N/A N/A $648.80 N/A N/A $446.05 N/A N/A $527.15 N/A N/A $271.69 N/A N/A N/A N/A N/A $486.60 N/A N/A $283.85 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $486.60 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A $811.00 $811.00 N/A 1501095 Supplies SCREW VAL 3.0X12MM 270 $811.00 $- $210.86 $- $- $648.80 $- N/A $210.86 N/A N/A $306.56 N/A N/A $486.60 N/A N/A $405.50 N/A N/A N/A N/A N/A $551.48 N/A N/A N/A N/A N/A $316.29 N/A N/A $369.01 N/A N/A $648.80 N/A N/A $446.05 N/A N/A $527.15 N/A N/A $271.69 N/A N/A N/A N/A N/A $486.60 N/A N/A $283.85 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $486.60 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A $811.00 $811.00 N/A 1501096 Supplies SCREW VAL 3.0X18MM 270 $811.00 $- $210.86 $- $- $648.80 $- N/A $210.86 N/A N/A $306.56 N/A N/A $486.60 N/A N/A $405.50 N/A N/A N/A N/A N/A $551.48 N/A N/A N/A N/A N/A $316.29 N/A N/A $369.01 N/A N/A $648.80 N/A N/A $446.05 N/A N/A $527.15 N/A N/A $271.69 N/A N/A N/A N/A N/A $486.60 N/A N/A $283.85 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $486.60 N/A N/A $527.15 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A N/A $243.30 N/A $811.00 $811.00 N/A 1501097 Supplies GUIDE WIRE .062 W/TROCAR TIP 270 $70.00 $- $18.20 $- $- $56.00 $- N/A $18.20 N/A N/A $26.46 N/A N/A $42.00 N/A N/A $35.00 N/A N/A N/A N/A N/A $47.60 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A $56.00 N/A N/A $38.50 N/A N/A $45.50 N/A N/A $23.45 N/A N/A N/A N/A N/A $42.00 N/A N/A $24.50 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $42.00 N/A N/A $45.50 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A N/A $21.00 N/A $70.00 $70.00 N/A 1501098 Supplies DRILL BIT 2.0 270 $394.00 $- $102.44 $- $- $315.20 $- N/A $102.44 N/A N/A $148.93 N/A N/A $236.40 N/A N/A $197.00 N/A N/A N/A N/A N/A $267.92 N/A N/A N/A N/A N/A $153.66 N/A N/A $179.27 N/A N/A $315.20 N/A N/A $216.70 N/A N/A $256.10 N/A N/A $131.99 N/A N/A N/A N/A N/A $236.40 N/A N/A $137.90 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $236.40 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A $394.00 $394.00 N/A 1501099 Supplies METATARSAL REAMER 22MM 270 $695.00 $- $180.70 $- $- $556.00 $- N/A $180.70 N/A N/A $262.71 N/A N/A $417.00 N/A N/A $347.50 N/A N/A N/A N/A N/A $472.60 N/A N/A N/A N/A N/A $271.05 N/A N/A $316.23 N/A N/A $556.00 N/A N/A $382.25 N/A N/A $451.75 N/A N/A $232.83 N/A N/A N/A N/A N/A $417.00 N/A N/A $243.25 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $417.00 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A $695.00 $695.00 N/A 1501100 Supplies PHALANGEAL REAMER 22MM 270 $695.00 $- $180.70 $- $- $556.00 $- N/A $180.70 N/A N/A $262.71 N/A N/A $417.00 N/A N/A $347.50 N/A N/A N/A N/A N/A $472.60 N/A N/A N/A N/A N/A $271.05 N/A N/A $316.23 N/A N/A $556.00 N/A N/A $382.25 N/A N/A $451.75 N/A N/A $232.83 N/A N/A N/A N/A N/A $417.00 N/A N/A $243.25 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $417.00 N/A N/A $451.75 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A N/A $208.50 N/A $695.00 $695.00 N/A 1501101 Supplies SCREW CORTICAL 3.0X16MM 270 $580.00 $- $150.80 $- $- $464.00 $- N/A $150.80 N/A N/A $219.24 N/A N/A $348.00 N/A N/A $290.00 N/A N/A N/A N/A N/A $394.40 N/A N/A N/A N/A N/A $226.20 N/A N/A $263.90 N/A N/A $464.00 N/A N/A $319.00 N/A N/A $377.00 N/A N/A $194.30 N/A N/A N/A N/A N/A $348.00 N/A N/A $203.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $348.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A $580.00 $580.00 N/A 1501102 Supplies SCREW CORTICAL 3.0X20MM 270 $580.00 $- $150.80 $- $- $464.00 $- N/A $150.80 N/A N/A $219.24 N/A N/A $348.00 N/A N/A $290.00 N/A N/A N/A N/A N/A $394.40 N/A N/A N/A N/A N/A $226.20 N/A N/A $263.90 N/A N/A $464.00 N/A N/A $319.00 N/A N/A $377.00 N/A N/A $194.30 N/A N/A N/A N/A N/A $348.00 N/A N/A $203.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $348.00 N/A N/A $377.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A N/A $174.00 N/A $580.00 $580.00 N/A 1501103 Supplies PLATE MAXFORCE MTP RIGHT 270 "$9,238.00 " $- "$2,401.88 " $- $- "$7,390.40 " $- N/A "$2,401.88 " N/A N/A "$3,491.96 " N/A N/A "$5,542.80 " N/A N/A "$4,619.00 " N/A N/A N/A N/A N/A "$6,281.84 " N/A N/A N/A N/A N/A "$3,602.82 " N/A N/A "$4,203.29 " N/A N/A "$7,390.40 " N/A N/A "$5,080.90 " N/A N/A "$6,004.70 " N/A N/A "$3,094.73 " N/A N/A N/A N/A N/A "$5,542.80 " N/A N/A "$3,233.30 " N/A N/A "$6,004.70 " N/A N/A "$2,771.40 " N/A N/A "$5,542.80 " N/A N/A "$6,004.70 " N/A N/A "$2,771.40 " N/A N/A "$2,771.40 " N/A N/A "$2,771.40 " N/A N/A "$2,771.40 " N/A N/A "$2,771.40 " N/A N/A "$2,771.40 " N/A "$9,238.00 " "$9,238.00 " N/A 1501107 Supplies EXTREMITY PACK 270 $197.00 $- $51.22 $- $- $157.60 $- N/A $51.22 N/A N/A $74.47 N/A N/A $118.20 N/A N/A $98.50 N/A N/A N/A N/A N/A $133.96 N/A N/A N/A N/A N/A $76.83 N/A N/A $89.64 N/A N/A $157.60 N/A N/A $108.35 N/A N/A $128.05 N/A N/A $66.00 N/A N/A N/A N/A N/A $118.20 N/A N/A $68.95 N/A N/A $128.05 N/A N/A $59.10 N/A N/A $118.20 N/A N/A $128.05 N/A N/A $59.10 N/A N/A $59.10 N/A N/A $59.10 N/A N/A $59.10 N/A N/A $59.10 N/A N/A $59.10 N/A $197.00 $197.00 N/A 1501108 Supplies ALLOSYNC DBM GEL 1CC 270 $926.00 $- $240.76 $- $- $740.80 $- N/A $240.76 N/A N/A $350.03 N/A N/A $555.60 N/A N/A $463.00 N/A N/A N/A N/A N/A $629.68 N/A N/A N/A N/A N/A $361.14 N/A N/A $421.33 N/A N/A $740.80 N/A N/A $509.30 N/A N/A $601.90 N/A N/A $310.21 N/A N/A N/A N/A N/A $555.60 N/A N/A $324.10 N/A N/A $601.90 N/A N/A $277.80 N/A N/A $555.60 N/A N/A $601.90 N/A N/A $277.80 N/A N/A $277.80 N/A N/A $277.80 N/A N/A $277.80 N/A N/A $277.80 N/A N/A $277.80 N/A $926.00 $926.00 N/A 1501109 Supplies BB-TAK 272 $232.00 $- $60.32 $- $- $185.60 $- N/A $60.32 N/A N/A $87.70 N/A N/A $139.20 N/A N/A $116.00 N/A N/A N/A N/A N/A $157.76 N/A N/A N/A N/A N/A $90.48 N/A N/A $105.56 N/A N/A $185.60 N/A N/A $127.60 N/A N/A $150.80 N/A N/A $77.72 N/A N/A N/A N/A N/A $139.20 N/A N/A $81.20 N/A N/A $150.80 N/A N/A $69.60 N/A N/A $139.20 N/A N/A $150.80 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A N/A $69.60 N/A $232.00 $232.00 N/A 1501110 Supplies BB-TAK THREADED 272 $394.00 $- $102.44 $- $- $315.20 $- N/A $102.44 N/A N/A $148.93 N/A N/A $236.40 N/A N/A $197.00 N/A N/A N/A N/A N/A $267.92 N/A N/A N/A N/A N/A $153.66 N/A N/A $179.27 N/A N/A $315.20 N/A N/A $216.70 N/A N/A $256.10 N/A N/A $131.99 N/A N/A N/A N/A N/A $236.40 N/A N/A $137.90 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $236.40 N/A N/A $256.10 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A N/A $118.20 N/A $394.00 $394.00 N/A 1501111 Supplies SCREW CORTEX 2.4X10MM 272 $510.00 $- $132.60 $- $- $408.00 $- N/A $132.60 N/A N/A $192.78 N/A N/A $306.00 N/A N/A $255.00 N/A N/A N/A N/A N/A $346.80 N/A N/A N/A N/A N/A $198.90 N/A N/A $232.05 N/A N/A $408.00 N/A N/A $280.50 N/A N/A $331.50 N/A N/A $170.85 N/A N/A N/A N/A N/A $306.00 N/A N/A $178.50 N/A N/A $331.50 N/A N/A $153.00 N/A N/A $306.00 N/A N/A $331.50 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A $510.00 $510.00 N/A 1501112 Supplies SCREW CORTEX 2.4X14MM 272 $510.00 $- $132.60 $- $- $408.00 $- N/A $132.60 N/A N/A $192.78 N/A N/A $306.00 N/A N/A $255.00 N/A N/A N/A N/A N/A $346.80 N/A N/A N/A N/A N/A $198.90 N/A N/A $232.05 N/A N/A $408.00 N/A N/A $280.50 N/A N/A $331.50 N/A N/A $170.85 N/A N/A N/A N/A N/A $306.00 N/A N/A $178.50 N/A N/A $331.50 N/A N/A $153.00 N/A N/A $306.00 N/A N/A $331.50 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A N/A $153.00 N/A $510.00 $510.00 N/A 1501113 Supplies SCREW VAL 2.4X10MM 272 $649.00 $- $168.74 $- $- $519.20 $- N/A $168.74 N/A N/A $245.32 N/A N/A $389.40 N/A N/A $324.50 N/A N/A N/A N/A N/A $441.32 N/A N/A N/A N/A N/A $253.11 N/A N/A $295.30 N/A N/A $519.20 N/A N/A $356.95 N/A N/A $421.85 N/A N/A $217.42 N/A N/A N/A N/A N/A $389.40 N/A N/A $227.15 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $389.40 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A $649.00 $649.00 N/A 1501114 Supplies SCREW VAL 2.4X12MM 272 $649.00 $- $168.74 $- $- $519.20 $- N/A $168.74 N/A N/A $245.32 N/A N/A $389.40 N/A N/A $324.50 N/A N/A N/A N/A N/A $441.32 N/A N/A N/A N/A N/A $253.11 N/A N/A $295.30 N/A N/A $519.20 N/A N/A $356.95 N/A N/A $421.85 N/A N/A $217.42 N/A N/A N/A N/A N/A $389.40 N/A N/A $227.15 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $389.40 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A $649.00 $649.00 N/A 1501115 Supplies SCREW VAL 2.4X14MM 272 $649.00 $- $168.74 $- $- $519.20 $- N/A $168.74 N/A N/A $245.32 N/A N/A $389.40 N/A N/A $324.50 N/A N/A N/A N/A N/A $441.32 N/A N/A N/A N/A N/A $253.11 N/A N/A $295.30 N/A N/A $519.20 N/A N/A $356.95 N/A N/A $421.85 N/A N/A $217.42 N/A N/A N/A N/A N/A $389.40 N/A N/A $227.15 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $389.40 N/A N/A $421.85 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A N/A $194.70 N/A $649.00 $649.00 N/A 1501116 Supplies DRILL BIT 1.7MM 272 $366.00 $- $95.16 $- $- $292.80 $- N/A $95.16 N/A N/A $138.35 N/A N/A $219.60 N/A N/A $183.00 N/A N/A N/A N/A N/A $248.88 N/A N/A N/A N/A N/A $142.74 N/A N/A $166.53 N/A N/A $292.80 N/A N/A $201.30 N/A N/A $237.90 N/A N/A $122.61 N/A N/A N/A N/A N/A $219.60 N/A N/A $128.10 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $219.60 N/A N/A $237.90 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A N/A $109.80 N/A $366.00 $366.00 N/A 1501117 Supplies T-PLATE 2.4MM 8 HOLE 272 "$3,218.00 " $- $836.68 $- $- "$2,574.40 " $- N/A $836.68 N/A N/A "$1,216.40 " N/A N/A "$1,930.80 " N/A N/A "$1,609.00 " N/A N/A N/A N/A N/A "$2,188.24 " N/A N/A N/A N/A N/A "$1,255.02 " N/A N/A "$1,464.19 " N/A N/A "$2,574.40 " N/A N/A "$1,769.90 " N/A N/A "$2,091.70 " N/A N/A "$1,078.03 " N/A N/A N/A N/A N/A "$1,930.80 " N/A N/A "$1,126.30 " N/A N/A "$2,091.70 " N/A N/A $965.40 N/A N/A "$1,930.80 " N/A N/A "$2,091.70 " N/A N/A $965.40 N/A N/A $965.40 N/A N/A $965.40 N/A N/A $965.40 N/A N/A $965.40 N/A N/A $965.40 N/A "$3,218.00 " "$3,218.00 " N/A 1501118 Supplies SUCTION CANISTER 3000CC. 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501119 Supplies DRAPE TOWEL D1010 270 $6.00 $- $1.56 $- $- $4.80 $- N/A $1.56 N/A N/A $2.27 N/A N/A $3.60 N/A N/A $3.00 N/A N/A N/A N/A N/A $4.08 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.73 N/A N/A $4.80 N/A N/A $3.30 N/A N/A $3.90 N/A N/A $2.01 N/A N/A N/A N/A N/A $3.60 N/A N/A $2.10 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $3.60 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A $6.00 $6.00 N/A 1501120 Supplies "CAST PADDING, 4 INCH STERILE" 272 $6.00 $- $1.56 $- $- $4.80 $- N/A $1.56 N/A N/A $2.27 N/A N/A $3.60 N/A N/A $3.00 N/A N/A N/A N/A N/A $4.08 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.73 N/A N/A $4.80 N/A N/A $3.30 N/A N/A $3.90 N/A N/A $2.01 N/A N/A N/A N/A N/A $3.60 N/A N/A $2.10 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $3.60 N/A N/A $3.90 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A N/A $1.80 N/A $6.00 $6.00 N/A 1501121 Supplies MESALT DRESSING 4X4 272 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A N/A N/A N/A $1.95 N/A N/A $2.28 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.25 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $1.50 N/A N/A $3.00 N/A N/A $3.25 N/A N/A $1.50 N/A N/A $1.50 N/A N/A $1.50 N/A N/A $1.50 N/A N/A $1.50 N/A N/A $1.50 N/A $5.00 $5.00 N/A 1501122 Supplies I.V. CATHETER 18GX1.88 270 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 1501123 Supplies "CATHETER, WORD" 270 $123.00 $- $31.98 $- $- $98.40 $- N/A $31.98 N/A N/A $46.49 N/A N/A $73.80 N/A N/A $61.50 N/A N/A N/A N/A N/A $83.64 N/A N/A N/A N/A N/A $47.97 N/A N/A $55.97 N/A N/A $98.40 N/A N/A $67.65 N/A N/A $79.95 N/A N/A $41.21 N/A N/A N/A N/A N/A $73.80 N/A N/A $43.05 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $73.80 N/A N/A $79.95 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A N/A $36.90 N/A $123.00 $123.00 N/A 1501125 Supplies "ARM SLING, XL" 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A 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N/A $8.80 N/A N/A $6.05 N/A N/A $7.15 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $6.60 N/A N/A $7.15 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A N/A $3.30 N/A $11.00 $11.00 N/A 1501128 Supplies TOURNIQUET 18x3 DISP. 270 $322.00 $- $83.72 $- $- $257.60 $- N/A $83.72 N/A N/A $121.72 N/A N/A $193.20 N/A N/A $161.00 N/A N/A N/A N/A N/A $218.96 N/A N/A N/A N/A N/A $125.58 N/A N/A $146.51 N/A N/A $257.60 N/A N/A $177.10 N/A N/A $209.30 N/A N/A $107.87 N/A N/A N/A N/A N/A $193.20 N/A N/A $112.70 N/A N/A $209.30 N/A N/A $96.60 N/A N/A $193.20 N/A N/A $209.30 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A N/A $96.60 N/A $322.00 $322.00 N/A 1501129 Supplies ANGIOCATH 10GX3 270 $131.00 $- $34.06 $- $- $104.80 $- N/A $34.06 N/A N/A $49.52 N/A N/A $78.60 N/A N/A $65.50 N/A N/A N/A N/A N/A $89.08 N/A N/A N/A N/A N/A $51.09 N/A N/A $59.61 N/A N/A $104.80 N/A N/A $72.05 N/A N/A $85.15 N/A N/A $43.89 N/A N/A N/A N/A N/A $78.60 N/A N/A $45.85 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $78.60 N/A N/A $85.15 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A N/A $39.30 N/A $131.00 $131.00 N/A 1501130 Supplies LAPIPLASTY SYSTEM 1 270 "$12,146.00 " $- "$3,157.96 " $- $- "$9,716.80 " $- N/A "$3,157.96 " N/A N/A "$4,591.19 " N/A N/A "$7,287.60 " N/A N/A "$6,073.00 " N/A N/A N/A N/A N/A "$8,259.28 " N/A N/A N/A N/A N/A "$4,736.94 " N/A N/A "$5,526.43 " N/A N/A "$9,716.80 " N/A N/A "$6,680.30 " N/A N/A "$7,894.90 " N/A N/A "$4,068.91 " N/A N/A N/A N/A N/A "$7,287.60 " N/A N/A "$4,251.10 " N/A N/A "$7,894.90 " N/A N/A "$3,643.80 " N/A N/A "$7,287.60 " N/A N/A "$7,894.90 " N/A N/A "$3,643.80 " N/A N/A "$3,643.80 " N/A N/A "$3,643.80 " N/A N/A "$3,643.80 " N/A N/A "$3,643.80 " N/A N/A "$3,643.80 " N/A "$12,146.00 " "$12,146.00 " N/A 1501131 Supplies Z-GUIDE WIRE 1.5X80 270 $566.00 $- $147.16 $- $- $452.80 $- N/A $147.16 N/A N/A $213.95 N/A N/A $339.60 N/A N/A $283.00 N/A N/A N/A N/A N/A $384.88 N/A N/A N/A N/A N/A $220.74 N/A N/A $257.53 N/A N/A $452.80 N/A N/A $311.30 N/A N/A $367.90 N/A N/A $189.61 N/A N/A N/A N/A N/A $339.60 N/A N/A $198.10 N/A N/A $367.90 N/A N/A $169.80 N/A N/A $339.60 N/A N/A $367.90 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A $566.00 $566.00 N/A 1501132 Supplies "SCREW, HIGH PITCH LOCKING 2.7MM" C1713 C1713 278 "$2,347.00 " $- $610.22 $- $- "$1,877.60 " $- N/A $610.22 N/A N/A $887.17 N/A N/A "$1,408.20 " N/A N/A "$1,173.50 " N/A N/A N/A N/A N/A "$1,595.96 " N/A N/A N/A N/A N/A $915.33 N/A N/A "$1,067.89 " N/A N/A "$1,877.60 " N/A N/A "$1,290.85 " N/A N/A "$1,525.55 " N/A N/A $786.25 N/A N/A N/A N/A N/A "$1,408.20 " N/A N/A $821.45 N/A N/A "$1,525.55 " N/A N/A $704.10 N/A N/A "$1,408.20 " N/A N/A "$1,525.55 " N/A N/A $704.10 N/A N/A $704.10 N/A N/A $704.10 N/A N/A $704.10 N/A N/A $704.10 N/A N/A $704.10 N/A "$2,347.00 " "$2,347.00 " N/A 1501133 Supplies Z-STAPLE 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$367.90 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A N/A $169.80 N/A $566.00 $566.00 N/A 1501135 Supplies I.V. 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LEFT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501149 Supplies THUMB SPICA WRIST BRACE MED. RIGHT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501150 Supplies THUMB SPICA WRIST BRACE LG. RIGHT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501151 Supplies THUMB SPICA WRIST BRACE LG. LEFT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501152 Supplies THUMB SPICA WRIST BRACE XL RIGHT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501153 Supplies THUMB SPICA WRIST BRACE XL LEFT L3807 L3807 274 $103.00 $- $26.78 $- $- $82.40 $- N/A $26.78 N/A N/A $38.93 N/A N/A $61.80 N/A N/A $51.50 N/A N/A N/A N/A N/A $70.04 N/A N/A N/A N/A N/A $40.17 N/A N/A $46.87 N/A N/A $82.40 N/A N/A $56.65 N/A N/A $66.95 N/A N/A $34.51 N/A N/A N/A N/A N/A $61.80 N/A N/A $36.05 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $61.80 N/A N/A $66.95 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A N/A $30.90 N/A $103.00 $103.00 N/A 1501154 Supplies LPT REGULAR GREAT TOE L8641 L8641 278 "$3,947.00 " $- "$1,026.22 " $- $- "$3,157.60 " $- N/A "$1,026.22 " N/A N/A "$1,491.97 " N/A N/A "$2,368.20 " N/A N/A "$1,973.50 " N/A N/A N/A N/A N/A "$2,683.96 " N/A N/A N/A N/A N/A "$1,539.33 " N/A N/A "$1,795.89 " N/A N/A "$3,157.60 " N/A N/A "$2,170.85 " N/A N/A "$2,565.55 " N/A N/A "$1,322.25 " N/A N/A N/A N/A N/A "$2,368.20 " N/A N/A "$1,381.45 " N/A N/A "$2,565.55 " N/A N/A "$1,184.10 " N/A N/A "$2,368.20 " N/A N/A "$2,565.55 " N/A N/A "$1,184.10 " N/A N/A "$1,184.10 " N/A N/A "$1,184.10 " N/A N/A "$1,184.10 " N/A N/A "$1,184.10 " N/A N/A "$1,184.10 " N/A "$3,947.00 " "$3,947.00 " N/A 1501155 Supplies "DIAPER, ADULT SMALL" 270 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A N/A N/A N/A $10.92 N/A N/A $12.74 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $18.20 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $8.40 N/A N/A $16.80 N/A N/A $18.20 N/A N/A $8.40 N/A N/A $8.40 N/A N/A $8.40 N/A N/A $8.40 N/A N/A $8.40 N/A N/A $8.40 N/A $28.00 $28.00 N/A 1501156 Supplies ACETIC ACID 0.25% 1000ML. 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1501157 Supplies KATZ EXTRACTOR 270 $437.00 $- $113.62 $- $- $349.60 $- N/A $113.62 N/A N/A $165.19 N/A N/A $262.20 N/A N/A $218.50 N/A N/A N/A N/A N/A $297.16 N/A N/A N/A N/A N/A $170.43 N/A N/A $198.84 N/A N/A $349.60 N/A N/A $240.35 N/A N/A $284.05 N/A N/A $146.40 N/A N/A N/A N/A N/A $262.20 N/A N/A $152.95 N/A N/A $284.05 N/A N/A $131.10 N/A N/A $262.20 N/A N/A $284.05 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A N/A $131.10 N/A $437.00 $437.00 N/A 1501158 Supplies STAT LOCK FOLEY 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1501159 Supplies DIGNISHIELD COLLECTION SYSTEM 270 "$1,125.00 " $- $292.50 $- $- $900.00 $- N/A $292.50 N/A N/A $425.25 N/A N/A $675.00 N/A N/A $562.50 N/A N/A N/A N/A N/A $765.00 N/A N/A N/A N/A N/A $438.75 N/A N/A $511.88 N/A N/A $900.00 N/A N/A $618.75 N/A N/A $731.25 N/A N/A $376.88 N/A N/A N/A N/A N/A $675.00 N/A N/A $393.75 N/A N/A $731.25 N/A N/A $337.50 N/A N/A $675.00 N/A N/A $731.25 N/A N/A $337.50 N/A N/A $337.50 N/A N/A $337.50 N/A N/A $337.50 N/A N/A $337.50 N/A N/A $337.50 N/A "$1,125.00 " "$1,125.00 " N/A 1501160 Supplies DIGNISHIELD COLLECTION BAG 270 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A $6.43 N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A N/A N/A N/A $6.63 N/A N/A $7.74 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.05 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $10.20 N/A N/A $11.05 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A N/A $5.10 N/A $17.00 $17.00 N/A 1501162 Supplies "AMNION THIN, 4X8 AMINOGRAFT" C1762 C1762 278 "$8,214.00 " $- "$2,135.64 " $- $- "$6,571.20 " $- N/A "$2,135.64 " N/A N/A "$3,104.89 " N/A N/A "$4,928.40 " N/A N/A "$4,107.00 " N/A N/A N/A N/A N/A "$5,585.52 " N/A N/A N/A N/A N/A "$3,203.46 " N/A N/A "$3,737.37 " N/A N/A "$6,571.20 " N/A N/A "$4,517.70 " N/A N/A "$5,339.10 " N/A N/A "$2,751.69 " N/A N/A N/A N/A N/A "$4,928.40 " N/A N/A "$2,874.90 " N/A N/A "$5,339.10 " N/A N/A "$2,464.20 " N/A N/A "$4,928.40 " N/A N/A "$5,339.10 " N/A N/A "$2,464.20 " N/A N/A "$2,464.20 " N/A N/A "$2,464.20 " N/A N/A "$2,464.20 " N/A N/A "$2,464.20 " N/A N/A "$2,464.20 " N/A "$8,214.00 " "$8,214.00 " N/A 1501163 Supplies IMPLANT: ACHILLES SPEED W/JUMP C1713 C1713 278 "$4,400.00 " $- "$1,144.00 " $- $- "$3,520.00 " $- N/A "$1,144.00 " N/A N/A "$1,663.20 " N/A N/A "$2,640.00 " N/A N/A "$2,200.00 " N/A N/A N/A N/A N/A "$2,992.00 " N/A N/A N/A N/A N/A "$1,716.00 " N/A N/A "$2,002.00 " N/A N/A "$3,520.00 " N/A N/A "$2,420.00 " N/A N/A "$2,860.00 " N/A N/A "$1,474.00 " N/A N/A N/A N/A N/A "$2,640.00 " N/A N/A "$1,540.00 " N/A N/A "$2,860.00 " N/A N/A "$1,320.00 " N/A N/A "$2,640.00 " N/A N/A "$2,860.00 " N/A N/A "$1,320.00 " N/A N/A "$1,320.00 " N/A N/A "$1,320.00 " N/A N/A "$1,320.00 " N/A N/A "$1,320.00 " N/A N/A "$1,320.00 " N/A "$4,400.00 " "$4,400.00 " N/A 1501171 Supplies STIMUPLEX NEEDLE 20X4 270 $60.00 $- $15.60 $- $- $48.00 $- N/A $15.60 N/A N/A $22.68 N/A N/A $36.00 N/A N/A $30.00 N/A N/A N/A N/A N/A $40.80 N/A N/A N/A N/A N/A $23.40 N/A N/A $27.30 N/A N/A $48.00 N/A N/A $33.00 N/A N/A $39.00 N/A N/A $20.10 N/A N/A N/A N/A N/A $36.00 N/A N/A $21.00 N/A N/A $39.00 N/A N/A $18.00 N/A N/A $36.00 N/A N/A $39.00 N/A N/A $18.00 N/A N/A $18.00 N/A N/A $18.00 N/A N/A $18.00 N/A N/A $18.00 N/A N/A $18.00 N/A $60.00 $60.00 N/A 1501172 Supplies "SCREW, LOCKING FASTPATCH 12MM" C1713 C1713 278 "$2,234.00 " $- $580.84 $- $- "$1,787.20 " $- N/A $580.84 N/A N/A $844.45 N/A N/A "$1,340.40 " N/A N/A "$1,117.00 " N/A N/A N/A N/A N/A "$1,519.12 " N/A N/A N/A N/A N/A $871.26 N/A N/A "$1,016.47 " N/A N/A "$1,787.20 " N/A N/A "$1,228.70 " N/A N/A "$1,452.10 " N/A N/A $748.39 N/A N/A N/A N/A N/A "$1,340.40 " N/A N/A $781.90 N/A N/A "$1,452.10 " N/A N/A $670.20 N/A N/A "$1,340.40 " N/A N/A "$1,452.10 " N/A N/A $670.20 N/A N/A $670.20 N/A N/A $670.20 N/A N/A $670.20 N/A N/A $670.20 N/A N/A $670.20 N/A "$2,234.00 " "$2,234.00 " N/A 1501173 Supplies "SAW BLADE, OSCILLATING 40MMX11MM" 270 $539.00 $- $140.14 $- $- $431.20 $- N/A $140.14 N/A N/A $203.74 N/A N/A $323.40 N/A N/A $269.50 N/A N/A N/A N/A N/A $366.52 N/A N/A N/A N/A N/A $210.21 N/A N/A $245.25 N/A N/A $431.20 N/A N/A $296.45 N/A N/A $350.35 N/A N/A $180.57 N/A N/A N/A N/A N/A $323.40 N/A N/A $188.65 N/A N/A $350.35 N/A N/A $161.70 N/A N/A $323.40 N/A N/A $350.35 N/A N/A $161.70 N/A N/A $161.70 N/A N/A $161.70 N/A N/A $161.70 N/A N/A $161.70 N/A N/A $161.70 N/A $539.00 $539.00 N/A 1501175 Supplies "PLATE, PINCH 6-HOLE" C1713 C1713 278 "$5,389.00 " $- "$1,401.14 " $- $- "$4,311.20 " $- N/A "$1,401.14 " N/A N/A "$2,037.04 " N/A N/A "$3,233.40 " N/A N/A "$2,694.50 " N/A N/A N/A N/A N/A "$3,664.52 " N/A N/A N/A N/A N/A "$2,101.71 " N/A N/A "$2,452.00 " N/A N/A "$4,311.20 " N/A N/A "$2,963.95 " N/A N/A "$3,502.85 " N/A N/A "$1,805.32 " N/A N/A N/A N/A N/A "$3,233.40 " N/A N/A "$1,886.15 " N/A N/A "$3,502.85 " N/A N/A "$1,616.70 " N/A N/A "$3,233.40 " N/A N/A "$3,502.85 " N/A N/A "$1,616.70 " N/A N/A "$1,616.70 " N/A N/A "$1,616.70 " N/A N/A "$1,616.70 " N/A N/A "$1,616.70 " N/A N/A "$1,616.70 " N/A "$5,389.00 " "$5,389.00 " N/A 1501176 Supplies "SCREW, LOCKING WRIGHT 2.4X10" C1713 C1713 278 "$1,266.00 " $- $329.16 $- $- "$1,012.80 " $- N/A $329.16 N/A N/A $478.55 N/A N/A $759.60 N/A N/A $633.00 N/A N/A N/A N/A N/A $860.88 N/A N/A N/A N/A N/A $493.74 N/A N/A $576.03 N/A N/A "$1,012.80 " N/A N/A $696.30 N/A N/A $822.90 N/A N/A $424.11 N/A N/A N/A N/A N/A $759.60 N/A N/A $443.10 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $759.60 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A "$1,266.00 " "$1,266.00 " N/A 1501177 Supplies "SCREW, LOCKING WRIGHT 2.4X12" C1713 C1713 278 "$1,266.00 " $- $329.16 $- $- "$1,012.80 " $- N/A $329.16 N/A N/A $478.55 N/A N/A $759.60 N/A N/A $633.00 N/A N/A N/A N/A N/A $860.88 N/A N/A N/A N/A N/A $493.74 N/A N/A $576.03 N/A N/A "$1,012.80 " N/A N/A $696.30 N/A N/A $822.90 N/A N/A $424.11 N/A N/A N/A N/A N/A $759.60 N/A N/A $443.10 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $759.60 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A "$1,266.00 " "$1,266.00 " N/A 1501178 Supplies "SCREW, LOCKING WRIGHT 2.4X14" C1713 C1713 278 "$1,266.00 " $- $329.16 $- $- "$1,012.80 " $- N/A $329.16 N/A N/A $478.55 N/A N/A $759.60 N/A N/A $633.00 N/A N/A N/A N/A N/A $860.88 N/A N/A N/A N/A N/A $493.74 N/A N/A $576.03 N/A N/A "$1,012.80 " N/A N/A $696.30 N/A N/A $822.90 N/A N/A $424.11 N/A N/A N/A N/A N/A $759.60 N/A N/A $443.10 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $759.60 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A "$1,266.00 " "$1,266.00 " N/A 1501179 Supplies "SCREW, CORTICAL WRIGHT 2.0X12" C1713 C1713 278 $536.00 $- $139.36 $- $- $428.80 $- N/A $139.36 N/A N/A $202.61 N/A N/A $321.60 N/A N/A $268.00 N/A N/A N/A N/A N/A $364.48 N/A N/A N/A N/A N/A $209.04 N/A N/A $243.88 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $348.40 N/A N/A $179.56 N/A N/A N/A N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 1501180 Supplies DRILL BIT 2.0 WRIGHT 270 $794.00 $- $206.44 $- $- $635.20 $- N/A $206.44 N/A N/A $300.13 N/A N/A $476.40 N/A N/A $397.00 N/A N/A N/A N/A N/A $539.92 N/A N/A N/A N/A N/A $309.66 N/A N/A $361.27 N/A N/A $635.20 N/A N/A $436.70 N/A N/A $516.10 N/A N/A $265.99 N/A N/A N/A N/A N/A $476.40 N/A N/A $277.90 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $476.40 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A $794.00 $794.00 N/A 1501181 Supplies "DRILL BIT, WRIGHT 1.6" 270 $794.00 $- $206.44 $- $- $635.20 $- N/A $206.44 N/A N/A $300.13 N/A N/A $476.40 N/A N/A $397.00 N/A N/A N/A N/A N/A $539.92 N/A N/A N/A N/A N/A $309.66 N/A N/A $361.27 N/A N/A $635.20 N/A N/A $436.70 N/A N/A $516.10 N/A N/A $265.99 N/A N/A N/A N/A N/A $476.40 N/A N/A $277.90 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $476.40 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A $794.00 $794.00 N/A 1501182 Supplies PIN WRIGHT 1.1 C1713 C1713 278 $342.00 $- $88.92 $- $- $273.60 $- N/A $88.92 N/A N/A $129.28 N/A N/A $205.20 N/A N/A $171.00 N/A N/A N/A N/A N/A $232.56 N/A N/A N/A N/A N/A $133.38 N/A N/A $155.61 N/A N/A $273.60 N/A N/A $188.10 N/A N/A $222.30 N/A N/A $114.57 N/A N/A N/A N/A N/A $205.20 N/A N/A $119.70 N/A N/A $222.30 N/A N/A $102.60 N/A N/A $205.20 N/A N/A $222.30 N/A N/A $102.60 N/A N/A $102.60 N/A N/A $102.60 N/A N/A $102.60 N/A N/A $102.60 N/A N/A $102.60 N/A $342.00 $342.00 N/A 1501183 Supplies "SCREW, LOCKING WRIGHT 3.5X18" C1713 C1713 278 $995.00 $- $258.70 $- $- $796.00 $- N/A $258.70 N/A N/A $376.11 N/A N/A $597.00 N/A N/A $497.50 N/A N/A N/A N/A N/A $676.60 N/A N/A N/A N/A N/A $388.05 N/A N/A $452.73 N/A N/A $796.00 N/A N/A $547.25 N/A N/A $646.75 N/A N/A $333.33 N/A N/A N/A N/A N/A $597.00 N/A N/A $348.25 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $597.00 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A $995.00 $995.00 N/A 1501184 Supplies "SCREW, CORTICAL WRIGHT 3.5X18" C1713 C1713 278 $508.00 $- $132.08 $- $- $406.40 $- N/A $132.08 N/A N/A $192.02 N/A N/A $304.80 N/A N/A $254.00 N/A N/A N/A N/A N/A $345.44 N/A N/A N/A N/A N/A $198.12 N/A N/A $231.14 N/A N/A $406.40 N/A N/A $279.40 N/A N/A $330.20 N/A N/A $170.18 N/A N/A N/A N/A N/A $304.80 N/A N/A $177.80 N/A N/A $330.20 N/A N/A $152.40 N/A N/A $304.80 N/A N/A $330.20 N/A N/A $152.40 N/A N/A $152.40 N/A N/A $152.40 N/A N/A $152.40 N/A N/A $152.40 N/A N/A $152.40 N/A $508.00 $508.00 N/A 1501185 Supplies "SCREW, LOCKING WRIGHT 3.5X14" C1713 C1713 278 $995.00 $- $258.70 $- $- $796.00 $- N/A $258.70 N/A N/A $376.11 N/A N/A $597.00 N/A N/A $497.50 N/A N/A N/A N/A N/A $676.60 N/A N/A N/A N/A N/A $388.05 N/A N/A $452.73 N/A N/A $796.00 N/A N/A $547.25 N/A N/A $646.75 N/A N/A $333.33 N/A N/A N/A N/A N/A $597.00 N/A N/A $348.25 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $597.00 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A $995.00 $995.00 N/A 1501186 Supplies "SCREW, LOCKING WRIGHT 3.5X16" C1713 C1713 278 $995.00 $- $258.70 $- $- $796.00 $- N/A $258.70 N/A N/A $376.11 N/A N/A $597.00 N/A N/A $497.50 N/A N/A N/A N/A N/A $676.60 N/A N/A N/A N/A N/A $388.05 N/A N/A $452.73 N/A N/A $796.00 N/A N/A $547.25 N/A N/A $646.75 N/A N/A $333.33 N/A N/A N/A N/A N/A $597.00 N/A N/A $348.25 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $597.00 N/A N/A $646.75 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A N/A $298.50 N/A $995.00 $995.00 N/A 1501187 Supplies "SCREW, LOCKING WRIGHT 2.4X16" C1713 C1713 278 "$1,266.00 " $- $329.16 $- $- "$1,012.80 " $- N/A $329.16 N/A N/A $478.55 N/A N/A $759.60 N/A N/A $633.00 N/A N/A N/A N/A N/A $860.88 N/A N/A N/A N/A N/A $493.74 N/A N/A $576.03 N/A N/A "$1,012.80 " N/A N/A $696.30 N/A N/A $822.90 N/A N/A $424.11 N/A N/A N/A N/A N/A $759.60 N/A N/A $443.10 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $759.60 N/A N/A $822.90 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A N/A $379.80 N/A "$1,266.00 " "$1,266.00 " N/A 1501188 Supplies "SCREW, NON-LOCK WRIGHT 2.4X12" C1713 C1713 278 $536.00 $- $139.36 $- $- $428.80 $- N/A $139.36 N/A N/A $202.61 N/A N/A $321.60 N/A N/A $268.00 N/A N/A N/A N/A N/A $364.48 N/A N/A N/A N/A N/A $209.04 N/A N/A $243.88 N/A N/A $428.80 N/A N/A $294.80 N/A N/A $348.40 N/A N/A $179.56 N/A N/A N/A N/A N/A $321.60 N/A N/A $187.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $321.60 N/A N/A $348.40 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A N/A $160.80 N/A $536.00 $536.00 N/A 1501189 Supplies T-PLATE WRIGHT C1713 C1713 278 "$5,269.00 " $- "$1,369.94 " $- $- "$4,215.20 " $- N/A "$1,369.94 " N/A N/A "$1,991.68 " N/A N/A "$3,161.40 " N/A N/A "$2,634.50 " N/A N/A N/A N/A N/A "$3,582.92 " N/A N/A N/A N/A N/A "$2,054.91 " N/A N/A "$2,397.40 " N/A N/A "$4,215.20 " N/A N/A "$2,897.95 " N/A N/A "$3,424.85 " N/A N/A "$1,765.12 " N/A N/A N/A N/A N/A "$3,161.40 " N/A N/A "$1,844.15 " N/A N/A "$3,424.85 " N/A N/A "$1,580.70 " N/A N/A "$3,161.40 " N/A N/A "$3,424.85 " N/A N/A "$1,580.70 " N/A N/A "$1,580.70 " N/A N/A "$1,580.70 " N/A N/A "$1,580.70 " N/A N/A "$1,580.70 " N/A N/A "$1,580.70 " N/A "$5,269.00 " "$5,269.00 " N/A 1501190 Supplies "PLATE, 8-HOLE STRAIGHT WRIGHT" C1713 C1713 278 "$3,236.00 " $- $841.36 $- $- "$2,588.80 " $- N/A $841.36 N/A N/A "$1,223.21 " N/A N/A "$1,941.60 " N/A N/A "$1,618.00 " N/A N/A N/A N/A N/A "$2,200.48 " N/A N/A N/A N/A N/A "$1,262.04 " N/A N/A "$1,472.38 " N/A N/A "$2,588.80 " N/A N/A "$1,779.80 " N/A N/A "$2,103.40 " N/A N/A "$1,084.06 " N/A N/A N/A N/A N/A "$1,941.60 " N/A N/A "$1,132.60 " N/A N/A "$2,103.40 " N/A N/A $970.80 N/A N/A "$1,941.60 " N/A N/A "$2,103.40 " N/A N/A $970.80 N/A N/A $970.80 N/A N/A $970.80 N/A N/A $970.80 N/A N/A $970.80 N/A N/A $970.80 N/A "$3,236.00 " "$3,236.00 " N/A 1501191 Supplies TRICORTICAL BLOCK MEDIUM C1762 C1762 278 "$7,037.00 " $- "$1,829.62 " $- $- "$5,629.60 " $- N/A "$1,829.62 " N/A N/A "$2,659.99 " N/A N/A "$4,222.20 " N/A N/A "$3,518.50 " N/A N/A N/A N/A N/A "$4,785.16 " N/A N/A N/A N/A N/A "$2,744.43 " N/A N/A "$3,201.84 " N/A N/A "$5,629.60 " N/A N/A "$3,870.35 " N/A N/A "$4,574.05 " N/A N/A "$2,357.40 " N/A N/A N/A N/A N/A "$4,222.20 " N/A N/A "$2,462.95 " N/A N/A "$4,574.05 " N/A N/A "$2,111.10 " N/A N/A "$4,222.20 " N/A N/A "$4,574.05 " N/A N/A "$2,111.10 " N/A N/A "$2,111.10 " N/A N/A "$2,111.10 " N/A N/A "$2,111.10 " N/A N/A "$2,111.10 " N/A N/A "$2,111.10 " N/A "$7,037.00 " "$7,037.00 " N/A 1501192 Supplies DRILL BIT WRIGHT 2.5 270 $794.00 $- $206.44 $- $- $635.20 $- N/A $206.44 N/A N/A $300.13 N/A N/A $476.40 N/A N/A $397.00 N/A N/A N/A N/A N/A $539.92 N/A N/A N/A N/A N/A $309.66 N/A N/A $361.27 N/A N/A $635.20 N/A N/A $436.70 N/A N/A $516.10 N/A N/A $265.99 N/A N/A N/A N/A N/A $476.40 N/A N/A $277.90 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $476.40 N/A N/A $516.10 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A N/A $238.20 N/A $794.00 $794.00 N/A 1501193 Supplies TLSO BRACE L0458 L0458 274 "$1,529.00 " $- $397.54 $- $- "$1,223.20 " $- N/A $397.54 N/A N/A $577.96 N/A N/A $917.40 N/A N/A $764.50 N/A N/A N/A N/A N/A "$1,039.72 " N/A N/A N/A N/A N/A $596.31 N/A N/A $695.70 N/A N/A "$1,223.20 " N/A N/A $840.95 N/A N/A $993.85 N/A N/A $512.22 N/A N/A N/A N/A N/A $917.40 N/A N/A $535.15 N/A N/A $993.85 N/A N/A $458.70 N/A N/A $917.40 N/A N/A $993.85 N/A N/A $458.70 N/A N/A $458.70 N/A N/A $458.70 N/A N/A $458.70 N/A N/A $458.70 N/A N/A $458.70 N/A "$1,529.00 " "$1,529.00 " N/A 1501194 Supplies OXISENSOR II D-25 270 $105.00 $- $27.30 $- $- $84.00 $- N/A $27.30 N/A N/A $39.69 N/A N/A $63.00 N/A N/A $52.50 N/A N/A N/A N/A N/A $71.40 N/A N/A N/A N/A N/A $40.95 N/A N/A $47.78 N/A N/A $84.00 N/A N/A $57.75 N/A N/A $68.25 N/A N/A $35.18 N/A N/A N/A N/A N/A $63.00 N/A N/A $36.75 N/A N/A $68.25 N/A N/A $31.50 N/A N/A $63.00 N/A N/A $68.25 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A N/A $31.50 N/A $105.00 $105.00 N/A 1501195 Supplies ENDOTRACHEAL TUBE 3.5 HI-LO 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501196 Supplies ENDOTRACHEAL TUBE 5.0 HI-LO 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501197 Supplies ANESTHESIA SET W/LUER LOCK ADAPTER 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 1501198 Supplies ACE STERILE 3 270 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.60 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A $1.20 N/A N/A $2.40 N/A N/A $2.60 N/A N/A $1.20 N/A N/A $1.20 N/A N/A $1.20 N/A N/A $1.20 N/A N/A $1.20 N/A N/A $1.20 N/A $4.00 $4.00 N/A 1501199 Supplies ARISTA HEMOSTATIC PARTICLES 270 $905.00 $- $235.30 $- $- $724.00 $- N/A $235.30 N/A N/A $342.09 N/A N/A $543.00 N/A N/A $452.50 N/A N/A N/A N/A N/A $615.40 N/A N/A N/A N/A N/A $352.95 N/A N/A $411.78 N/A N/A $724.00 N/A N/A $497.75 N/A N/A $588.25 N/A N/A $303.18 N/A N/A N/A N/A N/A $543.00 N/A N/A $316.75 N/A N/A $588.25 N/A N/A $271.50 N/A N/A $543.00 N/A N/A $588.25 N/A N/A $271.50 N/A N/A $271.50 N/A N/A $271.50 N/A N/A $271.50 N/A N/A $271.50 N/A N/A $271.50 N/A $905.00 $905.00 N/A 1501200 Supplies ANESTHESIA CIRCUIT PEDS 2L 270 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A N/A N/A N/A $7.80 N/A N/A $9.10 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $13.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $12.00 N/A N/A $13.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A N/A $6.00 N/A $20.00 $20.00 N/A 1501201 Supplies SUCTION CANISTER 1500ML. 270 $26.00 $- $6.76 $- $- $20.80 $- N/A $6.76 N/A N/A $9.83 N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.68 N/A N/A N/A N/A N/A $10.14 N/A N/A $11.83 N/A N/A $20.80 N/A N/A $14.30 N/A N/A $16.90 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $15.60 N/A N/A $16.90 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A N/A $7.80 N/A $26.00 $26.00 N/A 1501202 Supplies OBTURATOR Z-THREAD 5X100 MM 270 $76.00 $- $19.76 $- $- $60.80 $- N/A $19.76 N/A N/A $28.73 N/A N/A $45.60 N/A N/A $38.00 N/A N/A N/A N/A N/A $51.68 N/A N/A N/A N/A N/A $29.64 N/A N/A $34.58 N/A N/A $60.80 N/A N/A $41.80 N/A N/A $49.40 N/A N/A $25.46 N/A N/A N/A N/A N/A $45.60 N/A N/A $26.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $45.60 N/A N/A $49.40 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A N/A $22.80 N/A $76.00 $76.00 N/A 1501203 Supplies ENDOSCOPE VALVE GAUGE 270 $13.00 $- $3.38 $- $- $10.40 $- N/A $3.38 N/A N/A $4.91 N/A N/A $7.80 N/A N/A $6.50 N/A N/A N/A N/A N/A $8.84 N/A N/A N/A N/A N/A $5.07 N/A N/A $5.92 N/A N/A $10.40 N/A N/A $7.15 N/A N/A $8.45 N/A N/A $4.36 N/A N/A N/A N/A N/A $7.80 N/A N/A $4.55 N/A N/A $8.45 N/A N/A $3.90 N/A N/A $7.80 N/A N/A $8.45 N/A N/A $3.90 N/A N/A $3.90 N/A N/A $3.90 N/A N/A $3.90 N/A N/A $3.90 N/A N/A $3.90 N/A $13.00 $13.00 N/A 1501204 Supplies BIOPSY VALVE 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 1501205 Supplies BIOPSY VALVE ADAPTER 270 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501206 Supplies TXB PROCEDURE PACK 270 "$3,098.00 " $- $805.48 $- $- "$2,478.40 " $- N/A $805.48 N/A N/A "$1,171.04 " N/A N/A "$1,858.80 " N/A N/A "$1,549.00 " N/A N/A N/A N/A N/A "$2,106.64 " N/A N/A N/A N/A N/A "$1,208.22 " N/A N/A "$1,409.59 " N/A N/A "$2,478.40 " N/A N/A "$1,703.90 " N/A N/A "$2,013.70 " N/A N/A "$1,037.83 " N/A N/A N/A N/A N/A "$1,858.80 " N/A N/A "$1,084.30 " N/A N/A "$2,013.70 " N/A N/A $929.40 N/A N/A "$1,858.80 " N/A N/A "$2,013.70 " N/A N/A $929.40 N/A N/A $929.40 N/A N/A $929.40 N/A N/A $929.40 N/A N/A $929.40 N/A N/A $929.40 N/A "$3,098.00 " "$3,098.00 " N/A 1501207 Supplies "TED HOSE, KNEE XXXL" 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 3211982 Supplies DRAPE OPTHALMIC 270 $142.00 $- $36.92 $- $- $113.60 $- N/A $36.92 N/A N/A $53.68 N/A N/A $85.20 N/A N/A $71.00 N/A N/A N/A N/A N/A $96.56 N/A N/A N/A N/A N/A $55.38 N/A N/A $64.61 N/A N/A $113.60 N/A N/A $78.10 N/A N/A $92.30 N/A N/A $47.57 N/A N/A N/A N/A N/A $85.20 N/A N/A $49.70 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $85.20 N/A N/A $92.30 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A N/A $42.60 N/A $142.00 $142.00 N/A 3212210 Supplies BREATHING CIRCUIT ANES 270 $176.00 $- $45.76 $- $- $140.80 $- N/A $45.76 N/A N/A $66.53 N/A N/A $105.60 N/A N/A $88.00 N/A N/A N/A N/A N/A $119.68 N/A N/A N/A N/A N/A $68.64 N/A N/A $80.08 N/A N/A $140.80 N/A N/A $96.80 N/A N/A $114.40 N/A N/A $58.96 N/A N/A N/A N/A N/A $105.60 N/A N/A $61.60 N/A N/A $114.40 N/A N/A $52.80 N/A N/A $105.60 N/A N/A $114.40 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A N/A $52.80 N/A $176.00 $176.00 N/A 3212212 Supplies NASAL CANN. W/CO2 LINE 270 $90.00 $- $23.40 $- $- $72.00 $- N/A $23.40 N/A N/A $34.02 N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A N/A N/A N/A $35.10 N/A N/A $40.95 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $58.50 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $54.00 N/A N/A $58.50 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A N/A $27.00 N/A $90.00 $90.00 N/A 3212213 Supplies "NASAL CANNULA, ANES" 270 $8.00 $- $2.08 $- $- $6.40 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 3212306 Supplies TUBE ORAL RAE 8.5 CUFFED 270 $84.00 $- $21.84 $- $- $67.20 $- N/A $21.84 N/A N/A $31.75 N/A N/A $50.40 N/A N/A $42.00 N/A N/A N/A N/A N/A $57.12 N/A N/A N/A N/A N/A $32.76 N/A N/A $38.22 N/A N/A $67.20 N/A N/A $46.20 N/A N/A $54.60 N/A N/A $28.14 N/A N/A N/A N/A N/A $50.40 N/A N/A $29.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $50.40 N/A N/A $54.60 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A N/A $25.20 N/A $84.00 $84.00 N/A 3212309 Supplies T-ADAPTER 270 $51.00 $- $13.26 $- $- $40.80 $- N/A $13.26 N/A N/A $19.28 N/A N/A $30.60 N/A N/A $25.50 N/A N/A N/A N/A N/A $34.68 N/A N/A N/A N/A N/A $19.89 N/A N/A $23.21 N/A N/A $40.80 N/A N/A $28.05 N/A N/A $33.15 N/A N/A $17.09 N/A N/A N/A N/A N/A $30.60 N/A N/A $17.85 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $30.60 N/A N/A $33.15 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A N/A $15.30 N/A $51.00 $51.00 N/A 3212342 Supplies SLOTTED HEAD POSITIONER 270 $97.00 $- $25.22 $- $- $77.60 $- N/A $25.22 N/A N/A $36.67 N/A N/A $58.20 N/A N/A $48.50 N/A N/A N/A N/A N/A $65.96 N/A N/A N/A N/A N/A $37.83 N/A N/A $44.14 N/A N/A $77.60 N/A N/A $53.35 N/A N/A $63.05 N/A N/A $32.50 N/A N/A N/A N/A N/A $58.20 N/A N/A $33.95 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $58.20 N/A N/A $63.05 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A N/A $29.10 N/A $97.00 $97.00 N/A 3213211 Supplies TISSUE LINK 270 "$7,613.00 " $- "$1,979.38 " $- $- "$6,090.40 " $- N/A "$1,979.38 " N/A N/A "$2,877.71 " N/A N/A "$4,567.80 " N/A N/A "$3,806.50 " N/A N/A N/A N/A N/A "$5,176.84 " N/A N/A N/A N/A N/A "$2,969.07 " N/A N/A "$3,463.92 " N/A N/A "$6,090.40 " N/A N/A "$4,187.15 " N/A N/A "$4,948.45 " N/A N/A "$2,550.36 " N/A N/A N/A N/A N/A "$4,567.80 " N/A N/A "$2,664.55 " N/A N/A "$4,948.45 " N/A N/A "$2,283.90 " N/A N/A "$4,567.80 " N/A N/A "$4,948.45 " N/A N/A "$2,283.90 " N/A N/A "$2,283.90 " N/A N/A "$2,283.90 " N/A N/A "$2,283.90 " N/A N/A "$2,283.90 " N/A N/A "$2,283.90 " N/A "$7,613.00 " "$7,613.00 " N/A 3213457 Supplies "SHAVER, SLOTTED WHISKER" 270 "$1,160.00 " $- $301.60 $- $- $928.00 $- N/A $301.60 N/A N/A $438.48 N/A N/A $696.00 N/A N/A $580.00 N/A N/A N/A N/A N/A $788.80 N/A N/A N/A N/A N/A $452.40 N/A N/A $527.80 N/A N/A $928.00 N/A N/A $638.00 N/A N/A $754.00 N/A N/A $388.60 N/A N/A N/A N/A N/A $696.00 N/A N/A $406.00 N/A N/A $754.00 N/A N/A $348.00 N/A N/A $696.00 N/A N/A $754.00 N/A N/A $348.00 N/A N/A $348.00 N/A N/A $348.00 N/A N/A $348.00 N/A N/A $348.00 N/A N/A $348.00 N/A "$1,160.00 " "$1,160.00 " N/A 3213903 Supplies URETERAL CATH 5fr. SPIRAL 270 $128.00 $- $33.28 $- $- $102.40 $- N/A $33.28 N/A N/A $48.38 N/A N/A $76.80 N/A N/A $64.00 N/A N/A N/A N/A N/A $87.04 N/A N/A N/A N/A N/A $49.92 N/A N/A $58.24 N/A N/A $102.40 N/A N/A $70.40 N/A N/A $83.20 N/A N/A $42.88 N/A N/A N/A N/A N/A $76.80 N/A N/A $44.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $76.80 N/A N/A $83.20 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A N/A $38.40 N/A $128.00 $128.00 N/A 3214203 Supplies SERFAS WAND 3.5MM. 270 "$2,672.00 " $- $694.72 $- $- "$2,137.60 " $- N/A $694.72 N/A N/A "$1,010.02 " N/A N/A "$1,603.20 " N/A N/A "$1,336.00 " N/A N/A N/A N/A N/A "$1,816.96 " N/A N/A N/A N/A N/A "$1,042.08 " N/A N/A "$1,215.76 " N/A N/A "$2,137.60 " N/A N/A "$1,469.60 " N/A N/A "$1,736.80 " N/A N/A $895.12 N/A N/A N/A N/A N/A "$1,603.20 " N/A N/A $935.20 N/A N/A "$1,736.80 " N/A N/A $801.60 N/A N/A "$1,603.20 " N/A N/A "$1,736.80 " N/A N/A $801.60 N/A N/A $801.60 N/A N/A $801.60 N/A N/A $801.60 N/A N/A $801.60 N/A N/A $801.60 N/A "$2,672.00 " "$2,672.00 " N/A 3214204 Supplies SERFAS 3.5 (NON-SUCTION) 270 "$2,758.00 " $- $717.08 $- $- "$2,206.40 " $- N/A $717.08 N/A N/A "$1,042.52 " N/A N/A "$1,654.80 " N/A N/A "$1,379.00 " N/A N/A N/A N/A N/A "$1,875.44 " N/A N/A N/A N/A N/A "$1,075.62 " N/A N/A "$1,254.89 " N/A N/A "$2,206.40 " N/A N/A "$1,516.90 " N/A N/A "$1,792.70 " N/A N/A $923.93 N/A N/A N/A N/A N/A "$1,654.80 " N/A N/A $965.30 N/A N/A "$1,792.70 " N/A N/A $827.40 N/A N/A "$1,654.80 " N/A N/A "$1,792.70 " N/A N/A $827.40 N/A N/A $827.40 N/A N/A $827.40 N/A N/A $827.40 N/A N/A $827.40 N/A N/A $827.40 N/A "$2,758.00 " "$2,758.00 " N/A 3214209 Supplies "SHAVER, AGRESSIVE PLUS" 270 "$1,257.00 " $- $326.82 $- $- "$1,005.60 " $- N/A $326.82 N/A N/A $475.15 N/A N/A $754.20 N/A N/A $628.50 N/A N/A N/A N/A N/A $854.76 N/A N/A N/A N/A N/A $490.23 N/A N/A $571.94 N/A N/A "$1,005.60 " N/A N/A $691.35 N/A N/A $817.05 N/A N/A $421.10 N/A N/A N/A N/A N/A $754.20 N/A N/A $439.95 N/A N/A $817.05 N/A N/A $377.10 N/A N/A $754.20 N/A N/A $817.05 N/A N/A $377.10 N/A N/A $377.10 N/A N/A $377.10 N/A N/A $377.10 N/A N/A $377.10 N/A N/A $377.10 N/A "$1,257.00 " "$1,257.00 " N/A 3214215 Supplies ANGLED TOMCAT 5.0mm. 270 "$1,294.00 " $- $336.44 $- $- "$1,035.20 " $- N/A $336.44 N/A N/A $489.13 N/A N/A $776.40 N/A N/A $647.00 N/A N/A N/A N/A N/A $879.92 N/A N/A N/A N/A N/A $504.66 N/A N/A $588.77 N/A N/A "$1,035.20 " N/A N/A $711.70 N/A N/A $841.10 N/A N/A $433.49 N/A N/A N/A N/A N/A $776.40 N/A N/A $452.90 N/A N/A $841.10 N/A N/A $388.20 N/A N/A $776.40 N/A N/A $841.10 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A "$1,294.00 " "$1,294.00 " N/A 3214217 Supplies PLASTER SPLINT 4 X 15 270 $482.00 $- $125.32 $- $- $385.60 $- N/A $125.32 N/A N/A $182.20 N/A N/A $289.20 N/A N/A $241.00 N/A N/A N/A N/A N/A $327.76 N/A N/A N/A N/A N/A $187.98 N/A N/A $219.31 N/A N/A $385.60 N/A N/A $265.10 N/A N/A $313.30 N/A N/A $161.47 N/A N/A N/A N/A N/A $289.20 N/A N/A $168.70 N/A N/A $313.30 N/A N/A $144.60 N/A N/A $289.20 N/A N/A $313.30 N/A N/A $144.60 N/A N/A $144.60 N/A N/A $144.60 N/A N/A $144.60 N/A N/A $144.60 N/A N/A $144.60 N/A $482.00 $482.00 N/A 3214218 Supplies ANGLED AGRESS. PLUS 5.0mm 270 "$1,294.00 " $- $336.44 $- $- "$1,035.20 " $- N/A $336.44 N/A N/A $489.13 N/A N/A $776.40 N/A N/A $647.00 N/A N/A N/A N/A N/A $879.92 N/A N/A N/A N/A N/A $504.66 N/A N/A $588.77 N/A N/A "$1,035.20 " N/A N/A $711.70 N/A N/A $841.10 N/A N/A $433.49 N/A N/A N/A N/A N/A $776.40 N/A N/A $452.90 N/A N/A $841.10 N/A N/A $388.20 N/A N/A $776.40 N/A N/A $841.10 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A N/A $388.20 N/A "$1,294.00 " "$1,294.00 " N/A 3214239 Supplies DRAPE PREP NS ROLL 270 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 3214282 Supplies PORT-A-CATH INTRODUCER ST 270 $570.00 $- $148.20 $- $- $456.00 $- N/A $148.20 N/A N/A $215.46 N/A N/A $342.00 N/A N/A $285.00 N/A N/A N/A N/A N/A $387.60 N/A N/A N/A N/A N/A $222.30 N/A N/A $259.35 N/A N/A $456.00 N/A N/A $313.50 N/A N/A $370.50 N/A N/A $190.95 N/A N/A N/A N/A N/A $342.00 N/A N/A $199.50 N/A N/A $370.50 N/A N/A $171.00 N/A N/A $342.00 N/A N/A $370.50 N/A N/A $171.00 N/A N/A $171.00 N/A N/A $171.00 N/A N/A $171.00 N/A N/A $171.00 N/A N/A $171.00 N/A $570.00 $570.00 N/A 3214283 Supplies "PORT-A-CATH, LOW PROFILE" 270 "$6,608.00 " $- "$1,718.08 " $- $- "$5,286.40 " $- N/A "$1,718.08 " N/A N/A "$2,497.82 " N/A N/A "$3,964.80 " N/A N/A "$3,304.00 " N/A N/A N/A N/A N/A "$4,493.44 " N/A N/A N/A N/A N/A "$2,577.12 " N/A N/A "$3,006.64 " N/A N/A "$5,286.40 " N/A N/A "$3,634.40 " N/A N/A "$4,295.20 " N/A N/A "$2,213.68 " N/A N/A N/A N/A N/A "$3,964.80 " N/A N/A "$2,312.80 " N/A N/A "$4,295.20 " N/A N/A "$1,982.40 " N/A N/A "$3,964.80 " N/A N/A "$4,295.20 " N/A N/A "$1,982.40 " N/A N/A "$1,982.40 " N/A N/A "$1,982.40 " N/A N/A "$1,982.40 " N/A N/A "$1,982.40 " N/A N/A "$1,982.40 " N/A "$6,608.00 " "$6,608.00 " N/A 3214286 Supplies "PORT-A-CATH, REG. PROFILE" 270 "$6,398.00 " $- "$1,663.48 " $- $- "$5,118.40 " $- N/A "$1,663.48 " N/A N/A "$2,418.44 " N/A N/A "$3,838.80 " N/A N/A "$3,199.00 " N/A N/A N/A N/A N/A "$4,350.64 " N/A N/A N/A N/A N/A "$2,495.22 " N/A N/A "$2,911.09 " N/A N/A "$5,118.40 " N/A N/A "$3,518.90 " N/A N/A "$4,158.70 " N/A N/A "$2,143.33 " N/A N/A N/A N/A N/A "$3,838.80 " N/A N/A "$2,239.30 " N/A N/A "$4,158.70 " N/A N/A "$1,919.40 " N/A N/A "$3,838.80 " N/A N/A "$4,158.70 " N/A N/A "$1,919.40 " N/A N/A "$1,919.40 " N/A N/A "$1,919.40 " N/A N/A "$1,919.40 " N/A N/A "$1,919.40 " N/A N/A "$1,919.40 " N/A "$6,398.00 " "$6,398.00 " N/A 3214287 Supplies "PORT-A-CATH, MRI COMPAT." 270 "$9,050.00 " $- "$2,353.00 " $- $- "$7,240.00 " $- N/A "$2,353.00 " N/A N/A "$3,420.90 " N/A N/A "$5,430.00 " N/A N/A "$4,525.00 " N/A N/A N/A N/A N/A "$6,154.00 " N/A N/A N/A N/A N/A "$3,529.50 " N/A N/A "$4,117.75 " N/A N/A "$7,240.00 " N/A N/A "$4,977.50 " N/A N/A "$5,882.50 " N/A N/A "$3,031.75 " N/A N/A N/A N/A N/A "$5,430.00 " N/A N/A "$3,167.50 " N/A N/A "$5,882.50 " N/A N/A "$2,715.00 " N/A N/A "$5,430.00 " N/A N/A "$5,882.50 " N/A N/A "$2,715.00 " N/A N/A "$2,715.00 " N/A N/A "$2,715.00 " N/A N/A "$2,715.00 " N/A N/A "$2,715.00 " N/A N/A "$2,715.00 " N/A "$9,050.00 " "$9,050.00 " N/A 3214367 Supplies INJ. GOLD PROBE (CIRCON) 270 "$4,682.00 " $- "$1,217.32 " $- $- "$3,745.60 " $- N/A "$1,217.32 " N/A N/A "$1,769.80 " N/A N/A "$2,809.20 " N/A N/A "$2,341.00 " N/A N/A N/A N/A N/A "$3,183.76 " N/A N/A N/A N/A N/A "$1,825.98 " N/A N/A "$2,130.31 " N/A N/A "$3,745.60 " N/A N/A "$2,575.10 " N/A N/A "$3,043.30 " N/A N/A "$1,568.47 " N/A N/A N/A N/A N/A "$2,809.20 " N/A N/A "$1,638.70 " N/A N/A "$3,043.30 " N/A N/A "$1,404.60 " N/A N/A "$2,809.20 " N/A N/A "$3,043.30 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A "$4,682.00 " "$4,682.00 " N/A 3214533 Supplies SYRINGE PULSATOR ANES. 270 $47.00 $- $12.22 $- $- $37.60 $- N/A $12.22 N/A N/A $17.77 N/A N/A $28.20 N/A N/A $23.50 N/A N/A N/A N/A N/A $31.96 N/A N/A N/A N/A N/A $18.33 N/A N/A $21.39 N/A N/A $37.60 N/A N/A $25.85 N/A N/A $30.55 N/A N/A $15.75 N/A N/A N/A N/A N/A $28.20 N/A N/A $16.45 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $28.20 N/A N/A $30.55 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A N/A $14.10 N/A $47.00 $47.00 N/A 3214554 Supplies DRAPE APERTURE 270 $29.00 $- $7.54 $- $- $23.20 $- N/A $7.54 N/A N/A $10.96 N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $18.85 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $17.40 N/A N/A $18.85 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A N/A $8.70 N/A $29.00 $29.00 N/A 3214802 Supplies TUNNELLER IVS (GYN) 270 "$9,533.00 " $- "$2,478.58 " $- $- "$7,626.40 " $- N/A "$2,478.58 " N/A N/A "$3,603.47 " N/A N/A "$5,719.80 " N/A N/A "$4,766.50 " N/A N/A N/A N/A N/A "$6,482.44 " N/A N/A N/A N/A N/A "$3,717.87 " N/A N/A "$4,337.52 " N/A N/A "$7,626.40 " N/A N/A "$5,243.15 " N/A N/A "$6,196.45 " N/A N/A "$3,193.56 " N/A N/A N/A N/A N/A "$5,719.80 " N/A N/A "$3,336.55 " N/A N/A "$6,196.45 " N/A N/A "$2,859.90 " N/A N/A "$5,719.80 " N/A N/A "$6,196.45 " N/A N/A "$2,859.90 " N/A N/A "$2,859.90 " N/A N/A "$2,859.90 " N/A N/A "$2,859.90 " N/A N/A "$2,859.90 " N/A N/A "$2,859.90 " N/A "$9,533.00 " "$9,533.00 " N/A 3214876 Supplies NEEDLE EPIDURAL X-LONG 270 $359.00 $- $93.34 $- $- $287.20 $- N/A $93.34 N/A N/A $135.70 N/A N/A $215.40 N/A N/A $179.50 N/A N/A N/A N/A N/A $244.12 N/A N/A N/A N/A N/A $140.01 N/A N/A $163.35 N/A N/A $287.20 N/A N/A $197.45 N/A N/A $233.35 N/A N/A $120.27 N/A N/A N/A N/A N/A $215.40 N/A N/A $125.65 N/A N/A $233.35 N/A N/A $107.70 N/A N/A $215.40 N/A N/A $233.35 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A N/A $107.70 N/A $359.00 $359.00 N/A 3214925 Supplies DRAIN HEMOVAC 1/8 TROCAR 270 $163.00 $- $42.38 $- $- $130.40 $- N/A $42.38 N/A N/A $61.61 N/A N/A $97.80 N/A N/A $81.50 N/A N/A N/A N/A N/A $110.84 N/A N/A N/A N/A N/A $63.57 N/A N/A $74.17 N/A N/A $130.40 N/A N/A $89.65 N/A N/A $105.95 N/A N/A $54.61 N/A N/A N/A N/A N/A $97.80 N/A N/A $57.05 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $97.80 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A $163.00 $163.00 N/A 3215032 Supplies BALLOON DILATOR 8-9-10 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215034 Supplies BALLOON DILATOR 6-7-8 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215035 Supplies BALLOON DIL.CATH 10-11-12 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215037 Supplies BALLOON DILATOR 12-13.5 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215038 Supplies BALLOON DIL. SYRINGE ASSY 270 $613.00 $- $159.38 $- $- $490.40 $- N/A $159.38 N/A N/A $231.71 N/A N/A $367.80 N/A N/A $306.50 N/A N/A N/A N/A N/A $416.84 N/A N/A N/A N/A N/A $239.07 N/A N/A $278.92 N/A N/A $490.40 N/A N/A $337.15 N/A N/A $398.45 N/A N/A $205.36 N/A N/A N/A N/A N/A $367.80 N/A N/A $214.55 N/A N/A $398.45 N/A N/A $183.90 N/A N/A $367.80 N/A N/A $398.45 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A N/A $183.90 N/A $613.00 $613.00 N/A 3215039 Supplies BALLOON DILATOR 5MM. 270 "$4,682.00 " $- "$1,217.32 " $- $- "$3,745.60 " $- N/A "$1,217.32 " N/A N/A "$1,769.80 " N/A N/A "$2,809.20 " N/A N/A "$2,341.00 " N/A N/A N/A N/A N/A "$3,183.76 " N/A N/A N/A N/A N/A "$1,825.98 " N/A N/A "$2,130.31 " N/A N/A "$3,745.60 " N/A N/A "$2,575.10 " N/A N/A "$3,043.30 " N/A N/A "$1,568.47 " N/A N/A N/A N/A N/A "$2,809.20 " N/A N/A "$1,638.70 " N/A N/A "$3,043.30 " N/A N/A "$1,404.60 " N/A N/A "$2,809.20 " N/A N/A "$3,043.30 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A N/A "$1,404.60 " N/A "$4,682.00 " "$4,682.00 " N/A 3215040 Supplies "BALLOON, CRE WIRE 15-18" 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215043 Supplies "BALLOON DILATOR, 18-20" 270 "$3,619.00 " $- $940.94 $- $- "$2,895.20 " $- N/A $940.94 N/A N/A "$1,367.98 " N/A N/A "$2,171.40 " N/A N/A "$1,809.50 " N/A N/A N/A N/A N/A "$2,460.92 " N/A N/A N/A N/A N/A "$1,411.41 " N/A N/A "$1,646.65 " N/A N/A "$2,895.20 " N/A N/A "$1,990.45 " N/A N/A "$2,352.35 " N/A N/A "$1,212.37 " N/A N/A N/A N/A N/A "$2,171.40 " N/A N/A "$1,266.65 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$2,171.40 " N/A N/A "$2,352.35 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A N/A "$1,085.70 " N/A "$3,619.00 " "$3,619.00 " N/A 3215051 Supplies TOURNIQUET STERILE 18''''X4 270 $466.00 $- $121.16 $- $- $372.80 $- N/A $121.16 N/A N/A $176.15 N/A N/A $279.60 N/A N/A $233.00 N/A N/A N/A N/A N/A $316.88 N/A N/A N/A N/A N/A $181.74 N/A N/A $212.03 N/A N/A $372.80 N/A N/A $256.30 N/A N/A $302.90 N/A N/A $156.11 N/A N/A N/A N/A N/A $279.60 N/A N/A $163.10 N/A N/A $302.90 N/A N/A $139.80 N/A N/A $279.60 N/A N/A $302.90 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A N/A $139.80 N/A $466.00 $466.00 N/A 3215052 Supplies TOURNIQUET STERILE 34 270 $603.00 $- $156.78 $- $- $482.40 $- N/A $156.78 N/A N/A $227.93 N/A N/A $361.80 N/A N/A $301.50 N/A N/A N/A N/A N/A $410.04 N/A N/A N/A N/A N/A $235.17 N/A N/A $274.37 N/A N/A $482.40 N/A N/A $331.65 N/A N/A $391.95 N/A N/A $202.01 N/A N/A N/A N/A N/A $361.80 N/A N/A $211.05 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $361.80 N/A N/A $391.95 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A N/A $180.90 N/A $603.00 $603.00 N/A 3215053 Supplies TOURNIQUET STERILE 44 270 $658.00 $- $171.08 $- $- $526.40 $- N/A $171.08 N/A N/A $248.72 N/A N/A $394.80 N/A N/A $329.00 N/A N/A N/A N/A N/A $447.44 N/A N/A N/A N/A N/A $256.62 N/A N/A $299.39 N/A N/A $526.40 N/A N/A $361.90 N/A N/A $427.70 N/A N/A $220.43 N/A N/A N/A N/A N/A $394.80 N/A N/A $230.30 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $394.80 N/A N/A $427.70 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A N/A $197.40 N/A $658.00 $658.00 N/A 3215058 Supplies STIMUPLEX NEEDLE 20gX6 270 $205.00 $- $53.30 $- $- $164.00 $- N/A $53.30 N/A N/A $77.49 N/A N/A $123.00 N/A N/A $102.50 N/A N/A N/A N/A N/A $139.40 N/A N/A N/A N/A N/A $79.95 N/A N/A $93.28 N/A N/A $164.00 N/A N/A $112.75 N/A N/A $133.25 N/A N/A $68.68 N/A N/A N/A N/A N/A $123.00 N/A N/A $71.75 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $123.00 N/A N/A $133.25 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A N/A $61.50 N/A $205.00 $205.00 N/A 3215059 Supplies STIMUPLEX NEEDLE 21Gx4 270 $163.00 $- $42.38 $- $- $130.40 $- N/A $42.38 N/A N/A $61.61 N/A N/A $97.80 N/A N/A $81.50 N/A N/A N/A N/A N/A $110.84 N/A N/A N/A N/A N/A $63.57 N/A N/A $74.17 N/A N/A $130.40 N/A N/A $89.65 N/A N/A $105.95 N/A N/A $54.61 N/A N/A N/A N/A N/A $97.80 N/A N/A $57.05 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $97.80 N/A N/A $105.95 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A N/A $48.90 N/A $163.00 $163.00 N/A 3215060 Supplies STIMUPLEX NEEDLE 22GX2 270 $122.00 $- $31.72 $- $- $97.60 $- N/A $31.72 N/A N/A $46.12 N/A N/A $73.20 N/A N/A $61.00 N/A N/A N/A N/A N/A $82.96 N/A N/A N/A N/A N/A $47.58 N/A N/A $55.51 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $79.30 N/A N/A $40.87 N/A N/A N/A N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $73.20 N/A N/A $79.30 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A N/A $36.60 N/A $122.00 $122.00 N/A 3215061 Supplies STIMUPLEX NEEDLE 22GX3 270 $170.00 $- $44.20 $- $- $136.00 $- N/A $44.20 N/A N/A $64.26 N/A N/A $102.00 N/A N/A $85.00 N/A N/A N/A N/A N/A $115.60 N/A N/A N/A N/A N/A $66.30 N/A N/A $77.35 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $110.50 N/A N/A $56.95 N/A N/A N/A N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $102.00 N/A N/A $110.50 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A N/A $51.00 N/A $170.00 $170.00 N/A 3215151 Supplies CLIP/SCISSOR PROCED.KIT 270 "$1,204.00 " $- $313.04 $- $- $963.20 $- N/A $313.04 N/A N/A $455.11 N/A N/A $722.40 N/A N/A $602.00 N/A N/A N/A N/A N/A $818.72 N/A N/A N/A N/A N/A $469.56 N/A N/A $547.82 N/A N/A $963.20 N/A N/A $662.20 N/A N/A $782.60 N/A N/A $403.34 N/A N/A N/A N/A N/A $722.40 N/A N/A $421.40 N/A N/A $782.60 N/A N/A $361.20 N/A N/A $722.40 N/A N/A $782.60 N/A N/A $361.20 N/A N/A $361.20 N/A N/A $361.20 N/A N/A $361.20 N/A N/A $361.20 N/A N/A $361.20 N/A "$1,204.00 " "$1,204.00 " N/A 3215157 Supplies NEEDLE INJECTION GI LAB 270 $59.00 $- $15.34 $- $- $47.20 $- N/A $15.34 N/A N/A $22.30 N/A N/A $35.40 N/A N/A $29.50 N/A N/A N/A N/A N/A $40.12 N/A N/A N/A N/A N/A $23.01 N/A N/A $26.85 N/A N/A $47.20 N/A N/A $32.45 N/A N/A $38.35 N/A N/A $19.77 N/A N/A N/A N/A N/A $35.40 N/A N/A $20.65 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $35.40 N/A N/A $38.35 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A N/A $17.70 N/A $59.00 $59.00 N/A 3215196 Supplies TOURNIQUET 12x2 DISP. 270 $289.00 $- $75.14 $- $- $231.20 $- N/A $75.14 N/A N/A $109.24 N/A N/A $173.40 N/A N/A $144.50 N/A N/A N/A N/A N/A $196.52 N/A N/A N/A N/A N/A $112.71 N/A N/A $131.50 N/A N/A $231.20 N/A N/A $158.95 N/A N/A $187.85 N/A N/A $96.82 N/A N/A N/A N/A N/A $173.40 N/A N/A $101.15 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $173.40 N/A N/A $187.85 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A N/A $86.70 N/A $289.00 $289.00 N/A 3215198 Supplies TOURNIQUET 30x4 DISP. 270 $387.00 $- $100.62 $- $- $309.60 $- N/A $100.62 N/A N/A $146.29 N/A N/A $232.20 N/A N/A $193.50 N/A N/A N/A N/A N/A $263.16 N/A N/A N/A N/A N/A $150.93 N/A N/A $176.09 N/A N/A $309.60 N/A N/A $212.85 N/A N/A $251.55 N/A N/A $129.65 N/A N/A N/A N/A N/A $232.20 N/A N/A $135.45 N/A N/A $251.55 N/A N/A $116.10 N/A N/A $232.20 N/A N/A $251.55 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A N/A $116.10 N/A $387.00 $387.00 N/A 3215199 Supplies TOURNIQUET 34x4 DISP. 270 $414.00 $- $107.64 $- $- $331.20 $- N/A $107.64 N/A N/A $156.49 N/A N/A $248.40 N/A N/A $207.00 N/A N/A N/A N/A N/A $281.52 N/A N/A N/A N/A N/A $161.46 N/A N/A $188.37 N/A N/A $331.20 N/A N/A $227.70 N/A N/A $269.10 N/A N/A $138.69 N/A N/A N/A N/A N/A $248.40 N/A N/A $144.90 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $248.40 N/A N/A $269.10 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A N/A $124.20 N/A $414.00 $414.00 N/A 3215200 Supplies TOURNIQUET 24x5.5 DISP. 270 $569.00 $- $147.94 $- $- $455.20 $- N/A $147.94 N/A N/A $215.08 N/A N/A $341.40 N/A N/A $284.50 N/A N/A N/A N/A N/A $386.92 N/A N/A N/A N/A N/A $221.91 N/A N/A $258.90 N/A N/A $455.20 N/A N/A $312.95 N/A N/A $369.85 N/A N/A $190.62 N/A N/A N/A N/A N/A $341.40 N/A N/A $199.15 N/A N/A $369.85 N/A N/A $170.70 N/A N/A $341.40 N/A N/A $369.85 N/A N/A $170.70 N/A N/A $170.70 N/A N/A $170.70 N/A N/A $170.70 N/A N/A $170.70 N/A N/A $170.70 N/A $569.00 $569.00 N/A 3215201 Supplies TOURNIQUET 18x5.5 DISP. 270 $515.00 $- $133.90 $- $- $412.00 $- N/A $133.90 N/A N/A $194.67 N/A N/A $309.00 N/A N/A $257.50 N/A N/A N/A N/A N/A $350.20 N/A N/A N/A N/A N/A $200.85 N/A N/A $234.33 N/A N/A $412.00 N/A N/A $283.25 N/A N/A $334.75 N/A N/A $172.53 N/A N/A N/A N/A N/A $309.00 N/A N/A $180.25 N/A N/A $334.75 N/A N/A $154.50 N/A N/A $309.00 N/A N/A $334.75 N/A N/A $154.50 N/A N/A $154.50 N/A N/A $154.50 N/A N/A $154.50 N/A N/A $154.50 N/A N/A $154.50 N/A $515.00 $515.00 N/A 3215216 Supplies "KNEE BODY STRAP, DISP." 270 $63.00 $- $16.38 $- $- $50.40 $- N/A $16.38 N/A N/A $23.81 N/A N/A $37.80 N/A N/A $31.50 N/A N/A N/A N/A N/A $42.84 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A $50.40 N/A N/A $34.65 N/A N/A $40.95 N/A N/A $21.11 N/A N/A N/A N/A N/A $37.80 N/A N/A $22.05 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $37.80 N/A N/A $40.95 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A N/A $18.90 N/A $63.00 $63.00 N/A 3215222 Supplies CYSTOTOME 25gX7/8 270 $158.00 $- $41.08 $- $- $126.40 $- N/A $41.08 N/A N/A $59.72 N/A N/A $94.80 N/A N/A $79.00 N/A N/A N/A N/A N/A $107.44 N/A N/A N/A N/A N/A $61.62 N/A N/A $71.89 N/A N/A $126.40 N/A N/A $86.90 N/A N/A $102.70 N/A N/A $52.93 N/A N/A N/A N/A N/A $94.80 N/A N/A $55.30 N/A N/A $102.70 N/A N/A $47.40 N/A N/A $94.80 N/A N/A $102.70 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A N/A $47.40 N/A $158.00 $158.00 N/A 3215240 Supplies HEAD POS. 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N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A N/A N/A N/A $13.65 N/A N/A $15.93 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $22.75 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $21.00 N/A N/A $22.75 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A N/A $10.50 N/A $35.00 $35.00 N/A 3215258 Supplies SUTURE MERSILENE 4-0R691G 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 3215297 Supplies SUTURE MERSILENE 5 RS20 270 $504.00 $- $131.04 $- $- $403.20 $- N/A $131.04 N/A N/A $190.51 N/A N/A $302.40 N/A N/A $252.00 N/A N/A N/A N/A N/A $342.72 N/A N/A N/A N/A N/A $196.56 N/A N/A $229.32 N/A N/A $403.20 N/A N/A $277.20 N/A N/A $327.60 N/A N/A $168.84 N/A N/A N/A N/A N/A $302.40 N/A N/A $176.40 N/A N/A $327.60 N/A N/A $151.20 N/A N/A $302.40 N/A N/A $327.60 N/A N/A $151.20 N/A N/A $151.20 N/A N/A $151.20 N/A N/A $151.20 N/A N/A $151.20 N/A N/A $151.20 N/A $504.00 $504.00 N/A 3215336 Supplies PREP CHLORAPREP SWABS 270 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $7.80 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $7.20 N/A N/A $7.80 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A N/A $3.60 N/A $12.00 $12.00 N/A 1501106 Supplies AIRWAY ORAL 100MM RED 270 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A N/A N/A N/A $0.78 N/A N/A $0.91 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.30 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A $0.60 N/A N/A $1.20 N/A N/A $1.30 N/A N/A $0.60 N/A N/A $0.60 N/A N/A $0.60 N/A N/A $0.60 N/A N/A $0.60 N/A N/A $0.60 N/A $2.00 $2.00 N/A 1501138 Supplies "C-ARM DRAPE, GE" 270 $112.00 $- $29.12 $- $- $89.60 $- N/A $29.12 N/A N/A $42.34 N/A N/A $67.20 N/A $56.00 N/A N/A N/A N/A N/A $76.16 N/A N/A N/A N/A N/A $43.68 N/A N/A $50.96 N/A N/A $89.60 N/A N/A $61.60 N/A N/A $72.80 N/A N/A $37.52 N/A N/A N/A N/A N/A $67.20 N/A N/A $39.20 N/A N/A $72.80 N/A N/A $33.60 N/A N/A $67.20 N/A N/A $72.80 N/A N/A $33.60 N/A N/A $33.60 N/A N/A $33.60 N/A N/A $33.60 N/A N/A $33.60 N/A N/A $33.60 N/A $112.00 $112.00 N/A 1501164 Supplies LAPIPLASTY SYSTEM 4 278 "$13,379.00 " $- "$3,478.54 " $- $- "$10,703.20 " $- N/A "$3,478.54 " N/A N/A "$5,057.26 " N/A N/A "$8,027.40 " N/A "$6,689.50 " N/A N/A N/A N/A N/A "$9,097.72 " N/A N/A N/A N/A N/A "$5,217.81 " N/A N/A "$6,087.45 " N/A N/A "$10,703.20 " N/A N/A "$7,358.45 " N/A N/A "$8,696.35 " N/A N/A "$4,481.97 " N/A N/A N/A N/A N/A "$8,027.40 " N/A N/A "$4,682.65 " N/A N/A "$8,696.35 " N/A N/A "$4,013.70 " N/A N/A "$8,027.40 " N/A N/A "$8,696.35 " N/A N/A "$4,013.70 " N/A N/A "$4,013.70 " N/A N/A "$4,013.70 " N/A N/A "$4,013.70 " N/A N/A "$4,013.70 " N/A N/A "$4,013.70 " N/A "$13,379.00 " "$13,379.00 " N/A 1501165 Supplies "SCREW, LAPIPLASTY 2.0MM" 278 "$1,638.00 " $- $425.88 $- $- "$1,310.40 " $- N/A $425.88 N/A N/A $619.16 N/A N/A $982.80 N/A $819.00 N/A N/A N/A N/A N/A "$1,113.84 " N/A N/A N/A N/A N/A $638.82 N/A N/A $745.29 N/A N/A "$1,310.40 " N/A N/A $900.90 N/A N/A "$1,064.70 " N/A N/A $548.73 N/A N/A N/A N/A N/A $982.80 N/A N/A $573.30 N/A N/A "$1,064.70 " N/A N/A $491.40 N/A N/A $982.80 N/A N/A "$1,064.70 " N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A "$1,638.00 " "$1,638.00 " N/A 1501166 Supplies SCREW FASTPITCH 2.7MM. 278 "$2,127.00 " $- $553.02 $- $- "$1,701.60 " $- N/A $553.02 N/A N/A $804.01 N/A N/A "$1,276.20 " N/A "$1,063.50 " N/A N/A N/A N/A N/A "$1,446.36 " N/A N/A N/A N/A N/A $829.53 N/A N/A $967.79 N/A N/A "$1,701.60 " N/A N/A "$1,169.85 " N/A N/A "$1,382.55 " N/A N/A $712.55 N/A N/A N/A N/A N/A "$1,276.20 " N/A N/A $744.45 N/A N/A "$1,382.55 " N/A N/A $638.10 N/A N/A "$1,276.20 " N/A N/A "$1,382.55 " N/A N/A $638.10 N/A N/A $638.10 N/A N/A $638.10 N/A N/A $638.10 N/A N/A $638.10 N/A N/A $638.10 N/A "$2,127.00 " "$2,127.00 " N/A 1501167 Supplies "SCREW, TRANSVERSE LAPIPLASTY 3.5MM" 278 "$1,638.00 " $- $425.88 $- $- "$1,310.40 " $- N/A $425.88 N/A N/A $619.16 N/A N/A $982.80 N/A $819.00 N/A N/A N/A N/A N/A "$1,113.84 " N/A N/A N/A N/A N/A $638.82 N/A N/A $745.29 N/A N/A "$1,310.40 " N/A N/A $900.90 N/A N/A "$1,064.70 " N/A N/A $548.73 N/A N/A N/A N/A N/A $982.80 N/A N/A $573.30 N/A N/A "$1,064.70 " N/A N/A $491.40 N/A N/A $982.80 N/A N/A "$1,064.70 " N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A N/A $491.40 N/A N/A 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N/A N/A N/A N/A $5.44 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A $6.40 N/A N/A $4.40 N/A N/A $5.20 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $4.80 N/A N/A $5.20 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A N/A $2.40 N/A $8.00 $8.00 N/A 1501228 Supplies PUREWICK FEMALE CATH EXTERNAL 270 $55.00 $- $14.30 $- $- $44.00 $- N/A $14.30 N/A N/A $20.79 N/A N/A $33.00 N/A $27.50 N/A N/A N/A N/A N/A $37.40 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.03 N/A N/A $44.00 N/A N/A $30.25 N/A N/A $35.75 N/A N/A $18.43 N/A N/A N/A N/A N/A $33.00 N/A N/A $19.25 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $33.00 N/A N/A $35.75 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A N/A $16.50 N/A $55.00 $55.00 N/A 1501229 Supplies ZINC OXIDE SPRAY 2 OZ. 270 $57.00 $- $14.82 $- $- $45.60 $- N/A $14.82 N/A N/A $21.55 N/A N/A $34.20 N/A $28.50 N/A N/A N/A N/A N/A $38.76 N/A N/A N/A N/A N/A $22.23 N/A N/A $25.94 N/A N/A $45.60 N/A N/A $31.35 N/A N/A $37.05 N/A N/A $19.10 N/A N/A N/A N/A N/A $34.20 N/A N/A $19.95 N/A N/A $37.05 N/A N/A $17.10 N/A N/A $34.20 N/A N/A $37.05 N/A N/A $17.10 N/A N/A $17.10 N/A N/A $17.10 N/A N/A $17.10 N/A N/A $17.10 N/A N/A $17.10 N/A $57.00 $57.00 N/A 1501230 Supplies PNEUMOTHORAX SET WAYNE PIGTAIL 270 $994.00 $- $258.44 $- $- $795.20 $- N/A $258.44 N/A N/A $375.73 N/A N/A $596.40 N/A $497.00 N/A N/A N/A N/A N/A $675.92 N/A N/A N/A N/A N/A $387.66 N/A N/A $452.27 N/A N/A $795.20 N/A N/A $546.70 N/A N/A $646.10 N/A N/A $332.99 N/A N/A N/A N/A N/A $596.40 N/A N/A $347.90 N/A N/A $646.10 N/A N/A $298.20 N/A N/A $596.40 N/A N/A $646.10 N/A N/A $298.20 N/A N/A $298.20 N/A N/A $298.20 N/A N/A $298.20 N/A N/A $298.20 N/A N/A $298.20 N/A $994.00 $994.00 N/A 1501231 Supplies I.V. CATHETER 20GX2.5 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1501232 Supplies I.V. CATHETER 18GX2.5 270 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A N/A N/A N/A $13.26 N/A N/A $15.47 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $22.10 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $20.40 N/A N/A $22.10 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A N/A $10.20 N/A $34.00 $34.00 N/A 1501233 Supplies DRILL BIT 2.8 STRYKER 270 "$1,793.00 " $- $466.18 $- $- "$1,434.40 " $- N/A $466.18 N/A N/A $677.75 N/A N/A "$1,075.80 " N/A $896.50 N/A N/A N/A N/A N/A "$1,219.24 " N/A N/A N/A N/A N/A $699.27 N/A N/A $815.82 N/A N/A "$1,434.40 " N/A N/A $986.15 N/A N/A "$1,165.45 " N/A N/A $600.66 N/A N/A N/A N/A N/A "$1,075.80 " N/A N/A $627.55 N/A N/A "$1,165.45 " N/A N/A $537.90 N/A N/A "$1,075.80 " N/A N/A "$1,165.45 " N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A N/A $537.90 N/A "$1,793.00 " "$1,793.00 " N/A 1501234 Supplies SONIC ANCHOR KIT 2.5X10MM #0 FORCE FIBER 278 "$1,966.00 " $- $511.16 $- $- "$1,572.80 " $- N/A $511.16 N/A N/A $743.15 N/A N/A "$1,179.60 " N/A $983.00 N/A N/A N/A N/A N/A "$1,336.88 " N/A N/A N/A N/A N/A $766.74 N/A N/A $894.53 N/A N/A "$1,572.80 " N/A N/A "$1,081.30 " N/A N/A "$1,277.90 " N/A N/A $658.61 N/A N/A N/A N/A N/A "$1,179.60 " N/A N/A $688.10 N/A N/A "$1,277.90 " N/A N/A $589.80 N/A N/A "$1,179.60 " N/A N/A "$1,277.90 " N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A "$1,966.00 " "$1,966.00 " N/A 1501235 Supplies SONIC ANCHOR KIT 2.5X10MM #2-0 FORCE FIBER 278 "$1,966.00 " $- $511.16 $- $- "$1,572.80 " $- N/A $511.16 N/A N/A $743.15 N/A N/A "$1,179.60 " N/A $983.00 N/A N/A N/A N/A N/A "$1,336.88 " N/A N/A N/A N/A N/A $766.74 N/A N/A $894.53 N/A N/A "$1,572.80 " N/A N/A "$1,081.30 " N/A N/A "$1,277.90 " N/A N/A $658.61 N/A N/A N/A N/A N/A "$1,179.60 " N/A N/A $688.10 N/A N/A "$1,277.90 " N/A N/A $589.80 N/A N/A "$1,179.60 " N/A N/A "$1,277.90 " N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A N/A $589.80 N/A "$1,966.00 " "$1,966.00 " N/A 1501236 Supplies STAT-PACK TURNOVER KIT 270 $25.00 $- $6.50 $- $- $20.00 $- N/A $6.50 N/A N/A $9.45 N/A N/A $15.00 N/A $12.50 N/A N/A N/A N/A N/A $17.00 N/A N/A N/A N/A N/A $9.75 N/A N/A $11.38 N/A N/A $20.00 N/A N/A $13.75 N/A N/A $16.25 N/A N/A $8.38 N/A N/A N/A N/A N/A $15.00 N/A N/A $8.75 N/A N/A $16.25 N/A N/A $7.50 N/A N/A $15.00 N/A N/A $16.25 N/A N/A $7.50 N/A N/A $7.50 N/A N/A $7.50 N/A N/A $7.50 N/A N/A $7.50 N/A N/A $7.50 N/A $25.00 $25.00 N/A 1501237 Supplies OSTEOTOME SQUARE 7MM 270 "$1,865.00 " $- $484.90 $- $- "$1,492.00 " $- N/A $484.90 N/A N/A $704.97 N/A N/A "$1,119.00 " N/A $932.50 N/A N/A N/A N/A N/A "$1,268.20 " N/A N/A N/A N/A N/A $727.35 N/A N/A $848.58 N/A N/A "$1,492.00 " N/A N/A "$1,025.75 " N/A N/A "$1,212.25 " N/A N/A $624.78 N/A N/A N/A N/A N/A "$1,119.00 " N/A N/A $652.75 N/A N/A "$1,212.25 " N/A N/A $559.50 N/A N/A "$1,119.00 " N/A N/A "$1,212.25 " N/A N/A $559.50 N/A N/A $559.50 N/A N/A $559.50 N/A N/A $559.50 N/A N/A $559.50 N/A N/A $559.50 N/A "$1,865.00 " "$1,865.00 " N/A 1501238 Supplies SCOPE BUDDY OLYMPUS TUBING 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1501239 Supplies SCOPE BUDDY PUMP TUBING 270 $64.00 $- $16.64 $- $- $51.20 $- N/A $16.64 N/A N/A $24.19 N/A N/A $38.40 N/A $32.00 N/A N/A N/A N/A N/A $43.52 N/A N/A N/A N/A N/A $24.96 N/A N/A $29.12 N/A N/A $51.20 N/A N/A $35.20 N/A N/A $41.60 N/A N/A $21.44 N/A N/A N/A N/A N/A $38.40 N/A N/A $22.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $38.40 N/A N/A $41.60 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A N/A $19.20 N/A $64.00 $64.00 N/A 1501240 Supplies SCOPE BUDDY PLUS 24 HOUR TUBING 270 $18.00 $- $4.68 $- $- $14.40 $- N/A $4.68 N/A N/A $6.80 N/A N/A $10.80 N/A $9.00 N/A N/A N/A N/A N/A $12.24 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A $14.40 N/A N/A $9.90 N/A N/A $11.70 N/A N/A $6.03 N/A N/A N/A N/A N/A $10.80 N/A N/A $6.30 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $10.80 N/A N/A $11.70 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A N/A $5.40 N/A $18.00 $18.00 N/A 1501241 Supplies GAIT BELT 72 INCH 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 1501242 Supplies SUTURE VICRYL 6-0 P-1 270 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A N/A N/A N/A $5.85 N/A N/A $6.83 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $9.75 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $9.00 N/A N/A $9.75 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A N/A $4.50 N/A $15.00 $15.00 N/A 3215339 Supplies PREP CHLORA APPLICATOR 270 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.10 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $8.40 N/A N/A $9.10 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A N/A $4.20 N/A $14.00 $14.00 N/A 3215342 Supplies PREP CLOTH PRE-OP CHLOR. 270 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A $14.36 N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.84 N/A N/A N/A N/A N/A $14.82 N/A N/A $17.29 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $24.70 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 3215354 Supplies "VALVE, SUCTION" 270 $243.00 $- $63.18 $- $- $194.40 $- N/A $63.18 N/A N/A $91.85 N/A N/A $145.80 N/A N/A $121.50 N/A N/A N/A N/A N/A $165.24 N/A N/A N/A N/A N/A $94.77 N/A N/A $110.57 N/A N/A $194.40 N/A N/A $133.65 N/A N/A $157.95 N/A N/A $81.41 N/A N/A N/A N/A N/A $145.80 N/A N/A $85.05 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $145.80 N/A N/A $157.95 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A N/A $72.90 N/A $243.00 $243.00 N/A 3215363 Supplies "CANNULA, NASAL" 270 $56.00 $- $14.56 $- $- $44.80 $- N/A $14.56 N/A N/A $21.17 N/A N/A $33.60 N/A N/A $28.00 N/A N/A N/A N/A N/A $38.08 N/A N/A N/A N/A N/A $21.84 N/A N/A $25.48 N/A N/A $44.80 N/A N/A $30.80 N/A N/A $36.40 N/A N/A $18.76 N/A N/A N/A N/A N/A $33.60 N/A N/A $19.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $33.60 N/A N/A $36.40 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A N/A $16.80 N/A $56.00 $56.00 N/A 3215406 Supplies "LINE, GAS SAMPLING" 270 $40.00 $- $10.40 $- $- $32.00 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.00 N/A N/A $20.00 N/A N/A N/A N/A N/A $27.20 N/A N/A N/A N/A N/A $15.60 N/A N/A $18.20 N/A N/A $32.00 N/A N/A $22.00 N/A N/A $26.00 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.00 N/A N/A $14.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $24.00 N/A N/A $26.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A N/A $12.00 N/A $40.00 $40.00 N/A 3215477 Supplies ET TUBE REINFORCED 8.0 270 $340.00 $- $88.40 $- $- $272.00 $- N/A $88.40 N/A N/A $128.52 N/A N/A $204.00 N/A N/A $170.00 N/A N/A N/A N/A N/A $231.20 N/A N/A N/A N/A N/A $132.60 N/A N/A $154.70 N/A N/A $272.00 N/A N/A $187.00 N/A N/A $221.00 N/A N/A $113.90 N/A N/A N/A N/A N/A $204.00 N/A N/A $119.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $204.00 N/A N/A $221.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A N/A $102.00 N/A $340.00 $340.00 N/A 3215495 Supplies STRAP ARMBOARD 270 $19.00 $- $4.94 $- $- $15.20 $- N/A $4.94 N/A N/A $7.18 N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A N/A N/A N/A $7.41 N/A N/A $8.65 N/A N/A $15.20 N/A N/A $10.45 N/A N/A $12.35 N/A N/A $6.37 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $11.40 N/A N/A $12.35 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A N/A $5.70 N/A $19.00 $19.00 N/A 3215497 Supplies MASK #7 270 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A $14.36 N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.84 N/A N/A N/A N/A N/A $14.82 N/A N/A $17.29 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $24.70 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $22.80 N/A N/A $24.70 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 3215637 Supplies "KIT, SUPRAPUBIC" 270 "$1,398.00 " $- $363.48 $- $- "$1,118.40 " $- N/A $363.48 N/A N/A $528.44 N/A N/A $838.80 N/A N/A $699.00 N/A N/A N/A N/A N/A $950.64 N/A N/A N/A N/A N/A $545.22 N/A N/A $636.09 N/A N/A "$1,118.40 " N/A N/A $768.90 N/A N/A $908.70 N/A N/A $468.33 N/A N/A N/A N/A N/A $838.80 N/A N/A $489.30 N/A N/A $908.70 N/A N/A $419.40 N/A N/A $838.80 N/A N/A $908.70 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A "$1,398.00 " "$1,398.00 " N/A 3251460 Supplies FOLEY CATH TRAY 16FR 270 $290.00 $- $75.40 $- $- $232.00 $- N/A $75.40 N/A N/A $109.62 N/A N/A $174.00 N/A N/A $145.00 N/A N/A N/A N/A N/A $197.20 N/A N/A N/A N/A N/A $113.10 N/A N/A $131.95 N/A N/A $232.00 N/A N/A $159.50 N/A N/A $188.50 N/A N/A $97.15 N/A N/A N/A N/A N/A $174.00 N/A N/A $101.50 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $174.00 N/A N/A $188.50 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A N/A $87.00 N/A $290.00 $290.00 N/A 3256000 Supplies OSTOMY ODOR DROPS 270 $167.00 $- $43.42 $- $- $133.60 $- N/A $43.42 N/A N/A $63.13 N/A N/A $100.20 N/A N/A $83.50 N/A N/A N/A N/A N/A $113.56 N/A N/A N/A N/A N/A $65.13 N/A N/A $75.99 N/A N/A $133.60 N/A N/A $91.85 N/A N/A $108.55 N/A N/A $55.95 N/A N/A N/A N/A N/A $100.20 N/A N/A $58.45 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $100.20 N/A N/A $108.55 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A N/A $50.10 N/A $167.00 $167.00 N/A 3256008 Supplies OSTOMY ADAPT RINGS 270 $43.00 $- $11.18 $- $- $34.40 $- N/A $11.18 N/A N/A $16.25 N/A N/A $25.80 N/A N/A $21.50 N/A N/A N/A N/A N/A $29.24 N/A N/A N/A N/A N/A $16.77 N/A N/A $19.57 N/A N/A $34.40 N/A N/A $23.65 N/A N/A $27.95 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.80 N/A N/A $15.05 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $25.80 N/A N/A $27.95 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A N/A $12.90 N/A $43.00 $43.00 N/A 3257589 Supplies "DIAPER, CLOTHLIKE LARGE" 270 $107.00 $- $27.82 $- $- $85.60 $- N/A $27.82 N/A N/A $40.45 N/A N/A $64.20 N/A N/A $53.50 N/A N/A N/A N/A N/A $72.76 N/A N/A N/A N/A N/A $41.73 N/A N/A $48.69 N/A N/A $85.60 N/A N/A $58.85 N/A N/A $69.55 N/A N/A $35.85 N/A N/A N/A N/A N/A $64.20 N/A N/A $37.45 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $64.20 N/A N/A $69.55 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A N/A $32.10 N/A $107.00 $107.00 N/A 4061605 Supplies Universal Procedure Tray 272 $423.00 $- $109.98 $- $- $338.40 $- N/A $109.98 N/A N/A $159.89 N/A N/A $253.80 N/A N/A $211.50 N/A N/A N/A N/A N/A $287.64 N/A N/A N/A N/A N/A $164.97 N/A N/A $192.47 N/A N/A $338.40 N/A N/A $232.65 N/A N/A $274.95 N/A N/A $141.71 N/A N/A N/A N/A N/A $253.80 N/A N/A $148.05 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $253.80 N/A N/A $274.95 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A N/A $126.90 N/A $423.00 $423.00 N/A 6210038 Supplies "SYRINGE, 60CC. LUER SLIP N/S" 272 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A N/A N/A N/A $3.51 N/A N/A $4.10 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $5.85 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $5.40 N/A N/A $5.85 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A N/A $2.70 N/A $9.00 $9.00 N/A 6210048 Supplies ENDOSCOPE CLEANING BRUSH 272 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $14.30 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $13.20 N/A N/A $14.30 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A N/A $6.60 N/A $22.00 $22.00 N/A 6230091 Supplies MEROCEL STD. AIRWAY 4.5cm 272 $203.00 $- $52.78 $- $- $162.40 $- N/A $52.78 N/A N/A $76.73 N/A N/A $121.80 N/A N/A $101.50 N/A N/A N/A N/A N/A $138.04 N/A N/A N/A N/A N/A $79.17 N/A N/A $92.37 N/A N/A $162.40 N/A N/A $111.65 N/A N/A $131.95 N/A N/A $68.01 N/A N/A N/A N/A N/A $121.80 N/A N/A $71.05 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $121.80 N/A N/A $131.95 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A N/A $60.90 N/A $203.00 $203.00 N/A 6230092 Supplies MEROCEL STD AIRWAY 8cm. 272 $253.00 $- $65.78 $- $- $202.40 $- N/A $65.78 N/A N/A $95.63 N/A N/A $151.80 N/A N/A $126.50 N/A N/A N/A N/A N/A $172.04 N/A N/A N/A N/A N/A $98.67 N/A N/A $115.12 N/A N/A $202.40 N/A N/A $139.15 N/A N/A $164.45 N/A N/A $84.76 N/A N/A N/A N/A N/A $151.80 N/A N/A $88.55 N/A N/A $164.45 N/A N/A $75.90 N/A N/A $151.80 N/A N/A $164.45 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A N/A $75.90 N/A $253.00 $253.00 N/A 7000054 Supplies SERACULT SLIDES 272 $27.00 $- $7.02 $- $- $21.60 $- N/A $7.02 N/A N/A $10.21 N/A N/A $16.20 N/A N/A $13.50 N/A N/A N/A N/A N/A $18.36 N/A N/A N/A N/A N/A $10.53 N/A N/A $12.29 N/A N/A $21.60 N/A N/A $14.85 N/A N/A $17.55 N/A N/A $9.05 N/A N/A N/A N/A N/A $16.20 N/A N/A $9.45 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $16.20 N/A N/A $17.55 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A N/A $8.10 N/A $27.00 $27.00 N/A 49010080 Surgery Incision and Drainage Pilonidal Cyst 10080 490 $350.00 $- $91.00 $- $- "$1,625.00 " $- N/A $91.00 N/A N/A $750.00 N/A N/A $210.00 N/A N/A $175.00 N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A $542.00 N/A N/A $136.50 N/A N/A $159.25 N/A N/A $280.00 N/A N/A N/A N/A N/A $227.50 N/A N/A $165.29 N/A N/A N/A N/A N/A $165.29 N/A N/A $122.50 N/A N/A $432.00 N/A N/A $105.00 N/A N/A $686.00 N/A N/A $227.50 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A N/A $105.00 N/A $350.00 $350.00 N/A 49011042 Surgery Debridement Subcutaneous Tissue 20 SQ CM or Les 11042 490 "$1,409.00 " $- $99.69 $- $- "$1,177.00 " $- N/A $366.34 N/A N/A $950.00 N/A N/A $845.40 N/A N/A $704.50 N/A N/A $99.69 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $549.51 N/A N/A $641.10 N/A N/A "$1,127.20 " N/A N/A N/A N/A N/A $915.85 N/A N/A $161.45 N/A N/A $99.69 N/A N/A $161.45 N/A N/A $493.15 N/A N/A $939.00 N/A N/A $422.70 N/A N/A $474.00 N/A N/A $915.85 N/A N/A $422.70 N/A N/A $422.70 N/A N/A $422.70 N/A N/A $422.70 N/A N/A $422.70 N/A N/A $422.70 N/A "$1,409.00 " "$1,409.00 " N/A 49011111 Surgery COLORECTAL SCREENING HIGH RISK G0105 G0105 490 "$2,307.00 " $- $385.98 $- $- "$1,845.60 " $- N/A $599.82 N/A N/A $950.00 N/A N/A "$1,384.20 " N/A N/A "$1,153.50 " N/A N/A N/A N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $899.73 N/A N/A "$1,049.69 " N/A N/A "$1,845.60 " N/A N/A N/A N/A N/A "$1,499.55 " N/A N/A $385.98 N/A N/A N/A N/A N/A $385.98 N/A N/A $807.45 N/A N/A $939.00 N/A N/A $692.10 N/A N/A $686.00 N/A N/A "$1,499.55 " N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A "$2,307.00 " "$2,307.00 " N/A 49011771 Surgery Excision Cyst Pilonidal 11771 490 "$7,340.00 " $- $625.09 $- $- "$5,872.00 " $- N/A "$1,908.40 " N/A N/A "$1,150.00 " N/A N/A "$4,404.00 " N/A N/A "$3,670.00 " N/A N/A $625.09 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,862.60 " N/A N/A "$3,339.70 " N/A N/A "$5,872.00 " N/A N/A N/A N/A N/A "$4,771.00 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$2,569.00 " N/A N/A "$1,071.00 " N/A N/A "$2,202.00 " N/A N/A "$1,273.00 " N/A N/A "$4,771.00 " N/A N/A "$2,202.00 " N/A N/A "$2,202.00 " N/A N/A "$2,202.00 " N/A N/A "$2,202.00 " N/A N/A "$2,202.00 " N/A N/A "$2,202.00 " N/A "$7,340.00 " "$7,340.00 " N/A 49014020 Surgery ADJACENT TISSUE TRANSFER/REARRANGEMENT SCALP/ARMS/LEGS DEFE 14020 490 "$7,565.00 " $- $623.73 $- $- "$6,052.00 " $- N/A "$1,966.90 " N/A N/A "$1,150.00 " N/A N/A "$4,539.00 " N/A N/A "$3,782.50 " N/A N/A $623.73 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,950.35 " N/A N/A "$3,442.08 " N/A N/A "$6,052.00 " N/A N/A N/A N/A N/A "$4,917.25 " N/A N/A $819.95 N/A N/A $623.73 N/A N/A $819.95 N/A N/A "$2,647.75 " N/A N/A "$1,071.00 " N/A N/A "$2,269.50 " N/A N/A "$1,061.00 " N/A N/A "$4,917.25 " N/A N/A "$2,269.50 " N/A N/A "$2,269.50 " N/A N/A "$2,269.50 " N/A N/A "$2,269.50 " N/A N/A "$2,269.50 " N/A N/A "$2,269.50 " N/A "$7,565.00 " "$7,565.00 " N/A 49015820 Surgery Blepharoplasty Lower Eyelid 15820 490 "$3,744.00 " $- $623.73 $- $- "$2,995.20 " $- N/A $973.44 N/A N/A "$1,150.00 " N/A N/A "$2,246.40 " N/A N/A "$1,872.00 " N/A N/A $623.73 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,460.16 " N/A N/A "$1,703.52 " N/A N/A "$2,995.20 " N/A N/A N/A N/A N/A "$2,433.60 " N/A N/A $819.95 N/A N/A $623.73 N/A N/A $819.95 N/A N/A "$1,310.40 " N/A N/A "$1,071.00 " N/A N/A "$1,123.20 " N/A N/A "$1,061.00 " N/A N/A "$2,433.60 " N/A N/A "$1,123.20 " N/A N/A "$1,123.20 " N/A N/A "$1,123.20 " N/A N/A "$1,123.20 " N/A N/A "$1,123.20 " N/A N/A "$1,123.20 " N/A "$3,744.00 " "$3,744.00 " N/A 49015830 Surgery Panniculectomy 15830 490 "$8,745.00 " $- "$1,071.00 " $- $- "$6,996.00 " $- N/A "$2,273.70 " N/A N/A "$1,150.00 " N/A N/A "$5,247.00 " N/A N/A "$4,372.50 " N/A N/A "$1,611.95 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,410.55 " N/A N/A "$3,978.98 " N/A N/A "$6,996.00 " N/A N/A N/A N/A N/A "$5,684.25 " N/A N/A "$2,193.27 " N/A N/A "$1,611.95 " N/A N/A "$2,193.27 " N/A N/A "$3,060.75 " N/A N/A "$1,071.00 " N/A N/A "$2,623.50 " N/A N/A "$1,872.00 " N/A N/A "$5,684.25 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A "$8,745.00 " "$8,745.00 " N/A 49015830 Surgery Panniculectomy 15830 490 "$8,745.00 " $- "$1,071.00 " $- $- "$6,996.00 " $- N/A "$2,273.70 " N/A N/A "$1,150.00 " N/A N/A "$5,247.00 " N/A N/A "$4,372.50 " N/A N/A "$1,611.95 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,410.55 " N/A N/A "$3,978.98 " N/A N/A "$6,996.00 " N/A N/A N/A N/A N/A "$5,684.25 " N/A N/A "$2,193.27 " N/A N/A "$1,611.95 " N/A N/A "$2,193.27 " N/A N/A "$3,060.75 " N/A N/A "$1,071.00 " N/A N/A "$2,623.50 " N/A N/A "$1,872.00 " N/A N/A "$5,684.25 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A N/A "$2,623.50 " N/A "$8,745.00 " "$8,745.00 " N/A 49019020 Surgery "Incision and Drainage of Breast Abscess, Deep" 19020 490 "$2,483.00 " $- $576.39 $- $- "$1,986.40 " $- N/A $645.58 N/A N/A $950.00 N/A N/A "$1,489.80 " N/A N/A "$1,241.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $968.37 N/A N/A "$1,129.77 " N/A N/A "$1,986.40 " N/A N/A N/A N/A N/A "$1,613.95 " N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A $869.05 N/A N/A $939.00 N/A N/A $744.90 N/A N/A "$1,273.00 " N/A N/A "$1,613.95 " N/A N/A $744.90 N/A N/A $744.90 N/A N/A $744.90 N/A N/A $744.90 N/A N/A $744.90 N/A N/A $744.90 N/A "$2,483.00 " "$2,483.00 " N/A 49019100 Surgery Biopsy Breast 19100 490 "$1,299.00 " $- $337.74 $- $- "$1,061.00 " $- N/A $337.74 N/A N/A $750.00 N/A N/A $779.40 N/A N/A $649.50 N/A N/A $416.34 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $506.61 N/A N/A $591.05 N/A N/A "$1,039.20 " N/A N/A N/A N/A N/A $844.35 N/A N/A $576.39 N/A N/A $416.34 N/A N/A $576.39 N/A N/A $454.65 N/A N/A $700.00 N/A N/A $389.70 N/A N/A "$1,061.00 " N/A N/A $844.35 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A N/A $389.70 N/A "$1,299.00 " "$1,299.00 " N/A 49019120 Surgery REMOVAL OF BREAST LESION 19120 490 "$6,249.00 " $- $967.04 $- $- "$4,999.20 " $- N/A "$1,624.74 " N/A N/A "$1,150.00 " N/A N/A "$3,749.40 " N/A N/A "$3,124.50 " N/A N/A $967.04 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,437.11 " N/A N/A "$2,843.30 " N/A N/A "$4,999.20 " N/A N/A N/A N/A N/A "$4,061.85 " N/A N/A "$1,118.44 " N/A N/A $967.04 N/A N/A "$1,118.44 " N/A N/A "$2,187.15 " N/A N/A "$1,071.00 " N/A N/A "$1,874.70 " N/A N/A "$1,273.00 " N/A N/A "$4,061.85 " N/A N/A "$1,874.70 " N/A N/A "$1,874.70 " N/A N/A "$1,874.70 " N/A N/A "$1,874.70 " N/A N/A "$1,874.70 " N/A N/A "$1,874.70 " N/A "$6,249.00 " "$6,249.00 " N/A 49020200 Surgery Biopsy Muscle 20200 490 "$2,455.00 " $- $576.39 $- $- "$1,964.00 " $- N/A $638.30 N/A N/A $950.00 N/A N/A "$1,473.00 " N/A N/A "$1,227.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $957.45 N/A N/A "$1,117.03 " N/A N/A "$1,964.00 " N/A N/A N/A N/A N/A "$1,595.75 " N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A $859.25 N/A N/A $939.00 N/A N/A $736.50 N/A N/A "$1,061.00 " N/A N/A "$1,595.75 " N/A N/A $736.50 N/A N/A $736.50 N/A N/A $736.50 N/A N/A $736.50 N/A N/A $736.50 N/A N/A $736.50 N/A "$2,455.00 " "$2,455.00 " N/A 49020520 Surgery Foreign Body Removal Muscle 20520 490 "$1,713.00 " $- $138.94 $- $- "$1,370.40 " $- N/A $445.38 N/A N/A $950.00 N/A N/A "$1,027.80 " N/A N/A $856.50 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $668.07 N/A N/A $779.42 N/A N/A "$1,370.40 " N/A N/A N/A N/A N/A "$1,113.45 " N/A N/A $138.94 N/A N/A N/A N/A N/A $138.94 N/A N/A $599.55 N/A N/A $700.00 N/A N/A $513.90 N/A N/A $686.00 N/A N/A "$1,113.45 " N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A N/A $513.90 N/A "$1,713.00 " "$1,713.00 " N/A 49020680 Surgery Removal of Support Implant 20680 490 "$4,503.00 " $- $994.34 $- $- "$3,602.40 " $- N/A "$1,170.78 " N/A N/A "$1,150.00 " N/A N/A "$2,701.80 " N/A N/A "$2,251.50 " N/A N/A N/A N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,756.17 " N/A N/A "$2,048.87 " N/A N/A "$3,602.40 " N/A N/A N/A N/A N/A "$2,926.95 " N/A N/A $994.34 N/A N/A N/A N/A N/A $994.34 N/A N/A "$1,576.05 " N/A N/A "$1,071.00 " N/A N/A "$1,350.90 " N/A N/A "$1,273.00 " N/A N/A "$2,926.95 " N/A N/A "$1,350.90 " N/A N/A "$1,350.90 " N/A N/A "$1,350.90 " N/A N/A "$1,350.90 " N/A N/A "$1,350.90 " N/A N/A "$1,350.90 " N/A "$4,503.00 " "$4,503.00 " N/A 49021330 Surgery Open Reduction Internal Fixation Nasal 21330 490 "$4,090.00 " $- $714.65 $- $- "$3,272.00 " $- N/A "$1,063.40 " N/A N/A "$1,550.00 " N/A N/A "$2,454.00 " N/A N/A "$2,045.00 " N/A N/A $714.65 N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$1,595.10 " N/A N/A "$1,860.95 " N/A N/A "$3,272.00 " N/A N/A N/A N/A N/A "$2,658.50 " N/A N/A "$2,246.55 " N/A N/A N/A N/A N/A "$2,246.55 " N/A N/A "$1,431.50 " N/A N/A "$1,505.00 " N/A N/A "$1,227.00 " N/A N/A "$1,273.00 " N/A N/A "$2,658.50 " N/A N/A "$1,227.00 " N/A N/A "$1,227.00 " N/A N/A "$1,227.00 " N/A N/A "$1,227.00 " N/A N/A "$1,227.00 " N/A N/A "$1,227.00 " N/A "$4,090.00 " "$4,090.00 " N/A 49021556 Surgery Excision Neck Mass 21556 490 "$3,991.00 " $- $625.09 $- $- "$3,192.80 " $- N/A "$1,037.66 " N/A N/A $950.00 N/A N/A "$2,394.60 " N/A N/A "$1,995.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,556.49 " N/A N/A "$1,815.91 " N/A N/A "$3,192.80 " N/A N/A N/A N/A N/A "$2,594.15 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$1,396.85 " N/A N/A $939.00 N/A N/A "$1,197.30 " N/A N/A "$1,273.00 " N/A N/A "$2,594.15 " N/A N/A "$1,197.30 " N/A N/A "$1,197.30 " N/A N/A "$1,197.30 " N/A N/A "$1,197.30 " N/A N/A "$1,197.30 " N/A N/A "$1,197.30 " N/A "$3,991.00 " "$3,991.00 " N/A 49023040 Surgery Foreign Body Removal Shoulder 23040 490 "$7,295.00 " $- "$1,058.82 " $- $- "$5,836.00 " $- N/A "$1,896.70 " N/A N/A "$1,150.00 " N/A N/A "$4,377.00 " N/A N/A "$3,647.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,845.05 " N/A N/A "$3,319.23 " N/A N/A "$5,836.00 " N/A N/A N/A N/A N/A "$4,741.75 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$2,553.25 " N/A N/A "$1,071.00 " N/A N/A "$2,188.50 " N/A N/A "$1,441.00 " N/A N/A "$4,741.75 " N/A N/A "$2,188.50 " N/A N/A "$2,188.50 " N/A N/A "$2,188.50 " N/A N/A "$2,188.50 " N/A N/A "$2,188.50 " N/A N/A "$2,188.50 " N/A "$7,295.00 " "$7,295.00 " N/A 49023480 Surgery Osteotomy Clavicle 23480 490 "$6,548.00 " $- "$1,058.82 " $- $- "$5,238.40 " $- N/A "$1,702.48 " N/A N/A "$1,350.00 " N/A N/A "$3,928.80 " N/A N/A "$3,274.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,553.72 " N/A N/A "$2,979.34 " N/A N/A "$5,238.40 " N/A N/A N/A N/A N/A "$4,256.20 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,291.80 " N/A N/A "$1,321.00 " N/A N/A "$1,964.40 " N/A N/A "$1,872.00 " N/A N/A "$4,256.20 " N/A N/A "$1,964.40 " N/A N/A "$1,964.40 " N/A N/A "$1,964.40 " N/A N/A "$1,964.40 " N/A N/A "$1,964.40 " N/A N/A "$1,964.40 " N/A "$6,548.00 " "$6,548.00 " N/A 49023655 Surgery Manipulation Shoulder under Anesthesia 23655 490 "$2,315.00 " $- $484.61 $- $- "$1,852.00 " $- N/A $601.90 N/A N/A $750.00 N/A N/A "$1,389.00 " N/A N/A "$1,157.50 " N/A N/A $484.61 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $902.85 N/A N/A "$1,053.33 " N/A N/A "$1,852.00 " N/A N/A N/A N/A N/A "$1,504.75 " N/A N/A $713.00 N/A N/A $484.61 N/A N/A $713.00 N/A N/A $810.25 N/A N/A $700.00 N/A N/A $694.50 N/A N/A "$1,061.00 " N/A N/A "$1,504.75 " N/A N/A $694.50 N/A N/A $694.50 N/A N/A $694.50 N/A N/A $694.50 N/A N/A $694.50 N/A N/A $694.50 N/A "$2,315.00 " "$2,315.00 " N/A 49023800 Surgery Arthrodesis Shoulder 23800 490 "$14,409.00 " $- "$1,321.00 " $- $- "$11,527.20 " $- N/A "$3,746.34 " N/A N/A "$1,350.00 " N/A N/A "$8,645.40 " N/A N/A "$7,204.50 " N/A N/A "$2,792.29 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$5,619.51 " N/A N/A "$6,556.10 " N/A N/A "$11,527.20 " N/A N/A N/A N/A N/A "$9,365.85 " N/A N/A "$2,803.36 " N/A N/A "$2,792.29 " N/A N/A "$2,803.36 " N/A N/A "$5,043.15 " N/A N/A "$1,321.00 " N/A N/A "$4,322.70 " N/A N/A "$2,818.00 " N/A N/A "$9,365.85 " N/A N/A "$4,322.70 " N/A N/A "$4,322.70 " N/A N/A "$4,322.70 " N/A N/A "$4,322.70 " N/A N/A "$4,322.70 " N/A N/A "$4,322.70 " N/A "$14,409.00 " "$14,409.00 " N/A 49023930 Surgery Incision and Drainage Elbow 23930 490 "$2,292.00 " $- $595.92 $- $- "$1,833.60 " $- N/A $595.92 N/A N/A $750.00 N/A N/A "$1,375.20 " N/A N/A "$1,146.00 " N/A N/A $625.09 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $893.88 N/A N/A "$1,042.86 " N/A N/A "$1,833.60 " N/A N/A N/A N/A N/A "$1,489.80 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A $802.20 N/A N/A $700.00 N/A N/A $687.60 N/A N/A "$1,273.00 " N/A N/A "$1,489.80 " N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A "$2,292.00 " "$2,292.00 " N/A 49023930 Surgery Incison and Drainage Elbow 23930 490 "$2,292.00 " $- $595.92 $- $- "$1,833.60 " $- N/A $595.92 N/A N/A $750.00 N/A N/A "$1,375.20 " N/A N/A "$1,146.00 " N/A N/A $625.09 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $893.88 N/A N/A "$1,042.86 " N/A N/A "$1,833.60 " N/A N/A N/A N/A N/A "$1,489.80 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A $802.20 N/A N/A $700.00 N/A N/A $687.60 N/A N/A "$1,273.00 " N/A N/A "$1,489.80 " N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A N/A $687.60 N/A "$2,292.00 " "$2,292.00 " N/A 49024000 Surgery Foreign Body Removal Elbow 24000 490 "$5,739.00 " $- "$1,058.82 " $- $- "$4,591.20 " $- N/A "$1,492.14 " N/A N/A "$1,350.00 " N/A N/A "$3,443.40 " N/A N/A "$2,869.50 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,238.21 " N/A N/A "$2,611.25 " N/A N/A "$4,591.20 " N/A N/A N/A N/A N/A "$3,730.35 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$2,008.65 " N/A N/A "$1,321.00 " N/A N/A "$1,721.70 " N/A N/A "$1,441.00 " N/A N/A "$3,730.35 " N/A N/A "$1,721.70 " N/A N/A "$1,721.70 " N/A N/A "$1,721.70 " N/A N/A "$1,721.70 " N/A N/A "$1,721.70 " N/A N/A "$1,721.70 " N/A "$5,739.00 " "$5,739.00 " N/A 49024071 Surgery EXCISION ARM/ELBOW LESION SUBCUTANEOUS >3CM 24071 490 "$6,740.00 " $- $625.09 $- $- "$5,392.00 " $- N/A "$1,752.40 " N/A N/A "$1,150.00 " N/A N/A "$4,044.00 " N/A N/A "$3,370.00 " N/A N/A $625.09 N/A N/A "$2,266.00 " N/A N/A "$1,343.00 " N/A N/A "$2,628.60 " N/A N/A "$3,066.70 " N/A N/A "$5,392.00 " N/A N/A N/A N/A N/A "$4,381.00 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$2,359.00 " N/A N/A "$1,071.00 " N/A N/A "$2,022.00 " N/A N/A "$1,273.00 " N/A N/A "$4,381.00 " N/A N/A "$2,022.00 " N/A N/A "$2,022.00 " N/A N/A "$2,022.00 " N/A N/A "$2,022.00 " N/A N/A "$2,022.00 " N/A N/A "$2,022.00 " N/A "$6,740.00 " "$6,740.00 " N/A 49024200 Surgery 24200 490 "$1,116.00 " $- $147.25 $- $- "$1,177.00 " $- N/A $290.16 N/A N/A N/A N/A N/A $669.60 N/A N/A $558.00 N/A N/A N/A N/A N/A $756.00 N/A N/A "$1,177.00 " N/A N/A $435.24 N/A N/A $507.78 N/A N/A $892.80 N/A N/A N/A N/A N/A $725.40 N/A N/A $147.25 N/A N/A N/A N/A N/A $147.25 N/A N/A $390.60 N/A N/A $939.00 N/A N/A $334.80 N/A N/A $686.00 N/A N/A $725.40 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A N/A $334.80 N/A "$1,116.00 " "$1,116.00 " N/A 49024301 Surgery Tendon Transfer Upper Arm 24301 490 "$5,962.00 " $- "$1,058.82 " $- $- "$4,769.60 " $- N/A "$1,550.12 " N/A N/A "$1,350.00 " N/A N/A "$3,577.20 " N/A N/A "$2,981.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,325.18 " N/A N/A "$2,712.71 " N/A N/A "$4,769.60 " N/A N/A N/A N/A N/A "$3,875.30 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,086.70 " N/A N/A "$1,321.00 " N/A N/A "$1,788.60 " N/A N/A "$1,441.00 " N/A N/A "$3,875.30 " N/A N/A "$1,788.60 " N/A N/A "$1,788.60 " N/A N/A "$1,788.60 " N/A N/A "$1,788.60 " N/A N/A "$1,788.60 " N/A N/A "$1,788.60 " N/A "$5,962.00 " "$5,962.00 " N/A 49024332 Surgery Tendon Release Upper Arm 24332 490 "$6,923.00 " $- $950.00 $- $- "$5,538.40 " $- N/A "$1,799.98 " N/A N/A $950.00 N/A N/A "$4,153.80 " N/A N/A "$3,461.50 " N/A N/A N/A N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,699.97 " N/A N/A "$3,149.97 " N/A N/A "$5,538.40 " N/A N/A N/A N/A N/A "$4,499.95 " N/A N/A "$1,286.26 " N/A N/A N/A N/A N/A "$1,286.26 " N/A N/A "$2,423.05 " N/A N/A "$1,071.00 " N/A N/A "$2,076.90 " N/A N/A "$1,441.00 " N/A N/A "$4,499.95 " N/A N/A "$2,076.90 " N/A N/A "$2,076.90 " N/A N/A "$2,076.90 " N/A N/A "$2,076.90 " N/A N/A "$2,076.90 " N/A N/A "$2,076.90 " N/A "$6,923.00 " "$6,923.00 " N/A 49024800 Surgery Arthrodesis Elbow 24800 490 "$10,011.00 " $- "$1,321.00 " $- $- "$8,008.80 " $- N/A "$2,602.86 " N/A N/A "$1,350.00 " N/A N/A "$6,006.60 " N/A N/A "$5,005.50 " N/A N/A "$1,965.14 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,904.29 " N/A N/A "$4,555.01 " N/A N/A "$8,008.80 " N/A N/A N/A N/A N/A "$6,507.15 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$3,503.85 " N/A N/A "$1,321.00 " N/A N/A "$3,003.30 " N/A N/A "$1,872.00 " N/A N/A "$6,507.15 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A "$10,011.00 " "$10,011.00 " N/A 49025031 Surgery Incision and Drainage Wrist 25031 490 "$2,700.00 " $- $643.20 $- $- "$2,160.00 " $- N/A $702.00 N/A N/A $950.00 N/A N/A "$1,620.00 " N/A N/A "$1,350.00 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,053.00 " N/A N/A "$1,228.50 " N/A N/A "$2,160.00 " N/A N/A N/A N/A N/A "$1,755.00 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A $945.00 N/A N/A $939.00 N/A N/A $810.00 N/A N/A "$1,273.00 " N/A N/A "$1,755.00 " N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A "$2,700.00 " "$2,700.00 " N/A 49025031 Surgery Incision and Drainage Wrist 25031 490 "$2,700.00 " $- $643.20 $- $- "$2,160.00 " $- N/A $702.00 N/A N/A $950.00 N/A N/A "$1,620.00 " N/A N/A "$1,350.00 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,053.00 " N/A N/A "$1,228.50 " N/A N/A "$2,160.00 " N/A N/A N/A N/A N/A "$1,755.00 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A $945.00 N/A N/A $939.00 N/A N/A $810.00 N/A N/A "$1,273.00 " N/A N/A "$1,755.00 " N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A N/A $810.00 N/A "$2,700.00 " "$2,700.00 " N/A 49025248 Surgery Foreign Body Removal Lower Arm 25248 490 "$4,731.00 " $- $643.20 $- $- "$3,784.80 " $- N/A "$1,230.06 " N/A N/A $950.00 N/A N/A "$2,838.60 " N/A N/A "$2,365.50 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,845.09 " N/A N/A "$2,152.61 " N/A N/A "$3,784.80 " N/A N/A N/A N/A N/A "$3,075.15 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A "$1,655.85 " N/A N/A $939.00 N/A N/A "$1,419.30 " N/A N/A "$1,273.00 " N/A N/A "$3,075.15 " N/A N/A "$1,419.30 " N/A N/A "$1,419.30 " N/A N/A "$1,419.30 " N/A N/A "$1,419.30 " N/A N/A "$1,419.30 " N/A N/A "$1,419.30 " N/A "$4,731.00 " "$4,731.00 " N/A 49025295 Surgery Tendon Release Lower Arm 25295 490 "$2,633.00 " $- $643.20 $- $- "$2,106.40 " $- N/A $684.58 N/A N/A "$1,150.00 " N/A N/A "$1,579.80 " N/A N/A "$1,316.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,026.87 " N/A N/A "$1,198.02 " N/A N/A "$2,106.40 " N/A N/A N/A N/A N/A "$1,711.45 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A $921.55 N/A N/A "$1,071.00 " N/A N/A $789.90 N/A N/A "$1,273.00 " N/A N/A "$1,711.45 " N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A "$2,633.00 " "$2,633.00 " N/A 49025295 Surgery Tendon Release Wrist 25295 490 "$2,633.00 " $- $643.20 $- $- "$2,106.40 " $- N/A $684.58 N/A N/A "$1,150.00 " N/A N/A "$1,579.80 " N/A N/A "$1,316.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,026.87 " N/A N/A "$1,198.02 " N/A N/A "$2,106.40 " N/A N/A N/A N/A N/A "$1,711.45 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A $921.55 N/A N/A "$1,071.00 " N/A N/A $789.90 N/A N/A "$1,273.00 " N/A N/A "$1,711.45 " N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A N/A $789.90 N/A "$2,633.00 " "$2,633.00 " N/A 49025310 Surgery Tendon Transfer Lower Arm 25310 490 "$4,078.00 " $- "$1,058.82 " $- $- "$3,262.40 " $- N/A "$1,060.28 " N/A N/A "$1,150.00 " N/A N/A "$2,446.80 " N/A N/A "$2,039.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,590.42 " N/A N/A "$1,855.49 " N/A N/A "$3,262.40 " N/A N/A N/A N/A N/A "$2,650.70 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,427.30 " N/A N/A "$1,071.00 " N/A N/A "$1,223.40 " N/A N/A "$1,441.00 " N/A N/A "$2,650.70 " N/A N/A "$1,223.40 " N/A N/A "$1,223.40 " N/A N/A "$1,223.40 " N/A N/A "$1,223.40 " N/A N/A "$1,223.40 " N/A N/A "$1,223.40 " N/A "$4,078.00 " "$4,078.00 " N/A 49025365 Surgery Osteotomy Radius 25365 490 "$10,011.00 " $- "$1,071.00 " $- $- "$8,008.80 " $- N/A "$2,602.86 " N/A N/A "$1,150.00 " N/A N/A "$6,006.60 " N/A N/A "$5,005.50 " N/A N/A "$2,792.29 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,904.29 " N/A N/A "$4,555.01 " N/A N/A "$8,008.80 " N/A N/A N/A N/A N/A "$6,507.15 " N/A N/A "$5,727.13 " N/A N/A "$2,792.29 " N/A N/A "$5,727.13 " N/A N/A "$3,503.85 " N/A N/A "$1,071.00 " N/A N/A "$3,003.30 " N/A N/A "$1,872.00 " N/A N/A "$6,507.15 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A "$10,011.00 " "$10,011.00 " N/A 49025820 Surgery Arthrodesis Wrist 25820 490 "$6,246.00 " $- "$1,321.00 " $- $- "$4,996.80 " $- N/A "$1,623.96 " N/A N/A "$1,350.00 " N/A N/A "$3,747.60 " N/A N/A "$3,123.00 " N/A N/A "$1,965.14 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,435.94 " N/A N/A "$2,841.93 " N/A N/A "$4,996.80 " N/A N/A N/A N/A N/A "$4,059.90 " N/A N/A "$3,810.66 " N/A N/A "$1,965.14 " N/A N/A "$3,810.66 " N/A N/A "$2,186.10 " N/A N/A "$1,321.00 " N/A N/A "$1,873.80 " N/A N/A "$1,872.00 " N/A N/A "$4,059.90 " N/A N/A "$1,873.80 " N/A N/A "$1,873.80 " N/A N/A "$1,873.80 " N/A N/A "$1,873.80 " N/A N/A "$1,873.80 " N/A N/A "$1,873.80 " N/A "$6,246.00 " "$6,246.00 " N/A 49025830 Surgery Arthrodesis Distal Radioulnar Joint with Segmental Resection 25830 490 "$11,380.00 " $- "$1,505.00 " $- $- "$9,104.00 " $- N/A "$2,958.80 " N/A N/A "$1,550.00 " N/A N/A "$6,828.00 " N/A N/A "$5,690.00 " N/A N/A "$1,965.14 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$4,438.20 " N/A N/A "$5,177.90 " N/A N/A "$9,104.00 " N/A N/A N/A N/A N/A "$7,397.00 " N/A N/A "$3,715.14 " N/A N/A "$1,965.14 " N/A N/A "$3,715.14 " N/A N/A "$3,983.00 " N/A N/A "$1,505.00 " N/A N/A "$3,414.00 " N/A N/A "$1,872.00 " N/A N/A "$7,397.00 " N/A N/A "$3,414.00 " N/A N/A "$3,414.00 " N/A N/A "$3,414.00 " N/A N/A "$3,414.00 " N/A N/A "$3,414.00 " N/A N/A "$3,414.00 " N/A "$11,380.00 " "$11,380.00 " N/A 49026045 Surgery Dupuytren's Contracture Release 26045 490 "$5,880.00 " $- $643.20 $- $- "$4,704.00 " $- N/A "$1,528.80 " N/A N/A "$1,150.00 " N/A N/A "$3,528.00 " N/A N/A "$2,940.00 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,293.20 " N/A N/A "$2,675.40 " N/A N/A "$4,704.00 " N/A N/A N/A N/A N/A "$3,822.00 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$2,058.00 " N/A N/A "$1,071.00 " N/A N/A "$1,764.00 " N/A N/A "$1,441.00 " N/A N/A "$3,822.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A "$5,880.00 " "$5,880.00 " N/A 49026055 Surgery Trigger Finger Release 26055 490 "$2,391.00 " $- $621.66 $- $- "$1,912.80 " $- N/A $621.66 N/A N/A $950.00 N/A N/A "$1,434.60 " N/A N/A "$1,195.50 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $932.49 N/A N/A "$1,087.91 " N/A N/A "$1,912.80 " N/A N/A N/A N/A N/A "$1,554.15 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A $836.85 N/A N/A $939.00 N/A N/A $717.30 N/A N/A "$1,061.00 " N/A N/A "$1,554.15 " N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A "$2,391.00 " "$2,391.00 " N/A 49026055 Surgery Trigger Finger Release 26055 490 "$2,391.00 " $- $621.66 $- $- "$1,912.80 " $- N/A $621.66 N/A N/A $950.00 N/A N/A "$1,434.60 " N/A N/A "$1,195.50 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $932.49 N/A N/A "$1,087.91 " N/A N/A "$1,912.80 " N/A N/A N/A N/A N/A "$1,554.15 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A $836.85 N/A N/A $939.00 N/A N/A $717.30 N/A N/A "$1,061.00 " N/A N/A "$1,554.15 " N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A N/A $717.30 N/A "$2,391.00 " "$2,391.00 " N/A 49026111 Surgery EXC Tumor/SOFT TISSUE HAND/FINGER SUBCUTANEOUS>1.5 CM 26111 490 "$2,983.00 " $- $576.39 $- $- "$2,386.40 " $- N/A $775.58 N/A N/A "$1,150.00 " N/A N/A "$1,789.80 " N/A N/A "$1,491.50 " N/A N/A $625.09 N/A N/A "$2,266.00 " N/A N/A "$1,343.00 " N/A N/A "$1,163.37 " N/A N/A "$1,357.27 " N/A N/A "$2,386.40 " N/A N/A N/A N/A N/A "$1,938.95 " N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A "$1,044.05 " N/A N/A "$1,071.00 " N/A N/A $894.90 N/A N/A "$1,273.00 " N/A N/A "$1,938.95 " N/A N/A $894.90 N/A N/A $894.90 N/A N/A $894.90 N/A N/A $894.90 N/A N/A $894.90 N/A N/A $894.90 N/A "$2,983.00 " "$2,983.00 " N/A 49026116 Surgery EXC TUMOR/SOFT TISSUE HAND/FINGER DEEP < 1.5 CM 26116 490 "$3,571.00 " $- $576.39 $- $- "$2,856.80 " $- N/A $928.46 N/A N/A $950.00 N/A N/A "$2,142.60 " N/A N/A "$1,785.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,392.69 " N/A N/A "$1,624.81 " N/A N/A "$2,856.80 " N/A N/A N/A N/A N/A "$2,321.15 " N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A "$1,249.85 " N/A N/A $939.00 N/A N/A "$1,071.30 " N/A N/A "$1,061.00 " N/A N/A "$2,321.15 " N/A N/A "$1,071.30 " N/A N/A "$1,071.30 " N/A N/A "$1,071.30 " N/A N/A "$1,071.30 " N/A N/A "$1,071.30 " N/A N/A "$1,071.30 " N/A "$3,571.00 " "$3,571.00 " N/A 49026160 Surgery "Excision of lesion of tendon sheath or joint capsule (eg, cy" 26160 490 "$2,652.00 " $- $643.20 $- $- "$2,121.60 " $- N/A $689.52 N/A N/A "$1,150.00 " N/A N/A "$1,591.20 " N/A N/A "$1,326.00 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,034.28 " N/A N/A "$1,206.66 " N/A N/A "$2,121.60 " N/A N/A N/A N/A N/A "$1,723.80 " N/A N/A $713.00 N/A N/A $643.20 N/A N/A $713.00 N/A N/A $928.20 N/A N/A "$1,071.00 " N/A N/A $795.60 N/A N/A "$1,061.00 " N/A N/A "$1,723.80 " N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A N/A $795.60 N/A "$2,652.00 " "$2,652.00 " N/A 49026480 Surgery Tendon Transfer Hand 26480 490 "$3,673.00 " $- $643.20 $- $- "$2,938.40 " $- N/A $954.98 N/A N/A "$1,150.00 " N/A N/A "$2,203.80 " N/A N/A "$1,836.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,432.47 " N/A N/A "$1,671.22 " N/A N/A "$2,938.40 " N/A N/A N/A N/A N/A "$2,387.45 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,285.55 " N/A N/A "$1,071.00 " N/A N/A "$1,101.90 " N/A N/A "$1,441.00 " N/A N/A "$2,387.45 " N/A N/A "$1,101.90 " N/A N/A "$1,101.90 " N/A N/A "$1,101.90 " N/A N/A "$1,101.90 " N/A N/A "$1,101.90 " N/A N/A "$1,101.90 " N/A "$3,673.00 " "$3,673.00 " N/A 49026490 Surgery Tendon Transfer Thumb 26490 490 "$4,496.00 " $- "$1,058.82 " $- $- "$3,596.80 " $- N/A "$1,168.96 " N/A N/A "$1,150.00 " N/A N/A "$2,697.60 " N/A N/A "$2,248.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,753.44 " N/A N/A "$2,045.68 " N/A N/A "$3,596.80 " N/A N/A N/A N/A N/A "$2,922.40 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,573.60 " N/A N/A "$1,071.00 " N/A N/A "$1,348.80 " N/A N/A "$1,441.00 " N/A N/A "$2,922.40 " N/A N/A "$1,348.80 " N/A N/A "$1,348.80 " N/A N/A "$1,348.80 " N/A N/A "$1,348.80 " N/A N/A "$1,348.80 " N/A N/A "$1,348.80 " N/A "$4,496.00 " "$4,496.00 " N/A 49026498 Surgery Tendon Transfer Finger 26498 490 "$3,625.00 " $- $942.50 $- $- "$2,900.00 " $- N/A $942.50 N/A N/A "$1,350.00 " N/A N/A "$2,175.00 " N/A N/A "$1,812.50 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,413.75 " N/A N/A "$1,649.38 " N/A N/A "$2,900.00 " N/A N/A N/A N/A N/A "$2,356.25 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,268.75 " N/A N/A "$1,321.00 " N/A N/A "$1,087.50 " N/A N/A "$1,441.00 " N/A N/A "$2,356.25 " N/A N/A "$1,087.50 " N/A N/A "$1,087.50 " N/A N/A "$1,087.50 " N/A N/A "$1,087.50 " N/A N/A "$1,087.50 " N/A N/A "$1,087.50 " N/A "$3,625.00 " "$3,625.00 " N/A 49026565 Surgery Osteotomy Metacarpal 26565 490 "$4,274.00 " $- "$1,058.82 " $- $- "$3,419.20 " $- N/A "$1,111.24 " N/A N/A "$1,550.00 " N/A N/A "$2,564.40 " N/A N/A "$2,137.00 " N/A N/A "$1,058.82 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$1,666.86 " N/A N/A "$1,944.67 " N/A N/A "$3,419.20 " N/A N/A N/A N/A N/A "$2,778.10 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,495.90 " N/A N/A "$1,505.00 " N/A N/A "$1,282.20 " N/A N/A "$1,441.00 " N/A N/A "$2,778.10 " N/A N/A "$1,282.20 " N/A N/A "$1,282.20 " N/A N/A "$1,282.20 " N/A N/A "$1,282.20 " N/A N/A "$1,282.20 " N/A N/A "$1,282.20 " N/A "$4,274.00 " "$4,274.00 " N/A 49026567 Surgery Osteotomy Phlanges-Finger 26567 490 "$3,530.00 " $- $917.80 $- $- "$2,824.00 " $- N/A $917.80 N/A N/A "$1,550.00 " N/A N/A "$2,118.00 " N/A N/A "$1,765.00 " N/A N/A "$1,058.82 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$1,376.70 " N/A N/A "$1,606.15 " N/A N/A "$2,824.00 " N/A N/A N/A N/A N/A "$2,294.50 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,235.50 " N/A N/A "$1,505.00 " N/A N/A "$1,059.00 " N/A N/A "$1,441.00 " N/A N/A "$2,294.50 " N/A N/A "$1,059.00 " N/A N/A "$1,059.00 " N/A N/A "$1,059.00 " N/A N/A "$1,059.00 " N/A N/A "$1,059.00 " N/A N/A "$1,059.00 " N/A "$3,530.00 " "$3,530.00 " N/A 49026841 Surgery Arthrodesis Thumb 26841 490 "$5,880.00 " $- "$1,058.82 " $- $- "$4,704.00 " $- N/A "$1,528.80 " N/A N/A "$1,350.00 " N/A N/A "$3,528.00 " N/A N/A "$2,940.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,293.20 " N/A N/A "$2,675.40 " N/A N/A "$4,704.00 " N/A N/A N/A N/A N/A "$3,822.00 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,058.00 " N/A N/A "$1,321.00 " N/A N/A "$1,764.00 " N/A N/A "$1,441.00 " N/A N/A "$3,822.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A "$5,880.00 " "$5,880.00 " N/A 49026843 Surgery Arthrodesis Metacarpal-Carpal 26843 490 "$5,880.00 " $- "$1,071.00 " $- $- "$4,704.00 " $- N/A "$1,528.80 " N/A N/A "$1,150.00 " N/A N/A "$3,528.00 " N/A N/A "$2,940.00 " N/A N/A "$1,965.14 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,293.20 " N/A N/A "$2,675.40 " N/A N/A "$4,704.00 " N/A N/A N/A N/A N/A "$3,822.00 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$2,058.00 " N/A N/A "$1,071.00 " N/A N/A "$1,764.00 " N/A N/A "$1,441.00 " N/A N/A "$3,822.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A N/A "$1,764.00 " N/A "$5,880.00 " "$5,880.00 " N/A 49026850 Surgery Arthrodesis Metacarpophalangeal 26850 490 "$5,824.00 " $- "$1,058.82 " $- $- "$4,659.20 " $- N/A "$1,514.24 " N/A N/A "$1,350.00 " N/A N/A "$3,494.40 " N/A N/A "$2,912.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,271.36 " N/A N/A "$2,649.92 " N/A N/A "$4,659.20 " N/A N/A N/A N/A N/A "$3,785.60 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,038.40 " N/A N/A "$1,321.00 " N/A N/A "$1,747.20 " N/A N/A "$1,441.00 " N/A N/A "$3,785.60 " N/A N/A "$1,747.20 " N/A N/A "$1,747.20 " N/A N/A "$1,747.20 " N/A N/A "$1,747.20 " N/A N/A "$1,747.20 " N/A N/A "$1,747.20 " N/A "$5,824.00 " "$5,824.00 " N/A 49026860 Surgery Arthrodesis Interphalangeal 26860 490 "$4,261.00 " $- "$1,058.82 " $- $- "$3,408.80 " $- N/A "$1,107.86 " N/A N/A "$1,150.00 " N/A N/A "$2,556.60 " N/A N/A "$2,130.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,661.79 " N/A N/A "$1,938.76 " N/A N/A "$3,408.80 " N/A N/A N/A N/A N/A "$2,769.65 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,491.35 " N/A N/A "$1,071.00 " N/A N/A "$1,278.30 " N/A N/A "$1,441.00 " N/A N/A "$2,769.65 " N/A N/A "$1,278.30 " N/A N/A "$1,278.30 " N/A N/A "$1,278.30 " N/A N/A "$1,278.30 " N/A N/A "$1,278.30 " N/A N/A "$1,278.30 " N/A "$4,261.00 " "$4,261.00 " N/A 49027301 Surgery Incision and Drainage Knee 27301 490 "$2,987.00 " $- $625.09 $- $- "$2,389.60 " $- N/A $776.62 N/A N/A "$1,150.00 " N/A N/A "$1,792.20 " N/A N/A "$1,493.50 " N/A N/A $625.09 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,164.93 " N/A N/A "$1,359.09 " N/A N/A "$2,389.60 " N/A N/A N/A N/A N/A "$1,941.55 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$1,045.45 " N/A N/A "$1,071.00 " N/A N/A $896.10 N/A N/A "$1,273.00 " N/A N/A "$1,941.55 " N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A "$2,987.00 " "$2,987.00 " N/A 49027301 Surgery Incision and Drainage Knee 27301 490 "$2,987.00 " $- $625.09 $- $- "$2,389.60 " $- N/A $776.62 N/A N/A "$1,150.00 " N/A N/A "$1,792.20 " N/A N/A "$1,493.50 " N/A N/A $625.09 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,164.93 " N/A N/A "$1,359.09 " N/A N/A "$2,389.60 " N/A N/A N/A N/A N/A "$1,941.55 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$1,045.45 " N/A N/A "$1,071.00 " N/A N/A $896.10 N/A N/A "$1,273.00 " N/A N/A "$1,941.55 " N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A N/A $896.10 N/A "$2,987.00 " "$2,987.00 " N/A 49027310 Surgery Foreign Body Removal Knee 27310 490 "$3,672.00 " $- $954.72 $- $- "$2,937.60 " $- N/A $954.72 N/A N/A "$1,350.00 " N/A N/A "$2,203.20 " N/A N/A "$1,836.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,432.08 " N/A N/A "$1,670.76 " N/A N/A "$2,937.60 " N/A N/A N/A N/A N/A "$2,386.80 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,285.20 " N/A N/A "$1,321.00 " N/A N/A "$1,101.60 " N/A N/A "$1,441.00 " N/A N/A "$2,386.80 " N/A N/A "$1,101.60 " N/A N/A "$1,101.60 " N/A N/A "$1,101.60 " N/A N/A "$1,101.60 " N/A N/A "$1,101.60 " N/A N/A "$1,101.60 " N/A "$3,672.00 " "$3,672.00 " N/A 49027400 Surgery Tendon Transfer Upper Leg 27400 490 "$10,011.00 " $- "$1,058.82 " $- $- "$8,008.80 " $- N/A "$2,602.86 " N/A N/A "$1,150.00 " N/A N/A "$6,006.60 " N/A N/A "$5,005.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,904.29 " N/A N/A "$4,555.01 " N/A N/A "$8,008.80 " N/A N/A N/A N/A N/A "$6,507.15 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$3,503.85 " N/A N/A "$1,071.00 " N/A N/A "$3,003.30 " N/A N/A "$1,872.00 " N/A N/A "$6,507.15 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A N/A "$3,003.30 " N/A "$10,011.00 " "$10,011.00 " N/A 49027407 Surgery Anterior Cruciate Ligament Repair 27407 490 "$16,818.00 " $- "$1,321.00 " $- $- "$13,454.40 " $- N/A "$4,372.68 " N/A N/A "$1,350.00 " N/A N/A "$10,090.80 " N/A N/A "$8,409.00 " N/A N/A "$1,965.14 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$6,559.02 " N/A N/A "$7,652.19 " N/A N/A "$13,454.40 " N/A N/A N/A N/A N/A "$10,931.70 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$5,886.30 " N/A N/A "$1,321.00 " N/A N/A "$5,045.40 " N/A N/A "$2,818.00 " N/A N/A "$10,931.70 " N/A N/A "$5,045.40 " N/A N/A "$5,045.40 " N/A N/A "$5,045.40 " N/A N/A "$5,045.40 " N/A N/A "$5,045.40 " N/A N/A "$5,045.40 " N/A "$16,818.00 " "$16,818.00 " N/A 49027570 Surgery Lysis of AdhesionsManipulation Knee under Anesthesia 27570 490 "$2,230.00 " $- $484.61 $- $- "$1,784.00 " $- N/A $579.80 N/A N/A $750.00 N/A N/A "$1,338.00 " N/A N/A "$1,115.00 " N/A N/A $484.61 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $869.70 N/A N/A "$1,014.65 " N/A N/A "$1,784.00 " N/A N/A N/A N/A N/A "$1,449.50 " N/A N/A $713.00 N/A N/A $484.61 N/A N/A $713.00 N/A N/A $780.50 N/A N/A $700.00 N/A N/A $669.00 N/A N/A "$1,061.00 " N/A N/A "$1,449.50 " N/A N/A $669.00 N/A N/A $669.00 N/A N/A $669.00 N/A N/A $669.00 N/A N/A $669.00 N/A N/A $669.00 N/A "$2,230.00 " "$2,230.00 " N/A 49027603 Surgery Incision and Drainage Ankle 27603 490 "$2,495.00 " $- $625.09 $- $- "$1,996.00 " $- N/A $648.70 N/A N/A $950.00 N/A N/A "$1,497.00 " N/A N/A "$1,247.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $973.05 N/A N/A "$1,135.23 " N/A N/A "$1,996.00 " N/A N/A N/A N/A N/A "$1,621.75 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A $873.25 N/A N/A $939.00 N/A N/A $748.50 N/A N/A "$1,273.00 " N/A N/A "$1,621.75 " N/A N/A $748.50 N/A N/A $748.50 N/A N/A $748.50 N/A N/A $748.50 N/A N/A $748.50 N/A N/A $748.50 N/A "$2,495.00 " "$2,495.00 " N/A 49027610 Surgery Foreign Body Removal Ankle 27610 490 "$5,131.00 " $- $939.00 $- $- "$4,104.80 " $- N/A "$1,334.06 " N/A N/A $950.00 N/A N/A "$3,078.60 " N/A N/A "$2,565.50 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$2,001.09 " N/A N/A "$2,334.61 " N/A N/A "$4,104.80 " N/A N/A N/A N/A N/A "$3,335.15 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,795.85 " N/A N/A $939.00 N/A N/A "$1,539.30 " N/A N/A "$1,441.00 " N/A N/A "$3,335.15 " N/A N/A "$1,539.30 " N/A N/A "$1,539.30 " N/A N/A "$1,539.30 " N/A N/A "$1,539.30 " N/A N/A "$1,539.30 " N/A N/A "$1,539.30 " N/A "$5,131.00 " "$5,131.00 " N/A 49027690 Surgery Transfer or Transplant Single Tendon with Muscle Redirection 27690 490 "$4,931.00 " $- "$1,058.82 " $- $- "$3,944.80 " $- N/A "$1,282.06 " N/A N/A "$1,350.00 " N/A N/A "$2,958.60 " N/A N/A "$2,465.50 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,923.09 " N/A N/A "$2,243.61 " N/A N/A "$3,944.80 " N/A N/A N/A N/A N/A "$3,205.15 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$1,725.85 " N/A N/A "$1,321.00 " N/A N/A "$1,479.30 " N/A N/A "$1,872.00 " N/A N/A "$3,205.15 " N/A N/A "$1,479.30 " N/A N/A "$1,479.30 " N/A N/A "$1,479.30 " N/A N/A "$1,479.30 " N/A N/A "$1,479.30 " N/A N/A "$1,479.30 " N/A "$4,931.00 " "$4,931.00 " N/A 49027707 Surgery Osteotomy Fibula 27707 490 "$5,037.00 " $- $939.00 $- $- "$4,029.60 " $- N/A "$1,309.62 " N/A N/A $950.00 N/A N/A "$3,022.20 " N/A N/A "$2,518.50 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,964.43 " N/A N/A "$2,291.84 " N/A N/A "$4,029.60 " N/A N/A N/A N/A N/A "$3,274.05 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,762.95 " N/A N/A $939.00 N/A N/A "$1,511.10 " N/A N/A "$1,441.00 " N/A N/A "$3,274.05 " N/A N/A "$1,511.10 " N/A N/A "$1,511.10 " N/A N/A "$1,511.10 " N/A N/A "$1,511.10 " N/A N/A "$1,511.10 " N/A N/A "$1,511.10 " N/A "$5,037.00 " "$5,037.00 " N/A 49027848 Surgery Open Reduction Internal Fixation Ankle 27848 490 "$6,984.00 " $- "$1,058.82 " $- $- "$5,587.20 " $- N/A "$1,815.84 " N/A N/A "$1,150.00 " N/A N/A "$4,190.40 " N/A N/A "$3,492.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,723.76 " N/A N/A "$3,177.72 " N/A N/A "$5,587.20 " N/A N/A N/A N/A N/A "$4,539.60 " N/A N/A "$4,129.87 " N/A N/A "$1,058.82 " N/A N/A "$4,129.87 " N/A N/A "$2,444.40 " N/A N/A "$1,071.00 " N/A N/A "$2,095.20 " N/A N/A "$2,818.00 " N/A N/A "$4,539.60 " N/A N/A "$2,095.20 " N/A N/A "$2,095.20 " N/A N/A "$2,095.20 " N/A N/A "$2,095.20 " N/A N/A "$2,095.20 " N/A N/A "$2,095.20 " N/A "$6,984.00 " "$6,984.00 " N/A 49027870 Surgery Arthrodesis Ankle 27870 490 "$13,404.00 " $- "$1,321.00 " $- $- "$10,723.20 " $- N/A "$3,485.04 " N/A N/A "$1,350.00 " N/A N/A "$8,042.40 " N/A N/A "$6,702.00 " N/A N/A "$6,233.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$5,227.56 " N/A N/A "$6,098.82 " N/A N/A "$10,723.20 " N/A N/A N/A N/A N/A "$8,712.60 " N/A N/A "$8,448.33 " N/A N/A "$6,233.72 " N/A N/A "$8,448.33 " N/A N/A "$4,691.40 " N/A N/A "$1,321.00 " N/A N/A "$4,021.20 " N/A N/A "$2,818.00 " N/A N/A "$8,712.60 " N/A N/A "$4,021.20 " N/A N/A "$4,021.20 " N/A N/A "$4,021.20 " N/A N/A "$4,021.20 " N/A N/A "$4,021.20 " N/A N/A "$4,021.20 " N/A "$13,404.00 " "$13,404.00 " N/A 49027871 Surgery Arthrodesis Tibiofibular Joint 27871 490 "$13,850.00 " $- "$1,321.00 " $- $- "$11,080.00 " $- N/A "$3,601.00 " N/A N/A "$1,350.00 " N/A N/A "$8,310.00 " N/A N/A "$6,925.00 " N/A N/A "$2,792.29 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$5,401.50 " N/A N/A "$6,301.75 " N/A N/A "$11,080.00 " N/A N/A N/A N/A N/A "$9,002.50 " N/A N/A "$8,142.17 " N/A N/A "$2,792.29 " N/A N/A "$8,142.17 " N/A N/A "$4,847.50 " N/A N/A "$1,321.00 " N/A N/A "$4,155.00 " N/A N/A "$2,818.00 " N/A N/A "$9,002.50 " N/A N/A "$4,155.00 " N/A N/A "$4,155.00 " N/A N/A "$4,155.00 " N/A N/A "$4,155.00 " N/A N/A "$4,155.00 " N/A N/A "$4,155.00 " N/A "$13,850.00 " "$13,850.00 " N/A 49028008 Surgery Fasciotomy Plantar 28008 490 "$2,974.00 " $- $643.20 $- $- "$2,379.20 " $- N/A $773.24 N/A N/A "$1,150.00 " N/A N/A "$1,784.40 " N/A N/A "$1,487.00 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,159.86 " N/A N/A "$1,353.17 " N/A N/A "$2,379.20 " N/A N/A N/A N/A N/A "$1,933.10 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,040.90 " N/A N/A "$1,071.00 " N/A N/A $892.20 N/A N/A "$1,273.00 " N/A N/A "$1,933.10 " N/A N/A $892.20 N/A N/A $892.20 N/A N/A $892.20 N/A N/A $892.20 N/A N/A $892.20 N/A N/A $892.20 N/A "$2,974.00 " "$2,974.00 " N/A 49028190 Surgery Foreign Body Removal Foot 28190 490 "$1,591.00 " $- $182.25 $- $- "$1,272.80 " $- N/A $413.66 N/A N/A $950.00 N/A N/A $954.60 N/A N/A $795.50 N/A N/A N/A N/A N/A $756.00 N/A N/A $542.00 N/A N/A $620.49 N/A N/A $723.91 N/A N/A "$1,272.80 " N/A N/A N/A N/A N/A "$1,034.15 " N/A N/A $182.25 N/A N/A N/A N/A N/A $182.25 N/A N/A $556.85 N/A N/A $432.00 N/A N/A $477.30 N/A N/A $686.00 N/A N/A "$1,034.15 " N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A N/A $477.30 N/A "$1,591.00 " "$1,591.00 " N/A 49028285 Surgery Hammertoe Repair 28285 490 "$3,501.00 " $- $643.20 $- $- "$2,800.80 " $- N/A $910.26 N/A N/A "$1,150.00 " N/A N/A "$2,100.60 " N/A N/A "$1,750.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,365.39 " N/A N/A "$1,592.96 " N/A N/A "$2,800.80 " N/A N/A N/A N/A N/A "$2,275.65 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,225.35 " N/A N/A "$1,071.00 " N/A N/A "$1,050.30 " N/A N/A "$1,273.00 " N/A N/A "$2,275.65 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A "$3,501.00 " "$3,501.00 " N/A 49028285 Surgery Hammertoe Repair 28285 490 "$3,501.00 " $- $643.20 $- $- "$2,800.80 " $- N/A $910.26 N/A N/A "$1,150.00 " N/A N/A "$2,100.60 " N/A N/A "$1,750.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,365.39 " N/A N/A "$1,592.96 " N/A N/A "$2,800.80 " N/A N/A N/A N/A N/A "$2,275.65 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,225.35 " N/A N/A "$1,071.00 " N/A N/A "$1,050.30 " N/A N/A "$1,273.00 " N/A N/A "$2,275.65 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A N/A "$1,050.30 " N/A "$3,501.00 " "$3,501.00 " N/A 49028289 Surgery Correction Hallux Rigdus w/o Implant 28289 490 "$4,433.00 " $- "$1,058.82 " $- $- "$3,546.40 " $- N/A "$1,152.58 " N/A N/A "$1,150.00 " N/A N/A "$2,659.80 " N/A N/A "$2,216.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,728.87 " N/A N/A "$2,017.02 " N/A N/A "$3,546.40 " N/A N/A N/A N/A N/A "$2,881.45 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,551.55 " N/A N/A "$1,071.00 " N/A N/A "$1,329.90 " N/A N/A "$1,273.00 " N/A N/A "$2,881.45 " N/A N/A "$1,329.90 " N/A N/A "$1,329.90 " N/A N/A "$1,329.90 " N/A N/A "$1,329.90 " N/A N/A "$1,329.90 " N/A N/A "$1,329.90 " N/A "$4,433.00 " "$4,433.00 " N/A 49028292 Surgery CORRECTION HALLUX VALGUS WITH RESECTION OF PROXIMAL PHALANX 28292 490 "$6,753.00 " $- $939.00 $- $- "$5,402.40 " $- N/A "$1,755.78 " N/A N/A $950.00 N/A N/A "$4,051.80 " N/A N/A "$3,376.50 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$2,633.67 " N/A N/A "$3,072.62 " N/A N/A "$5,402.40 " N/A N/A N/A N/A N/A "$4,389.45 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$2,363.55 " N/A N/A $939.00 N/A N/A "$2,025.90 " N/A N/A "$1,441.00 " N/A N/A "$4,389.45 " N/A N/A "$2,025.90 " N/A N/A "$2,025.90 " N/A N/A "$2,025.90 " N/A N/A "$2,025.90 " N/A N/A "$2,025.90 " N/A N/A "$2,025.90 " N/A "$6,753.00 " "$6,753.00 " N/A 49028298 Surgery Bunionectomy Akin 28298 490 "$5,094.00 " $- "$1,058.82 " $- $- "$4,075.20 " $- N/A "$1,324.44 " N/A N/A "$1,150.00 " N/A N/A "$3,056.40 " N/A N/A "$2,547.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,986.66 " N/A N/A "$2,317.77 " N/A N/A "$4,075.20 " N/A N/A N/A N/A N/A "$3,311.10 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$1,782.90 " N/A N/A "$1,071.00 " N/A N/A "$1,528.20 " N/A N/A "$1,441.00 " N/A N/A "$3,311.10 " N/A N/A "$1,528.20 " N/A N/A "$1,528.20 " N/A N/A "$1,528.20 " N/A N/A "$1,528.20 " N/A N/A "$1,528.20 " N/A N/A "$1,528.20 " N/A "$5,094.00 " "$5,094.00 " N/A 49028304 Surgery Osteotomy Tarsal Bones 28304 490 "$8,718.00 " $- $939.00 $- $- "$6,974.40 " $- N/A "$2,266.68 " N/A N/A $950.00 N/A N/A "$5,230.80 " N/A N/A "$4,359.00 " N/A N/A "$1,965.14 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$3,400.02 " N/A N/A "$3,966.69 " N/A N/A "$6,974.40 " N/A N/A N/A N/A N/A "$5,666.70 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$3,051.30 " N/A N/A $939.00 N/A N/A "$2,615.40 " N/A N/A "$2,818.00 " N/A N/A "$5,666.70 " N/A N/A "$2,615.40 " N/A N/A "$2,615.40 " N/A N/A "$2,615.40 " N/A N/A "$2,615.40 " N/A N/A "$2,615.40 " N/A N/A "$2,615.40 " N/A "$8,718.00 " "$8,718.00 " N/A 49028306 Surgery Osteotomy Metatarsal 28306 490 "$3,426.00 " $- $890.76 $- $- "$2,803.36 " $- N/A $890.76 N/A N/A "$1,350.00 " N/A N/A "$2,055.60 " N/A N/A "$1,713.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,336.14 " N/A N/A "$1,558.83 " N/A N/A "$2,740.80 " N/A N/A N/A N/A N/A "$2,226.90 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$1,199.10 " N/A N/A "$1,321.00 " N/A N/A "$1,027.80 " N/A N/A "$1,273.00 " N/A N/A "$2,226.90 " N/A N/A "$1,027.80 " N/A N/A "$1,027.80 " N/A N/A "$1,027.80 " N/A N/A "$1,027.80 " N/A N/A "$1,027.80 " N/A N/A "$1,027.80 " N/A "$3,426.00 " "$3,426.00 " N/A 49028312 Surgery Osteotomy Phalanges-Toe 28312 490 "$3,143.00 " $- $817.18 $- $- "$2,514.40 " $- N/A $817.18 N/A N/A "$1,150.00 " N/A N/A "$1,885.80 " N/A N/A "$1,571.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,225.77 " N/A N/A "$1,430.07 " N/A N/A "$2,514.40 " N/A N/A N/A N/A N/A "$2,042.95 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,100.05 " N/A N/A "$1,071.00 " N/A N/A $942.90 N/A N/A "$1,273.00 " N/A N/A "$2,042.95 " N/A N/A $942.90 N/A N/A $942.90 N/A N/A $942.90 N/A N/A $942.90 N/A N/A $942.90 N/A N/A $942.90 N/A "$3,143.00 " "$3,143.00 " N/A 49028315 Surgery Sesamoidectomy First Toe Separate Procedure 28315 490 "$5,620.00 " $- $643.20 $- $- "$4,496.00 " $- N/A "$1,461.20 " N/A N/A "$1,350.00 " N/A N/A "$3,372.00 " N/A N/A "$2,810.00 " N/A N/A $643.20 N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,191.80 " N/A N/A "$2,557.10 " N/A N/A "$4,496.00 " N/A N/A N/A N/A N/A "$3,653.00 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,967.00 " N/A N/A "$1,321.00 " N/A N/A "$1,686.00 " N/A N/A "$1,273.00 " N/A N/A "$3,653.00 " N/A N/A "$1,686.00 " N/A N/A "$1,686.00 " N/A N/A "$1,686.00 " N/A N/A "$1,686.00 " N/A N/A "$1,686.00 " N/A N/A "$1,686.00 " N/A "$5,620.00 " "$5,620.00 " N/A 49028485 Surgery OPEN TX METATARSAL FX INTERNAL FIXATION 28485 490 "$10,010.00 " $- "$1,058.82 " $- $- "$8,008.00 " $- N/A "$2,602.60 " N/A N/A "$1,350.00 " N/A N/A "$6,006.00 " N/A N/A "$5,005.00 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,903.90 " N/A N/A "$4,554.55 " N/A N/A "$8,008.00 " N/A N/A N/A N/A N/A "$6,506.50 " N/A N/A "$3,731.89 " N/A N/A "$1,058.82 " N/A N/A "$3,731.89 " N/A N/A "$3,503.50 " N/A N/A "$1,321.00 " N/A N/A "$3,003.00 " N/A N/A "$2,818.00 " N/A N/A "$6,506.50 " N/A N/A "$3,003.00 " N/A N/A "$3,003.00 " N/A N/A "$3,003.00 " N/A N/A "$3,003.00 " N/A N/A "$3,003.00 " N/A N/A "$3,003.00 " N/A "$10,010.00 " "$10,010.00 " N/A 49028585 Surgery OPEN TX TALOTARSAL-FOOT JNT DISLOCATION 28585 490 "$4,450.00 " $- "$1,058.82 " $- $- "$4,134.53 " $- N/A "$1,157.00 " N/A N/A "$1,150.00 " N/A N/A "$2,670.00 " N/A N/A "$2,225.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,735.50 " N/A N/A "$2,024.75 " N/A N/A "$3,560.00 " N/A N/A N/A N/A N/A "$2,892.50 " N/A N/A "$4,134.53 " N/A N/A "$1,058.82 " N/A N/A "$4,134.53 " N/A N/A "$1,557.50 " N/A N/A "$1,071.00 " N/A N/A "$1,335.00 " N/A N/A "$1,273.00 " N/A N/A "$2,892.50 " N/A N/A "$1,335.00 " N/A N/A "$1,335.00 " N/A N/A "$1,335.00 " N/A N/A "$1,335.00 " N/A N/A "$1,335.00 " N/A N/A "$1,335.00 " N/A "$4,450.00 " "$4,450.00 " N/A 49028705 Surgery Arthrodesis Pantalar 28705 490 "$9,281.00 " $- "$1,321.00 " $- $- "$11,578.82 " $- N/A "$2,413.06 " N/A N/A "$1,350.00 " N/A N/A "$5,568.60 " N/A N/A "$4,640.50 " N/A N/A "$6,233.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,619.59 " N/A N/A "$4,222.86 " N/A N/A "$7,424.80 " N/A N/A N/A N/A N/A "$6,032.65 " N/A N/A "$11,578.82 " N/A N/A "$6,233.72 " N/A N/A "$11,578.82 " N/A N/A "$3,248.35 " N/A N/A "$1,321.00 " N/A N/A "$2,784.30 " N/A N/A "$2,818.00 " N/A N/A "$6,032.65 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A "$9,281.00 " "$9,281.00 " N/A 49028705 Surgery Arthrodesis Subtalar 28705 490 "$9,281.00 " $- "$1,321.00 " $- $- "$11,578.82 " $- N/A "$2,413.06 " N/A N/A "$1,350.00 " N/A N/A "$5,568.60 " N/A N/A "$4,640.50 " N/A N/A "$6,233.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,619.59 " N/A N/A "$4,222.86 " N/A N/A "$7,424.80 " N/A N/A N/A N/A N/A "$6,032.65 " N/A N/A "$11,578.82 " N/A N/A "$6,233.72 " N/A N/A "$11,578.82 " N/A N/A "$3,248.35 " N/A N/A "$1,321.00 " N/A N/A "$2,784.30 " N/A N/A "$2,818.00 " N/A N/A "$6,032.65 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A N/A "$2,784.30 " N/A "$9,281.00 " "$9,281.00 " N/A 49028715 Surgery Arthrodesis Triple 28715 490 "$19,312.00 " $- "$1,321.00 " $- $- "$15,449.60 " $- N/A "$5,021.12 " N/A N/A "$1,350.00 " N/A N/A "$11,587.20 " N/A N/A "$9,656.00 " N/A N/A "$6,233.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$7,531.68 " N/A N/A "$8,786.96 " N/A N/A "$15,449.60 " N/A N/A N/A N/A N/A "$12,552.80 " N/A N/A "$8,838.59 " N/A N/A "$6,233.72 " N/A N/A "$8,838.59 " N/A N/A "$6,759.20 " N/A N/A "$1,321.00 " N/A N/A "$5,793.60 " N/A N/A "$2,818.00 " N/A N/A "$12,552.80 " N/A N/A "$5,793.60 " N/A N/A "$5,793.60 " N/A N/A "$5,793.60 " N/A N/A "$5,793.60 " N/A N/A "$5,793.60 " N/A N/A "$5,793.60 " N/A "$19,312.00 " "$19,312.00 " N/A 49028730 Surgery Arthrodesis Tarsal Joint 28730 490 "$9,595.00 " $- "$1,321.00 " $- $- "$8,734.86 " $- N/A "$2,494.70 " N/A N/A "$1,350.00 " N/A N/A "$5,757.00 " N/A N/A "$4,797.50 " N/A N/A "$2,792.29 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,742.05 " N/A N/A "$4,365.73 " N/A N/A "$7,676.00 " N/A N/A N/A N/A N/A "$6,236.75 " N/A N/A "$8,734.86 " N/A N/A "$2,792.29 " N/A N/A "$8,734.86 " N/A N/A "$3,358.25 " N/A N/A "$1,321.00 " N/A N/A "$2,878.50 " N/A N/A "$2,818.00 " N/A N/A "$6,236.75 " N/A N/A "$2,878.50 " N/A N/A "$2,878.50 " N/A N/A "$2,878.50 " N/A N/A "$2,878.50 " N/A N/A "$2,878.50 " N/A N/A "$2,878.50 " N/A "$9,595.00 " "$9,595.00 " N/A 49028737 Surgery Arthrodesis Tendon Lengthening 28737 490 "$8,542.00 " $- "$1,505.00 " $- $- "$8,386.65 " $- N/A "$2,220.92 " N/A N/A "$1,550.00 " N/A N/A "$5,125.20 " N/A N/A "$4,271.00 " N/A N/A "$2,792.29 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$3,331.38 " N/A N/A "$3,886.61 " N/A N/A "$6,833.60 " N/A N/A N/A N/A N/A "$5,552.30 " N/A N/A "$8,386.65 " N/A N/A "$2,792.29 " N/A N/A "$8,386.65 " N/A N/A "$2,989.70 " N/A N/A "$1,505.00 " N/A N/A "$2,562.60 " N/A N/A "$2,818.00 " N/A N/A "$5,552.30 " N/A N/A "$2,562.60 " N/A N/A "$2,562.60 " N/A N/A "$2,562.60 " N/A N/A "$2,562.60 " N/A N/A "$2,562.60 " N/A N/A "$2,562.60 " N/A "$8,542.00 " "$8,542.00 " N/A 49028740 Surgery Arthrodesis Midtarsal Foot 28740 490 "$7,699.00 " $- "$1,321.00 " $- $- "$6,159.20 " $- N/A "$2,001.74 " N/A N/A "$1,350.00 " N/A N/A "$4,619.40 " N/A N/A "$3,849.50 " N/A N/A "$2,792.29 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,002.61 " N/A N/A "$3,503.05 " N/A N/A "$6,159.20 " N/A N/A N/A N/A N/A "$5,004.35 " N/A N/A "$4,144.69 " N/A N/A "$2,792.29 " N/A N/A "$4,144.69 " N/A N/A "$2,694.65 " N/A N/A "$1,321.00 " N/A N/A "$2,309.70 " N/A N/A "$2,818.00 " N/A N/A "$5,004.35 " N/A N/A "$2,309.70 " N/A N/A "$2,309.70 " N/A N/A "$2,309.70 " N/A N/A "$2,309.70 " N/A N/A "$2,309.70 " N/A N/A "$2,309.70 " N/A "$7,699.00 " "$7,699.00 " N/A 49028750 Surgery Arthrodesis Metatarsal-Tarsal 28750 490 "$8,265.00 " $- "$1,321.00 " $- $- "$6,612.00 " $- N/A "$2,148.90 " N/A N/A "$1,350.00 " N/A N/A "$4,959.00 " N/A N/A "$4,132.50 " N/A N/A "$1,965.14 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,223.35 " N/A N/A "$3,760.58 " N/A N/A "$6,612.00 " N/A N/A N/A N/A N/A "$5,372.25 " N/A N/A "$4,068.66 " N/A N/A "$1,965.14 " N/A N/A "$4,068.66 " N/A N/A "$2,892.75 " N/A N/A "$1,321.00 " N/A N/A "$2,479.50 " N/A N/A "$2,818.00 " N/A N/A "$5,372.25 " N/A N/A "$2,479.50 " N/A N/A "$2,479.50 " N/A N/A "$2,479.50 " N/A N/A "$2,479.50 " N/A N/A "$2,479.50 " N/A N/A "$2,479.50 " N/A "$8,265.00 " "$8,265.00 " N/A 49028755 Surgery Arthrodesis Great Toe Interphalangeal Joint 28755 490 "$10,021.00 " $- "$1,058.82 " $- $- "$8,016.80 " $- N/A "$2,605.46 " N/A N/A "$1,350.00 " N/A N/A "$6,012.60 " N/A N/A "$5,010.50 " N/A N/A "$1,058.82 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,908.19 " N/A N/A "$4,559.56 " N/A N/A "$8,016.80 " N/A N/A N/A N/A N/A "$6,513.65 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$3,507.35 " N/A N/A "$1,321.00 " N/A N/A "$3,006.30 " N/A N/A "$1,273.00 " N/A N/A "$6,513.65 " N/A N/A "$3,006.30 " N/A N/A "$3,006.30 " N/A N/A "$3,006.30 " N/A N/A "$3,006.30 " N/A N/A "$3,006.30 " N/A N/A "$3,006.30 " N/A "$10,021.00 " "$10,021.00 " N/A 49028810 Surgery Amputation Toe 28810 490 "$3,413.00 " $- $643.20 $- $- "$2,730.40 " $- N/A $887.38 N/A N/A $950.00 N/A N/A "$2,047.80 " N/A N/A "$1,706.50 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,331.07 " N/A N/A "$1,552.92 " N/A N/A "$2,730.40 " N/A N/A N/A N/A N/A "$2,218.45 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,194.55 " N/A N/A $939.00 N/A N/A "$1,023.90 " N/A N/A "$1,273.00 " N/A N/A "$2,218.45 " N/A N/A "$1,023.90 " N/A N/A "$1,023.90 " N/A N/A "$1,023.90 " N/A N/A "$1,023.90 " N/A N/A "$1,023.90 " N/A N/A "$1,023.90 " N/A "$3,413.00 " "$3,413.00 " N/A 49028825 Surgery PARTIAL AMPUTATION TOE INTERPHALANGEAL JNT 28825 490 "$6,190.00 " $- $643.20 $- $- "$4,952.00 " $- N/A "$1,609.40 " N/A N/A $950.00 N/A N/A "$3,714.00 " N/A N/A "$3,095.00 " N/A N/A $643.20 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$2,414.10 " N/A N/A "$2,816.45 " N/A N/A "$4,952.00 " N/A N/A N/A N/A N/A "$4,023.50 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$2,166.50 " N/A N/A $939.00 N/A N/A "$1,857.00 " N/A N/A "$1,273.00 " N/A N/A "$4,023.50 " N/A N/A "$1,857.00 " N/A N/A "$1,857.00 " N/A N/A "$1,857.00 " N/A N/A "$1,857.00 " N/A N/A "$1,857.00 " N/A N/A "$1,857.00 " N/A "$6,190.00 " "$6,190.00 " N/A 49029805 Surgery Arthroscopy Shoulder 29805 490 "$4,041.00 " $- "$1,050.66 " $- $- "$3,232.80 " $- N/A "$1,050.66 " N/A N/A "$1,150.00 " N/A N/A "$2,424.60 " N/A N/A "$2,020.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,575.99 " N/A N/A "$1,838.66 " N/A N/A "$3,232.80 " N/A N/A N/A N/A N/A "$2,626.65 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,414.35 " N/A N/A "$1,071.00 " N/A N/A "$1,212.30 " N/A N/A "$1,441.00 " N/A N/A "$2,626.65 " N/A N/A "$1,212.30 " N/A N/A "$1,212.30 " N/A N/A "$1,212.30 " N/A N/A "$1,212.30 " N/A N/A "$1,212.30 " N/A N/A "$1,212.30 " N/A "$4,041.00 " "$4,041.00 " N/A 49029806 Surgery Shoulder Capsulorrhaphy 29806 490 "$7,896.00 " $- "$1,071.00 " $- $- "$6,316.80 " $- N/A "$2,052.96 " N/A N/A "$1,150.00 " N/A N/A "$4,737.60 " N/A N/A "$3,948.00 " N/A N/A "$1,965.14 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,079.44 " N/A N/A "$3,592.68 " N/A N/A "$6,316.80 " N/A N/A N/A N/A N/A "$5,132.40 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$2,763.60 " N/A N/A "$1,071.00 " N/A N/A "$2,368.80 " N/A N/A "$2,818.00 " N/A N/A "$5,132.40 " N/A N/A "$2,368.80 " N/A N/A "$2,368.80 " N/A N/A "$2,368.80 " N/A N/A "$2,368.80 " N/A N/A "$2,368.80 " N/A N/A "$2,368.80 " N/A "$7,896.00 " "$7,896.00 " N/A 49029820 Surgery Shoulder Synovectomy Partial 29820 490 "$10,046.00 " $- "$1,058.82 " $- $- "$8,036.80 " $- N/A "$2,611.96 " N/A N/A "$1,150.00 " N/A N/A "$6,027.60 " N/A N/A "$5,023.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$3,917.94 " N/A N/A "$4,570.93 " N/A N/A "$8,036.80 " N/A N/A N/A N/A N/A "$6,529.90 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$3,516.10 " N/A N/A "$1,071.00 " N/A N/A "$3,013.80 " N/A N/A "$2,818.00 " N/A N/A "$6,529.90 " N/A N/A "$3,013.80 " N/A N/A "$3,013.80 " N/A N/A "$3,013.80 " N/A N/A "$3,013.80 " N/A N/A "$3,013.80 " N/A N/A "$3,013.80 " N/A "$10,046.00 " "$10,046.00 " N/A 49029824 Surgery Distal Claviculectomy Including Distal Articular Surface - M 29824 490 "$6,039.00 " $- "$1,058.82 " $- $- "$4,831.20 " $- N/A "$1,570.14 " N/A N/A "$1,550.00 " N/A N/A "$3,623.40 " N/A N/A "$3,019.50 " N/A N/A "$1,058.82 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,355.21 " N/A N/A "$2,747.75 " N/A N/A "$4,831.20 " N/A N/A N/A N/A N/A "$3,925.35 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$2,113.65 " N/A N/A "$1,505.00 " N/A N/A "$1,811.70 " N/A N/A "$2,818.00 " N/A N/A "$3,925.35 " N/A N/A "$1,811.70 " N/A N/A "$1,811.70 " N/A N/A "$1,811.70 " N/A N/A "$1,811.70 " N/A N/A "$1,811.70 " N/A N/A "$1,811.70 " N/A "$6,039.00 " "$6,039.00 " N/A 49029826 Surgery Shoulder Decompression Subacromial with Partial Acromioplast 29826 490 "$5,939.00 " $- $- $- $- "$4,751.20 " $- N/A "$1,544.14 " N/A N/A "$1,150.00 " N/A N/A "$3,563.40 " N/A N/A "$2,969.50 " N/A N/A N/A N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,316.21 " N/A N/A "$2,702.25 " N/A N/A "$4,751.20 " N/A N/A N/A N/A N/A "$3,860.35 " N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A "$2,078.65 " N/A N/A "$1,071.00 " N/A N/A "$1,781.70 " N/A N/A $474.00 N/A N/A "$3,860.35 " N/A N/A "$1,781.70 " N/A N/A "$1,781.70 " N/A N/A "$1,781.70 " N/A N/A "$1,781.70 " N/A N/A "$1,781.70 " N/A N/A "$1,781.70 " N/A "$5,939.00 " "$5,939.00 " N/A 49029827 Surgery Shoulder Rotator Cuff Repair 29827 490 "$4,332.00 " $- "$1,126.32 " $- $- "$3,465.60 " $- N/A "$1,126.32 " N/A N/A "$1,550.00 " N/A N/A "$2,599.20 " N/A N/A "$2,166.00 " N/A N/A "$1,965.14 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$1,689.48 " N/A N/A "$1,971.06 " N/A N/A "$3,465.60 " N/A N/A N/A N/A N/A "$2,815.80 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$1,516.20 " N/A N/A "$1,505.00 " N/A N/A "$1,299.60 " N/A N/A "$2,818.00 " N/A N/A "$2,815.80 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A "$4,332.00 " "$4,332.00 " N/A 49029830 Surgery Arthroscopy Elbow 29830 490 "$11,559.00 " $- $643.20 $- $- "$9,247.20 " $- N/A "$3,005.34 " N/A N/A "$1,150.00 " N/A N/A "$6,935.40 " N/A N/A "$5,779.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$4,508.01 " N/A N/A "$5,259.35 " N/A N/A "$9,247.20 " N/A N/A N/A N/A N/A "$7,513.35 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$4,045.65 " N/A N/A "$1,071.00 " N/A N/A "$3,467.70 " N/A N/A "$2,818.00 " N/A N/A "$7,513.35 " N/A N/A "$3,467.70 " N/A N/A "$3,467.70 " N/A N/A "$3,467.70 " N/A N/A "$3,467.70 " N/A N/A "$3,467.70 " N/A N/A "$3,467.70 " N/A "$11,559.00 " "$11,559.00 " N/A 49029870 Surgery Arthroscopy Knee 29870 490 "$5,727.00 " $- "$1,058.82 " $- $- "$4,581.60 " $- N/A "$1,489.02 " N/A N/A "$1,150.00 " N/A N/A "$3,436.20 " N/A N/A "$2,863.50 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,233.53 " N/A N/A "$2,605.79 " N/A N/A "$4,581.60 " N/A N/A N/A N/A N/A "$3,722.55 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$2,004.45 " N/A N/A "$1,071.00 " N/A N/A "$1,718.10 " N/A N/A "$1,441.00 " N/A N/A "$3,722.55 " N/A N/A "$1,718.10 " N/A N/A "$1,718.10 " N/A N/A "$1,718.10 " N/A N/A "$1,718.10 " N/A N/A "$1,718.10 " N/A N/A "$1,718.10 " N/A "$5,727.00 " "$5,727.00 " N/A 49030520 Surgery Septoplasty 30520 490 "$3,688.00 " $- $714.65 $- $- "$2,950.40 " $- N/A $958.88 N/A N/A "$1,350.00 " N/A N/A "$2,212.80 " N/A N/A "$1,844.00 " N/A N/A $714.65 N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,438.32 " N/A N/A "$1,678.04 " N/A N/A "$2,950.40 " N/A N/A N/A N/A N/A "$2,397.20 " N/A N/A "$1,055.06 " N/A N/A $714.65 N/A N/A "$1,055.06 " N/A N/A "$1,290.80 " N/A N/A "$1,321.00 " N/A N/A "$1,106.40 " N/A N/A "$1,273.00 " N/A N/A "$2,397.20 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A "$3,688.00 " "$3,688.00 " N/A 49030520 Surgery Septoplasty 30520 490 "$3,688.00 " $- $714.65 $- $- "$2,950.40 " $- N/A $958.88 N/A N/A "$1,350.00 " N/A N/A "$2,212.80 " N/A N/A "$1,844.00 " N/A N/A $714.65 N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$1,438.32 " N/A N/A "$1,678.04 " N/A N/A "$2,950.40 " N/A N/A N/A N/A N/A "$2,397.20 " N/A N/A "$1,055.06 " N/A N/A $714.65 N/A N/A "$1,055.06 " N/A N/A "$1,290.80 " N/A N/A "$1,321.00 " N/A N/A "$1,106.40 " N/A N/A "$1,273.00 " N/A N/A "$2,397.20 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A N/A "$1,106.40 " N/A "$3,688.00 " "$3,688.00 " N/A 49031233 Surgery Endoscopic Sinus 31233 490 "$1,031.00 " $- $190.95 $- $- "$1,177.00 " $- N/A $268.06 N/A N/A $950.00 N/A N/A $618.60 N/A N/A $515.50 N/A N/A N/A N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $402.09 N/A N/A $469.11 N/A N/A $824.80 N/A N/A N/A N/A N/A $670.15 N/A N/A $190.95 N/A N/A N/A N/A N/A $190.95 N/A N/A $360.85 N/A N/A $939.00 N/A N/A $309.30 N/A N/A $474.00 N/A N/A $670.15 N/A N/A $309.30 N/A N/A $309.30 N/A N/A $309.30 N/A N/A $309.30 N/A N/A $309.30 N/A N/A $309.30 N/A "$1,031.00 " "$1,031.00 " N/A 49031622 Surgery Bronchoscopy Flexible with Biopsy or Washings 31622 490 "$2,241.00 " $- $458.56 $- $- "$1,792.80 " $- N/A $582.66 N/A N/A $950.00 N/A N/A "$1,344.60 " N/A N/A "$1,120.50 " N/A N/A $458.56 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $873.99 N/A N/A "$1,019.66 " N/A N/A "$1,792.80 " N/A N/A N/A N/A N/A "$1,456.65 " N/A N/A $611.69 N/A N/A $458.56 N/A N/A $611.69 N/A N/A $784.35 N/A N/A $700.00 N/A N/A $672.30 N/A N/A "$1,061.00 " N/A N/A "$1,456.65 " N/A N/A $672.30 N/A N/A $672.30 N/A N/A $672.30 N/A N/A $672.30 N/A N/A $672.30 N/A N/A $672.30 N/A "$2,241.00 " "$2,241.00 " N/A 49031630 Surgery Bronchoscopy with Dilatation 31630 490 "$3,106.00 " $- $807.56 $- $- "$2,484.80 " $- N/A $807.56 N/A N/A $950.00 N/A N/A "$1,863.60 " N/A N/A "$1,553.00 " N/A N/A $880.40 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,211.34 " N/A N/A "$1,413.23 " N/A N/A "$2,484.80 " N/A N/A N/A N/A N/A "$2,018.90 " N/A N/A "$1,237.71 " N/A N/A $880.40 N/A N/A "$1,237.71 " N/A N/A "$1,087.10 " N/A N/A $939.00 N/A N/A $931.80 N/A N/A "$1,441.00 " N/A N/A "$2,018.90 " N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A N/A $931.80 N/A "$3,106.00 " "$3,106.00 " N/A 49038745 Surgery Radical Lymphadenectomy Total 38745 490 "$8,686.00 " $- "$1,321.00 " $- $- "$6,948.80 " $- N/A "$2,258.36 " N/A N/A "$1,350.00 " N/A N/A "$5,211.60 " N/A N/A "$4,343.00 " N/A N/A "$1,589.51 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,387.54 " N/A N/A "$3,952.13 " N/A N/A "$6,948.80 " N/A N/A N/A N/A N/A "$5,645.90 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$3,040.10 " N/A N/A "$1,321.00 " N/A N/A "$2,605.80 " N/A N/A "$2,818.00 " N/A N/A "$5,645.90 " N/A N/A "$2,605.80 " N/A N/A "$2,605.80 " N/A N/A "$2,605.80 " N/A N/A "$2,605.80 " N/A N/A "$2,605.80 " N/A N/A "$2,605.80 " N/A "$8,686.00 " "$8,686.00 " N/A 49042440 Surgery Excision Submandibular 42440 490 "$6,084.00 " $- "$1,071.00 " $- $- "$4,867.20 " $- N/A "$1,581.84 " N/A N/A "$1,150.00 " N/A N/A "$3,650.40 " N/A N/A "$3,042.00 " N/A N/A "$1,576.25 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,372.76 " N/A N/A "$2,768.22 " N/A N/A "$4,867.20 " N/A N/A N/A N/A N/A "$3,954.60 " N/A N/A "$2,246.55 " N/A N/A "$1,576.25 " N/A N/A "$2,246.55 " N/A N/A "$2,129.40 " N/A N/A "$1,071.00 " N/A N/A "$1,825.20 " N/A N/A "$1,872.00 " N/A N/A "$3,954.60 " N/A N/A "$1,825.20 " N/A N/A "$1,825.20 " N/A N/A "$1,825.20 " N/A N/A "$1,825.20 " N/A N/A "$1,825.20 " N/A N/A "$1,825.20 " N/A "$6,084.00 " "$6,084.00 " N/A 49042820 Surgery Tonsillectomy and Adenoidectomy 42820 490 "$4,697.00 " $- $714.65 $- $- "$3,757.60 " $- N/A "$1,221.22 " N/A N/A "$1,150.00 " N/A N/A "$2,818.20 " N/A N/A "$2,348.50 " N/A N/A $714.65 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,831.83 " N/A N/A "$2,137.14 " N/A N/A "$3,757.60 " N/A N/A N/A N/A N/A "$3,053.05 " N/A N/A "$2,246.55 " N/A N/A $714.65 N/A N/A "$2,246.55 " N/A N/A "$1,643.95 " N/A N/A "$1,071.00 " N/A N/A "$1,409.10 " N/A N/A "$1,273.00 " N/A N/A "$3,053.05 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A "$4,697.00 " "$4,697.00 " N/A 49042820 Surgery Tonsillectomy and Adenoidectomy 42820 490 "$4,697.00 " $- $714.65 $- $- "$3,757.60 " $- N/A "$1,221.22 " N/A N/A "$1,150.00 " N/A N/A "$2,818.20 " N/A N/A "$2,348.50 " N/A N/A $714.65 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,831.83 " N/A N/A "$2,137.14 " N/A N/A "$3,757.60 " N/A N/A N/A N/A N/A "$3,053.05 " N/A N/A "$2,246.55 " N/A N/A $714.65 N/A N/A "$2,246.55 " N/A N/A "$1,643.95 " N/A N/A "$1,071.00 " N/A N/A "$1,409.10 " N/A N/A "$1,273.00 " N/A N/A "$3,053.05 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A N/A "$1,409.10 " N/A "$4,697.00 " "$4,697.00 " N/A 49043235 Surgery Esophagogastroduodenoscopy 43235 490 "$1,935.00 " $- $329.44 $- $- "$1,548.00 " $- N/A $503.10 N/A N/A $750.00 N/A N/A "$1,161.00 " N/A N/A $967.50 N/A N/A $329.44 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $754.65 N/A N/A $880.43 N/A N/A "$1,548.00 " N/A N/A N/A N/A N/A "$1,257.75 " N/A N/A $397.12 N/A N/A $329.44 N/A N/A $397.12 N/A N/A $677.25 N/A N/A $700.00 N/A N/A $580.50 N/A N/A "$1,061.00 " N/A N/A "$1,257.75 " N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A "$1,935.00 " "$1,935.00 " N/A 49043235 Surgery Esophagogastroduodenoscopy 43235 490 "$1,935.00 " $- $329.44 $- $- "$1,548.00 " $- N/A $503.10 N/A N/A $750.00 N/A N/A "$1,161.00 " N/A N/A $967.50 N/A N/A $329.44 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $754.65 N/A N/A $880.43 N/A N/A "$1,548.00 " N/A N/A N/A N/A N/A "$1,257.75 " N/A N/A $397.12 N/A N/A $329.44 N/A N/A $397.12 N/A N/A $677.25 N/A N/A $700.00 N/A N/A $580.50 N/A N/A "$1,061.00 " N/A N/A "$1,257.75 " N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A N/A $580.50 N/A "$1,935.00 " "$1,935.00 " N/A 49043239 Surgery Esophagogastroduodenoscopy with Biopsy 43239 490 "$1,999.00 " $- $329.44 $- $- "$1,599.20 " $- N/A $519.74 N/A N/A $950.00 N/A N/A "$1,199.40 " N/A N/A $999.50 N/A N/A $329.44 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $779.61 N/A N/A $909.55 N/A N/A "$1,599.20 " N/A N/A N/A N/A N/A "$1,299.35 " N/A N/A $397.12 N/A N/A $329.44 N/A N/A $397.12 N/A N/A $699.65 N/A N/A $939.00 N/A N/A $599.70 N/A N/A "$1,061.00 " N/A N/A "$1,299.35 " N/A N/A $599.70 N/A N/A $599.70 N/A N/A $599.70 N/A N/A $599.70 N/A N/A $599.70 N/A N/A $599.70 N/A "$1,999.00 " "$1,999.00 " N/A 49043245 Surgery Esophagogastroduodenoscopy with Dilation 43245 490 "$2,059.00 " $- $480.88 $- $- "$1,647.20 " $- N/A $535.34 N/A N/A $950.00 N/A N/A "$1,235.40 " N/A N/A "$1,029.50 " N/A N/A $480.88 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $803.01 N/A N/A $936.85 N/A N/A "$1,647.20 " N/A N/A N/A N/A N/A "$1,338.35 " N/A N/A $663.06 N/A N/A $480.88 N/A N/A $663.06 N/A N/A $720.65 N/A N/A $939.00 N/A N/A $617.70 N/A N/A "$1,061.00 " N/A N/A "$1,338.35 " N/A N/A $617.70 N/A N/A $617.70 N/A N/A $617.70 N/A N/A $617.70 N/A N/A $617.70 N/A N/A $617.70 N/A "$2,059.00 " "$2,059.00 " N/A 49043281 Surgery Hernia Repair Hiatal Laparoscopic 43281 490 "$8,833.00 " $- "$1,550.00 " $- $- "$7,066.40 " $- N/A "$2,296.58 " N/A N/A "$1,550.00 " N/A N/A "$5,299.80 " N/A N/A "$4,416.50 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$2,187.00 " N/A N/A "$3,444.87 " N/A N/A "$4,019.02 " N/A N/A "$7,066.40 " N/A N/A N/A N/A N/A "$5,741.45 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,091.55 " N/A N/A "$1,744.00 " N/A N/A "$2,649.90 " N/A N/A "$2,818.00 " N/A N/A "$5,741.45 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A "$8,833.00 " "$8,833.00 " N/A 49043281 Surgery Hernia Repair Hiatal Laparoscopic 43281 490 "$8,833.00 " $- "$1,550.00 " $- $- "$7,066.40 " $- N/A "$2,296.58 " N/A N/A "$1,550.00 " N/A N/A "$5,299.80 " N/A N/A "$4,416.50 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$2,187.00 " N/A N/A "$3,444.87 " N/A N/A "$4,019.02 " N/A N/A "$7,066.40 " N/A N/A N/A N/A N/A "$5,741.45 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,091.55 " N/A N/A "$1,744.00 " N/A N/A "$2,649.90 " N/A N/A "$2,818.00 " N/A N/A "$5,741.45 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A N/A "$2,649.90 " N/A "$8,833.00 " "$8,833.00 " N/A 49043644 Surgery Gastric Bypass Laparoscopic 43644 490 "$15,516.00 " $- $- $- $- "$12,412.80 " $- N/A "$4,034.16 " N/A N/A N/A N/A N/A "$9,309.60 " N/A N/A "$7,758.00 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A "$6,051.24 " N/A N/A "$7,059.78 " N/A N/A "$12,412.80 " N/A N/A N/A N/A N/A "$10,085.40 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$5,430.60 " N/A N/A N/A N/A N/A "$4,654.80 " N/A N/A "$2,818.00 " N/A N/A "$10,085.40 " N/A N/A "$4,654.80 " N/A N/A "$4,654.80 " N/A N/A "$4,654.80 " N/A N/A "$4,654.80 " N/A N/A "$4,654.80 " N/A N/A "$4,654.80 " N/A "$15,516.00 " "$15,516.00 " N/A 49043770 Surgery Gastric Band Insertion Laparoscopic 43770 490 "$9,412.00 " $- $- $- $- "$7,529.60 " $- N/A "$2,447.12 " N/A N/A "$1,150.00 " N/A N/A "$5,647.20 " N/A N/A "$4,706.00 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A "$3,670.68 " N/A N/A "$4,282.46 " N/A N/A "$7,529.60 " N/A N/A N/A N/A N/A "$6,117.80 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,294.20 " N/A N/A N/A N/A N/A "$2,823.60 " N/A N/A "$2,818.00 " N/A N/A "$6,117.80 " N/A N/A "$2,823.60 " N/A N/A "$2,823.60 " N/A N/A "$2,823.60 " N/A N/A "$2,823.60 " N/A N/A "$2,823.60 " N/A N/A "$2,823.60 " N/A "$9,412.00 " "$9,412.00 " N/A 49043774 Surgery Gastric Band Removal Laparoscopic 43774 490 "$10,967.00 " $- "$1,150.00 " $- $- "$8,773.60 " $- N/A "$2,851.42 " N/A N/A "$1,150.00 " N/A N/A "$6,580.20 " N/A N/A "$5,483.50 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$2,620.00 " N/A N/A "$4,277.13 " N/A N/A "$4,989.99 " N/A N/A "$8,773.60 " N/A N/A N/A N/A N/A "$7,128.55 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,838.45 " N/A N/A "$2,090.00 " N/A N/A "$3,290.10 " N/A N/A "$3,025.00 " N/A N/A "$7,128.55 " N/A N/A "$3,290.10 " N/A N/A "$3,290.10 " N/A N/A "$3,290.10 " N/A N/A "$3,290.10 " N/A N/A "$3,290.10 " N/A N/A "$3,290.10 " N/A "$10,967.00 " "$10,967.00 " N/A 49044340 Surgery Colostomy Takedown 44340 490 "$4,136.00 " $- $944.74 $- $- "$3,308.80 " $- N/A "$1,075.36 " N/A N/A "$1,150.00 " N/A N/A "$2,481.60 " N/A N/A "$2,068.00 " N/A N/A $944.74 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,613.04 " N/A N/A "$1,881.88 " N/A N/A "$3,308.80 " N/A N/A N/A N/A N/A "$2,688.40 " N/A N/A "$1,504.38 " N/A N/A $944.74 N/A N/A "$1,504.38 " N/A N/A "$1,447.60 " N/A N/A "$1,071.00 " N/A N/A "$1,240.80 " N/A N/A "$1,441.00 " N/A N/A "$2,688.40 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A "$4,136.00 " "$4,136.00 " N/A 49044340 Surgery Colostomy Takedown 44340 490 "$4,136.00 " $- $944.74 $- $- "$3,308.80 " $- N/A "$1,075.36 " N/A N/A "$1,150.00 " N/A N/A "$2,481.60 " N/A N/A "$2,068.00 " N/A N/A $944.74 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,613.04 " N/A N/A "$1,881.88 " N/A N/A "$3,308.80 " N/A N/A N/A N/A N/A "$2,688.40 " N/A N/A "$1,504.38 " N/A N/A $944.74 N/A N/A "$1,504.38 " N/A N/A "$1,447.60 " N/A N/A "$1,071.00 " N/A N/A "$1,240.80 " N/A N/A "$1,441.00 " N/A N/A "$2,688.40 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A N/A "$1,240.80 " N/A "$4,136.00 " "$4,136.00 " N/A 49044950 Surgery Appendectomy 44950 490 "$4,188.00 " $- "$1,071.00 " $- $- "$3,350.40 " $- N/A "$1,088.88 " N/A N/A "$1,350.00 " N/A N/A "$2,512.80 " N/A N/A "$2,094.00 " N/A N/A "$1,154.72 " N/A N/A "$1,625.00 " N/A N/A "$1,343.00 " N/A N/A "$1,633.32 " N/A N/A "$1,905.54 " N/A N/A "$3,350.40 " N/A N/A N/A N/A N/A "$2,722.20 " N/A N/A N/A N/A N/A "$1,154.72 " N/A N/A N/A N/A N/A "$1,465.80 " N/A N/A "$1,071.00 " N/A N/A "$1,256.40 " N/A N/A "$1,441.00 " N/A N/A "$2,722.20 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A "$4,188.00 " "$4,188.00 " N/A 49044950 Surgery Appendectomy 44950 490 "$4,188.00 " $- "$1,071.00 " $- $- "$3,350.40 " $- N/A "$1,088.88 " N/A N/A "$1,350.00 " N/A N/A "$2,512.80 " N/A N/A "$2,094.00 " N/A N/A "$1,154.72 " N/A N/A "$1,625.00 " N/A N/A "$1,343.00 " N/A N/A "$1,633.32 " N/A N/A "$1,905.54 " N/A N/A "$3,350.40 " N/A N/A N/A N/A N/A "$2,722.20 " N/A N/A N/A N/A N/A "$1,154.72 " N/A N/A N/A N/A N/A "$1,465.80 " N/A N/A "$1,071.00 " N/A N/A "$1,256.40 " N/A N/A "$1,441.00 " N/A N/A "$2,722.20 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A N/A "$1,256.40 " N/A "$4,188.00 " "$4,188.00 " N/A 49044970 Surgery Appendectomy Laparoscopic 44970 490 "$7,596.00 " $- "$1,150.00 " $- $- "$6,076.80 " $- N/A "$1,974.96 " N/A N/A "$1,150.00 " N/A N/A "$4,557.60 " N/A N/A "$3,798.00 " N/A N/A "$1,589.51 " N/A N/A "$1,427.00 " N/A N/A "$1,887.00 " N/A N/A "$2,962.44 " N/A N/A "$3,456.18 " N/A N/A "$6,076.80 " N/A N/A N/A N/A N/A "$4,937.40 " N/A N/A N/A N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$2,658.60 " N/A N/A "$1,505.00 " N/A N/A "$2,278.80 " N/A N/A "$2,818.00 " N/A N/A "$4,937.40 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A "$7,596.00 " "$7,596.00 " N/A 49044970 Surgery Appendectomy Laparoscopic 44970 490 "$7,596.00 " $- "$1,150.00 " $- $- "$6,076.80 " $- N/A "$1,974.96 " N/A N/A "$1,150.00 " N/A N/A "$4,557.60 " N/A N/A "$3,798.00 " N/A N/A "$1,589.51 " N/A N/A "$1,427.00 " N/A N/A "$1,887.00 " N/A N/A "$2,962.44 " N/A N/A "$3,456.18 " N/A N/A "$6,076.80 " N/A N/A N/A N/A N/A "$4,937.40 " N/A N/A N/A N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$2,658.60 " N/A N/A "$1,505.00 " N/A N/A "$2,278.80 " N/A N/A "$2,818.00 " N/A N/A "$4,937.40 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A N/A "$2,278.80 " N/A "$7,596.00 " "$7,596.00 " N/A 49045005 Surgery Incision and Drainage Rectal 45005 490 "$3,108.00 " $- $507.42 $- $- "$2,486.40 " $- N/A $808.08 N/A N/A $950.00 N/A N/A "$1,864.80 " N/A N/A "$1,554.00 " N/A N/A $734.36 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,212.12 " N/A N/A "$1,414.14 " N/A N/A "$2,486.40 " N/A N/A N/A N/A N/A "$2,020.20 " N/A N/A $507.42 N/A N/A $734.36 N/A N/A $507.42 N/A N/A "$1,087.80 " N/A N/A $939.00 N/A N/A $932.40 N/A N/A "$1,061.00 " N/A N/A "$2,020.20 " N/A N/A $932.40 N/A N/A $932.40 N/A N/A $932.40 N/A N/A $932.40 N/A N/A $932.40 N/A N/A $932.40 N/A "$3,108.00 " "$3,108.00 " N/A 49045330 Surgery Sigmoidoscopy Flexible 45330 490 "$1,584.00 " $- $145.44 $- $- "$1,267.20 " $- N/A $411.84 N/A N/A $750.00 N/A N/A $950.40 N/A N/A $792.00 N/A N/A N/A N/A N/A $756.00 N/A N/A $542.00 N/A N/A $617.76 N/A N/A $720.72 N/A N/A "$1,267.20 " N/A N/A N/A N/A N/A "$1,029.60 " N/A N/A $145.44 N/A N/A N/A N/A N/A $145.44 N/A N/A $554.40 N/A N/A $432.00 N/A N/A $475.20 N/A N/A $686.00 N/A N/A "$1,029.60 " N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A "$1,584.00 " "$1,584.00 " N/A 49045330 Surgery Sigmoidoscopy Flexible 45330 490 "$1,584.00 " $- $145.44 $- $- "$1,267.20 " $- N/A $411.84 N/A N/A $750.00 N/A N/A $950.40 N/A N/A $792.00 N/A N/A N/A N/A N/A $756.00 N/A N/A $542.00 N/A N/A $617.76 N/A N/A $720.72 N/A N/A "$1,267.20 " N/A N/A N/A N/A N/A "$1,029.60 " N/A N/A $145.44 N/A N/A N/A N/A N/A $145.44 N/A N/A $554.40 N/A N/A $432.00 N/A N/A $475.20 N/A N/A $686.00 N/A N/A "$1,029.60 " N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A N/A $475.20 N/A "$1,584.00 " "$1,584.00 " N/A 49045378 Surgery Colonoscopy 45378 G0121 490 "$2,307.00 " $- $332.71 $- $- "$1,845.60 " $- N/A $599.82 N/A N/A $950.00 N/A N/A "$1,384.20 " N/A N/A "$1,153.50 " N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $899.73 N/A N/A "$1,049.69 " N/A N/A "$1,845.60 " N/A N/A N/A N/A N/A "$1,499.55 " N/A N/A $385.98 N/A N/A $332.71 N/A N/A $385.98 N/A N/A $807.45 N/A N/A $939.00 N/A N/A $692.10 N/A N/A "$1,061.00 " N/A N/A "$1,499.55 " N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A "$2,307.00 " "$2,307.00 " N/A 49045378 Surgery Colonoscopy 45378 G0121 490 "$2,307.00 " $- $332.71 $- $- "$1,845.60 " $- N/A $599.82 N/A N/A $950.00 N/A N/A "$1,384.20 " N/A N/A "$1,153.50 " N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $899.73 N/A N/A "$1,049.69 " N/A N/A "$1,845.60 " N/A N/A N/A N/A N/A "$1,499.55 " N/A N/A $385.98 N/A N/A $332.71 N/A N/A $385.98 N/A N/A $807.45 N/A N/A $939.00 N/A N/A $692.10 N/A N/A "$1,061.00 " N/A N/A "$1,499.55 " N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A N/A $692.10 N/A "$2,307.00 " "$2,307.00 " N/A 49045380 Surgery Colonoscopy with Biopsy 45380 490 "$2,349.00 " $- $332.71 $- $- "$1,879.20 " $- N/A $610.74 N/A N/A $950.00 N/A N/A "$1,409.40 " N/A N/A "$1,174.50 " N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $916.11 N/A N/A "$1,068.80 " N/A N/A "$1,879.20 " N/A N/A N/A N/A N/A "$1,526.85 " N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A $822.15 N/A N/A $939.00 N/A N/A $704.70 N/A N/A "$1,061.00 " N/A N/A "$1,526.85 " N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A "$2,349.00 " "$2,349.00 " N/A 49045381 Surgery Colonoscopy w/ Submucosal Injection 45381 490 "$1,444.00 " $- $332.71 $- $- "$1,177.00 " $- N/A $375.44 N/A N/A $950.00 N/A N/A $866.40 N/A N/A $722.00 N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $563.16 N/A N/A $657.02 N/A N/A "$1,155.20 " N/A N/A N/A N/A N/A $938.60 N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A $505.40 N/A N/A $939.00 N/A N/A $433.20 N/A N/A "$1,061.00 " N/A N/A $938.60 N/A N/A $433.20 N/A N/A $433.20 N/A N/A $433.20 N/A N/A $433.20 N/A N/A $433.20 N/A N/A $433.20 N/A "$1,444.00 " "$1,444.00 " N/A 49045384 Surgery Colonoscopy with Lesion Removal 45384 490 "$2,078.00 " $- $332.71 $- $- "$1,662.40 " $- N/A $540.28 N/A N/A $950.00 N/A N/A "$1,246.80 " N/A N/A "$1,039.00 " N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $810.42 N/A N/A $945.49 N/A N/A "$1,662.40 " N/A N/A N/A N/A N/A "$1,350.70 " N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A $727.30 N/A N/A $939.00 N/A N/A $623.40 N/A N/A "$1,061.00 " N/A N/A "$1,350.70 " N/A N/A $623.40 N/A N/A $623.40 N/A N/A $623.40 N/A N/A $623.40 N/A N/A $623.40 N/A N/A $623.40 N/A "$2,078.00 " "$2,078.00 " N/A 49045385 Surgery Colonoscopy with Lesion Removal Snare Technique 45385 490 "$2,200.00 " $- $332.71 $- $- "$1,760.00 " $- N/A $572.00 N/A N/A $950.00 N/A N/A "$1,320.00 " N/A N/A "$1,100.00 " N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $858.00 N/A N/A "$1,001.00 " N/A N/A "$1,760.00 " N/A N/A N/A N/A N/A "$1,430.00 " N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A $770.00 N/A N/A $939.00 N/A N/A $660.00 N/A N/A "$1,061.00 " N/A N/A "$1,430.00 " N/A N/A $660.00 N/A N/A $660.00 N/A N/A $660.00 N/A N/A $660.00 N/A N/A $660.00 N/A N/A $660.00 N/A "$2,200.00 " "$2,200.00 " N/A 49045386 Surgery Colonoscopy with Dilation 45386 490 "$1,782.00 " $- $332.71 $- $- "$1,425.60 " $- N/A $463.32 N/A N/A $950.00 N/A N/A "$1,069.20 " N/A N/A $891.00 N/A N/A $332.71 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $694.98 N/A N/A $810.81 N/A N/A "$1,425.60 " N/A N/A N/A N/A N/A "$1,158.30 " N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A $623.70 N/A N/A $939.00 N/A N/A $534.60 N/A N/A "$1,061.00 " N/A N/A "$1,158.30 " N/A N/A $534.60 N/A N/A $534.60 N/A N/A $534.60 N/A N/A $534.60 N/A N/A $534.60 N/A N/A $534.60 N/A "$1,782.00 " "$1,782.00 " N/A 49045390 Surgery COLONOSCOPY FLEXIBLE W/ENDOSCOPIC MUCOSAL RESECTION 45390 490 "$2,349.00 " $- $332.71 $- $- "$1,879.20 " $- N/A $610.74 N/A N/A $950.00 N/A N/A "$1,409.40 " N/A N/A "$1,174.50 " N/A N/A $332.71 N/A N/A "$1,427.00 " N/A N/A "$1,177.00 " N/A N/A $916.11 N/A N/A "$1,068.80 " N/A N/A "$1,879.20 " N/A N/A N/A N/A N/A "$1,526.85 " N/A N/A "$1,100.20 " N/A N/A $332.71 N/A N/A "$1,100.20 " N/A N/A $822.15 N/A N/A $939.00 N/A N/A $704.70 N/A N/A "$1,061.00 " N/A N/A "$1,526.85 " N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A N/A $704.70 N/A "$2,349.00 " "$2,349.00 " N/A 49046255 Surgery Hemorrhoidectomy 46255 490 "$3,789.00 " $- $734.36 $- $- "$3,031.20 " $- N/A $985.14 N/A N/A "$1,150.00 " N/A N/A "$2,273.40 " N/A N/A "$1,894.50 " N/A N/A $734.36 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,477.71 " N/A N/A "$1,724.00 " N/A N/A "$3,031.20 " N/A N/A N/A N/A N/A "$2,462.85 " N/A N/A "$1,100.20 " N/A N/A $734.36 N/A N/A "$1,100.20 " N/A N/A "$1,326.15 " N/A N/A "$1,071.00 " N/A N/A "$1,136.70 " N/A N/A "$1,273.00 " N/A N/A "$2,462.85 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A "$3,789.00 " "$3,789.00 " N/A 49046255 Surgery Hemorrhoidectomy 46255 490 "$3,789.00 " $- $734.36 $- $- "$3,031.20 " $- N/A $985.14 N/A N/A "$1,150.00 " N/A N/A "$2,273.40 " N/A N/A "$1,894.50 " N/A N/A $734.36 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,477.71 " N/A N/A "$1,724.00 " N/A N/A "$3,031.20 " N/A N/A N/A N/A N/A "$2,462.85 " N/A N/A "$1,100.20 " N/A N/A $734.36 N/A N/A "$1,100.20 " N/A N/A "$1,326.15 " N/A N/A "$1,071.00 " N/A N/A "$1,136.70 " N/A N/A "$1,273.00 " N/A N/A "$2,462.85 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A N/A "$1,136.70 " N/A "$3,789.00 " "$3,789.00 " N/A 49046608 Surgery Foreign Body Removal Rectum 46608 490 "$1,358.00 " $- $332.71 $- $- "$1,086.40 " $- N/A $353.08 N/A N/A $750.00 N/A N/A $814.80 N/A N/A $679.00 N/A N/A $332.71 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $529.62 N/A N/A $617.89 N/A N/A "$1,086.40 " N/A N/A N/A N/A N/A $882.70 N/A N/A $385.98 N/A N/A $332.71 N/A N/A $385.98 N/A N/A $475.30 N/A N/A $700.00 N/A N/A $407.40 N/A N/A "$1,061.00 " N/A N/A $882.70 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A "$1,358.00 " "$1,358.00 " N/A 49046608 Surgery Foreign Body Removal Rectum 46608 490 "$1,358.00 " $- $332.71 $- $- "$1,086.40 " $- N/A $353.08 N/A N/A $750.00 N/A N/A $814.80 N/A N/A $679.00 N/A N/A $332.71 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $529.62 N/A N/A $617.89 N/A N/A "$1,086.40 " N/A N/A N/A N/A N/A $882.70 N/A N/A $385.98 N/A N/A $332.71 N/A N/A $385.98 N/A N/A $475.30 N/A N/A $700.00 N/A N/A $407.40 N/A N/A "$1,061.00 " N/A N/A $882.70 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A N/A $407.40 N/A "$1,358.00 " "$1,358.00 " N/A 49047000 Surgery Biopsy Liver 47000 490 "$2,148.00 " $- $416.34 $- $- "$1,718.40 " $- N/A $558.48 N/A N/A $750.00 N/A N/A "$1,288.80 " N/A N/A "$1,074.00 " N/A N/A $416.34 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $837.72 N/A N/A $977.34 N/A N/A "$1,718.40 " N/A N/A N/A N/A N/A "$1,396.20 " N/A N/A $576.39 N/A N/A $416.34 N/A N/A $576.39 N/A N/A $751.80 N/A N/A $700.00 N/A N/A $644.40 N/A N/A "$1,061.00 " N/A N/A "$1,396.20 " N/A N/A $644.40 N/A N/A $644.40 N/A N/A $644.40 N/A N/A $644.40 N/A N/A $644.40 N/A N/A $644.40 N/A "$2,148.00 " "$2,148.00 " N/A 49047350 Surgery "Hemorrahage Liver Procedure, Simple" 47350 490 "$3,037.00 " $- $- $- $- "$2,429.60 " $- N/A $789.62 N/A N/A N/A N/A N/A "$1,822.20 " N/A N/A "$1,518.50 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A "$1,184.43 " N/A N/A "$1,381.84 " N/A N/A "$2,429.60 " N/A N/A N/A N/A N/A "$1,974.05 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,062.95 " N/A N/A N/A N/A N/A $911.10 N/A N/A "$1,061.00 " N/A N/A "$1,974.05 " N/A N/A $911.10 N/A N/A $911.10 N/A N/A $911.10 N/A N/A $911.10 N/A N/A $911.10 N/A N/A $911.10 N/A "$3,037.00 " "$3,037.00 " N/A 49047562 Surgery Cholecystectomy Laparoscopic 47562 490 "$8,090.00 " $- "$1,505.00 " $- $- "$6,472.00 " $- N/A "$2,103.40 " N/A N/A "$1,550.00 " N/A N/A "$4,854.00 " N/A N/A "$4,045.00 " N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$1,887.00 " N/A N/A "$3,155.10 " N/A N/A "$3,680.95 " N/A N/A "$6,472.00 " N/A N/A N/A N/A N/A "$5,258.50 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,831.50 " N/A N/A "$1,505.00 " N/A N/A "$2,427.00 " N/A N/A "$2,818.00 " N/A N/A "$5,258.50 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A "$8,090.00 " "$8,090.00 " N/A 49047562 Surgery Cholecystectomy Laparoscopic 47562 490 "$8,090.00 " $- "$1,505.00 " $- $- "$6,472.00 " $- N/A "$2,103.40 " N/A N/A "$1,550.00 " N/A N/A "$4,854.00 " N/A N/A "$4,045.00 " N/A N/A "$1,589.51 " N/A N/A N/A N/A N/A "$1,887.00 " N/A N/A "$3,155.10 " N/A N/A "$3,680.95 " N/A N/A "$6,472.00 " N/A N/A N/A N/A N/A "$5,258.50 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,831.50 " N/A N/A "$1,505.00 " N/A N/A "$2,427.00 " N/A N/A "$2,818.00 " N/A N/A "$5,258.50 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A N/A "$2,427.00 " N/A "$8,090.00 " "$8,090.00 " N/A 49049000 Surgery Laparotomy Exploratory 49000 490 "$4,726.00 " $- "$1,228.76 " $- $- "$3,780.80 " $- N/A "$1,228.76 " N/A N/A "$1,350.00 " N/A N/A "$2,835.60 " N/A N/A "$2,363.00 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$1,656.00 " N/A N/A "$1,843.14 " N/A N/A "$2,150.33 " N/A N/A "$3,780.80 " N/A N/A N/A N/A N/A "$3,071.90 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,654.10 " N/A N/A "$1,321.00 " N/A N/A "$1,417.80 " N/A N/A "$1,441.00 " N/A N/A "$3,071.90 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A "$4,726.00 " "$4,726.00 " N/A 49049000 Surgery Laparotomy Exploratory 49000 490 "$4,726.00 " $- "$1,228.76 " $- $- "$3,780.80 " $- N/A "$1,228.76 " N/A N/A "$1,350.00 " N/A N/A "$2,835.60 " N/A N/A "$2,363.00 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$1,656.00 " N/A N/A "$1,843.14 " N/A N/A "$2,150.33 " N/A N/A "$3,780.80 " N/A N/A N/A N/A N/A "$3,071.90 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,654.10 " N/A N/A "$1,321.00 " N/A N/A "$1,417.80 " N/A N/A "$1,441.00 " N/A N/A "$3,071.90 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A N/A "$1,417.80 " N/A "$4,726.00 " "$4,726.00 " N/A 49049082 Surgery Incision and Drainage Abdomen 49082 490 $973.00 $- $252.98 $- $- "$1,061.00 " $- N/A $252.98 N/A N/A $950.00 N/A N/A $583.80 N/A N/A $486.50 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $379.47 N/A N/A $442.72 N/A N/A $778.40 N/A N/A N/A N/A N/A $632.45 N/A N/A $397.12 N/A N/A N/A N/A N/A $397.12 N/A N/A $340.55 N/A N/A $700.00 N/A N/A $291.90 N/A N/A "$1,061.00 " N/A N/A $632.45 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A $973.00 $973.00 N/A 49049082 Surgery Paracentesis 49082 490 $973.00 $- $252.98 $- $- "$1,061.00 " $- N/A $252.98 N/A N/A $950.00 N/A N/A $583.80 N/A N/A $486.50 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $379.47 N/A N/A $442.72 N/A N/A $778.40 N/A N/A N/A N/A N/A $632.45 N/A N/A $397.12 N/A N/A N/A N/A N/A $397.12 N/A N/A $340.55 N/A N/A $700.00 N/A N/A $291.90 N/A N/A "$1,061.00 " N/A N/A $632.45 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A $973.00 $973.00 N/A 49049082 Surgery Paracentesis 49082 490 $973.00 $- $252.98 $- $- "$1,061.00 " $- N/A $252.98 N/A N/A $950.00 N/A N/A $583.80 N/A N/A $486.50 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $379.47 N/A N/A $442.72 N/A N/A $778.40 N/A N/A N/A N/A N/A $632.45 N/A N/A $397.12 N/A N/A N/A N/A N/A $397.12 N/A N/A $340.55 N/A N/A $700.00 N/A N/A $291.90 N/A N/A "$1,061.00 " N/A N/A $632.45 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A N/A $291.90 N/A $973.00 $973.00 N/A 49049320 Surgery Laparoscopy Diagnostic 49320 490 "$7,466.00 " $- "$1,071.00 " $- $- "$5,972.80 " $- N/A "$1,941.16 " N/A N/A "$1,150.00 " N/A N/A "$4,479.60 " N/A N/A "$3,733.00 " N/A N/A "$1,589.51 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,911.74 " N/A N/A "$3,397.03 " N/A N/A "$5,972.80 " N/A N/A N/A N/A N/A "$4,852.90 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,613.10 " N/A N/A "$1,071.00 " N/A N/A "$2,239.80 " N/A N/A "$1,872.00 " N/A N/A "$4,852.90 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A "$7,466.00 " "$7,466.00 " N/A 49049320 Surgery Laparoscopy Diagnostic 49320 490 "$7,466.00 " $- "$1,071.00 " $- $- "$5,972.80 " $- N/A "$1,941.16 " N/A N/A "$1,150.00 " N/A N/A "$4,479.60 " N/A N/A "$3,733.00 " N/A N/A "$1,589.51 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,911.74 " N/A N/A "$3,397.03 " N/A N/A "$5,972.80 " N/A N/A N/A N/A N/A "$4,852.90 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,613.10 " N/A N/A "$1,071.00 " N/A N/A "$2,239.80 " N/A N/A "$1,872.00 " N/A N/A "$4,852.90 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A N/A "$2,239.80 " N/A "$7,466.00 " "$7,466.00 " N/A 49049419 Surgery Portacath Placement 49419 490 "$4,369.00 " $- $700.00 $- $- "$3,495.20 " $- N/A "$1,135.94 " N/A N/A $950.00 N/A N/A "$2,621.40 " N/A N/A "$2,184.50 " N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,703.91 " N/A N/A "$1,987.90 " N/A N/A "$3,495.20 " N/A N/A N/A N/A N/A "$2,839.85 " N/A N/A "$2,321.81 " N/A N/A N/A N/A N/A "$2,321.81 " N/A N/A "$1,529.15 " N/A N/A $700.00 N/A N/A "$1,310.70 " N/A N/A "$2,818.00 " N/A N/A "$2,839.85 " N/A N/A "$1,310.70 " N/A N/A "$1,310.70 " N/A N/A "$1,310.70 " N/A N/A "$1,310.70 " N/A N/A "$1,310.70 " N/A N/A "$1,310.70 " N/A "$4,369.00 " "$4,369.00 " N/A 49049505 Surgery Hernia Repair Inguinal 49505 490 "$6,719.00 " $- "$1,154.72 " $- $- "$5,375.20 " $- N/A "$1,746.94 " N/A N/A "$1,350.00 " N/A N/A "$4,031.40 " N/A N/A "$3,359.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,620.41 " N/A N/A "$3,057.15 " N/A N/A "$5,375.20 " N/A N/A N/A N/A N/A "$4,367.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,351.65 " N/A N/A "$1,321.00 " N/A N/A "$2,015.70 " N/A N/A "$1,441.00 " N/A N/A "$4,367.35 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A "$6,719.00 " "$6,719.00 " N/A 49049505 Surgery Hernia Repair Inguinal 49505 490 "$6,719.00 " $- "$1,154.72 " $- $- "$5,375.20 " $- N/A "$1,746.94 " N/A N/A "$1,350.00 " N/A N/A "$4,031.40 " N/A N/A "$3,359.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,620.41 " N/A N/A "$3,057.15 " N/A N/A "$5,375.20 " N/A N/A N/A N/A N/A "$4,367.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,351.65 " N/A N/A "$1,321.00 " N/A N/A "$2,015.70 " N/A N/A "$1,441.00 " N/A N/A "$4,367.35 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A "$6,719.00 " "$6,719.00 " N/A 49049525 Surgery "Repair Inguinal Hernia, Sliding" 49525 490 "$9,926.00 " $- "$1,154.72 " $- $- "$7,940.80 " $- N/A "$2,580.76 " N/A N/A "$1,350.00 " N/A N/A "$5,955.60 " N/A N/A "$4,963.00 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,871.14 " N/A N/A "$4,516.33 " N/A N/A "$7,940.80 " N/A N/A N/A N/A N/A "$6,451.90 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$3,474.10 " N/A N/A "$1,321.00 " N/A N/A "$2,977.80 " N/A N/A "$1,441.00 " N/A N/A "$6,451.90 " N/A N/A "$2,977.80 " N/A N/A "$2,977.80 " N/A N/A "$2,977.80 " N/A N/A "$2,977.80 " N/A N/A "$2,977.80 " N/A N/A "$2,977.80 " N/A "$9,926.00 " "$9,926.00 " N/A 49049560 Surgery Hernia Repair Ventral 49560 490 "$5,893.00 " $- "$1,154.72 " $- $- "$4,714.40 " $- N/A "$1,532.18 " N/A N/A "$1,350.00 " N/A N/A "$3,535.80 " N/A N/A "$2,946.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,298.27 " N/A N/A "$2,681.32 " N/A N/A "$4,714.40 " N/A N/A N/A N/A N/A "$3,830.45 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,062.55 " N/A N/A "$1,321.00 " N/A N/A "$1,767.90 " N/A N/A "$1,441.00 " N/A N/A "$3,830.45 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A "$5,893.00 " "$5,893.00 " N/A 49049560 Surgery Hernia Repair Ventral 49560 490 "$5,893.00 " $- "$1,154.72 " $- $- "$4,714.40 " $- N/A "$1,532.18 " N/A N/A "$1,350.00 " N/A N/A "$3,535.80 " N/A N/A "$2,946.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,298.27 " N/A N/A "$2,681.32 " N/A N/A "$4,714.40 " N/A N/A N/A N/A N/A "$3,830.45 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,062.55 " N/A N/A "$1,321.00 " N/A N/A "$1,767.90 " N/A N/A "$1,441.00 " N/A N/A "$3,830.45 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A N/A "$1,767.90 " N/A "$5,893.00 " "$5,893.00 " N/A 49049568 Surgery Hernia Repair with Mesh 49568 490 "$3,695.00 " $- $- $- $- "$2,956.00 " $- N/A $960.70 N/A N/A "$1,950.00 " N/A N/A "$2,217.00 " N/A N/A "$1,847.50 " N/A N/A N/A N/A N/A Incidental N/A N/A "$2,620.00 " N/A N/A "$1,441.05 " N/A N/A "$1,681.23 " N/A N/A "$2,956.00 " N/A N/A N/A N/A N/A "$2,401.75 " N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A "$1,293.25 " N/A N/A "$2,090.00 " N/A N/A "$1,108.50 " N/A N/A $474.00 N/A N/A "$2,401.75 " N/A N/A "$1,108.50 " N/A N/A "$1,108.50 " N/A N/A "$1,108.50 " N/A N/A "$1,108.50 " N/A N/A "$1,108.50 " N/A N/A "$1,108.50 " N/A "$3,695.00 " "$3,695.00 " N/A 49049585 Surgery Hernia Repair Umbilical 49585 490 "$6,059.00 " $- "$1,154.72 " $- $- "$4,847.20 " $- N/A "$1,575.34 " N/A N/A "$1,350.00 " N/A N/A "$3,635.40 " N/A N/A "$3,029.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,363.01 " N/A N/A "$2,756.85 " N/A N/A "$4,847.20 " N/A N/A N/A N/A N/A "$3,938.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,120.65 " N/A N/A "$1,321.00 " N/A N/A "$1,817.70 " N/A N/A "$1,441.00 " N/A N/A "$3,938.35 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A "$6,059.00 " "$6,059.00 " N/A 49049585 Surgery Hernia Repair Umbilical 49585 490 "$6,059.00 " $- "$1,154.72 " $- $- "$4,847.20 " $- N/A "$1,575.34 " N/A N/A "$1,350.00 " N/A N/A "$3,635.40 " N/A N/A "$3,029.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,363.01 " N/A N/A "$2,756.85 " N/A N/A "$4,847.20 " N/A N/A N/A N/A N/A "$3,938.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,120.65 " N/A N/A "$1,321.00 " N/A N/A "$1,817.70 " N/A N/A "$1,441.00 " N/A N/A "$3,938.35 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A N/A "$1,817.70 " N/A "$6,059.00 " "$6,059.00 " N/A 49049650 Surgery Hernia Repair Inguinal Laparoscopic 49650 490 "$9,743.00 " $- "$1,321.00 " $- $- "$7,794.40 " $- N/A "$2,533.18 " N/A N/A "$1,350.00 " N/A N/A "$5,845.80 " N/A N/A "$4,871.50 " N/A N/A "$1,589.51 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,799.77 " N/A N/A "$4,433.07 " N/A N/A "$7,794.40 " N/A N/A N/A N/A N/A "$6,332.95 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$3,410.05 " N/A N/A "$1,321.00 " N/A N/A "$2,922.90 " N/A N/A "$2,818.00 " N/A N/A "$6,332.95 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A "$9,743.00 " "$9,743.00 " N/A 49049650 Surgery Hernia Repair Incisional Laparoscopic 49650 490 "$9,743.00 " $- "$1,321.00 " $- $- "$7,794.40 " $- N/A "$2,533.18 " N/A N/A "$1,350.00 " N/A N/A "$5,845.80 " N/A N/A "$4,871.50 " N/A N/A "$1,589.51 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$3,799.77 " N/A N/A "$4,433.07 " N/A N/A "$7,794.40 " N/A N/A N/A N/A N/A "$6,332.95 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$3,410.05 " N/A N/A "$1,321.00 " N/A N/A "$2,922.90 " N/A N/A "$2,818.00 " N/A N/A "$6,332.95 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A N/A "$2,922.90 " N/A "$9,743.00 " "$9,743.00 " N/A 49049651 Surgery LAPAROSCOPY INGUINAL HERNIA REPAIR RECURRENT 49651 490 "$13,437.00 " $- "$1,589.51 " $- $- "$10,749.60 " $- N/A "$3,493.62 " N/A N/A "$1,950.00 " N/A N/A "$8,062.20 " N/A N/A "$6,718.50 " N/A N/A "$1,589.51 " N/A N/A "$2,257.00 " N/A N/A "$2,620.00 " N/A N/A "$5,240.43 " N/A N/A "$6,113.84 " N/A N/A "$10,749.60 " N/A N/A N/A N/A N/A "$8,734.05 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$4,702.95 " N/A N/A "$2,090.00 " N/A N/A "$4,031.10 " N/A N/A "$2,818.00 " N/A N/A "$8,734.05 " N/A N/A "$4,031.10 " N/A N/A "$4,031.10 " N/A N/A "$4,031.10 " N/A N/A "$4,031.10 " N/A N/A "$4,031.10 " N/A N/A "$4,031.10 " N/A "$13,437.00 " "$13,437.00 " N/A 49049652 Surgery LAPAROSCOPY SURG REP VENTRAL/UMBILICAL/SPIGELIAN OR EPIGASTR 49652 490 "$14,932.00 " $- "$1,321.00 " $- $- "$11,945.60 " $- N/A "$3,882.32 " N/A N/A "$1,350.00 " N/A N/A "$8,959.20 " N/A N/A "$7,466.00 " N/A N/A "$1,589.51 " N/A N/A "$2,266.00 " N/A N/A "$1,656.00 " N/A N/A "$5,823.48 " N/A N/A "$6,794.06 " N/A N/A "$11,945.60 " N/A N/A N/A N/A N/A "$9,705.80 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$5,226.20 " N/A N/A "$1,321.00 " N/A N/A "$4,479.60 " N/A N/A "$2,818.00 " N/A N/A "$9,705.80 " N/A N/A "$4,479.60 " N/A N/A "$4,479.60 " N/A N/A "$4,479.60 " N/A N/A "$4,479.60 " N/A N/A "$4,479.60 " N/A N/A "$4,479.60 " N/A "$14,932.00 " "$14,932.00 " N/A 49049653 Surgery LAPAROSCOPY SURG REP VENTRAL/UMBILICAL/SPIGELIAN OR EPIGASTR 49653 490 "$16,430.00 " $- "$1,350.00 " $- $- "$13,144.00 " $- N/A "$4,271.80 " N/A N/A "$1,350.00 " N/A N/A "$9,858.00 " N/A N/A "$8,215.00 " N/A N/A "$1,589.51 " N/A N/A "$2,266.00 " N/A N/A "$2,620.00 " N/A N/A "$6,407.70 " N/A N/A "$7,475.65 " N/A N/A "$13,144.00 " N/A N/A N/A N/A N/A "$10,679.50 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$5,750.50 " N/A N/A "$2,090.00 " N/A N/A "$4,929.00 " N/A N/A "$2,818.00 " N/A N/A "$10,679.50 " N/A N/A "$4,929.00 " N/A N/A "$4,929.00 " N/A N/A "$4,929.00 " N/A N/A "$4,929.00 " N/A N/A "$4,929.00 " N/A N/A "$4,929.00 " N/A "$16,430.00 " "$16,430.00 " N/A 49055250 Surgery Vasectomy 55250 490 "$5,126.00 " $- $665.81 $- $- "$4,100.80 " $- N/A "$1,332.76 " N/A N/A $950.00 N/A N/A "$3,075.60 " N/A N/A "$2,563.00 " N/A N/A $665.81 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,999.14 " N/A N/A "$2,332.33 " N/A N/A "$4,100.80 " N/A N/A N/A N/A N/A "$3,331.90 " N/A N/A $789.71 N/A N/A $665.81 N/A N/A $789.71 N/A N/A "$1,794.10 " N/A N/A $939.00 N/A N/A "$1,537.80 " N/A N/A "$1,273.00 " N/A N/A "$3,331.90 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A N/A "$1,537.80 " N/A "$5,126.00 " "$5,126.00 " N/A 49057288 Surgery Vaginal Vault Suspension 57288 490 "$7,651.00 " $- "$1,430.56 " $- $- "$6,120.80 " $- N/A "$1,989.26 " N/A N/A "$1,550.00 " N/A N/A "$4,590.60 " N/A N/A "$3,825.50 " N/A N/A "$1,430.56 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,983.89 " N/A N/A "$3,481.21 " N/A N/A "$6,120.80 " N/A N/A N/A N/A N/A "$4,973.15 " N/A N/A "$2,451.77 " N/A N/A "$1,430.56 " N/A N/A "$2,451.77 " N/A N/A "$2,677.85 " N/A N/A "$1,505.00 " N/A N/A "$2,295.30 " N/A N/A "$1,872.00 " N/A N/A "$4,973.15 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A "$7,651.00 " "$7,651.00 " N/A 49057288 Surgery Vaginal Vault Suspension 57288 490 "$7,651.00 " $- "$1,430.56 " $- $- "$6,120.80 " $- N/A "$1,989.26 " N/A N/A "$1,550.00 " N/A N/A "$4,590.60 " N/A N/A "$3,825.50 " N/A N/A "$1,430.56 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,983.89 " N/A N/A "$3,481.21 " N/A N/A "$6,120.80 " N/A N/A N/A N/A N/A "$4,973.15 " N/A N/A "$2,451.77 " N/A N/A "$1,430.56 " N/A N/A "$2,451.77 " N/A N/A "$2,677.85 " N/A N/A "$1,505.00 " N/A N/A "$2,295.30 " N/A N/A "$1,872.00 " N/A N/A "$4,973.15 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A N/A "$2,295.30 " N/A "$7,651.00 " "$7,651.00 " N/A 49057700 Surgery Cervial Cerclage 57700 490 "$4,913.00 " $- $700.00 $- $- "$3,930.40 " $- N/A "$1,277.38 " N/A N/A $750.00 N/A N/A "$2,947.80 " N/A N/A "$2,456.50 " N/A N/A $822.61 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,916.07 " N/A N/A "$2,235.42 " N/A N/A "$3,930.40 " N/A N/A N/A N/A N/A "$3,193.45 " N/A N/A "$1,235.31 " N/A N/A $822.61 N/A N/A "$1,235.31 " N/A N/A "$1,719.55 " N/A N/A $700.00 N/A N/A "$1,473.90 " N/A N/A "$1,273.00 " N/A N/A "$3,193.45 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A "$4,913.00 " "$4,913.00 " N/A 49057700 Surgery Cervical Cerclage 57700 490 "$4,913.00 " $- $700.00 $- $- "$3,930.40 " $- N/A "$1,277.38 " N/A N/A $750.00 N/A N/A "$2,947.80 " N/A N/A "$2,456.50 " N/A N/A $822.61 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,916.07 " N/A N/A "$2,235.42 " N/A N/A "$3,930.40 " N/A N/A N/A N/A N/A "$3,193.45 " N/A N/A "$1,235.31 " N/A N/A $822.61 N/A N/A "$1,235.31 " N/A N/A "$1,719.55 " N/A N/A $700.00 N/A N/A "$1,473.90 " N/A N/A "$1,273.00 " N/A N/A "$3,193.45 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A "$4,913.00 " "$4,913.00 " N/A 49057700 Surgery Cervical Cerclage 57700 490 "$4,913.00 " $- $700.00 $- $- "$3,930.40 " $- N/A "$1,277.38 " N/A N/A $750.00 N/A N/A "$2,947.80 " N/A N/A "$2,456.50 " N/A N/A $822.61 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,916.07 " N/A N/A "$2,235.42 " N/A N/A "$3,930.40 " N/A N/A N/A N/A N/A "$3,193.45 " N/A N/A "$1,235.31 " N/A N/A $822.61 N/A N/A "$1,235.31 " N/A N/A "$1,719.55 " N/A N/A $700.00 N/A N/A "$1,473.90 " N/A N/A "$1,273.00 " N/A N/A "$3,193.45 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A N/A "$1,473.90 " N/A "$4,913.00 " "$4,913.00 " N/A 49058150 Surgery Hysterectomy Abdominal Total 58150 490 "$13,076.00 " $- "$1,061.00 " $- $- "$10,460.80 " $- N/A "$3,399.76 " N/A N/A "$1,950.00 " N/A N/A "$7,845.60 " N/A N/A "$6,538.00 " N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$5,099.64 " N/A N/A "$5,949.58 " N/A N/A "$10,460.80 " N/A N/A N/A N/A N/A "$8,499.40 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$4,576.60 " N/A N/A "$1,505.00 " N/A N/A "$3,922.80 " N/A N/A "$1,061.00 " N/A N/A "$8,499.40 " N/A N/A "$3,922.80 " N/A N/A "$3,922.80 " N/A N/A "$3,922.80 " N/A N/A "$3,922.80 " N/A N/A "$3,922.80 " N/A N/A "$3,922.80 " N/A "$13,076.00 " "$13,076.00 " N/A 49058353 Surgery Endometrial Ablation 58353 490 "$10,631.00 " $- "$1,430.56 " $- $- "$8,504.80 " $- N/A "$2,764.06 " N/A N/A "$1,950.00 " N/A N/A "$6,378.60 " N/A N/A "$5,315.50 " N/A N/A "$1,430.56 " N/A N/A "$2,257.00 " N/A N/A "$2,620.00 " N/A N/A "$4,146.09 " N/A N/A "$4,837.11 " N/A N/A "$8,504.80 " N/A N/A N/A N/A N/A "$6,910.15 " N/A N/A "$1,816.36 " N/A N/A "$1,430.56 " N/A N/A "$1,816.36 " N/A N/A "$3,720.85 " N/A N/A "$2,090.00 " N/A N/A "$3,189.30 " N/A N/A "$1,441.00 " N/A N/A "$6,910.15 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A "$10,631.00 " "$10,631.00 " N/A 49058353 Surgery Endometrial Ablation 58353 490 "$10,631.00 " $- "$1,430.56 " $- $- "$8,504.80 " $- N/A "$2,764.06 " N/A N/A "$1,950.00 " N/A N/A "$6,378.60 " N/A N/A "$5,315.50 " N/A N/A "$1,430.56 " N/A N/A "$2,257.00 " N/A N/A "$2,620.00 " N/A N/A "$4,146.09 " N/A N/A "$4,837.11 " N/A N/A "$8,504.80 " N/A N/A N/A N/A N/A "$6,910.15 " N/A N/A "$1,816.36 " N/A N/A "$1,430.56 " N/A N/A "$1,816.36 " N/A N/A "$3,720.85 " N/A N/A "$2,090.00 " N/A N/A "$3,189.30 " N/A N/A "$1,441.00 " N/A N/A "$6,910.15 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A N/A "$3,189.30 " N/A "$10,631.00 " "$10,631.00 " N/A 49058550 Surgery Hysterectomy Laparoscopic Assisted Vaginal 58550 490 "$13,289.00 " $- "$1,589.51 " $- $- "$10,631.20 " $- N/A "$3,455.14 " N/A N/A "$1,750.00 " N/A N/A "$7,973.40 " N/A N/A "$6,644.50 " N/A N/A "$1,589.51 " N/A N/A "$2,266.00 " N/A N/A "$2,630.00 " N/A N/A "$5,182.71 " N/A N/A "$6,046.50 " N/A N/A "$10,631.20 " N/A N/A N/A N/A N/A "$8,637.85 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$4,651.15 " N/A N/A "$2,098.00 " N/A N/A "$3,986.70 " N/A N/A "$2,818.00 " N/A N/A "$8,637.85 " N/A N/A "$3,986.70 " N/A N/A "$3,986.70 " N/A N/A "$3,986.70 " N/A N/A "$3,986.70 " N/A N/A "$3,986.70 " N/A N/A "$3,986.70 " N/A "$13,289.00 " "$13,289.00 " N/A 49058563 Surgery Endometrial Ablation with Novasure 58563 490 "$6,529.00 " $- "$1,430.56 " $- $- "$5,223.20 " $- N/A "$1,697.54 " N/A N/A "$1,550.00 " N/A N/A "$3,917.40 " N/A N/A "$3,264.50 " N/A N/A "$1,430.56 " N/A N/A "$2,266.00 " N/A N/A "$2,630.00 " N/A N/A "$2,546.31 " N/A N/A "$2,970.70 " N/A N/A "$5,223.20 " N/A N/A N/A N/A N/A "$4,243.85 " N/A N/A "$1,816.36 " N/A N/A "$1,430.56 " N/A N/A "$1,816.36 " N/A N/A "$2,285.15 " N/A N/A "$2,098.00 " N/A N/A "$1,958.70 " N/A N/A "$1,441.00 " N/A N/A "$4,243.85 " N/A N/A "$1,958.70 " N/A N/A "$1,958.70 " N/A N/A "$1,958.70 " N/A N/A "$1,958.70 " N/A N/A "$1,958.70 " N/A N/A "$1,958.70 " N/A "$6,529.00 " "$6,529.00 " N/A 49058660 Surgery Lysis of Adhesions 58660 490 "$7,044.00 " $- "$1,505.00 " $- $- "$5,635.20 " $- N/A "$1,831.44 " N/A N/A "$1,550.00 " N/A N/A "$4,226.40 " N/A N/A "$3,522.00 " N/A N/A "$1,589.51 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,747.16 " N/A N/A "$3,205.02 " N/A N/A "$5,635.20 " N/A N/A N/A N/A N/A "$4,578.60 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,465.40 " N/A N/A "$1,505.00 " N/A N/A "$2,113.20 " N/A N/A "$2,818.00 " N/A N/A "$4,578.60 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A "$7,044.00 " "$7,044.00 " N/A 49058660 Surgery Lysis of Adhesions 58660 490 "$7,044.00 " $- "$1,505.00 " $- $- "$5,635.20 " $- N/A "$1,831.44 " N/A N/A "$1,550.00 " N/A N/A "$4,226.40 " N/A N/A "$3,522.00 " N/A N/A "$1,589.51 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,747.16 " N/A N/A "$3,205.02 " N/A N/A "$5,635.20 " N/A N/A N/A N/A N/A "$4,578.60 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,465.40 " N/A N/A "$1,505.00 " N/A N/A "$2,113.20 " N/A N/A "$2,818.00 " N/A N/A "$4,578.60 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A N/A "$2,113.20 " N/A "$7,044.00 " "$7,044.00 " N/A 49058670 Surgery Tubal Ligation 58670 490 "$6,912.00 " $- "$1,071.00 " $- $- "$5,529.60 " $- N/A "$1,797.12 " N/A N/A "$1,150.00 " N/A N/A "$4,147.20 " N/A N/A "$3,456.00 " N/A N/A "$1,589.51 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,695.68 " N/A N/A "$3,144.96 " N/A N/A "$5,529.60 " N/A N/A N/A N/A N/A "$4,492.80 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$2,419.20 " N/A N/A "$1,071.00 " N/A N/A "$2,073.60 " N/A N/A "$2,818.00 " N/A N/A "$4,492.80 " N/A N/A "$2,073.60 " N/A N/A "$2,073.60 " N/A N/A "$2,073.60 " N/A N/A "$2,073.60 " N/A N/A "$2,073.60 " N/A N/A "$2,073.60 " N/A "$6,912.00 " "$6,912.00 " N/A 49064721 Surgery Carpal Tunnel Release 64721 490 "$3,388.00 " $- $615.49 $- $- "$2,710.40 " $- N/A $880.88 N/A N/A $950.00 N/A N/A "$2,032.80 " N/A N/A "$1,694.00 " N/A N/A $615.49 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,321.32 " N/A N/A "$1,541.54 " N/A N/A "$2,710.40 " N/A N/A N/A N/A N/A "$2,202.20 " N/A N/A $796.79 N/A N/A $615.49 N/A N/A $796.79 N/A N/A "$1,185.80 " N/A N/A $939.00 N/A N/A "$1,016.40 " N/A N/A "$1,273.00 " N/A N/A "$2,202.20 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A "$3,388.00 " "$3,388.00 " N/A 49064721 Surgery Carpal Tunnel Release 64721 490 "$3,388.00 " $- $615.49 $- $- "$2,710.40 " $- N/A $880.88 N/A N/A $950.00 N/A N/A "$2,032.80 " N/A N/A "$1,694.00 " N/A N/A $615.49 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,321.32 " N/A N/A "$1,541.54 " N/A N/A "$2,710.40 " N/A N/A N/A N/A N/A "$2,202.20 " N/A N/A $796.79 N/A N/A $615.49 N/A N/A $796.79 N/A N/A "$1,185.80 " N/A N/A $939.00 N/A N/A "$1,016.40 " N/A N/A "$1,273.00 " N/A N/A "$2,202.20 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A N/A "$1,016.40 " N/A "$3,388.00 " "$3,388.00 " N/A 49065235 Surgery Foreign Body Removal Eye 65235 490 "$3,125.00 " $- $771.57 $- $- "$2,500.00 " $- N/A $812.50 N/A N/A $950.00 N/A N/A "$1,875.00 " N/A N/A "$1,562.50 " N/A N/A $771.57 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,218.75 " N/A N/A "$1,421.88 " N/A N/A "$2,500.00 " N/A N/A N/A N/A N/A "$2,031.25 " N/A N/A "$1,012.72 " N/A N/A $771.57 N/A N/A "$1,012.72 " N/A N/A "$1,093.75 " N/A N/A $939.00 N/A N/A $937.50 N/A N/A "$1,273.00 " N/A N/A "$2,031.25 " N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A "$3,125.00 " "$3,125.00 " N/A 49065426 Surgery EXC OR TRANSPOSITION OF PTERYGIUM W/GRAFT 65426 490 "$6,536.00 " $- $619.29 $- $- "$5,228.80 " $- N/A "$1,699.36 " N/A N/A "$1,550.00 " N/A N/A "$3,921.60 " N/A N/A "$3,268.00 " N/A N/A $619.29 N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$2,549.04 " N/A N/A "$2,973.88 " N/A N/A "$5,228.80 " N/A N/A N/A N/A N/A "$4,248.40 " N/A N/A $836.94 N/A N/A $619.29 N/A N/A $836.94 N/A N/A "$2,287.60 " N/A N/A "$1,505.00 " N/A N/A "$1,960.80 " N/A N/A "$1,273.00 " N/A N/A "$4,248.40 " N/A N/A "$1,960.80 " N/A N/A "$1,960.80 " N/A N/A "$1,960.80 " N/A N/A "$1,960.80 " N/A N/A "$1,960.80 " N/A N/A "$1,960.80 " N/A "$6,536.00 " "$6,536.00 " N/A 49066821 Surgery DISCISSION OF SECONDARY MEMBRANOUS CATARACT; LASER SURGERY-Y 66821 490 "$2,126.00 " $- $194.64 $- $- "$1,700.80 " $- N/A $552.76 N/A N/A $950.00 N/A N/A "$1,275.60 " N/A N/A "$1,063.00 " N/A N/A $194.64 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A $829.14 N/A N/A $967.33 N/A N/A "$1,700.80 " N/A N/A N/A N/A N/A "$1,381.90 " N/A N/A $256.14 N/A N/A $194.64 N/A N/A $256.14 N/A N/A $744.10 N/A N/A $939.00 N/A N/A $637.80 N/A N/A $686.00 N/A N/A "$1,381.90 " N/A N/A $637.80 N/A N/A $637.80 N/A N/A $637.80 N/A N/A $637.80 N/A N/A $637.80 N/A N/A $637.80 N/A "$2,126.00 " "$2,126.00 " N/A 49066982 Surgery CATARACT SURGERY COMPLEX 66982 490 "$6,233.00 " $- $771.57 $- $- "$4,986.40 " $- N/A "$1,620.58 " N/A N/A "$2,150.00 " N/A N/A "$3,739.80 " N/A N/A "$3,116.50 " N/A N/A $771.57 N/A N/A "$2,217.00 " N/A N/A "$2,574.00 " N/A N/A "$2,430.87 " N/A N/A "$2,836.02 " N/A N/A "$4,986.40 " N/A N/A N/A N/A N/A "$4,051.45 " N/A N/A "$1,012.72 " N/A N/A $771.57 N/A N/A "$1,012.72 " N/A N/A "$2,181.55 " N/A N/A "$2,053.00 " N/A N/A "$1,869.90 " N/A N/A "$1,273.00 " N/A N/A "$4,051.45 " N/A N/A "$1,869.90 " N/A N/A "$1,869.90 " N/A N/A "$1,869.90 " N/A N/A "$1,869.90 " N/A N/A "$1,869.90 " N/A N/A "$1,869.90 " N/A "$6,233.00 " "$6,233.00 " N/A 49066984 Surgery Cataract Extraction with Intraocular Lens Implantation 66984 490 "$5,783.00 " $- $771.57 $- $- "$4,626.40 " $- N/A "$1,503.58 " N/A N/A "$2,150.00 " N/A N/A "$3,469.80 " N/A N/A "$2,891.50 " N/A N/A $771.57 N/A N/A "$2,217.00 " N/A N/A "$2,574.00 " N/A N/A "$2,255.37 " N/A N/A "$2,631.27 " N/A N/A "$4,626.40 " N/A N/A N/A N/A N/A "$3,758.95 " N/A N/A "$1,012.72 " N/A N/A $771.57 N/A N/A "$1,012.72 " N/A N/A "$2,024.05 " N/A N/A "$2,053.00 " N/A N/A "$1,734.90 " N/A N/A "$1,273.00 " N/A N/A "$3,758.95 " N/A N/A "$1,734.90 " N/A N/A "$1,734.90 " N/A N/A "$1,734.90 " N/A N/A "$1,734.90 " N/A N/A "$1,734.90 " N/A N/A "$1,734.90 " N/A "$5,783.00 " "$5,783.00 " N/A 49066985 Surgery INSERTION OF INTRAOCULAR LENS PROSTHESIS (SECONDARY IMPLANT) 66985 490 "$5,457.00 " $- $771.57 $- $- "$4,365.60 " $- N/A "$1,418.82 " N/A N/A "$1,750.00 " N/A N/A "$3,274.20 " N/A N/A "$2,728.50 " N/A N/A $771.57 N/A N/A "$1,884.00 " N/A N/A "$2,187.00 " N/A N/A "$2,128.23 " N/A N/A "$2,482.94 " N/A N/A "$4,365.60 " N/A N/A N/A N/A N/A "$3,547.05 " N/A N/A "$1,012.72 " N/A N/A $771.57 N/A N/A "$1,012.72 " N/A N/A "$1,909.95 " N/A N/A "$1,744.00 " N/A N/A "$1,637.10 " N/A N/A "$1,273.00 " N/A N/A "$3,547.05 " N/A N/A "$1,637.10 " N/A N/A "$1,637.10 " N/A N/A "$1,637.10 " N/A N/A "$1,637.10 " N/A N/A "$1,637.10 " N/A N/A "$1,637.10 " N/A "$5,457.00 " "$5,457.00 " N/A 49069200 Surgery Foreign Body Removal Ear w/o Anesthesia 69200 490 $308.00 $- $- $- $- "$1,625.00 " $- N/A $80.08 N/A N/A N/A N/A N/A $184.80 N/A N/A $154.00 N/A N/A N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A $120.12 N/A N/A $140.14 N/A N/A $246.40 N/A N/A N/A N/A N/A $200.20 N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $107.80 N/A N/A N/A N/A N/A $92.40 N/A N/A $474.00 N/A N/A $200.20 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A N/A $92.40 N/A $308.00 $308.00 N/A 49069205 Surgery Foreign Body Removal Ear 69205 490 "$3,930.00 " $- $416.34 $- $- "$3,144.00 " $- N/A "$1,021.80 " N/A N/A $750.00 N/A N/A "$2,358.00 " N/A N/A "$1,965.00 " N/A N/A $416.34 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,532.70 " N/A N/A "$1,788.15 " N/A N/A "$3,144.00 " N/A N/A N/A N/A N/A "$2,554.50 " N/A N/A $576.39 N/A N/A $416.34 N/A N/A $576.39 N/A N/A "$1,375.50 " N/A N/A $700.00 N/A N/A "$1,179.00 " N/A N/A "$1,061.00 " N/A N/A "$2,554.50 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A "$3,930.00 " "$3,930.00 " N/A 49069205 Surgery Foreign Body Removal Ear 69205 490 "$3,930.00 " $- $416.34 $- $- "$3,144.00 " $- N/A "$1,021.80 " N/A N/A $750.00 N/A N/A "$2,358.00 " N/A N/A "$1,965.00 " N/A N/A $416.34 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,532.70 " N/A N/A "$1,788.15 " N/A N/A "$3,144.00 " N/A N/A N/A N/A N/A "$2,554.50 " N/A N/A $576.39 N/A N/A $416.34 N/A N/A $576.39 N/A N/A "$1,375.50 " N/A N/A $700.00 N/A N/A "$1,179.00 " N/A N/A "$1,061.00 " N/A N/A "$2,554.50 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A N/A "$1,179.00 " N/A "$3,930.00 " "$3,930.00 " N/A 49069420 Surgery Myringotomy with Ear Tube Insertion 69420 490 $628.00 $- $102.89 $- $- "$1,150.00 " $- N/A $163.28 N/A N/A "$1,150.00 " N/A N/A $376.80 N/A N/A $314.00 N/A N/A N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $244.92 N/A N/A $285.74 N/A N/A $502.40 N/A N/A N/A N/A N/A $408.20 N/A N/A $102.89 N/A N/A N/A N/A N/A $102.89 N/A N/A $219.80 N/A N/A $700.00 N/A N/A $188.40 N/A N/A $474.00 N/A N/A $408.20 N/A N/A $188.40 N/A N/A $188.40 N/A N/A $188.40 N/A N/A $188.40 N/A N/A $188.40 N/A N/A $188.40 N/A $628.00 $628.00 N/A 49028110 Surgery Charges OSTECTOMY/PARTIAL EXCISION FIFTH METATARSAL CHARGE 28110 490 "$2,829.00 " $- $643.20 $- $- "$2,263.20 " $- N/A $735.54 N/A N/A "$1,150.00 " N/A N/A "$1,697.40 " N/A N/A "$1,414.50 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,103.31 " N/A N/A "$1,287.20 " N/A N/A "$2,263.20 " N/A N/A N/A N/A N/A "$1,838.85 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A $990.15 N/A N/A "$1,071.00 " N/A N/A $848.70 N/A N/A "$1,273.00 " N/A N/A "$1,838.85 " N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A N/A $848.70 N/A "$2,829.00 " "$2,829.00 " N/A 49028122 Surgery Charges Partial Excision Tarsal/Metatarsal Bone Except Talus or Calc 28122 490 "$3,466.00 " $- $643.20 $- $- "$2,772.80 " $- N/A $901.16 N/A N/A "$1,150.00 " N/A N/A "$2,079.60 " N/A N/A "$1,733.00 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,351.74 " N/A N/A "$1,577.03 " N/A N/A "$2,772.80 " N/A N/A N/A N/A N/A "$2,252.90 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,213.10 " N/A N/A "$1,071.00 " N/A N/A "$1,039.80 " N/A N/A "$1,273.00 " N/A N/A "$2,252.90 " N/A N/A "$1,039.80 " N/A N/A "$1,039.80 " N/A N/A "$1,039.80 " N/A N/A "$1,039.80 " N/A N/A "$1,039.80 " N/A N/A "$1,039.80 " N/A "$3,466.00 " "$3,466.00 " N/A 49028291 Surgery Charges Correction Hallux Rigidus with Cheilectomy 1st Metatarsal Ph 28291 490 "$5,940.00 " $- "$1,150.00 " $- $- "$4,752.00 " $- N/A "$1,544.40 " N/A N/A "$1,150.00 " N/A N/A "$3,564.00 " N/A N/A "$2,970.00 " N/A N/A "$2,817.12 " N/A N/A "$1,625.00 " N/A N/A N/A N/A N/A "$2,316.60 " N/A N/A "$2,702.70 " N/A N/A "$4,752.00 " N/A N/A N/A N/A N/A "$3,861.00 " N/A N/A "$4,300.59 " N/A N/A "$2,817.12 " N/A N/A "$4,300.59 " N/A N/A "$2,079.00 " N/A N/A N/A N/A N/A "$1,782.00 " N/A N/A "$2,818.00 " N/A N/A "$3,861.00 " N/A N/A "$1,782.00 " N/A N/A "$1,782.00 " N/A N/A "$1,782.00 " N/A N/A "$1,782.00 " N/A N/A "$1,782.00 " N/A N/A "$1,782.00 " N/A "$5,940.00 " "$5,940.00 " N/A 49028296 Surgery Charges CORRECTION OF BUNION CHARGE 28296 490 "$4,780.00 " $- "$1,058.82 " $- $- "$3,824.00 " $- N/A "$1,242.80 " N/A N/A "$1,150.00 " N/A N/A "$2,868.00 " N/A N/A "$2,390.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,864.20 " N/A N/A "$2,174.90 " N/A N/A "$3,824.00 " N/A N/A N/A N/A N/A "$3,107.00 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,673.00 " N/A N/A "$1,071.00 " N/A N/A "$1,434.00 " N/A N/A "$1,441.00 " N/A N/A "$3,107.00 " N/A N/A "$1,434.00 " N/A N/A "$1,434.00 " N/A N/A "$1,434.00 " N/A N/A "$1,434.00 " N/A N/A "$1,434.00 " N/A N/A "$1,434.00 " N/A "$4,780.00 " "$4,780.00 " N/A 49044389 Surgery Charges "COLONSCOPY THROUGH STOMA, WITH BIOPSY CHARGE" 44389 409 "$3,456.00 " $- $332.71 $- $- "$2,764.80 " $- N/A $898.56 N/A N/A $750.00 N/A N/A "$2,073.60 " N/A N/A "$1,728.00 " N/A N/A $332.71 N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,347.84 " N/A N/A "$1,572.48 " N/A N/A "$2,764.80 " N/A N/A N/A N/A N/A "$2,246.40 " N/A N/A $507.42 N/A N/A $332.71 N/A N/A $507.42 N/A N/A "$1,209.60 " N/A N/A $700.00 N/A N/A "$1,036.80 " N/A N/A "$1,061.00 " N/A N/A "$2,246.40 " N/A N/A "$1,036.80 " N/A N/A "$1,036.80 " N/A N/A "$1,036.80 " N/A N/A "$1,036.80 " N/A N/A "$1,036.80 " N/A N/A "$1,036.80 " N/A "$3,456.00 " "$3,456.00 " N/A 49045331 Surgery Charges SIGMOIDOSCOPY AND BIOPSY CHARGE 45331 G0104 490 "$2,554.00 " $- $217.65 $- $- "$2,043.20 " $- N/A $664.04 N/A N/A $750.00 N/A N/A "$1,532.40 " N/A N/A "$1,277.00 " N/A N/A $217.65 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $996.06 N/A N/A "$1,162.07 " N/A N/A "$2,043.20 " N/A N/A N/A N/A N/A "$1,660.10 " N/A N/A $385.98 N/A N/A $217.65 N/A N/A $385.98 N/A N/A $893.90 N/A N/A $700.00 N/A N/A $766.20 N/A N/A $686.00 N/A N/A "$1,660.10 " N/A N/A $766.20 N/A N/A $766.20 N/A N/A $766.20 N/A N/A $766.20 N/A N/A $766.20 N/A N/A $766.20 N/A "$2,554.00 " "$2,554.00 " N/A 36023472 Surgery Arthroplasty Shoulder 23472 360 "$7,409.00 " $- #N/A $- $- #N/A $- N/A "$1,926.34 " N/A N/A #N/A N/A N/A "$4,445.40 " N/A N/A "$3,704.50 " N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A "$2,620.00 " N/A N/A "$2,889.51 " N/A N/A "$3,371.10 " N/A N/A "$5,927.20 " N/A N/A N/A N/A N/A "$4,815.85 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A "$2,593.15 " N/A N/A "$2,090.00 " N/A N/A "$2,222.70 " N/A N/A "$3,025.00 " N/A N/A "$4,815.85 " N/A N/A "$2,222.70 " N/A N/A "$2,222.70 " N/A N/A "$2,222.70 " N/A N/A "$2,222.70 " N/A N/A "$2,222.70 " N/A N/A "$2,222.70 " N/A "$7,409.00 " "$7,409.00 " N/A 36027130 Surgery Arthroplasty Hip Total 27130 360 "$12,544.00 " $- #N/A $- $- #N/A $- N/A "$3,261.44 " N/A N/A "$1,750.00 " N/A N/A "$7,526.40 " N/A N/A "$6,272.00 " N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A "$4,892.16 " N/A N/A "$5,707.52 " N/A N/A "$10,035.20 " N/A N/A N/A N/A N/A "$8,153.60 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A "$4,390.40 " N/A N/A #N/A N/A N/A "$3,763.20 " N/A N/A "$3,025.00 " N/A N/A "$8,153.60 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A "$12,544.00 " "$12,544.00 " N/A 36027130 Surgery Arthroplasty Hip Total Anterior Approach 27130 360 "$12,544.00 " $- #N/A $- $- #N/A $- N/A "$3,261.44 " N/A N/A "$1,750.00 " N/A N/A "$7,526.40 " N/A N/A "$6,272.00 " N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A $- N/A N/A "$4,892.16 " N/A N/A "$5,707.52 " N/A N/A "$10,035.20 " N/A N/A N/A N/A N/A "$8,153.60 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A "$4,390.40 " N/A N/A #N/A N/A N/A "$3,763.20 " N/A N/A "$3,025.00 " N/A N/A "$8,153.60 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A N/A "$3,763.20 " N/A "$12,544.00 " "$12,544.00 " N/A 36027447 Surgery Knee Arthroplasty 27447 360 "$11,397.00 " $- #N/A $- $- #N/A $- N/A "$2,963.22 " N/A N/A "$1,750.00 " N/A N/A "$6,838.20 " N/A N/A "$5,698.50 " N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A "$2,187.00 " N/A N/A "$4,444.83 " N/A N/A "$5,185.64 " N/A N/A "$9,117.60 " N/A N/A N/A N/A N/A "$7,408.05 " N/A N/A "$8,609.82 " N/A N/A #N/A N/A N/A "$8,609.82 " N/A N/A "$3,988.95 " N/A N/A "$1,744.00 " N/A N/A "$3,419.10 " N/A N/A "$3,025.00 " N/A N/A "$7,408.05 " N/A N/A "$3,419.10 " N/A N/A "$3,419.10 " N/A N/A "$3,419.10 " N/A N/A "$3,419.10 " N/A N/A "$3,419.10 " N/A N/A "$3,419.10 " N/A "$11,397.00 " "$11,397.00 " N/A 36028899 Surgery Other - Podiatry 28899 490 "$2,287.00 " $- #N/A $- $- #N/A $- N/A $594.62 N/A N/A $750.00 N/A N/A "$1,372.20 " N/A N/A "$1,143.50 " N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A "$1,343.00 " N/A N/A $891.93 N/A N/A "$1,040.59 " N/A N/A "$1,829.60 " N/A N/A N/A N/A N/A "$1,486.55 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A $800.45 N/A N/A "$1,071.00 " N/A N/A $686.10 N/A N/A $474.00 N/A N/A "$1,486.55 " N/A N/A $686.10 N/A N/A $686.10 N/A N/A $686.10 N/A N/A $686.10 N/A N/A $686.10 N/A N/A $686.10 N/A "$2,287.00 " "$2,287.00 " N/A 36029827 Surgery Arthroscopy Shoulder with Subacromial Decompression and Rota 29827 360 "$4,332.00 " $- "$1,126.32 " $- $- "$3,465.60 " $- N/A "$1,126.32 " N/A N/A "$1,550.00 " N/A N/A "$2,599.20 " N/A N/A "$2,166.00 " N/A N/A "$1,965.14 " N/A N/A "$1,625.00 " N/A N/A "$1,887.00 " N/A N/A "$1,689.48 " N/A N/A "$1,971.06 " N/A N/A "$3,465.60 " N/A N/A N/A N/A N/A "$2,815.80 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$1,516.20 " N/A N/A "$1,505.00 " N/A N/A "$1,299.60 " N/A N/A "$2,818.00 " N/A N/A "$2,815.80 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A N/A "$1,299.60 " N/A "$4,332.00 " "$4,332.00 " N/A 36064455 Surgery Nerve Block Popliteal 64455 360 $210.00 $- $20.57 $- $- "$1,625.00 " $- N/A $54.60 N/A N/A $750.00 N/A N/A $126.00 N/A N/A $105.00 N/A N/A $98.89 N/A N/A "$1,625.00 " N/A N/A $878.00 N/A N/A $81.90 N/A N/A $95.55 N/A N/A $168.00 N/A N/A N/A N/A N/A $136.50 N/A N/A $20.57 N/A N/A $98.89 N/A N/A $20.57 N/A N/A $73.50 N/A N/A $700.00 N/A N/A $63.00 N/A N/A $474.00 N/A N/A $136.50 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A N/A $63.00 N/A $210.00 $210.00 N/A 49007071 Surgery Subchondroplasty 0707T 490 "$3,125.00 " $- #N/A $- $- #N/A $- N/A $812.50 N/A N/A #N/A N/A N/A "$1,875.00 " N/A N/A "$1,562.50 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A "$1,218.75 " N/A N/A "$1,421.88 " N/A N/A "$2,500.00 " N/A N/A N/A N/A N/A "$2,031.25 " N/A N/A #N/A N/A N/A #N/A N/A N/A #N/A N/A N/A "$1,093.75 " N/A N/A #N/A N/A N/A $937.50 N/A N/A #N/A N/A N/A "$2,031.25 " N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A N/A $937.50 N/A "$3,125.00 " "$3,125.00 " N/A 49010021 Surgery Fine Needle Aspiration 10021 490 $378.00 $- #N/A $- $- #N/A $- N/A $98.28 N/A N/A $750.00 N/A N/A $226.80 N/A N/A $189.00 N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A $542.00 N/A N/A $147.42 N/A N/A $171.99 N/A N/A $302.40 N/A N/A N/A N/A N/A $245.70 N/A N/A $59.19 N/A N/A #N/A N/A N/A $59.19 N/A N/A $132.30 N/A N/A $432.00 N/A N/A $113.40 N/A N/A $474.00 N/A N/A $245.70 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A N/A $113.40 N/A $378.00 $378.00 N/A 49010060 Surgery Incision and Drainage 10060 490 $432.00 $- #N/A $- $- #N/A $- N/A $112.32 N/A N/A $750.00 N/A N/A $259.20 N/A N/A $216.00 N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A $542.00 N/A N/A $168.48 N/A N/A $196.56 N/A N/A $345.60 N/A N/A N/A N/A N/A $280.80 N/A N/A $75.43 N/A N/A #N/A N/A N/A $75.43 N/A N/A $151.20 N/A N/A $432.00 N/A N/A $129.60 N/A N/A $474.00 N/A N/A $280.80 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A $432.00 $432.00 N/A 49010060 Surgery Incision and Drainage 10060 490 $432.00 $- #N/A $- $- #N/A $- N/A $112.32 N/A N/A $750.00 N/A N/A $259.20 N/A N/A $216.00 N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A $542.00 N/A N/A $168.48 N/A N/A $196.56 N/A N/A $345.60 N/A N/A N/A N/A N/A $280.80 N/A N/A $75.43 N/A N/A #N/A N/A N/A $75.43 N/A N/A $151.20 N/A N/A $432.00 N/A N/A $129.60 N/A N/A $474.00 N/A N/A $280.80 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A N/A $129.60 N/A $432.00 $432.00 N/A 49011420 Surgery Excision Lesion Benign 11420 490 "$1,436.00 " $- #N/A $- $- #N/A $- N/A $373.36 N/A N/A $950.00 N/A N/A $861.60 N/A N/A $718.00 N/A N/A #N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $560.04 N/A N/A $653.38 N/A N/A "$1,148.80 " N/A N/A N/A N/A N/A $933.40 N/A N/A $88.78 N/A N/A #N/A N/A N/A $88.78 N/A N/A $502.60 N/A N/A $700.00 N/A N/A $430.80 N/A N/A $686.00 N/A N/A $933.40 N/A N/A $430.80 N/A N/A $430.80 N/A N/A $430.80 N/A N/A $430.80 N/A N/A $430.80 N/A N/A $430.80 N/A "$1,436.00 " "$1,436.00 " N/A 49011450 Surgery Resection Hidradenitis 11450 490 "$4,009.00 " $- $625.09 $- $- "$3,207.20 " $- N/A "$1,042.34 " N/A N/A $950.00 N/A N/A "$2,405.40 " N/A N/A "$2,004.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,563.51 " N/A N/A "$1,824.10 " N/A N/A "$3,207.20 " N/A N/A N/A N/A N/A "$2,605.85 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$1,403.15 " N/A N/A $939.00 N/A N/A "$1,202.70 " N/A N/A "$1,273.00 " N/A N/A "$2,605.85 " N/A N/A "$1,202.70 " N/A N/A "$1,202.70 " N/A N/A "$1,202.70 " N/A N/A "$1,202.70 " N/A N/A "$1,202.70 " N/A N/A "$1,202.70 " N/A "$4,009.00 " "$4,009.00 " N/A 49011620 Surgery Excision Lesion Malignant 11620 490 "$1,398.00 " $- #N/A $- $- #N/A $- N/A $363.48 N/A N/A $750.00 N/A N/A $838.80 N/A N/A $699.00 N/A N/A #N/A N/A N/A $756.00 N/A N/A $878.00 N/A N/A $545.22 N/A N/A $636.09 N/A N/A "$1,118.40 " N/A N/A N/A N/A N/A $908.70 N/A N/A $136.42 N/A N/A #N/A N/A N/A $136.42 N/A N/A $489.30 N/A N/A $700.00 N/A N/A $419.40 N/A N/A $686.00 N/A N/A $908.70 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A N/A $419.40 N/A "$1,398.00 " "$1,398.00 " N/A 49012032 Surgery Wound Repair 12032 490 $666.00 $- $99.69 $- $- "$1,625.00 " $- N/A $173.16 N/A N/A $750.00 N/A N/A $399.60 N/A N/A $333.00 N/A N/A $99.69 N/A N/A "$1,625.00 " N/A N/A $878.00 N/A N/A $259.74 N/A N/A $303.03 N/A N/A $532.80 N/A N/A N/A N/A N/A $432.90 N/A N/A $161.45 N/A N/A $99.69 N/A N/A $161.45 N/A N/A $233.10 N/A N/A $700.00 N/A N/A $199.80 N/A N/A $474.00 N/A N/A $432.90 N/A N/A $199.80 N/A N/A $199.80 N/A N/A $199.80 N/A N/A $199.80 N/A N/A $199.80 N/A N/A $199.80 N/A $666.00 $666.00 N/A 49015734 Surgery Transverse Rectus Abdominis Myocutaneous Flap 15734 490 "$4,054.00 " $- $944.74 $- $- "$3,243.20 " $- N/A "$1,054.04 " N/A N/A "$1,150.00 " N/A N/A "$2,432.40 " N/A N/A "$2,027.00 " N/A N/A $944.74 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,581.06 " N/A N/A "$1,844.57 " N/A N/A "$3,243.20 " N/A N/A N/A N/A N/A "$2,635.10 " N/A N/A "$1,504.38 " N/A N/A $944.74 N/A N/A "$1,504.38 " N/A N/A "$1,418.90 " N/A N/A "$1,071.00 " N/A N/A "$1,216.20 " N/A N/A "$1,441.00 " N/A N/A "$2,635.10 " N/A N/A "$1,216.20 " N/A N/A "$1,216.20 " N/A N/A "$1,216.20 " N/A N/A "$1,216.20 " N/A N/A "$1,216.20 " N/A N/A "$1,216.20 " N/A "$4,054.00 " "$4,054.00 " N/A 49021012 Surgery Minor Soft Tissue Procedure 21012 490 "$2,715.00 " $- $576.39 $- $- "$2,172.00 " $- N/A $705.90 N/A N/A $750.00 N/A N/A "$1,629.00 " N/A N/A "$1,357.50 " N/A N/A $625.09 N/A N/A "$1,014.00 " N/A N/A $878.00 N/A N/A "$1,058.85 " N/A N/A "$1,235.33 " N/A N/A "$2,172.00 " N/A N/A N/A N/A N/A "$1,764.75 " N/A N/A $576.39 N/A N/A $625.09 N/A N/A $576.39 N/A N/A $950.25 N/A N/A $700.00 N/A N/A $814.50 N/A N/A $686.00 N/A N/A "$1,764.75 " N/A N/A $814.50 N/A N/A $814.50 N/A N/A $814.50 N/A N/A $814.50 N/A N/A $814.50 N/A N/A $814.50 N/A "$2,715.00 " "$2,715.00 " N/A 49021600 Surgery Rib Resection 21600 490 "$6,946.00 " $- $939.00 $- $- "$5,556.80 " $- N/A "$1,805.96 " N/A N/A $950.00 N/A N/A "$4,167.60 " N/A N/A "$3,473.00 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$2,708.94 " N/A N/A "$3,160.43 " N/A N/A "$5,556.80 " N/A N/A N/A N/A N/A "$4,514.90 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,431.10 " N/A N/A $939.00 N/A N/A "$2,083.80 " N/A N/A "$1,441.00 " N/A N/A "$4,514.90 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A "$6,946.00 " "$6,946.00 " N/A 49021600 Surgery Rib Resection 21600 490 "$6,946.00 " $- $939.00 $- $- "$5,556.80 " $- N/A "$1,805.96 " N/A N/A $950.00 N/A N/A "$4,167.60 " N/A N/A "$3,473.00 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$2,708.94 " N/A N/A "$3,160.43 " N/A N/A "$5,556.80 " N/A N/A N/A N/A N/A "$4,514.90 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A "$2,431.10 " N/A N/A $939.00 N/A N/A "$2,083.80 " N/A N/A "$1,441.00 " N/A N/A "$4,514.90 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A N/A "$2,083.80 " N/A "$6,946.00 " "$6,946.00 " N/A 49021932 Surgery Excision Tumor 21932 490 "$4,095.00 " $- $625.09 $- $- "$3,276.00 " $- N/A "$1,064.70 " N/A N/A $950.00 N/A N/A "$2,457.00 " N/A N/A "$2,047.50 " N/A N/A $625.09 N/A N/A "$2,257.00 " N/A N/A "$1,177.00 " N/A N/A "$1,597.05 " N/A N/A "$1,863.23 " N/A N/A "$3,276.00 " N/A N/A N/A N/A N/A "$2,661.75 " N/A N/A $994.34 N/A N/A $625.09 N/A N/A $994.34 N/A N/A "$1,433.25 " N/A N/A $939.00 N/A N/A "$1,228.50 " N/A N/A "$1,061.00 " N/A N/A "$2,661.75 " N/A N/A "$1,228.50 " N/A N/A "$1,228.50 " N/A N/A "$1,228.50 " N/A N/A "$1,228.50 " N/A N/A "$1,228.50 " N/A N/A "$1,228.50 " N/A "$4,095.00 " "$4,095.00 " N/A 49027654 Surgery Tendon Repair Achilles 27654 490 "$4,298.00 " $- "$1,071.00 " $- $- "$3,438.40 " $- N/A "$1,117.48 " N/A N/A "$1,150.00 " N/A N/A "$2,578.80 " N/A N/A "$2,149.00 " N/A N/A "$1,965.14 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,676.22 " N/A N/A "$1,955.59 " N/A N/A "$3,438.40 " N/A N/A N/A N/A N/A "$2,793.70 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$1,504.30 " N/A N/A "$1,071.00 " N/A N/A "$1,289.40 " N/A N/A "$1,872.00 " N/A N/A "$2,793.70 " N/A N/A "$1,289.40 " N/A N/A "$1,289.40 " N/A N/A "$1,289.40 " N/A N/A "$1,289.40 " N/A N/A "$1,289.40 " N/A N/A "$1,289.40 " N/A "$4,298.00 " "$4,298.00 " N/A 49027658 Surgery Peroneal Tendon Repair with Debridement 27658 490 "$3,731.00 " $- $700.00 $- $- "$2,984.80 " $- N/A $970.06 N/A N/A $750.00 N/A N/A "$2,238.60 " N/A N/A "$1,865.50 " N/A N/A "$1,058.82 " N/A N/A $756.00 N/A N/A $878.00 N/A N/A "$1,455.09 " N/A N/A "$1,697.61 " N/A N/A "$2,984.80 " N/A N/A N/A N/A N/A "$2,425.15 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,305.85 " N/A N/A $700.00 N/A N/A "$1,119.30 " N/A N/A "$1,273.00 " N/A N/A "$2,425.15 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A N/A "$1,119.30 " N/A "$3,731.00 " "$3,731.00 " N/A 49028010 Surgery Tenotomy of toe 28010 490 "$1,474.00 " $- #N/A $- $- #N/A $- N/A $383.24 N/A N/A $950.00 N/A N/A $884.40 N/A N/A $737.00 N/A N/A #N/A N/A N/A "$1,625.00 " N/A N/A "$1,177.00 " N/A N/A $574.86 N/A N/A $670.67 N/A N/A "$1,179.20 " N/A N/A N/A N/A N/A $958.10 N/A N/A $124.51 N/A N/A #N/A N/A N/A $124.51 N/A N/A $515.90 N/A N/A $939.00 N/A N/A $442.20 N/A N/A "$1,273.00 " N/A N/A $958.10 N/A N/A $442.20 N/A N/A $442.20 N/A N/A $442.20 N/A N/A $442.20 N/A N/A $442.20 N/A N/A $442.20 N/A "$1,474.00 " "$1,474.00 " N/A 49028120 Surgery Excision Calcaneal Spur 28120 490 "$3,253.00 " $- $845.78 $- $- "$2,620.00 " $- N/A $845.78 N/A N/A "$1,950.00 " N/A N/A "$1,951.80 " N/A N/A "$1,626.50 " N/A N/A "$1,058.82 " N/A N/A "$2,257.00 " N/A N/A "$2,620.00 " N/A N/A "$1,268.67 " N/A N/A "$1,480.12 " N/A N/A "$2,602.40 " N/A N/A N/A N/A N/A "$2,114.45 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,138.55 " N/A N/A "$2,090.00 " N/A N/A $975.90 N/A N/A "$1,273.00 " N/A N/A "$2,114.45 " N/A N/A $975.90 N/A N/A $975.90 N/A N/A $975.90 N/A N/A $975.90 N/A N/A $975.90 N/A N/A $975.90 N/A "$3,253.00 " "$3,253.00 " N/A 49028124 Surgery Exostectomy Metatarsal Base 28124 490 "$2,955.00 " $- #N/A $- $- #N/A $- N/A $768.30 N/A N/A $950.00 N/A N/A "$1,773.00 " N/A N/A "$1,477.50 " N/A N/A #N/A N/A N/A "$1,157.00 " N/A N/A "$1,177.00 " N/A N/A "$1,152.45 " N/A N/A "$1,344.53 " N/A N/A "$2,364.00 " N/A N/A N/A N/A N/A "$1,920.75 " N/A N/A $301.71 N/A N/A #N/A N/A N/A $301.71 N/A N/A "$1,034.25 " N/A N/A $939.00 N/A N/A $886.50 N/A N/A "$1,273.00 " N/A N/A "$1,920.75 " N/A N/A $886.50 N/A N/A $886.50 N/A N/A $886.50 N/A N/A $886.50 N/A N/A $886.50 N/A N/A $886.50 N/A "$2,955.00 " "$2,955.00 " N/A 49028270 Surgery Hammertoe Repair with Tenotomy and Capsulotomy 28270 490 "$1,811.00 " $- $470.86 $- $- "$1,448.80 " $- N/A $470.86 N/A N/A "$1,150.00 " N/A N/A "$1,086.60 " N/A N/A $905.50 N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A $706.29 N/A N/A $824.01 N/A N/A "$1,448.80 " N/A N/A N/A N/A N/A "$1,177.15 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A $633.85 N/A N/A "$1,071.00 " N/A N/A $543.30 N/A N/A "$1,273.00 " N/A N/A "$1,177.15 " N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A N/A $543.30 N/A "$1,811.00 " "$1,811.00 " N/A 49028308 Surgery Tailors Bunionectomy 28308 490 "$2,608.00 " $- $678.08 $- $- "$2,086.40 " $- N/A $678.08 N/A N/A $950.00 N/A N/A "$1,564.80 " N/A N/A "$1,304.00 " N/A N/A "$1,058.82 " N/A N/A "$1,014.00 " N/A N/A "$1,177.00 " N/A N/A "$1,017.12 " N/A N/A "$1,186.64 " N/A N/A "$2,086.40 " N/A N/A N/A N/A N/A "$1,695.20 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A $912.80 N/A N/A $939.00 N/A N/A $782.40 N/A N/A "$1,273.00 " N/A N/A "$1,695.20 " N/A N/A $782.40 N/A N/A $782.40 N/A N/A $782.40 N/A N/A $782.40 N/A N/A $782.40 N/A N/A $782.40 N/A "$2,608.00 " "$2,608.00 " N/A 49028310 Surgery Bunionectomy with Osteotomy 28310 490 "$1,863.00 " $- $484.38 $- $- "$2,803.36 " $- N/A $484.38 N/A N/A "$1,150.00 " N/A N/A "$1,117.80 " N/A N/A $931.50 N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A $726.57 N/A N/A $847.67 N/A N/A "$1,490.40 " N/A N/A N/A N/A N/A "$1,210.95 " N/A N/A "$2,803.36 " N/A N/A "$1,058.82 " N/A N/A "$2,803.36 " N/A N/A $652.05 N/A N/A "$1,071.00 " N/A N/A $558.90 N/A N/A "$1,273.00 " N/A N/A "$1,210.95 " N/A N/A $558.90 N/A N/A $558.90 N/A N/A $558.90 N/A N/A $558.90 N/A N/A $558.90 N/A N/A $558.90 N/A "$1,863.00 " "$1,863.00 " N/A 49029807 Surgery Arthroscopy Shoulder with SLAP Repair 29807 490 "$3,484.00 " $- $905.84 $- $- "$2,818.00 " $- N/A $905.84 N/A N/A "$1,150.00 " N/A N/A "$2,090.40 " N/A N/A "$1,742.00 " N/A N/A "$1,965.14 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,358.76 " N/A N/A "$1,585.22 " N/A N/A "$2,787.20 " N/A N/A N/A N/A N/A "$2,264.60 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$1,219.40 " N/A N/A "$1,071.00 " N/A N/A "$1,045.20 " N/A N/A "$2,818.00 " N/A N/A "$2,264.60 " N/A N/A "$1,045.20 " N/A N/A "$1,045.20 " N/A N/A "$1,045.20 " N/A N/A "$1,045.20 " N/A N/A "$1,045.20 " N/A N/A "$1,045.20 " N/A "$3,484.00 " "$3,484.00 " N/A 49029828 Surgery Arthroscopy Shoulder with Bicep Tendon Repair 29828 490 "$2,910.00 " $- $756.60 $- $- "$2,818.00 " $- N/A $756.60 N/A N/A "$1,150.00 " N/A N/A "$1,746.00 " N/A N/A "$1,455.00 " N/A N/A "$1,965.14 " N/A N/A "$2,266.00 " N/A N/A "$1,177.00 " N/A N/A "$1,134.90 " N/A N/A "$1,324.05 " N/A N/A "$2,328.00 " N/A N/A N/A N/A N/A "$1,891.50 " N/A N/A "$2,803.36 " N/A N/A "$1,965.14 " N/A N/A "$2,803.36 " N/A N/A "$1,018.50 " N/A N/A $939.00 N/A N/A $873.00 N/A N/A "$2,818.00 " N/A N/A "$1,891.50 " N/A N/A $873.00 N/A N/A $873.00 N/A N/A $873.00 N/A N/A $873.00 N/A N/A $873.00 N/A N/A $873.00 N/A "$2,910.00 " "$2,910.00 " N/A 49029888 Surgery Arthroscopy Knee with Anterior Cruciate Ligament Reconstruct 29888 490 "$6,235.00 " $- "$1,071.00 " $- $- "$4,988.00 " $- N/A "$1,621.10 " N/A N/A "$1,150.00 " N/A N/A "$3,741.00 " N/A N/A "$3,117.50 " N/A N/A "$2,792.29 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$2,431.65 " N/A N/A "$2,836.93 " N/A N/A "$4,988.00 " N/A N/A N/A N/A N/A "$4,052.75 " N/A N/A "$3,873.24 " N/A N/A "$2,792.29 " N/A N/A "$3,873.24 " N/A N/A "$2,182.25 " N/A N/A "$1,071.00 " N/A N/A "$1,870.50 " N/A N/A "$2,818.00 " N/A N/A "$4,052.75 " N/A N/A "$1,870.50 " N/A N/A "$1,870.50 " N/A N/A "$1,870.50 " N/A N/A "$1,870.50 " N/A N/A "$1,870.50 " N/A N/A "$1,870.50 " N/A "$6,235.00 " "$6,235.00 " N/A 49029895 Surgery ARTHROSCOPY ANKLE P SYNOVECTOMY 29895 29895 490 "$3,326.00 " $- $864.76 $- $- "$2,660.80 " $- N/A $864.76 N/A N/A "$1,150.00 " N/A N/A "$1,995.60 " N/A N/A "$1,663.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,297.14 " N/A N/A "$1,513.33 " N/A N/A "$2,660.80 " N/A N/A N/A N/A N/A "$2,161.90 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A "$1,164.10 " N/A N/A "$1,071.00 " N/A N/A $997.80 N/A N/A "$1,441.00 " N/A N/A "$2,161.90 " N/A N/A $997.80 N/A N/A $997.80 N/A N/A $997.80 N/A N/A $997.80 N/A N/A $997.80 N/A N/A $997.80 N/A "$3,326.00 " "$3,326.00 " N/A 49029897 Surgery Arthroscopy Ankle 29897 490 "$2,634.00 " $- $684.84 $- $- "$2,107.20 " $- N/A $684.84 N/A N/A "$1,150.00 " N/A N/A "$1,580.40 " N/A N/A "$1,317.00 " N/A N/A "$1,058.82 " N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,027.26 " N/A N/A "$1,198.47 " N/A N/A "$2,107.20 " N/A N/A N/A N/A N/A "$1,712.10 " N/A N/A "$1,286.26 " N/A N/A "$1,058.82 " N/A N/A "$1,286.26 " N/A N/A $921.90 N/A N/A "$1,071.00 " N/A N/A $790.20 N/A N/A "$1,441.00 " N/A N/A "$1,712.10 " N/A N/A $790.20 N/A N/A $790.20 N/A N/A $790.20 N/A N/A $790.20 N/A N/A $790.20 N/A N/A $790.20 N/A "$2,634.00 " "$2,634.00 " N/A 49036571 Surgery Peripherally Inserted Central Catheter Line Placement 36571 490 "$3,730.00 " $- $969.80 $- $- "$2,984.00 " $- N/A $969.80 N/A N/A "$1,150.00 " N/A N/A "$2,238.00 " N/A N/A "$1,865.00 " N/A N/A $993.29 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,454.70 " N/A N/A "$1,697.15 " N/A N/A "$2,984.00 " N/A N/A N/A N/A N/A "$2,424.50 " N/A N/A "$1,341.23 " N/A N/A $993.29 N/A N/A "$1,341.23 " N/A N/A "$1,305.50 " N/A N/A "$1,071.00 " N/A N/A "$1,119.00 " N/A N/A "$1,441.00 " N/A N/A "$2,424.50 " N/A N/A "$1,119.00 " N/A N/A "$1,119.00 " N/A N/A "$1,119.00 " N/A N/A "$1,119.00 " N/A N/A "$1,119.00 " N/A N/A "$1,119.00 " N/A "$3,730.00 " "$3,730.00 " N/A 49045300 Surgery Proctosigmoidoscopy 45300 490 "$1,201.00 " $- #N/A $- $- #N/A $- N/A $312.26 N/A N/A $750.00 N/A N/A $720.60 N/A N/A $600.50 N/A N/A #N/A N/A N/A $756.00 N/A N/A $542.00 N/A N/A $468.39 N/A N/A $546.46 N/A N/A $960.80 N/A N/A N/A N/A N/A $780.65 N/A N/A $94.19 N/A N/A #N/A N/A N/A $94.19 N/A N/A $420.35 N/A N/A $432.00 N/A N/A $360.30 N/A N/A $686.00 N/A N/A $780.65 N/A N/A $360.30 N/A N/A $360.30 N/A N/A $360.30 N/A N/A $360.30 N/A N/A $360.30 N/A N/A $360.30 N/A "$1,201.00 " "$1,201.00 " N/A 49047563 Surgery Cholecystectomy Laparoscopic with Cholangiogram 47563 490 "$8,988.00 " $- #N/A $- $- #N/A $- N/A "$2,336.88 " N/A N/A "$1,550.00 " N/A N/A "$5,392.80 " N/A N/A "$4,494.00 " N/A N/A "$1,589.51 " N/A N/A #N/A N/A N/A "$1,887.00 " N/A N/A "$3,505.32 " N/A N/A "$4,089.54 " N/A N/A "$7,190.40 " N/A N/A N/A N/A N/A "$5,842.20 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$3,145.80 " N/A N/A "$1,505.00 " N/A N/A "$2,696.40 " N/A N/A "$2,818.00 " N/A N/A "$5,842.20 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A "$8,988.00 " "$8,988.00 " N/A 49047563 Surgery Cholecystectomy Laparoscopic with Cholangiogram 47563 490 "$8,988.00 " $- #N/A $- $- #N/A $- N/A "$2,336.88 " N/A N/A "$1,550.00 " N/A N/A "$5,392.80 " N/A N/A "$4,494.00 " N/A N/A "$1,589.51 " N/A N/A #N/A N/A N/A "$1,887.00 " N/A N/A "$3,505.32 " N/A N/A "$4,089.54 " N/A N/A "$7,190.40 " N/A N/A N/A N/A N/A "$5,842.20 " N/A N/A "$2,194.07 " N/A N/A "$1,589.51 " N/A N/A "$2,194.07 " N/A N/A "$3,145.80 " N/A N/A "$1,505.00 " N/A N/A "$2,696.40 " N/A N/A "$2,818.00 " N/A N/A "$5,842.20 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A N/A "$2,696.40 " N/A "$8,988.00 " "$8,988.00 " N/A 49049083 Surgery Paracentesis with Imaging Guidance 49083 490 "$1,573.00 " $- #N/A $- $- #N/A $- N/A $408.98 N/A N/A $950.00 N/A N/A $943.80 N/A N/A $786.50 N/A N/A #N/A N/A N/A $756.00 N/A N/A "$1,177.00 " N/A N/A $613.47 N/A N/A $715.72 N/A N/A "$1,258.40 " N/A N/A N/A N/A N/A "$1,022.45 " N/A N/A $397.12 N/A N/A #N/A N/A N/A $397.12 N/A N/A $550.55 N/A N/A $939.00 N/A N/A $471.90 N/A N/A "$1,061.00 " N/A N/A "$1,022.45 " N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A N/A $471.90 N/A "$1,573.00 " "$1,573.00 " N/A 49128122 Surgery Excision Bone Accessory 28122 490 "$3,300.00 " $- $643.20 $- $- "$2,640.00 " $- N/A $858.00 N/A N/A "$1,150.00 " N/A N/A "$1,980.00 " N/A N/A "$1,650.00 " N/A N/A $643.20 N/A N/A "$1,157.00 " N/A N/A "$1,343.00 " N/A N/A "$1,287.00 " N/A N/A "$1,501.50 " N/A N/A "$2,640.00 " N/A N/A N/A N/A N/A "$2,145.00 " N/A N/A "$1,286.26 " N/A N/A $643.20 N/A N/A "$1,286.26 " N/A N/A "$1,155.00 " N/A N/A "$1,071.00 " N/A N/A $990.00 N/A N/A "$1,273.00 " N/A N/A "$2,145.00 " N/A N/A $990.00 N/A N/A $990.00 N/A N/A $990.00 N/A N/A $990.00 N/A N/A $990.00 N/A N/A $990.00 N/A "$3,300.00 " "$3,300.00 " N/A 49143235 Surgery Esophagogastroduodenoscopy (ASC) 43235 490 "$2,045.00 " $- $329.44 $- $- "$1,636.00 " $- N/A $531.70 N/A N/A $750.00 N/A N/A "$1,227.00 " N/A N/A "$1,022.50 " N/A N/A $329.44 N/A N/A $756.00 N/A N/A $878.00 N/A N/A $797.55 N/A N/A $930.48 N/A N/A "$1,636.00 " N/A N/A N/A N/A N/A "$1,329.25 " N/A N/A $397.12 N/A N/A $329.44 N/A N/A $397.12 N/A N/A $715.75 N/A N/A $700.00 N/A N/A $613.50 N/A N/A "$1,061.00 " N/A N/A "$1,329.25 " N/A N/A $613.50 N/A N/A $613.50 N/A N/A $613.50 N/A N/A $613.50 N/A N/A $613.50 N/A N/A $613.50 N/A "$2,045.00 " "$2,045.00 " N/A 49149505 Surgery Hernia Repair Inguinal Child 49505 490 "$6,719.00 " $- "$1,154.72 " $- $- "$5,375.20 " $- N/A "$1,746.94 " N/A N/A "$1,350.00 " N/A N/A "$4,031.40 " N/A N/A "$3,359.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,620.41 " N/A N/A "$3,057.15 " N/A N/A "$5,375.20 " N/A N/A N/A N/A N/A "$4,367.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,351.65 " N/A N/A "$1,321.00 " N/A N/A "$2,015.70 " N/A N/A "$1,441.00 " N/A N/A "$4,367.35 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A "$6,719.00 " "$6,719.00 " N/A 49149505 Surgery Hernia Repair Inguinal Child 49505 490 "$6,719.00 " $- "$1,154.72 " $- $- "$5,375.20 " $- N/A "$1,746.94 " N/A N/A "$1,350.00 " N/A N/A "$4,031.40 " N/A N/A "$3,359.50 " N/A N/A "$1,154.72 " N/A N/A "$1,427.00 " N/A N/A "$1,656.00 " N/A N/A "$2,620.41 " N/A N/A "$3,057.15 " N/A N/A "$5,375.20 " N/A N/A N/A N/A N/A "$4,367.35 " N/A N/A "$1,377.21 " N/A N/A "$1,154.72 " N/A N/A "$1,377.21 " N/A N/A "$2,351.65 " N/A N/A "$1,321.00 " N/A N/A "$2,015.70 " N/A N/A "$1,441.00 " N/A N/A "$4,367.35 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A N/A "$2,015.70 " N/A "$6,719.00 " "$6,719.00 " N/A 49049654 Surgery Charges LAPAROSCOPY INCISIONAL HERNIA REPAIR W/MESH CHARGE 49654 490 "$12,534.00 " $- "$1,321.00 " $- $- "$10,027.20 " $- N/A "$3,258.84 " N/A N/A "$1,350.00 " N/A N/A "$7,520.40 " N/A N/A "$6,267.00 " N/A N/A "$2,590.67 " N/A N/A "$2,266.00 " N/A N/A "$1,656.00 " N/A N/A "$4,888.26 " N/A N/A "$5,702.97 " N/A N/A "$10,027.20 " N/A N/A N/A N/A N/A "$8,147.10 " N/A N/A "$3,588.58 " N/A N/A "$2,590.67 " N/A N/A "$3,588.58 " N/A N/A "$4,386.90 " N/A N/A "$1,321.00 " N/A N/A "$3,760.20 " N/A N/A "$2,818.00 " N/A N/A "$8,147.10 " N/A N/A "$3,760.20 " N/A N/A "$3,760.20 " N/A N/A "$3,760.20 " N/A N/A "$3,760.20 " N/A N/A "$3,760.20 " N/A N/A "$3,760.20 " N/A "$12,534.00 " "$12,534.00 " N/A 4000078 Task Blood Glucose Monitoring POC 82962 301 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A N/A N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.82 N/A N/A $17.29 N/A N/A $30.40 N/A N/A N/A N/A N/A $24.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.30 N/A N/A N/A N/A N/A $11.40 N/A N/A N/A N/A N/A $24.70 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A N/A $11.40 N/A $38.00 $38.00 N/A 4400117 Pharmacy OLANZapine 5 mg Dis Tab [BCH] 250 $31.72 $- $8.25 $- $- $25.38 $- N/A $8.25 N/A N/A $11.99 N/A N/A $19.03 N/A N/A $15.86 N/A N/A N/A N/A N/A $21.57 N/A N/A $19.67 N/A N/A $13.01 N/A N/A $22.20 N/A N/A $25.38 N/A N/A $17.45 N/A N/A $22.20 N/A N/A $10.63 N/A N/A N/A N/A N/A $19.03 N/A N/A $11.10 N/A N/A $20.62 N/A N/A N/A N/A N/A $19.03 N/A N/A $22.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $31.72 $31.72 N/A 4400470 Pharmacy insulin lispro 100 units/mL SubQ Inj [BCH] J1815 636 $170.64 $- $0.83 $- $- $136.51 $- N/A $44.37 N/A N/A Not Reimbursed N/A N/A $102.38 N/A N/A $85.32 N/A N/A N/A N/A N/A $116.04 N/A N/A $105.80 N/A N/A $69.96 N/A N/A $119.45 N/A N/A $136.51 N/A N/A $93.85 N/A N/A $119.45 N/A N/A $57.16 N/A N/A N/A N/A N/A $102.38 N/A N/A $59.72 N/A N/A $110.92 N/A N/A $0.83 N/A N/A $102.38 N/A N/A $119.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $170.64 $170.64 N/A 4400923 Pharmacy insulin lispro-insulin lispro protamine 25 units-75 units/mL Sus J1815 636 $633.84 $- $0.83 $- $- $507.07 $- N/A $164.80 N/A N/A Not Reimbursed N/A N/A $380.30 N/A N/A $316.92 N/A N/A N/A N/A N/A $431.01 N/A N/A $392.98 N/A N/A $259.87 N/A N/A $443.69 N/A N/A $507.07 N/A N/A $348.61 N/A N/A $443.69 N/A N/A $212.34 N/A N/A N/A N/A N/A $380.30 N/A N/A $221.84 N/A N/A $412.00 N/A N/A $0.83 N/A N/A $380.30 N/A N/A $443.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $633.84 $633.84 N/A 4400694 Pharmacy OLANZapine 10 mg IM Inj [BCH] 636 $93.74 $- $24.37 $- $- $74.99 $- N/A $24.37 N/A N/A $35.43 N/A N/A $56.24 N/A N/A $46.87 N/A N/A N/A N/A N/A $63.74 N/A N/A $58.12 N/A N/A $38.43 N/A N/A $65.62 N/A N/A $74.99 N/A N/A $51.56 N/A N/A $65.62 N/A N/A $31.40 N/A N/A N/A N/A N/A $56.24 N/A N/A $32.81 N/A N/A $60.93 N/A N/A N/A N/A N/A $56.24 N/A N/A $65.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $93.74 $93.74 N/A 4400468 Pharmacy insulin regular human recombinant 100 units/mL Inj Sol [BCH] J1815 636 $92.38 $- $0.83 $- $- $73.90 $- N/A $24.02 N/A N/A Not Reimbursed N/A N/A $55.43 N/A N/A $46.19 N/A N/A N/A N/A N/A $62.82 N/A N/A $57.28 N/A N/A $37.88 N/A N/A $64.67 N/A N/A $73.90 N/A N/A $50.81 N/A N/A $64.67 N/A N/A $30.95 N/A N/A N/A N/A N/A $55.43 N/A N/A $32.33 N/A N/A $60.05 N/A N/A $0.83 N/A N/A $55.43 N/A N/A $64.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $92.38 $92.38 N/A 4400469 Pharmacy insulin isophane human recombinant 100 units/mL SubQ Inj [BCH] J1815 636 $92.38 $- $0.83 $- $- $73.90 $- N/A $24.02 N/A N/A Not Reimbursed N/A N/A $55.43 N/A N/A $46.19 N/A N/A N/A N/A N/A $62.82 N/A N/A $57.28 N/A N/A $37.88 N/A N/A $64.67 N/A N/A $73.90 N/A N/A $50.81 N/A N/A $64.67 N/A N/A $30.95 N/A N/A N/A N/A N/A $55.43 N/A N/A $32.33 N/A N/A $60.05 N/A N/A $0.83 N/A N/A $55.43 N/A N/A $64.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $92.38 $92.38 N/A 4400839 Pharmacy insulin isophane (NPH)-insulin regular human recombinant 70 units-30 units/mL Sus[BCH] J1815 636 $92.38 $- $0.83 $- $- $73.90 $- N/A $24.02 N/A N/A Not Reimbursed N/A N/A $55.43 N/A N/A $46.19 N/A N/A N/A N/A N/A $62.82 N/A N/A $57.28 N/A N/A $37.88 N/A N/A $64.67 N/A N/A $73.90 N/A N/A $50.81 N/A N/A $64.67 N/A N/A $30.95 N/A N/A N/A N/A N/A $55.43 N/A N/A $32.33 N/A N/A $60.05 N/A N/A $0.83 N/A N/A $55.43 N/A N/A $64.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $92.38 $92.38 N/A 4403060 Pharmacy triamcinolone acetonide 40 mg/mL Inj Susp [BCH] J3301 636 $20.52 $- $1.48 $- $- $16.42 $- N/A $5.34 N/A N/A Not Reimbursed N/A N/A $12.31 N/A N/A $10.26 N/A N/A N/A N/A N/A $13.95 N/A N/A $12.72 N/A N/A $8.41 N/A N/A $14.36 N/A N/A $16.42 N/A N/A $11.29 N/A N/A $14.36 N/A N/A $6.87 N/A N/A N/A N/A N/A $12.31 N/A N/A $7.18 N/A N/A $13.34 N/A N/A $1.48 N/A N/A $12.31 N/A N/A $14.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.52 $20.52 N/A 4400890 Pharmacy apixaban 2.5 mg Tab [BCH] 250 $14.40 $- $3.74 $- $- $11.52 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A N/A N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400890 Pharmacy apixaban 2.5 mg Tab [BCH] 250 $19.96 $- $5.19 $- $- $15.97 $- N/A $5.19 N/A N/A $7.55 N/A N/A $11.98 N/A N/A $9.98 N/A N/A N/A N/A N/A $13.58 N/A N/A $12.38 N/A N/A $8.19 N/A N/A $13.98 N/A N/A $15.97 N/A N/A $10.98 N/A N/A $13.98 N/A N/A $6.69 N/A N/A N/A N/A N/A $11.98 N/A N/A $6.99 N/A N/A $12.98 N/A N/A N/A N/A N/A $11.98 N/A N/A $13.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.96 $19.96 N/A 4400886 Pharmacy apixaban 5 mg Tab [BCH] 250 $14.40 $- $3.74 $- $- $11.52 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A N/A N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400886 Pharmacy apixaban 5 mg Tab [BCH] 250 $18.83 $- $4.90 $- $- $15.07 $- N/A $4.90 N/A N/A $7.12 N/A N/A $11.30 N/A N/A $9.42 N/A N/A N/A N/A N/A $12.81 N/A N/A $11.68 N/A N/A $7.72 N/A N/A $13.18 N/A N/A $15.07 N/A N/A $10.36 N/A N/A $13.18 N/A N/A $6.31 N/A N/A N/A N/A N/A $11.30 N/A N/A $6.59 N/A N/A $12.24 N/A N/A N/A N/A N/A $11.30 N/A N/A $13.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.83 $18.83 N/A 4400443 Pharmacy aztreonam 1 g Inj [BCH] 250 $69.60 $- $18.10 $- $- $55.68 $- N/A $18.10 N/A N/A $26.31 N/A N/A $41.76 N/A N/A $34.80 N/A N/A N/A N/A N/A $47.33 N/A N/A $43.15 N/A N/A $28.54 N/A N/A $48.72 N/A N/A $55.68 N/A N/A $38.28 N/A N/A $48.72 N/A N/A $23.32 N/A N/A N/A N/A N/A $41.76 N/A N/A $24.36 N/A N/A $45.24 N/A N/A N/A N/A N/A $41.76 N/A N/A $48.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.60 $69.60 N/A 4400841 Pharmacy hydroxyurea 200 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409479 Pharmacy oseltamivir 75 mg Cap [BCH] 250 $34.39 $- $8.94 $- $- $27.51 $- N/A $8.94 N/A N/A $13.00 N/A N/A $20.63 N/A N/A $17.19 N/A N/A N/A N/A N/A $23.38 N/A N/A $21.32 N/A N/A $14.10 N/A N/A $24.07 N/A N/A $27.51 N/A N/A $18.91 N/A N/A $24.07 N/A N/A $11.52 N/A N/A N/A N/A N/A $20.63 N/A N/A $12.04 N/A N/A $22.35 N/A N/A N/A N/A N/A $20.63 N/A N/A $24.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.39 $34.39 N/A 4400837 Pharmacy oseltamivir 6 mg/mL Pow [BCH] 250 $315.48 $- $82.02 $- $- $252.38 $- N/A $82.02 N/A N/A $119.25 N/A N/A $189.29 N/A N/A $157.74 N/A N/A N/A N/A N/A $214.53 N/A N/A $195.60 N/A N/A $129.35 N/A N/A $220.84 N/A N/A $252.38 N/A N/A $173.51 N/A N/A $220.84 N/A N/A $105.69 N/A N/A N/A N/A N/A $189.29 N/A N/A $110.42 N/A N/A $205.06 N/A N/A N/A N/A N/A $189.29 N/A N/A $220.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $315.48 $315.48 N/A 4400915 Pharmacy pneumococcal 13-valent conjugate vaccine - Sus 90670 636 $418.22 $- $108.74 $- $- $334.58 $- N/A $108.74 N/A N/A $158.09 N/A N/A $250.93 N/A N/A $209.11 N/A N/A N/A N/A N/A $284.39 N/A N/A $259.30 N/A N/A $171.47 N/A N/A $292.75 N/A N/A $334.58 N/A N/A $230.02 N/A N/A $292.75 N/A N/A $140.10 N/A N/A N/A N/A N/A $250.93 N/A N/A $146.38 N/A N/A $271.84 N/A N/A N/A N/A N/A $250.93 N/A N/A $292.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $418.22 $418.22 N/A 4400915 Pharmacy pneumococcal 13-valent conjugate vaccine - Sus 90670 636 $714.17 $- $185.68 $- $- $571.34 $- N/A $185.68 N/A N/A $269.96 N/A N/A $428.50 N/A N/A $357.09 N/A N/A N/A N/A N/A $485.64 N/A N/A $442.79 N/A N/A $292.81 N/A N/A $499.92 N/A N/A $571.34 N/A N/A $392.79 N/A N/A $499.92 N/A N/A $239.25 N/A N/A N/A N/A N/A $428.50 N/A N/A $249.96 N/A N/A $464.21 N/A N/A N/A N/A N/A $428.50 N/A N/A $499.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $714.17 $714.17 N/A 4400414 Pharmacy multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400011 Pharmacy sitaGLIPtin 50 mg oral tablet [BCH] 250 $29.07 $- $7.56 $- $- $23.26 $- N/A $7.56 N/A N/A $10.99 N/A N/A $17.44 N/A N/A $14.54 N/A N/A N/A N/A N/A $19.77 N/A N/A $18.02 N/A N/A $11.92 N/A N/A $20.35 N/A N/A $23.26 N/A N/A $15.99 N/A N/A $20.35 N/A N/A $9.74 N/A N/A N/A N/A N/A $17.44 N/A N/A $10.18 N/A N/A $18.90 N/A N/A N/A N/A N/A $17.44 N/A N/A $20.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.07 $29.07 N/A 4400660 Pharmacy raltegravir 400 mg oral tablet [BCH] 250 $51.50 $- $13.39 $- $- $41.20 $- N/A $13.39 N/A N/A $19.47 N/A N/A $30.90 N/A N/A $25.75 N/A N/A N/A N/A N/A $35.02 N/A N/A $31.93 N/A N/A $21.12 N/A N/A $36.05 N/A N/A $41.20 N/A N/A $28.33 N/A N/A $36.05 N/A N/A $17.25 N/A N/A N/A N/A N/A $30.90 N/A N/A $18.03 N/A N/A $33.48 N/A N/A N/A N/A N/A $30.90 N/A N/A $36.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $51.50 $51.50 N/A 4401961 Pharmacy imipenem-cilastatin 500 mg Inj [BCH] J0743 636 $78.36 $- $5.77 $- $- $62.69 $- N/A $20.37 N/A N/A Not Reimbursed N/A N/A $47.02 N/A N/A $39.18 N/A N/A N/A N/A N/A $53.29 N/A N/A $48.59 N/A N/A $32.13 N/A N/A $54.85 N/A N/A $62.69 N/A N/A $43.10 N/A N/A $54.85 N/A N/A $26.25 N/A N/A N/A N/A N/A $47.02 N/A N/A $27.43 N/A N/A $50.94 N/A N/A $5.77 N/A N/A $47.02 N/A N/A $54.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $78.36 $78.36 N/A 4409695 Pharmacy ertapenem 1 g Inj [BCH] J1335 636 $260.40 $- $35.33 $- $- $208.32 $- N/A $67.70 N/A N/A Not Reimbursed N/A N/A $156.24 N/A N/A $130.20 N/A N/A N/A N/A N/A $177.07 N/A N/A $161.45 N/A N/A $106.76 N/A N/A $182.28 N/A N/A $208.32 N/A N/A $143.22 N/A N/A $182.28 N/A N/A $87.23 N/A N/A N/A N/A N/A $156.24 N/A N/A $91.14 N/A N/A $169.26 N/A N/A $35.33 N/A N/A $156.24 N/A N/A $182.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $260.40 $260.40 N/A 4407240 Pharmacy pneumococcal 23-polyvalent vaccine - Sol [BCH] 90732 636 $113.42 $- $29.49 $- $- $90.73 $- N/A $29.49 N/A N/A $42.87 N/A N/A $68.05 N/A N/A $56.71 N/A N/A N/A N/A N/A $77.12 N/A N/A $70.32 N/A N/A $46.50 N/A N/A $79.39 N/A N/A $90.73 N/A N/A $62.38 N/A N/A $79.39 N/A N/A $37.99 N/A N/A N/A N/A N/A $68.05 N/A N/A $39.70 N/A N/A $73.72 N/A N/A N/A N/A N/A $68.05 N/A N/A $79.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $113.42 $113.42 N/A 4407240 Pharmacy pneumococcal 23-valent vaccine Inj Sol 0 mL [BCH] 90732 636 $208.10 $- $54.11 $- $- $166.48 $- N/A $54.11 N/A N/A $78.66 N/A N/A $124.86 N/A N/A $104.05 N/A N/A N/A N/A N/A $141.51 N/A N/A $129.02 N/A N/A $85.32 N/A N/A $145.67 N/A N/A $166.48 N/A N/A $114.46 N/A N/A $145.67 N/A N/A $69.71 N/A N/A N/A N/A N/A $124.86 N/A N/A $72.84 N/A N/A $135.27 N/A N/A N/A N/A N/A $124.86 N/A N/A $145.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $208.10 $208.10 N/A 4400687 Pharmacy zoster vaccine live SC Inj [BCH] 636 $495.82 $- $128.91 $- $- $396.66 $- N/A $128.91 N/A N/A $187.42 N/A N/A $297.49 N/A N/A $247.91 N/A N/A N/A N/A N/A $337.16 N/A N/A $307.41 N/A N/A $203.29 N/A N/A $347.07 N/A N/A $396.66 N/A N/A $272.70 N/A N/A $347.07 N/A N/A $166.10 N/A N/A N/A N/A N/A $297.49 N/A N/A $173.54 N/A N/A $322.28 N/A N/A N/A N/A N/A $297.49 N/A N/A $347.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $495.82 $495.82 N/A 4401955 Pharmacy hepatitis B adult vaccine 10 mcg/mL Sus [BCH] 636 $141.52 $- $36.80 $- $- $113.22 $- N/A $36.80 N/A N/A $53.50 N/A N/A $84.91 N/A N/A $70.76 N/A N/A N/A N/A N/A $96.24 N/A N/A $87.74 N/A N/A $58.02 N/A N/A $99.07 N/A N/A $113.22 N/A N/A $77.84 N/A N/A $99.07 N/A N/A $47.41 N/A N/A N/A N/A N/A $84.91 N/A N/A $49.53 N/A N/A $91.99 N/A N/A N/A N/A N/A $84.91 N/A N/A $99.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $141.52 $141.52 N/A 4401000 Pharmacy sugammadex 100 mg/mL Sol [BCH] 636 $125.63 $- $32.66 $- $- $100.50 $- N/A $32.66 N/A N/A $47.49 N/A N/A $75.38 N/A N/A $62.81 N/A N/A N/A N/A N/A $85.43 N/A N/A $77.89 N/A N/A $51.51 N/A N/A $87.94 N/A N/A $100.50 N/A N/A $69.09 N/A N/A $87.94 N/A N/A $42.08 N/A N/A N/A N/A N/A $75.38 N/A N/A $43.97 N/A N/A $81.66 N/A N/A N/A N/A N/A $75.38 N/A N/A $87.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $125.63 $125.63 N/A 4400570 Pharmacy pantoprazole 40 mg oral Gran [BCH] 250 $26.27 $- $6.83 $- $- $21.02 $- N/A $6.83 N/A N/A $9.93 N/A N/A $15.76 N/A N/A $13.13 N/A N/A N/A N/A N/A $17.86 N/A N/A $16.29 N/A N/A $10.77 N/A N/A $18.39 N/A N/A $21.02 N/A N/A $14.45 N/A N/A $18.39 N/A N/A $8.80 N/A N/A N/A N/A N/A $15.76 N/A N/A $9.19 N/A N/A $17.08 N/A N/A N/A N/A N/A $15.76 N/A N/A $18.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.27 $26.27 N/A 4409538 Pharmacy pantoprazole 40 mg IV Inj [BCH] S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409538 Pharmacy pantoprazole 40 mg Pow S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409538 Pharmacy pantoprazole 40 mg IV Inj [BCH] S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409538 Pharmacy pantoprazole 40 mg Powder-Inj [BCH] S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409538 Pharmacy pantoprazole 40 mg Pow S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400215 Pharmacy tigecycline 50 mg IV Inj [BCH] J3243 636 $375.60 $- $1.45 $- $- $300.48 $- N/A $97.66 N/A N/A Not Reimbursed N/A N/A $225.36 N/A N/A $187.80 N/A N/A N/A N/A N/A $255.41 N/A N/A $232.87 N/A N/A $154.00 N/A N/A $262.92 N/A N/A $300.48 N/A N/A $206.58 N/A N/A $262.92 N/A N/A $125.83 N/A N/A N/A N/A N/A $225.36 N/A N/A $131.46 N/A N/A $244.14 N/A N/A $1.45 N/A N/A $225.36 N/A N/A $262.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $375.60 $375.60 N/A 4400107 Pharmacy hydrocortisone 100 mg preservative-free Pow J1720 636 $35.26 $- $9.17 $- $- $28.21 $- N/A $9.17 N/A N/A Not Reimbursed N/A N/A $21.16 N/A N/A $17.63 N/A N/A N/A N/A N/A $23.98 N/A N/A $21.86 N/A N/A $14.46 N/A N/A $24.68 N/A N/A $28.21 N/A N/A $19.39 N/A N/A $24.68 N/A N/A $11.81 N/A N/A N/A N/A N/A $21.16 N/A N/A $12.34 N/A N/A $22.92 N/A N/A $14.14 N/A N/A $21.16 N/A N/A $24.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.26 $35.26 N/A 4400107 Pharmacy hydrocortisone 100 mg Inj [BCH] J1720 636 $20.64 $- $5.37 $- $- $16.51 $- N/A $5.37 N/A N/A Not Reimbursed N/A N/A $12.38 N/A N/A $10.32 N/A N/A N/A N/A N/A $14.04 N/A N/A $12.80 N/A N/A $8.46 N/A N/A $14.45 N/A N/A $16.51 N/A N/A $11.35 N/A N/A $14.45 N/A N/A $6.91 N/A N/A N/A N/A N/A $12.38 N/A N/A $7.22 N/A N/A $13.42 N/A N/A $14.14 N/A N/A $12.38 N/A N/A $14.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.64 $20.64 N/A 4400644 Pharmacy hydrocortisone 5 mg Tab [BCH] 250 $2.39 $- $0.62 $- $- $1.91 $- N/A $0.62 N/A N/A $0.90 N/A N/A $1.43 N/A N/A $1.19 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.48 N/A N/A $0.98 N/A N/A $1.67 N/A N/A $1.91 N/A N/A $1.31 N/A N/A $1.67 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.43 N/A N/A $0.84 N/A N/A $1.55 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.39 $2.39 N/A 4407913 Pharmacy methylPREDNISolone 40 mg preservative-free Pow [BCH] J2920 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $4.52 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407913 Pharmacy methylPREDNISolone 40 mg preservative-free Pow [BCH] J2920 636 $14.44 $- $3.75 $- $- $11.55 $- N/A $3.75 N/A N/A Not Reimbursed N/A N/A $8.66 N/A N/A $7.22 N/A N/A N/A N/A N/A $9.82 N/A N/A $8.95 N/A N/A $5.92 N/A N/A $10.11 N/A N/A $11.55 N/A N/A $7.94 N/A N/A $10.11 N/A N/A $4.84 N/A N/A N/A N/A N/A $8.66 N/A N/A $5.05 N/A N/A $9.38 N/A N/A $4.52 N/A N/A $8.66 N/A N/A $10.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.44 $14.44 N/A 4406048 Pharmacy methylPREDNISolone 125 mg preservative-free Pow [BCH] J2930 636 $18.99 $- $4.94 $- $- $15.19 $- N/A $4.94 N/A N/A Not Reimbursed N/A N/A $11.40 N/A N/A $9.50 N/A N/A N/A N/A N/A $12.92 N/A N/A $11.78 N/A N/A $7.79 N/A N/A $13.30 N/A N/A $15.19 N/A N/A $10.45 N/A N/A $13.30 N/A N/A $6.36 N/A N/A N/A N/A N/A $11.40 N/A N/A $6.65 N/A N/A $12.35 N/A N/A $6.72 N/A N/A $11.40 N/A N/A $13.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.99 $18.99 N/A 4406048 Pharmacy methylPREDNISolone 125 mg preservative-free Pow [BCH] J2930 636 $23.25 $- $6.05 $- $- $18.60 $- N/A $6.05 N/A N/A Not Reimbursed N/A N/A $13.95 N/A N/A $11.63 N/A N/A N/A N/A N/A $15.81 N/A N/A $14.42 N/A N/A $9.53 N/A N/A $16.28 N/A N/A $18.60 N/A N/A $12.79 N/A N/A $16.28 N/A N/A $7.79 N/A N/A N/A N/A N/A $13.95 N/A N/A $8.14 N/A N/A $15.11 N/A N/A $6.72 N/A N/A $13.95 N/A N/A $16.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.25 $23.25 N/A 4405438 Pharmacy bacitracin 50000 units Pow [BCH] 250 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400286 Pharmacy methylPREDNISolone 500 mg Inj [BCH] J2930 636 $45.32 $- $6.72 $- $- $36.26 $- N/A $11.78 N/A N/A Not Reimbursed N/A N/A $27.19 N/A N/A $22.66 N/A N/A N/A N/A N/A $30.82 N/A N/A $28.10 N/A N/A $18.58 N/A N/A $31.72 N/A N/A $36.26 N/A N/A $24.93 N/A N/A $31.72 N/A N/A $15.18 N/A N/A N/A N/A N/A $27.19 N/A N/A $15.86 N/A N/A $29.46 N/A N/A $6.72 N/A N/A $27.19 N/A N/A $31.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.32 $45.32 N/A 4404612 Pharmacy clindamycin 150 mg/mL IV Sol [BCH] 258 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400718 Pharmacy clindamycin 150 mg/mL IV Sol [BCH] 250 $- $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400718 Pharmacy clindamycin 150 mg/mL Sol [BCH] 636 $- $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4409844 Pharmacy methylPREDNISolone 80 mg/mL Inj Susp [BCH] J1040 636 $34.48 $- $8.97 $- $- $27.59 $- N/A $8.97 N/A N/A Not Reimbursed N/A N/A $20.69 N/A N/A $17.24 N/A N/A N/A N/A N/A $23.45 N/A N/A $21.38 N/A N/A $14.14 N/A N/A $24.14 N/A N/A $27.59 N/A N/A $18.97 N/A N/A $24.14 N/A N/A $11.55 N/A N/A N/A N/A N/A $20.69 N/A N/A $12.07 N/A N/A $22.41 N/A N/A $11.70 N/A N/A $20.69 N/A N/A $24.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.48 $34.48 N/A 4409733 Pharmacy ibutilide 0.1 mg/mL IV Sol [BCH] J1742 258 "$1,085.44 " $- $237.99 $- $- $868.35 $- N/A $282.21 N/A N/A Not Reimbursed N/A N/A $651.26 N/A N/A $542.72 N/A N/A N/A N/A N/A $738.10 N/A N/A $672.97 N/A N/A $445.03 N/A N/A $759.81 N/A N/A $868.35 N/A N/A $596.99 N/A N/A $759.81 N/A N/A $363.62 N/A N/A N/A N/A N/A $651.26 N/A N/A $379.90 N/A N/A $705.54 N/A N/A $237.99 N/A N/A $651.26 N/A N/A $759.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,085.44 " "$1,085.44 " N/A 4404612 Pharmacy clindamycin 150 mg/mL Sol [BCH] 258 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409535 Pharmacy linezolid 2 mg/mL-D5% Sol [BCH] J2020 636 $192.00 $- $6.46 $- $- $153.60 $- N/A $49.92 N/A N/A Not Reimbursed N/A N/A $115.20 N/A N/A $96.00 N/A N/A N/A N/A N/A $130.56 N/A N/A $119.04 N/A N/A $78.72 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A N/A N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $6.46 N/A N/A $115.20 N/A N/A $134.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $192.00 $192.00 N/A 4409755 Pharmacy linezolid 600 mg Tab [BCH] 250 $408.16 $- $106.12 $- $- $326.53 $- N/A $106.12 N/A N/A $154.28 N/A N/A $244.90 N/A N/A $204.08 N/A N/A N/A N/A N/A $277.55 N/A N/A $253.06 N/A N/A $167.35 N/A N/A $285.71 N/A N/A $326.53 N/A N/A $224.49 N/A N/A $285.71 N/A N/A $136.73 N/A N/A N/A N/A N/A $244.90 N/A N/A $142.86 N/A N/A $265.30 N/A N/A N/A N/A N/A $244.90 N/A N/A $285.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $408.16 $408.16 N/A 4409535 Pharmacy linezolid 2 mg/mL IV Sol [BCH] J2020 258 $192.00 $- $6.46 $- $- $153.60 $- N/A $49.92 N/A N/A Not Reimbursed N/A N/A $115.20 N/A N/A $96.00 N/A N/A N/A N/A N/A $130.56 N/A N/A $119.04 N/A N/A $78.72 N/A N/A $134.40 N/A N/A $153.60 N/A N/A $105.60 N/A N/A $134.40 N/A N/A $64.32 N/A N/A N/A N/A N/A $115.20 N/A N/A $67.20 N/A N/A $124.80 N/A N/A $6.46 N/A N/A $115.20 N/A N/A $134.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $192.00 $192.00 N/A 4400240 Pharmacy sulfaSALAzine 500 mg Tab [BCH] 250 $3.64 $- $0.95 $- $- $2.91 $- N/A $0.95 N/A N/A $1.38 N/A N/A $2.18 N/A N/A $1.82 N/A N/A N/A N/A N/A $2.48 N/A N/A $2.26 N/A N/A $1.49 N/A N/A $2.55 N/A N/A $2.91 N/A N/A $2.00 N/A N/A $2.55 N/A N/A $1.22 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.27 N/A N/A $2.37 N/A N/A N/A N/A N/A $2.18 N/A N/A $2.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.64 $3.64 N/A 4400122 Pharmacy ocular lubricant Oint [BCH] 250 $22.78 $- $5.92 $- $- $18.22 $- N/A $5.92 N/A N/A $8.61 N/A N/A $13.67 N/A N/A $11.39 N/A N/A N/A N/A N/A $15.49 N/A N/A $14.12 N/A N/A $9.34 N/A N/A $15.95 N/A N/A $18.22 N/A N/A $12.53 N/A N/A $15.95 N/A N/A $7.63 N/A N/A N/A N/A N/A $13.67 N/A N/A $7.97 N/A N/A $14.81 N/A N/A N/A N/A N/A $13.67 N/A N/A $15.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.78 $22.78 N/A 4400555 Pharmacy ocular lubricant Sol [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400804 Pharmacy ocular lubricant Sol [BCH] 250 $13.33 $- $3.47 $- $- $10.66 $- N/A $3.47 N/A N/A $5.04 N/A N/A $8.00 N/A N/A $6.66 N/A N/A N/A N/A N/A $9.06 N/A N/A $8.26 N/A N/A $5.47 N/A N/A $9.33 N/A N/A $10.66 N/A N/A $7.33 N/A N/A $9.33 N/A N/A $4.47 N/A N/A N/A N/A N/A $8.00 N/A N/A $4.67 N/A N/A $8.66 N/A N/A N/A N/A N/A $8.00 N/A N/A $9.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.33 $13.33 N/A 4409700 Pharmacy ketorolac Ophth 0.5% Sol [BCH] 250 $547.56 $- $142.37 $- $- $438.05 $- N/A $142.37 N/A N/A $206.98 N/A N/A $328.54 N/A N/A $273.78 N/A N/A N/A N/A N/A $372.34 N/A N/A $339.49 N/A N/A $224.50 N/A N/A $383.29 N/A N/A $438.05 N/A N/A $301.16 N/A N/A $383.29 N/A N/A $183.43 N/A N/A N/A N/A N/A $328.54 N/A N/A $191.65 N/A N/A $355.91 N/A N/A N/A N/A N/A $328.54 N/A N/A $383.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $547.56 $547.56 N/A 4409699 Pharmacy bimatoprost ophthalmic 0.01% Sol [BCH] 250 $360.04 $- $93.61 $- $- $288.03 $- N/A $93.61 N/A N/A $136.10 N/A N/A $216.02 N/A N/A $180.02 N/A N/A N/A N/A N/A $244.83 N/A N/A $223.22 N/A N/A $147.62 N/A N/A $252.03 N/A N/A $288.03 N/A N/A $198.02 N/A N/A $252.03 N/A N/A $120.61 N/A N/A N/A N/A N/A $216.02 N/A N/A $126.01 N/A N/A $234.03 N/A N/A N/A N/A N/A $216.02 N/A N/A $252.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $360.04 $360.04 N/A 4400862 Pharmacy mesalamine 400 mg Cap 250 $9.31 $- $2.42 $- $- $7.45 $- N/A $2.42 N/A N/A $3.52 N/A N/A $5.59 N/A N/A $4.66 N/A N/A N/A N/A N/A $6.33 N/A N/A $5.77 N/A N/A $3.82 N/A N/A $6.52 N/A N/A $7.45 N/A N/A $5.12 N/A N/A $6.52 N/A N/A $3.12 N/A N/A N/A N/A N/A $5.59 N/A N/A $3.26 N/A N/A $6.05 N/A N/A N/A N/A N/A $5.59 N/A N/A $6.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.31 $9.31 N/A 4405172 Pharmacy iron dextran 50 mg/mL Sol [BCH] J1750 636 $73.62 $- $15.02 $- $- $58.89 $- N/A $19.14 N/A N/A Not Reimbursed N/A N/A $44.17 N/A N/A $36.81 N/A N/A N/A N/A N/A $50.06 N/A N/A $45.64 N/A N/A $30.18 N/A N/A $51.53 N/A N/A $58.89 N/A N/A $40.49 N/A N/A $51.53 N/A N/A $24.66 N/A N/A N/A N/A N/A $44.17 N/A N/A $25.77 N/A N/A $47.85 N/A N/A $15.02 N/A N/A $44.17 N/A N/A $51.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $73.62 $73.62 N/A 4400953 Pharmacy Pancrelipase 5k-17k-24k Cap 250 $3.71 $- $0.97 $- $- $2.97 $- N/A $0.97 N/A N/A $1.40 N/A N/A $2.23 N/A N/A $1.86 N/A N/A N/A N/A N/A $2.53 N/A N/A $2.30 N/A N/A $1.52 N/A N/A $2.60 N/A N/A $2.97 N/A N/A $2.04 N/A N/A $2.60 N/A N/A $1.24 N/A N/A N/A N/A N/A $2.23 N/A N/A $1.30 N/A N/A $2.41 N/A N/A N/A N/A N/A $2.23 N/A N/A $2.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.71 $3.71 N/A 4400798 Pharmacy polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Sol [BCH] 250 $191.68 $- $49.84 $- $- $153.34 $- N/A $49.84 N/A N/A $72.46 N/A N/A $115.01 N/A N/A $95.84 N/A N/A N/A N/A N/A $130.34 N/A N/A $118.84 N/A N/A $78.59 N/A N/A $134.18 N/A N/A $153.34 N/A N/A $105.42 N/A N/A $134.18 N/A N/A $64.21 N/A N/A N/A N/A N/A $115.01 N/A N/A $67.09 N/A N/A $124.59 N/A N/A N/A N/A N/A $115.01 N/A N/A $134.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $191.68 $191.68 N/A 4400595 Pharmacy cycloSPORINE Ophth 0.05% Emul [BCH] 250 $17.07 $- $4.44 $- $- $13.66 $- N/A $4.44 N/A N/A $6.45 N/A N/A $10.24 N/A N/A $8.53 N/A N/A N/A N/A N/A $11.61 N/A N/A $10.58 N/A N/A $7.00 N/A N/A $11.95 N/A N/A $13.66 N/A N/A $9.39 N/A N/A $11.95 N/A N/A $5.72 N/A N/A N/A N/A N/A $10.24 N/A N/A $5.97 N/A N/A $11.10 N/A N/A N/A N/A N/A $10.24 N/A N/A $11.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.07 $17.07 N/A 4400573 Pharmacy brimonidine-timolol Ophth 0.2%-0.5% Sol [BCH] 250 $322.32 $- $83.80 $- $- $257.86 $- N/A $83.80 N/A N/A $121.84 N/A N/A $193.39 N/A N/A $161.16 N/A N/A N/A N/A N/A $219.18 N/A N/A $199.84 N/A N/A $132.15 N/A N/A $225.62 N/A N/A $257.86 N/A N/A $177.28 N/A N/A $225.62 N/A N/A $107.98 N/A N/A N/A N/A N/A $193.39 N/A N/A $112.81 N/A N/A $209.51 N/A N/A N/A N/A N/A $193.39 N/A N/A $225.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $322.32 $322.32 N/A 4400374 Pharmacy brimonidine Ophth 0.1% Sol [BCH] 250 $292.42 $- $76.03 $- $- $233.94 $- N/A $76.03 N/A N/A $110.53 N/A N/A $175.45 N/A N/A $146.21 N/A N/A N/A N/A N/A $198.85 N/A N/A $181.30 N/A N/A $119.89 N/A N/A $204.69 N/A N/A $233.94 N/A N/A $160.83 N/A N/A $204.69 N/A N/A $97.96 N/A N/A N/A N/A N/A $175.45 N/A N/A $102.35 N/A N/A $190.07 N/A N/A N/A N/A N/A $175.45 N/A N/A $204.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $292.42 $292.42 N/A 4400363 Pharmacy phenylephrine nasal 0.25% Sol 15 mL [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4400160 Pharmacy phenylephrine Nasal 0.5% Spry [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4409022 Pharmacy celecoxib 100 mg Cap [BCH] 250 $14.73 $- $3.83 $- $- $11.78 $- N/A $3.83 N/A N/A $5.57 N/A N/A $8.84 N/A N/A $7.36 N/A N/A N/A N/A N/A $10.02 N/A N/A $9.13 N/A N/A $6.04 N/A N/A $10.31 N/A N/A $11.78 N/A N/A $8.10 N/A N/A $10.31 N/A N/A $4.93 N/A N/A N/A N/A N/A $8.84 N/A N/A $5.16 N/A N/A $9.57 N/A N/A N/A N/A N/A $8.84 N/A N/A $10.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.73 $14.73 N/A 4408966 Pharmacy celecoxib 200 mg Cap [BCH] 250 $24.16 $- $6.28 $- $- $19.33 $- N/A $6.28 N/A N/A $9.13 N/A N/A $14.50 N/A N/A $12.08 N/A N/A N/A N/A N/A $16.43 N/A N/A $14.98 N/A N/A $9.91 N/A N/A $16.91 N/A N/A $19.33 N/A N/A $13.29 N/A N/A $16.91 N/A N/A $8.09 N/A N/A N/A N/A N/A $14.50 N/A N/A $8.46 N/A N/A $15.70 N/A N/A N/A N/A N/A $14.50 N/A N/A $16.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.16 $24.16 N/A 4405123 Pharmacy tetanus immune globulin 250 units IM Sol 1 mL [BCH] J1670 636 "$1,096.58 " $- $285.11 $- $- $877.26 $- N/A $285.11 N/A N/A Not Reimbursed N/A N/A $657.95 N/A N/A $548.29 N/A N/A N/A N/A N/A $745.67 N/A N/A $679.88 N/A N/A $449.60 N/A N/A $767.61 N/A N/A $877.26 N/A N/A $603.12 N/A N/A $767.61 N/A N/A $367.35 N/A N/A N/A N/A N/A $657.95 N/A N/A $383.80 N/A N/A $712.78 N/A N/A $535.78 N/A N/A $657.95 N/A N/A $767.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,096.58 " "$1,096.58 " N/A 4401748 Pharmacy mupirocin Top 2% nasal Oint w/appl [BCH] 250 $40.97 $- $10.65 $- $- $32.78 $- N/A $10.65 N/A N/A $15.49 N/A N/A $24.58 N/A N/A $20.49 N/A N/A N/A N/A N/A $27.86 N/A N/A $25.40 N/A N/A $16.80 N/A N/A $28.68 N/A N/A $32.78 N/A N/A $22.53 N/A N/A $28.68 N/A N/A $13.73 N/A N/A N/A N/A N/A $24.58 N/A N/A $14.34 N/A N/A $26.63 N/A N/A N/A N/A N/A $24.58 N/A N/A $28.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.97 $40.97 N/A 4404353 Pharmacy conjugated estrogens 0.625 mg/g Vag Crm w/Appl [BCH] 250 $757.48 $- $196.95 $- $- $605.99 $- N/A $196.95 N/A N/A $286.33 N/A N/A $454.49 N/A N/A $378.74 N/A N/A N/A N/A N/A $515.09 N/A N/A $469.64 N/A N/A $310.57 N/A N/A $530.24 N/A N/A $605.99 N/A N/A $416.62 N/A N/A $530.24 N/A N/A $253.76 N/A N/A N/A N/A N/A $454.49 N/A N/A $265.12 N/A N/A $492.36 N/A N/A N/A N/A N/A $454.49 N/A N/A $530.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $757.48 $757.48 N/A 4407327 Pharmacy conjugated estrogens 0.625 mg Tab [BCH] 250 $11.40 $- $2.96 $- $- $9.12 $- N/A $2.96 N/A N/A $4.31 N/A N/A $6.84 N/A N/A $5.70 N/A N/A N/A N/A N/A $7.75 N/A N/A $7.07 N/A N/A $4.67 N/A N/A $7.98 N/A N/A $9.12 N/A N/A $6.27 N/A N/A $7.98 N/A N/A $3.82 N/A N/A N/A N/A N/A $6.84 N/A N/A $3.99 N/A N/A $7.41 N/A N/A N/A N/A N/A $6.84 N/A N/A $7.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.40 $11.40 N/A 4400791 Pharmacy conjugated estrogens 1.25 mg Tab [BCH] 250 $11.40 $- $2.96 $- $- $9.12 $- N/A $2.96 N/A N/A $4.31 N/A N/A $6.84 N/A N/A $5.70 N/A N/A N/A N/A N/A $7.75 N/A N/A $7.07 N/A N/A $4.67 N/A N/A $7.98 N/A N/A $9.12 N/A N/A $6.27 N/A N/A $7.98 N/A N/A $3.82 N/A N/A N/A N/A N/A $6.84 N/A N/A $3.99 N/A N/A $7.41 N/A N/A N/A N/A N/A $6.84 N/A N/A $7.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.40 $11.40 N/A 4400746 Pharmacy conjugated estrogens-medroxyPROGESTERone 0.45 mg-1.5 mg Tab [BCH] 250 $13.99 $- $3.64 $- $- $11.19 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.39 N/A N/A $6.99 N/A N/A N/A N/A N/A $9.51 N/A N/A $8.67 N/A N/A $5.73 N/A N/A $9.79 N/A N/A $11.19 N/A N/A $7.69 N/A N/A $9.79 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.39 N/A N/A $4.90 N/A N/A $9.09 N/A N/A N/A N/A N/A $8.39 N/A N/A $9.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.99 $13.99 N/A 4406964 Pharmacy ampicillin-sulbactam 1 g-0.5 g Inj [BCH] J0295 636 $28.00 $- $2.76 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.76 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400177 Pharmacy ampicillin-sulbactam 2 g-1 g Inj [BCH] J0295 636 $34.43 $- $2.76 $- $- $27.54 $- N/A $8.95 N/A N/A Not Reimbursed N/A N/A $20.66 N/A N/A $17.22 N/A N/A N/A N/A N/A $23.41 N/A N/A $21.35 N/A N/A $14.12 N/A N/A $24.10 N/A N/A $27.54 N/A N/A $18.94 N/A N/A $24.10 N/A N/A $11.53 N/A N/A N/A N/A N/A $20.66 N/A N/A $12.05 N/A N/A $22.38 N/A N/A $2.76 N/A N/A $20.66 N/A N/A $24.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.43 $34.43 N/A 4400946 Pharmacy "penicillin G potassium 20,000,000 units Pow" J2540 636 $- $- $1.11 $- $- $97.18 $- N/A $31.58 N/A N/A Not Reimbursed N/A N/A $72.89 N/A N/A $60.74 N/A N/A N/A N/A N/A $82.61 N/A N/A $75.32 N/A N/A $49.81 N/A N/A $85.04 N/A N/A $97.18 N/A N/A $66.81 N/A N/A $85.04 N/A N/A $40.70 N/A N/A N/A N/A N/A $72.89 N/A N/A $42.52 N/A N/A $78.96 N/A N/A $1.11 N/A N/A $72.89 N/A N/A $85.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400672 Pharmacy ziprasidone 20 mg IM Inj [BCH] J3486 636 $90.96 $- $17.22 $- $- $72.77 $- N/A $23.65 N/A N/A Not Reimbursed N/A N/A $54.58 N/A N/A $45.48 N/A N/A N/A N/A N/A $61.85 N/A N/A $56.40 N/A N/A $37.29 N/A N/A $63.67 N/A N/A $72.77 N/A N/A $50.03 N/A N/A $63.67 N/A N/A $30.47 N/A N/A N/A N/A N/A $54.58 N/A N/A $31.84 N/A N/A $59.13 N/A N/A $17.22 N/A N/A $54.58 N/A N/A $63.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.96 $90.96 N/A 4400480 Pharmacy testosterone 50 mg/5 g TD Gel [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400500 Pharmacy alpha 1-proteinase inhibitor human Pow [BCH] J0256 636 "$1,494.00 " $- $4.38 $- $- "$1,195.20 " $- N/A $388.44 N/A N/A Not Reimbursed N/A N/A $896.40 N/A N/A $747.00 N/A N/A N/A N/A N/A "$1,015.92 " N/A N/A $926.28 N/A N/A $612.54 N/A N/A "$1,045.80 " N/A N/A "$1,195.20 " N/A N/A $821.70 N/A N/A "$1,045.80 " N/A N/A $500.49 N/A N/A N/A N/A N/A $896.40 N/A N/A $522.90 N/A N/A $971.10 N/A N/A $4.38 N/A N/A $896.40 N/A N/A "$1,045.80 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,494.00 " "$1,494.00 " N/A 4406143 Pharmacy flecainide 50 mg Tab 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.63 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4406143 Pharmacy flecainide 50 mg Tab [BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.63 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4406143 Pharmacy flecainide 50 mg Tab [BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.63 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4408453 Pharmacy predniSONE 10 mg Tab J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408453 Pharmacy predniSONE 10 mg Tab [BCH] J7506 250 $5.01 $- $1.30 $- $- $4.01 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.05 N/A N/A $3.51 N/A N/A $4.01 N/A N/A $2.76 N/A N/A $3.51 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.75 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4408446 Pharmacy predniSONE 20 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408446 Pharmacy predniSONE 20 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409385 Pharmacy cilostazol 100 mg Tab [BCH] 250 $3.65 $- $0.95 $- $- $2.92 $- N/A $0.95 N/A N/A $1.38 N/A N/A $2.19 N/A N/A $1.82 N/A N/A N/A N/A N/A $2.48 N/A N/A $2.26 N/A N/A $1.50 N/A N/A $2.55 N/A N/A $2.92 N/A N/A $2.01 N/A N/A $2.55 N/A N/A $1.22 N/A N/A N/A N/A N/A $2.19 N/A N/A $1.28 N/A N/A $2.37 N/A N/A N/A N/A N/A $2.19 N/A N/A $2.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.65 $3.65 N/A 4400795 Pharmacy ipratropium Nasal 0.03% Spry [BCH] 250 $7.44 $- $1.94 $- $- $5.96 $- N/A $1.94 N/A N/A $2.81 N/A N/A $4.47 N/A N/A $3.72 N/A N/A N/A N/A N/A $5.06 N/A N/A $4.62 N/A N/A $3.05 N/A N/A $5.21 N/A N/A $5.96 N/A N/A $4.09 N/A N/A $5.21 N/A N/A $2.49 N/A N/A N/A N/A N/A $4.47 N/A N/A $2.61 N/A N/A $4.84 N/A N/A N/A N/A N/A $4.47 N/A N/A $5.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.44 $7.44 N/A 4409505 Pharmacy ipratropium Nasal 0.06% Spry [BCH] 250 $191.42 $- $49.77 $- $- $153.14 $- N/A $49.77 N/A N/A $72.36 N/A N/A $114.85 N/A N/A $95.71 N/A N/A N/A N/A N/A $130.17 N/A N/A $118.68 N/A N/A $78.48 N/A N/A $133.99 N/A N/A $153.14 N/A N/A $105.28 N/A N/A $133.99 N/A N/A $64.13 N/A N/A N/A N/A N/A $114.85 N/A N/A $67.00 N/A N/A $124.42 N/A N/A N/A N/A N/A $114.85 N/A N/A $133.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $191.42 $191.42 N/A 4400705 Pharmacy calcium acetate 667 mg Cap [BCH] 250 $2.05 $- $0.53 $- $- $1.64 $- N/A $0.53 N/A N/A $0.78 N/A N/A $1.23 N/A N/A $1.03 N/A N/A N/A N/A N/A $1.40 N/A N/A $1.27 N/A N/A $0.84 N/A N/A $1.44 N/A N/A $1.64 N/A N/A $1.13 N/A N/A $1.44 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.23 N/A N/A $0.72 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.23 N/A N/A $1.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.05 $2.05 N/A 4409537 Pharmacy galantamine 4 mg Tab 250 $6.36 $- $1.65 $- $- $5.09 $- N/A $1.65 N/A N/A $2.41 N/A N/A $3.82 N/A N/A $3.18 N/A N/A N/A N/A N/A $4.33 N/A N/A $3.95 N/A N/A $2.61 N/A N/A $4.46 N/A N/A $5.09 N/A N/A $3.50 N/A N/A $4.46 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.82 N/A N/A $2.23 N/A N/A $4.14 N/A N/A N/A N/A N/A $3.82 N/A N/A $4.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.36 $6.36 N/A 4409660 Pharmacy OXcarbazepine 150 mg Tab 250 $3.05 $- $0.79 $- $- $2.44 $- N/A $0.79 N/A N/A $1.15 N/A N/A $1.83 N/A N/A $1.53 N/A N/A N/A N/A N/A $2.08 N/A N/A $1.89 N/A N/A $1.25 N/A N/A $2.14 N/A N/A $2.44 N/A N/A $1.68 N/A N/A $2.14 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.07 N/A N/A $1.98 N/A N/A N/A N/A N/A $1.83 N/A N/A $2.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.05 $3.05 N/A 4409660 Pharmacy oxcarbazepine 150 mg Tab [BCH] 250 $2.91 $- $0.76 $- $- $2.33 $- N/A $0.76 N/A N/A $1.10 N/A N/A $1.74 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.98 N/A N/A $1.80 N/A N/A $1.19 N/A N/A $2.04 N/A N/A $2.33 N/A N/A $1.60 N/A N/A $2.04 N/A N/A $0.97 N/A N/A N/A N/A N/A $1.74 N/A N/A $1.02 N/A N/A $1.89 N/A N/A N/A N/A N/A $1.74 N/A N/A $2.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.91 $2.91 N/A 4400712 Pharmacy OXcarbazepine 300 mg Tab 250 $5.57 $- $1.45 $- $- $4.46 $- N/A $1.45 N/A N/A $2.11 N/A N/A $3.34 N/A N/A $2.79 N/A N/A N/A N/A N/A $3.79 N/A N/A $3.46 N/A N/A $2.29 N/A N/A $3.90 N/A N/A $4.46 N/A N/A $3.07 N/A N/A $3.90 N/A N/A $1.87 N/A N/A N/A N/A N/A $3.34 N/A N/A $1.95 N/A N/A $3.62 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.57 $5.57 N/A 4400712 Pharmacy oxcarbazepine 300 mg Tab [BCH] 250 $5.31 $- $1.38 $- $- $4.25 $- N/A $1.38 N/A N/A $2.01 N/A N/A $3.19 N/A N/A $2.65 N/A N/A N/A N/A N/A $3.61 N/A N/A $3.29 N/A N/A $2.18 N/A N/A $3.72 N/A N/A $4.25 N/A N/A $2.92 N/A N/A $3.72 N/A N/A $1.78 N/A N/A N/A N/A N/A $3.19 N/A N/A $1.86 N/A N/A $3.45 N/A N/A N/A N/A N/A $3.19 N/A N/A $3.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.31 $5.31 N/A 4405673 Pharmacy ramipril 2.5 mg Cap [BCH] 250 $3.61 $- $0.94 $- $- $2.89 $- N/A $0.94 N/A N/A $1.37 N/A N/A $2.17 N/A N/A $1.81 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.24 N/A N/A $1.48 N/A N/A $2.53 N/A N/A $2.89 N/A N/A $1.99 N/A N/A $2.53 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.26 N/A N/A $2.35 N/A N/A N/A N/A N/A $2.17 N/A N/A $2.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.61 $3.61 N/A 4409147 Pharmacy ropinirole 0.25 mg Tab [BCH] 250 $5.01 $- $1.30 $- $- $4.01 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.05 N/A N/A $3.51 N/A N/A $4.01 N/A N/A $2.76 N/A N/A $3.51 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.75 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4400762 Pharmacy morphine 15 mg IR Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403812 Pharmacy morphine 20 mg/mL Oral Conc [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403812 Pharmacy morphine 20 mg/mL Oral Conc [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400792 Pharmacy ritonavir 100 mg Tab [BCH] 250 $18.52 $- $4.81 $- $- $14.81 $- N/A $4.81 N/A N/A $7.00 N/A N/A $11.11 N/A N/A $9.26 N/A N/A N/A N/A N/A $12.59 N/A N/A $11.48 N/A N/A $7.59 N/A N/A $12.96 N/A N/A $14.81 N/A N/A $10.18 N/A N/A $12.96 N/A N/A $6.20 N/A N/A N/A N/A N/A $11.11 N/A N/A $6.48 N/A N/A $12.04 N/A N/A N/A N/A N/A $11.11 N/A N/A $12.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.52 $18.52 N/A 4409838 Pharmacy lithium 150 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400128 Pharmacy dexamethasone 0.5 mg/5 mL Oral Elix [BCH] J8540 636 $127.38 $- $0.10 $- $- $101.90 $- N/A $33.12 N/A N/A Not Reimbursed N/A N/A $76.43 N/A N/A $63.69 N/A N/A N/A N/A N/A $86.62 N/A N/A $78.98 N/A N/A $52.23 N/A N/A $89.17 N/A N/A $101.90 N/A N/A $70.06 N/A N/A $89.17 N/A N/A $42.67 N/A N/A N/A N/A N/A $76.43 N/A N/A $44.58 N/A N/A $82.80 N/A N/A $0.10 N/A N/A $76.43 N/A N/A $89.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $127.38 $127.38 N/A 4409030 Pharmacy fluticasone Nasal 0.05 mg/inh Spry [BCH] 250 $150.54 $- $39.14 $- $- $120.43 $- N/A $39.14 N/A N/A $56.90 N/A N/A $90.32 N/A N/A $75.27 N/A N/A N/A N/A N/A $102.37 N/A N/A $93.33 N/A N/A $61.72 N/A N/A $105.38 N/A N/A $120.43 N/A N/A $82.80 N/A N/A $105.38 N/A N/A $50.43 N/A N/A N/A N/A N/A $90.32 N/A N/A $52.69 N/A N/A $97.85 N/A N/A N/A N/A N/A $90.32 N/A N/A $105.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $150.54 $150.54 N/A 4409950 Pharmacy lidocaine Top 4% Sol [BCH] 250 $36.64 $- $9.53 $- $- $29.31 $- N/A $9.53 N/A N/A $13.85 N/A N/A $21.98 N/A N/A $18.32 N/A N/A N/A N/A N/A $24.92 N/A N/A $22.72 N/A N/A $15.02 N/A N/A $25.65 N/A N/A $29.31 N/A N/A $20.15 N/A N/A $25.65 N/A N/A $12.27 N/A N/A N/A N/A N/A $21.98 N/A N/A $12.82 N/A N/A $23.82 N/A N/A N/A N/A N/A $21.98 N/A N/A $25.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.64 $36.64 N/A 4400297 Pharmacy LORazepam 2 mg/mL Oral Conc [BCH] 250 $96.06 $- $24.98 $- $- $76.85 $- N/A $24.98 N/A N/A $36.31 N/A N/A $57.64 N/A N/A $48.03 N/A N/A N/A N/A N/A $65.32 N/A N/A $59.56 N/A N/A $39.38 N/A N/A $67.24 N/A N/A $76.85 N/A N/A $52.83 N/A N/A $67.24 N/A N/A $32.18 N/A N/A N/A N/A N/A $57.64 N/A N/A $33.62 N/A N/A $62.44 N/A N/A N/A N/A N/A $57.64 N/A N/A $67.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $96.06 $96.06 N/A 4400797 Pharmacy methadone 10 mg/mL Oral Conc [BCH] 250 $10.14 $- $2.64 $- $- $8.11 $- N/A $2.64 N/A N/A $3.83 N/A N/A $6.08 N/A N/A $5.07 N/A N/A N/A N/A N/A $6.90 N/A N/A $6.29 N/A N/A $4.16 N/A N/A $7.10 N/A N/A $8.11 N/A N/A $5.58 N/A N/A $7.10 N/A N/A $3.40 N/A N/A N/A N/A N/A $6.08 N/A N/A $3.55 N/A N/A $6.59 N/A N/A N/A N/A N/A $6.08 N/A N/A $7.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.14 $10.14 N/A 4400728 Pharmacy azaTHIOprine 50 mg Tab [BCH] J7500 636 $2.62 $- $0.68 $- $- $2.10 $- N/A $0.68 N/A N/A Not Reimbursed N/A N/A $1.57 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.78 N/A N/A $1.63 N/A N/A $1.07 N/A N/A $1.84 N/A N/A $2.10 N/A N/A $1.44 N/A N/A $1.84 N/A N/A $0.88 N/A N/A N/A N/A N/A $1.57 N/A N/A $0.92 N/A N/A $1.70 N/A N/A $0.68 N/A N/A $1.57 N/A N/A $1.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.62 $2.62 N/A 4409360 Pharmacy clotrimazole 10 mg Loz [BCH] 250 $6.43 $- $1.67 $- $- $5.14 $- N/A $1.67 N/A N/A $2.43 N/A N/A $3.86 N/A N/A $3.22 N/A N/A N/A N/A N/A $4.37 N/A N/A $3.99 N/A N/A $2.64 N/A N/A $4.50 N/A N/A $5.14 N/A N/A $3.54 N/A N/A $4.50 N/A N/A $2.15 N/A N/A N/A N/A N/A $3.86 N/A N/A $2.25 N/A N/A $4.18 N/A N/A N/A N/A N/A $3.86 N/A N/A $4.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.43 $6.43 N/A 4402095 Pharmacy dexamethasone 4 mg Tab [BCH] J8540 250 $2.00 $- $0.10 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A $0.10 N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401910 Pharmacy methotrexate 2.5 mg Tab [BCH] J8610 250 $7.13 $- $0.22 $- $- $5.70 $- N/A $1.85 N/A N/A Not Reimbursed N/A N/A $4.28 N/A N/A $3.56 N/A N/A N/A N/A N/A $4.85 N/A N/A $4.42 N/A N/A $2.92 N/A N/A $4.99 N/A N/A $5.70 N/A N/A $3.92 N/A N/A $4.99 N/A N/A $2.39 N/A N/A N/A N/A N/A $4.28 N/A N/A $2.49 N/A N/A $4.63 N/A N/A $0.22 N/A N/A $4.28 N/A N/A $4.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.13 $7.13 N/A 4409613 Pharmacy methadone 5 mg Tab [BCH] S0109 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408960 Pharmacy meperidine 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403868 Pharmacy predniSONE 1 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402095 Pharmacy dexamethasone 4 mg Tab [BCH] J8540 250 $2.41 $- $0.10 $- $- $1.93 $- N/A $0.63 N/A N/A Not Reimbursed N/A N/A $1.45 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.49 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.93 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.84 N/A N/A $1.57 N/A N/A $0.10 N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4403110 Pharmacy furosemide 20 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409838 Pharmacy lithium 150 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401910 Pharmacy methotrexate 2.5 mg Tab [BCH] J8610 636 $7.13 $- $0.22 $- $- $5.70 $- N/A $1.85 N/A N/A Not Reimbursed N/A N/A $4.28 N/A N/A $3.56 N/A N/A N/A N/A N/A $4.85 N/A N/A $4.42 N/A N/A $2.92 N/A N/A $4.99 N/A N/A $5.70 N/A N/A $3.92 N/A N/A $4.99 N/A N/A $2.39 N/A N/A N/A N/A N/A $4.28 N/A N/A $2.49 N/A N/A $4.63 N/A N/A $0.22 N/A N/A $4.28 N/A N/A $4.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.13 $7.13 N/A 4403868 Pharmacy predniSONE 1 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400675 Pharmacy warfarin 4 mg Tab [BCH] 250 $4.90 $- $1.27 $- $- $3.92 $- N/A $1.27 N/A N/A $1.85 N/A N/A $2.94 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.33 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.43 N/A N/A $3.92 N/A N/A $2.69 N/A N/A $3.43 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.94 N/A N/A $1.71 N/A N/A $3.18 N/A N/A N/A N/A N/A $2.94 N/A N/A $3.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.90 $4.90 N/A 4402641 Pharmacy warfarin 2 mg Tab [BCH] 250 $4.71 $- $1.23 $- $- $3.77 $- N/A $1.23 N/A N/A $1.78 N/A N/A $2.83 N/A N/A $2.36 N/A N/A N/A N/A N/A $3.21 N/A N/A $2.92 N/A N/A $1.93 N/A N/A $3.30 N/A N/A $3.77 N/A N/A $2.59 N/A N/A $3.30 N/A N/A $1.58 N/A N/A N/A N/A N/A $2.83 N/A N/A $1.65 N/A N/A $3.06 N/A N/A N/A N/A N/A $2.83 N/A N/A $3.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.71 $4.71 N/A 4405610 Pharmacy warfarin 5 mg Tab [BCH] 250 $5.07 $- $1.32 $- $- $4.06 $- N/A $1.32 N/A N/A $1.92 N/A N/A $3.04 N/A N/A $2.54 N/A N/A N/A N/A N/A $3.45 N/A N/A $3.14 N/A N/A $2.08 N/A N/A $3.55 N/A N/A $4.06 N/A N/A $2.79 N/A N/A $3.55 N/A N/A $1.70 N/A N/A N/A N/A N/A $3.04 N/A N/A $1.77 N/A N/A $3.30 N/A N/A N/A N/A N/A $3.04 N/A N/A $3.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.07 $5.07 N/A 4405602 Pharmacy warfarin 2.5 mg Tab [BCH] 250 $4.87 $- $1.26 $- $- $3.89 $- N/A $1.26 N/A N/A $1.84 N/A N/A $2.92 N/A N/A $2.43 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.02 N/A N/A $1.99 N/A N/A $3.41 N/A N/A $3.89 N/A N/A $2.68 N/A N/A $3.41 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.92 N/A N/A $1.70 N/A N/A $3.16 N/A N/A N/A N/A N/A $2.92 N/A N/A $3.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.87 $4.87 N/A 4402414 Pharmacy warfarin 3 mg Tab [BCH] 250 $4.88 $- $1.27 $- $- $3.91 $- N/A $1.27 N/A N/A $1.85 N/A N/A $2.93 N/A N/A $2.44 N/A N/A N/A N/A N/A $3.32 N/A N/A $3.03 N/A N/A $2.00 N/A N/A $3.42 N/A N/A $3.91 N/A N/A $2.69 N/A N/A $3.42 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.93 N/A N/A $1.71 N/A N/A $3.17 N/A N/A N/A N/A N/A $2.93 N/A N/A $3.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.88 $4.88 N/A 4402390 Pharmacy collagenase Top 250 units/g Oint [BCH] 250 $491.52 $- $127.80 $- $- $393.22 $- N/A $127.80 N/A N/A $185.79 N/A N/A $294.91 N/A N/A $245.76 N/A N/A N/A N/A N/A $334.23 N/A N/A $304.74 N/A N/A $201.52 N/A N/A $344.06 N/A N/A $393.22 N/A N/A $270.34 N/A N/A $344.06 N/A N/A $164.66 N/A N/A N/A N/A N/A $294.91 N/A N/A $172.03 N/A N/A $319.49 N/A N/A N/A N/A N/A $294.91 N/A N/A $344.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $491.52 $491.52 N/A 4400664 Pharmacy nepafenac Ophth 0.1% Susp [BCH] 250 $540.00 $- $140.40 $- $- $432.00 $- N/A $140.40 N/A N/A $204.12 N/A N/A $324.00 N/A N/A $270.00 N/A N/A N/A N/A N/A $367.20 N/A N/A $334.80 N/A N/A $221.40 N/A N/A $378.00 N/A N/A $432.00 N/A N/A $297.00 N/A N/A $378.00 N/A N/A $180.90 N/A N/A N/A N/A N/A $324.00 N/A N/A $189.00 N/A N/A $351.00 N/A N/A N/A N/A N/A $324.00 N/A N/A $378.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $540.00 $540.00 N/A 4409774 Pharmacy naphazoline-pheniramine Ophth 0.025%-0.3% Sol [BCH] 250 $18.04 $- $4.69 $- $- $14.43 $- N/A $4.69 N/A N/A $6.82 N/A N/A $10.82 N/A N/A $9.02 N/A N/A N/A N/A N/A $12.27 N/A N/A $11.18 N/A N/A $7.40 N/A N/A $12.63 N/A N/A $14.43 N/A N/A $9.92 N/A N/A $12.63 N/A N/A $6.04 N/A N/A N/A N/A N/A $10.82 N/A N/A $6.31 N/A N/A $11.73 N/A N/A N/A N/A N/A $10.82 N/A N/A $12.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.04 $18.04 N/A 4409637 Pharmacy travoprost 0.004% Ophth Sol [BCH] 250 $359.76 $- $93.54 $- $- $287.81 $- N/A $93.54 N/A N/A $135.99 N/A N/A $215.86 N/A N/A $179.88 N/A N/A N/A N/A N/A $244.64 N/A N/A $223.05 N/A N/A $147.50 N/A N/A $251.83 N/A N/A $287.81 N/A N/A $197.87 N/A N/A $251.83 N/A N/A $120.52 N/A N/A N/A N/A N/A $215.86 N/A N/A $125.92 N/A N/A $233.84 N/A N/A N/A N/A N/A $215.86 N/A N/A $251.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $359.76 $359.76 N/A 4409483 Pharmacy olopatadine Ophth 0.1% Sol [BCH] 250 $570.00 $- $148.20 $- $- $456.00 $- N/A $148.20 N/A N/A $215.46 N/A N/A $342.00 N/A N/A $285.00 N/A N/A N/A N/A N/A $387.60 N/A N/A $353.40 N/A N/A $233.70 N/A N/A $399.00 N/A N/A $456.00 N/A N/A $313.50 N/A N/A $399.00 N/A N/A $190.95 N/A N/A N/A N/A N/A $342.00 N/A N/A $199.50 N/A N/A $370.50 N/A N/A N/A N/A N/A $342.00 N/A N/A $399.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $570.00 $570.00 N/A 4409519 Pharmacy brinzolamide Ophth 1% Susp [BCH] 250 $600.00 $- $156.00 $- $- $480.00 $- N/A $156.00 N/A N/A $226.80 N/A N/A $360.00 N/A N/A $300.00 N/A N/A N/A N/A N/A $408.00 N/A N/A $372.00 N/A N/A $246.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A N/A N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A N/A N/A N/A $360.00 N/A N/A $420.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $600.00 $600.00 N/A 4409655 Pharmacy atropine ophthalmic 1% Sol [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407521 Pharmacy ocular lubricant preserved Sol [BCH] 250 $13.20 $- $3.43 $- $- $10.56 $- N/A $3.43 N/A N/A $4.99 N/A N/A $7.92 N/A N/A $6.60 N/A N/A N/A N/A N/A $8.98 N/A N/A $8.18 N/A N/A $5.41 N/A N/A $9.24 N/A N/A $10.56 N/A N/A $7.26 N/A N/A $9.24 N/A N/A $4.42 N/A N/A N/A N/A N/A $7.92 N/A N/A $4.62 N/A N/A $8.58 N/A N/A N/A N/A N/A $7.92 N/A N/A $9.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.20 $13.20 N/A 4407521 Pharmacy ocular lubricant preserved Sol 250 $14.38 $- $3.74 $- $- $11.50 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.63 N/A N/A $7.19 N/A N/A N/A N/A N/A $9.78 N/A N/A $8.92 N/A N/A $5.90 N/A N/A $10.07 N/A N/A $11.50 N/A N/A $7.91 N/A N/A $10.07 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.63 N/A N/A $5.03 N/A N/A $9.35 N/A N/A N/A N/A N/A $8.63 N/A N/A $10.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.38 $14.38 N/A 4407521 Pharmacy ocular lubricant preserved Sol [BCH] 250 $14.40 $- $3.74 $- $- $11.52 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A N/A N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400280 Pharmacy tobramycin Ophth 0.3% Oint [BCH] 250 $462.24 $- $120.18 $- $- $369.79 $- N/A $120.18 N/A N/A $174.73 N/A N/A $277.34 N/A N/A $231.12 N/A N/A N/A N/A N/A $314.32 N/A N/A $286.59 N/A N/A $189.52 N/A N/A $323.57 N/A N/A $369.79 N/A N/A $254.23 N/A N/A $323.57 N/A N/A $154.85 N/A N/A N/A N/A N/A $277.34 N/A N/A $161.78 N/A N/A $300.46 N/A N/A N/A N/A N/A $277.34 N/A N/A $323.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $462.24 $462.24 N/A 4404510 Pharmacy dexamethasone-tobramycin Ophth 0.1%-0.3% Oint [BCH] 250 $470.04 $- $122.21 $- $- $376.03 $- N/A $122.21 N/A N/A $177.68 N/A N/A $282.02 N/A N/A $235.02 N/A N/A N/A N/A N/A $319.63 N/A N/A $291.42 N/A N/A $192.72 N/A N/A $329.03 N/A N/A $376.03 N/A N/A $258.52 N/A N/A $329.03 N/A N/A $157.46 N/A N/A N/A N/A N/A $282.02 N/A N/A $164.51 N/A N/A $305.53 N/A N/A N/A N/A N/A $282.02 N/A N/A $329.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $470.04 $470.04 N/A 4409597 Pharmacy ciprofloxacin Ophth 0.3% Oint [BCH] 250 $462.24 $- $120.18 $- $- $369.79 $- N/A $120.18 N/A N/A $174.73 N/A N/A $277.34 N/A N/A $231.12 N/A N/A N/A N/A N/A $314.32 N/A N/A $286.59 N/A N/A $189.52 N/A N/A $323.57 N/A N/A $369.79 N/A N/A $254.23 N/A N/A $323.57 N/A N/A $154.85 N/A N/A N/A N/A N/A $277.34 N/A N/A $161.78 N/A N/A $300.46 N/A N/A N/A N/A N/A $277.34 N/A N/A $323.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $462.24 $462.24 N/A 4409804 Pharmacy apracloNIDine Ophth 1% Sol [BCH] 250 $119.58 $- $31.09 $- $- $95.66 $- N/A $31.09 N/A N/A $45.20 N/A N/A $71.75 N/A N/A $59.79 N/A N/A N/A N/A N/A $81.31 N/A N/A $74.14 N/A N/A $49.03 N/A N/A $83.71 N/A N/A $95.66 N/A N/A $65.77 N/A N/A $83.71 N/A N/A $40.06 N/A N/A N/A N/A N/A $71.75 N/A N/A $41.85 N/A N/A $77.73 N/A N/A N/A N/A N/A $71.75 N/A N/A $83.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $119.58 $119.58 N/A 4402467 Pharmacy tetracaine Ophth 0.5% Sol [BCH] 250 $22.06 $- $5.73 $- $- $17.65 $- N/A $5.73 N/A N/A $8.34 N/A N/A $13.23 N/A N/A $11.03 N/A N/A N/A N/A N/A $15.00 N/A N/A $13.68 N/A N/A $9.04 N/A N/A $15.44 N/A N/A $17.65 N/A N/A $12.13 N/A N/A $15.44 N/A N/A $7.39 N/A N/A N/A N/A N/A $13.23 N/A N/A $7.72 N/A N/A $14.34 N/A N/A N/A N/A N/A $13.23 N/A N/A $15.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.06 $22.06 N/A 4400928 Pharmacy tetracaine ophthalmic 0.5% Sol [BCH] 250 $5.79 $- $1.50 $- $- $4.63 $- N/A $1.50 N/A N/A $2.19 N/A N/A $3.47 N/A N/A $2.89 N/A N/A N/A N/A N/A $3.94 N/A N/A $3.59 N/A N/A $2.37 N/A N/A $4.05 N/A N/A $4.63 N/A N/A $3.18 N/A N/A $4.05 N/A N/A $1.94 N/A N/A N/A N/A N/A $3.47 N/A N/A $2.03 N/A N/A $3.76 N/A N/A N/A N/A N/A $3.47 N/A N/A $4.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.79 $5.79 N/A 4400206 Pharmacy "Ophth irrigation, intraocular Balanced Salt Sol [BCH]" 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409798 Pharmacy moxifloxacin 0.5% Ophth Sol [BCH] 250 $357.60 $- $92.98 $- $- $286.08 $- N/A $92.98 N/A N/A $135.17 N/A N/A $214.56 N/A N/A $178.80 N/A N/A N/A N/A N/A $243.17 N/A N/A $221.71 N/A N/A $146.62 N/A N/A $250.32 N/A N/A $286.08 N/A N/A $196.68 N/A N/A $250.32 N/A N/A $119.80 N/A N/A N/A N/A N/A $214.56 N/A N/A $125.16 N/A N/A $232.44 N/A N/A N/A N/A N/A $214.56 N/A N/A $250.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $357.60 $357.60 N/A 4400497 Pharmacy Antioxidant Multiple Vitamins and Minerals Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400768 Pharmacy acetaminophen/aspirin/caffeine 250 mg-250 mg-65 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400768 Pharmacy APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408503 Pharmacy scopolamine 1.5 mg Transderm ER Film [BCH] 250 $42.80 $- $11.13 $- $- $34.24 $- N/A $11.13 N/A N/A $16.18 N/A N/A $25.68 N/A N/A $21.40 N/A N/A N/A N/A N/A $29.10 N/A N/A $26.54 N/A N/A $17.55 N/A N/A $29.96 N/A N/A $34.24 N/A N/A $23.54 N/A N/A $29.96 N/A N/A $14.34 N/A N/A N/A N/A N/A $25.68 N/A N/A $14.98 N/A N/A $27.82 N/A N/A N/A N/A N/A $25.68 N/A N/A $29.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.80 $42.80 N/A 4408289 Pharmacy nicotine 7 mg/24 hr Transderm ER Film [BCH] 250 $5.04 $- $1.31 $- $- $4.03 $- N/A $1.31 N/A N/A $1.90 N/A N/A $3.02 N/A N/A $2.52 N/A N/A N/A N/A N/A $3.43 N/A N/A $3.12 N/A N/A $2.07 N/A N/A $3.53 N/A N/A $4.03 N/A N/A $2.77 N/A N/A $3.53 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.02 N/A N/A $1.76 N/A N/A $3.27 N/A N/A N/A N/A N/A $3.02 N/A N/A $3.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.04 $5.04 N/A 4408297 Pharmacy nicotine 14 mg/24 hr Transderm ER Film [BCH] 250 $5.04 $- $1.31 $- $- $4.03 $- N/A $1.31 N/A N/A $1.90 N/A N/A $3.02 N/A N/A $2.52 N/A N/A N/A N/A N/A $3.43 N/A N/A $3.12 N/A N/A $2.07 N/A N/A $3.53 N/A N/A $4.03 N/A N/A $2.77 N/A N/A $3.53 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.02 N/A N/A $1.76 N/A N/A $3.27 N/A N/A N/A N/A N/A $3.02 N/A N/A $3.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.04 $5.04 N/A 4408297 Pharmacy nicotine 14 mg/24 hr Transderm ER Film [BCH] 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Transderm ER Film [BCH] 250 $5.04 $- $1.31 $- $- $4.03 $- N/A $1.31 N/A N/A $1.90 N/A N/A $3.02 N/A N/A $2.52 N/A N/A N/A N/A N/A $3.43 N/A N/A $3.12 N/A N/A $2.07 N/A N/A $3.53 N/A N/A $4.03 N/A N/A $2.77 N/A N/A $3.53 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.02 N/A N/A $1.76 N/A N/A $3.27 N/A N/A N/A N/A N/A $3.02 N/A N/A $3.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.04 $5.04 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Transderm ER Film [BCH] 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4409481 Pharmacy rifAMPin 600 mg Pow [BCH] 636 $428.54 $- $111.42 $- $- $342.83 $- N/A $111.42 N/A N/A $161.99 N/A N/A $257.12 N/A N/A $214.27 N/A N/A N/A N/A N/A $291.41 N/A N/A $265.69 N/A N/A $175.70 N/A N/A $299.98 N/A N/A $342.83 N/A N/A $235.70 N/A N/A $299.98 N/A N/A $143.56 N/A N/A N/A N/A N/A $257.12 N/A N/A $149.99 N/A N/A $278.55 N/A N/A N/A N/A N/A $257.12 N/A N/A $299.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $428.54 $428.54 N/A 4409481 Pharmacy rifAMPin 600 mg Pow [BCH] 636 $428.54 $- $111.42 $- $- $342.83 $- N/A $111.42 N/A N/A $161.99 N/A N/A $257.12 N/A N/A $214.27 N/A N/A N/A N/A N/A $291.41 N/A N/A $265.69 N/A N/A $175.70 N/A N/A $299.98 N/A N/A $342.83 N/A N/A $235.70 N/A N/A $299.98 N/A N/A $143.56 N/A N/A N/A N/A N/A $257.12 N/A N/A $149.99 N/A N/A $278.55 N/A N/A N/A N/A N/A $257.12 N/A N/A $299.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $428.54 $428.54 N/A 4401771 Pharmacy etomidate 2 mg/mL IV Sol [BCH] 258 $23.54 $- $6.12 $- $- $18.84 $- N/A $6.12 N/A N/A $8.90 N/A N/A $14.13 N/A N/A $11.77 N/A N/A N/A N/A N/A $16.01 N/A N/A $14.60 N/A N/A $9.65 N/A N/A $16.48 N/A N/A $18.84 N/A N/A $12.95 N/A N/A $16.48 N/A N/A $7.89 N/A N/A N/A N/A N/A $14.13 N/A N/A $8.24 N/A N/A $15.30 N/A N/A N/A N/A N/A $14.13 N/A N/A $16.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.54 $23.54 N/A 4406062 Pharmacy fluconazole 200 mg/100 mL-NS IV Sol [BCH] J1450 636 $75.00 $- $16.11 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $16.11 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4405016 Pharmacy heparin 5000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404593 Pharmacy flumazenil 0.1 mg/mL IV Sol [BCH] 258 $16.32 $- $4.24 $- $- $13.06 $- N/A $4.24 N/A N/A $6.17 N/A N/A $9.79 N/A N/A $8.16 N/A N/A N/A N/A N/A $11.10 N/A N/A $10.12 N/A N/A $6.69 N/A N/A $11.42 N/A N/A $13.06 N/A N/A $8.98 N/A N/A $11.42 N/A N/A $5.47 N/A N/A N/A N/A N/A $9.79 N/A N/A $5.71 N/A N/A $10.61 N/A N/A N/A N/A N/A $9.79 N/A N/A $11.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.32 $16.32 N/A 4400210 Pharmacy pamidronate 3 mg/mL IV Sol [BCH] J2430 258 $64.80 $- $12.63 $- $- $51.84 $- N/A $16.85 N/A N/A Not Reimbursed N/A N/A $38.88 N/A N/A $32.40 N/A N/A N/A N/A N/A $44.06 N/A N/A $40.18 N/A N/A $26.57 N/A N/A $45.36 N/A N/A $51.84 N/A N/A $35.64 N/A N/A $45.36 N/A N/A $21.71 N/A N/A N/A N/A N/A $38.88 N/A N/A $22.68 N/A N/A $42.12 N/A N/A $12.63 N/A N/A $38.88 N/A N/A $45.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.80 $64.80 N/A 4409481 Pharmacy rifampin 600 mg IV Inj [BCH] 250 $156.00 $- $40.56 $- $- $124.80 $- N/A $40.56 N/A N/A $58.97 N/A N/A $93.60 N/A N/A $78.00 N/A N/A N/A N/A N/A $106.08 N/A N/A $96.72 N/A N/A $63.96 N/A N/A $109.20 N/A N/A $124.80 N/A N/A $85.80 N/A N/A $109.20 N/A N/A $52.26 N/A N/A N/A N/A N/A $93.60 N/A N/A $54.60 N/A N/A $101.40 N/A N/A N/A N/A N/A $93.60 N/A N/A $109.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $156.00 $156.00 N/A 4402019 Pharmacy azithromycin 250 mg Tab [BCH] 250 $5.10 $- $1.33 $- $- $4.08 $- N/A $1.33 N/A N/A $1.93 N/A N/A $3.06 N/A N/A $2.55 N/A N/A N/A N/A N/A $3.47 N/A N/A $3.16 N/A N/A $2.09 N/A N/A $3.57 N/A N/A $4.08 N/A N/A $2.81 N/A N/A $3.57 N/A N/A $1.71 N/A N/A N/A N/A N/A $3.06 N/A N/A $1.79 N/A N/A $3.32 N/A N/A N/A N/A N/A $3.06 N/A N/A $3.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.10 $5.10 N/A 4401515 Pharmacy azithromycin 500 mg IV Inj [BCH] J0456 636 $28.00 $- $3.42 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.42 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400624 Pharmacy fosphenytoin 500 mgPE/10 mL Sol [BCH] Q2009 636 $238.84 $- $62.10 $- $- $191.08 $- N/A $62.10 N/A N/A Not Reimbursed N/A N/A $143.31 N/A N/A $119.42 N/A N/A N/A N/A N/A $162.41 N/A N/A $148.08 N/A N/A $97.93 N/A N/A $167.19 N/A N/A $191.08 N/A N/A $131.36 N/A N/A $167.19 N/A N/A $80.01 N/A N/A N/A N/A N/A $143.31 N/A N/A $83.60 N/A N/A $155.25 N/A N/A N/A N/A N/A $143.31 N/A N/A $167.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $238.84 $238.84 N/A 4400624 Pharmacy fosphenytoin (PE) 500 mg/10 mL Inj Sol [BCH] Q2009 636 $238.84 $- $62.10 $- $- $191.08 $- N/A $62.10 N/A N/A Not Reimbursed N/A N/A $143.31 N/A N/A $119.42 N/A N/A N/A N/A N/A $162.41 N/A N/A $148.08 N/A N/A $97.93 N/A N/A $167.19 N/A N/A $191.08 N/A N/A $131.36 N/A N/A $167.19 N/A N/A $80.01 N/A N/A N/A N/A N/A $143.31 N/A N/A $83.60 N/A N/A $155.25 N/A N/A N/A N/A N/A $143.31 N/A N/A $167.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $238.84 $238.84 N/A 4405965 Pharmacy phenytoin 100 mg ERCap [BCH] 250 $2.26 $- $0.59 $- $- $1.81 $- N/A $0.59 N/A N/A $0.86 N/A N/A $1.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $1.54 N/A N/A $1.40 N/A N/A $0.93 N/A N/A $1.58 N/A N/A $1.81 N/A N/A $1.24 N/A N/A $1.58 N/A N/A $0.76 N/A N/A N/A N/A N/A $1.36 N/A N/A $0.79 N/A N/A $1.47 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.26 $2.26 N/A 4403728 Pharmacy nitroglycerin 0.4 mg Tab [BCH] 250 $2.28 $- $0.59 $- $- $1.83 $- N/A $0.59 N/A N/A $0.86 N/A N/A $1.37 N/A N/A $1.14 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.41 N/A N/A $0.94 N/A N/A $1.60 N/A N/A $1.83 N/A N/A $1.26 N/A N/A $1.60 N/A N/A $0.76 N/A N/A N/A N/A N/A $1.37 N/A N/A $0.80 N/A N/A $1.48 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.28 $2.28 N/A 4400135 Pharmacy pregabalin 50 mg oral capsule [BCH] 250 $13.80 $- $3.59 $- $- $11.04 $- N/A $3.59 N/A N/A $5.22 N/A N/A $8.28 N/A N/A $6.90 N/A N/A N/A N/A N/A $9.38 N/A N/A $8.56 N/A N/A $5.66 N/A N/A $9.66 N/A N/A $11.04 N/A N/A $7.59 N/A N/A $9.66 N/A N/A $4.62 N/A N/A N/A N/A N/A $8.28 N/A N/A $4.83 N/A N/A $8.97 N/A N/A N/A N/A N/A $8.28 N/A N/A $9.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.80 $13.80 N/A 4400187 Pharmacy pregabalin 75 mg oral capsule [BCH] 250 $13.80 $- $3.59 $- $- $11.04 $- N/A $3.59 N/A N/A $5.22 N/A N/A $8.28 N/A N/A $6.90 N/A N/A N/A N/A N/A $9.38 N/A N/A $8.56 N/A N/A $5.66 N/A N/A $9.66 N/A N/A $11.04 N/A N/A $7.59 N/A N/A $9.66 N/A N/A $4.62 N/A N/A N/A N/A N/A $8.28 N/A N/A $4.83 N/A N/A $8.97 N/A N/A N/A N/A N/A $8.28 N/A N/A $9.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.80 $13.80 N/A 4400641 Pharmacy pregabalin 100 mg oral capsule [BCH] 250 $13.80 $- $3.59 $- $- $11.04 $- N/A $3.59 N/A N/A $5.22 N/A N/A $8.28 N/A N/A $6.90 N/A N/A N/A N/A N/A $9.38 N/A N/A $8.56 N/A N/A $5.66 N/A N/A $9.66 N/A N/A $11.04 N/A N/A $7.59 N/A N/A $9.66 N/A N/A $4.62 N/A N/A N/A N/A N/A $8.28 N/A N/A $4.83 N/A N/A $8.97 N/A N/A N/A N/A N/A $8.28 N/A N/A $9.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.80 $13.80 N/A 4400792 Pharmacy ritonavir 100 mg Tab [BCH] 250 $20.57 $- $5.35 $- $- $16.46 $- N/A $5.35 N/A N/A $7.78 N/A N/A $12.34 N/A N/A $10.29 N/A N/A N/A N/A N/A $13.99 N/A N/A $12.76 N/A N/A $8.44 N/A N/A $14.40 N/A N/A $16.46 N/A N/A $11.32 N/A N/A $14.40 N/A N/A $6.89 N/A N/A N/A N/A N/A $12.34 N/A N/A $7.20 N/A N/A $13.37 N/A N/A N/A N/A N/A $12.34 N/A N/A $14.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.57 $20.57 N/A 4409561 Pharmacy levothyroxine 137 mcg (0.137 mg) Tab [BCH] 250 $2.59 $- $0.67 $- $- $2.08 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.82 N/A N/A $2.08 N/A N/A $1.43 N/A N/A $1.82 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.69 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.59 $2.59 N/A 4400723 Pharmacy paricalcitol 1 mcg Cap [BCH] 250 $31.25 $- $8.13 $- $- $25.00 $- N/A $8.13 N/A N/A $11.81 N/A N/A $18.75 N/A N/A $15.63 N/A N/A N/A N/A N/A $21.25 N/A N/A $19.38 N/A N/A $12.81 N/A N/A $21.88 N/A N/A $25.00 N/A N/A $17.19 N/A N/A $21.88 N/A N/A $10.47 N/A N/A N/A N/A N/A $18.75 N/A N/A $10.94 N/A N/A $20.31 N/A N/A N/A N/A N/A $18.75 N/A N/A $21.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $31.25 $31.25 N/A 4400942 Pharmacy levothyroxine 25 mcg (0.025 mg) Tab [BCH] 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.48 N/A N/A $1.89 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4403090 Pharmacy levothyroxine 50 mcg (0.05 mg) Tab [BCH] 250 $2.64 $- $0.69 $- $- $2.11 $- N/A $0.69 N/A N/A $1.00 N/A N/A $1.58 N/A N/A $1.32 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.64 N/A N/A $1.08 N/A N/A $1.85 N/A N/A $2.11 N/A N/A $1.45 N/A N/A $1.85 N/A N/A $0.88 N/A N/A N/A N/A N/A $1.58 N/A N/A $0.92 N/A N/A $1.72 N/A N/A N/A N/A N/A $1.58 N/A N/A $1.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.64 $2.64 N/A 4404759 Pharmacy levothyroxine 75 mcg (0.075 mg) Tab [BCH] 250 $2.53 $- $0.66 $- $- $2.03 $- N/A $0.66 N/A N/A $0.96 N/A N/A $1.52 N/A N/A $1.27 N/A N/A N/A N/A N/A $1.72 N/A N/A $1.57 N/A N/A $1.04 N/A N/A $1.77 N/A N/A $2.03 N/A N/A $1.39 N/A N/A $1.77 N/A N/A $0.85 N/A N/A N/A N/A N/A $1.52 N/A N/A $0.89 N/A N/A $1.65 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.53 $2.53 N/A 4406515 Pharmacy divalproex sodium 125 mg Oral Cap sprinkle [BCH] 250 $3.85 $- $1.00 $- $- $3.08 $- N/A $1.00 N/A N/A $1.46 N/A N/A $2.31 N/A N/A $1.93 N/A N/A N/A N/A N/A $2.62 N/A N/A $2.39 N/A N/A $1.58 N/A N/A $2.70 N/A N/A $3.08 N/A N/A $2.12 N/A N/A $2.70 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.31 N/A N/A $1.35 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.85 $3.85 N/A 4403713 Pharmacy divalproex sodium 250 mg DR Oral EC Tab [BCH] 250 $7.49 $- $1.95 $- $- $5.99 $- N/A $1.95 N/A N/A $2.83 N/A N/A $4.49 N/A N/A $3.74 N/A N/A N/A N/A N/A $5.09 N/A N/A $4.64 N/A N/A $3.07 N/A N/A $5.24 N/A N/A $5.99 N/A N/A $4.12 N/A N/A $5.24 N/A N/A $2.51 N/A N/A N/A N/A N/A $4.49 N/A N/A $2.62 N/A N/A $4.87 N/A N/A N/A N/A N/A $4.49 N/A N/A $5.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.49 $7.49 N/A 4400392 Pharmacy levothyroxine 88 mcg (0.088 mg) Tab [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.80 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.80 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.67 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4401945 Pharmacy levothyroxine 100 mcg (0.1 mg) Tab [BCH] 250 $2.59 $- $0.67 $- $- $2.07 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.81 N/A N/A $2.07 N/A N/A $1.43 N/A N/A $1.81 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.68 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.59 $2.59 N/A 4402712 Pharmacy levothyroxine 125 mcg (0.125 mg) Tab [BCH] 250 $2.89 $- $0.75 $- $- $2.31 $- N/A $0.75 N/A N/A $1.09 N/A N/A $1.73 N/A N/A $1.44 N/A N/A N/A N/A N/A $1.96 N/A N/A $1.79 N/A N/A $1.18 N/A N/A $2.02 N/A N/A $2.31 N/A N/A $1.59 N/A N/A $2.02 N/A N/A $0.97 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.01 N/A N/A $1.88 N/A N/A N/A N/A N/A $1.73 N/A N/A $2.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.89 $2.89 N/A 4402712 Pharmacy levothyroxine 125 mcg (0.125 mg) Tab [BCH] 250 $2.60 $- $0.67 $- $- $2.08 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.77 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.82 N/A N/A $2.08 N/A N/A $1.43 N/A N/A $1.82 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.69 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.60 $2.60 N/A 4405343 Pharmacy levothyroxine 150 mcg (0.15 mg) Tab [BCH] 250 $2.60 $- $0.67 $- $- $2.08 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.82 N/A N/A $2.08 N/A N/A $1.43 N/A N/A $1.82 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.69 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.60 $2.60 N/A 4400350 Pharmacy levothyroxine 112 mcg (0.112 mg) Tab [BCH] 250 $2.59 $- $0.67 $- $- $2.08 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.82 N/A N/A $2.08 N/A N/A $1.43 N/A N/A $1.82 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.69 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.59 $2.59 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL SC Sol [BCH] J1650 636 $79.38 $- $0.69 $- $- $63.51 $- N/A $20.64 N/A N/A Not Reimbursed N/A N/A $47.63 N/A N/A $39.69 N/A N/A N/A N/A N/A $53.98 N/A N/A $49.22 N/A N/A $32.55 N/A N/A $55.57 N/A N/A $63.51 N/A N/A $43.66 N/A N/A $55.57 N/A N/A $26.59 N/A N/A N/A N/A N/A $47.63 N/A N/A $27.78 N/A N/A $51.60 N/A N/A $0.69 N/A N/A $47.63 N/A N/A $55.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $79.38 $79.38 N/A 4400111 Pharmacy enoxaparin 60 mg/0.6 mL SC Sol [BCH] J1650 636 $119.22 $- $0.69 $- $- $95.37 $- N/A $31.00 N/A N/A Not Reimbursed N/A N/A $71.53 N/A N/A $59.61 N/A N/A N/A N/A N/A $81.07 N/A N/A $73.91 N/A N/A $48.88 N/A N/A $83.45 N/A N/A $95.37 N/A N/A $65.57 N/A N/A $83.45 N/A N/A $39.94 N/A N/A N/A N/A N/A $71.53 N/A N/A $41.73 N/A N/A $77.49 N/A N/A $0.69 N/A N/A $71.53 N/A N/A $83.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $119.22 $119.22 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL SC Sol [BCH] J1650 636 $158.95 $- $0.69 $- $- $127.16 $- N/A $41.33 N/A N/A Not Reimbursed N/A N/A $95.37 N/A N/A $79.48 N/A N/A N/A N/A N/A $108.09 N/A N/A $98.55 N/A N/A $65.17 N/A N/A $111.27 N/A N/A $127.16 N/A N/A $87.42 N/A N/A $111.27 N/A N/A $53.25 N/A N/A N/A N/A N/A $95.37 N/A N/A $55.63 N/A N/A $103.32 N/A N/A $0.69 N/A N/A $95.37 N/A N/A $111.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $158.95 $158.95 N/A 4408965 Pharmacy enoxaparin 100 mg/mL SubQ Sol [BCH] J1650 636 $198.69 $- $0.69 $- $- $158.95 $- N/A $51.66 N/A N/A Not Reimbursed N/A N/A $119.21 N/A N/A $99.34 N/A N/A N/A N/A N/A $135.11 N/A N/A $123.19 N/A N/A $81.46 N/A N/A $139.08 N/A N/A $158.95 N/A N/A $109.28 N/A N/A $139.08 N/A N/A $66.56 N/A N/A N/A N/A N/A $119.21 N/A N/A $69.54 N/A N/A $129.15 N/A N/A $0.69 N/A N/A $119.21 N/A N/A $139.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $198.69 $198.69 N/A 4406671 Pharmacy enoxaparin 30 mg/0.3 mL SC Sol [BCH] J1650 636 $59.54 $- $0.69 $- $- $47.63 $- N/A $15.48 N/A N/A Not Reimbursed N/A N/A $35.72 N/A N/A $29.77 N/A N/A N/A N/A N/A $40.49 N/A N/A $36.91 N/A N/A $24.41 N/A N/A $41.68 N/A N/A $47.63 N/A N/A $32.75 N/A N/A $41.68 N/A N/A $19.95 N/A N/A N/A N/A N/A $35.72 N/A N/A $20.84 N/A N/A $38.70 N/A N/A $0.69 N/A N/A $35.72 N/A N/A $41.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $59.54 $59.54 N/A 4400115 Pharmacy valsartan 80 mg Tab [BCH] 250 $14.95 $- $3.89 $- $- $11.96 $- N/A $3.89 N/A N/A $5.65 N/A N/A $8.97 N/A N/A $7.48 N/A N/A N/A N/A N/A $10.17 N/A N/A $9.27 N/A N/A $6.13 N/A N/A $10.47 N/A N/A $11.96 N/A N/A $8.22 N/A N/A $10.47 N/A N/A $5.01 N/A N/A N/A N/A N/A $8.97 N/A N/A $5.23 N/A N/A $9.72 N/A N/A N/A N/A N/A $8.97 N/A N/A $10.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.95 $14.95 N/A 4404510 Pharmacy dexamethasone-tobramycin ophthalmic 0.1%-0.3% Oin [BCH] 250 $547.70 $- $142.40 $- $- $438.16 $- N/A $142.40 N/A N/A $207.03 N/A N/A $328.62 N/A N/A $273.85 N/A N/A N/A N/A N/A $372.44 N/A N/A $339.57 N/A N/A $224.56 N/A N/A $383.39 N/A N/A $438.16 N/A N/A $301.24 N/A N/A $383.39 N/A N/A $183.48 N/A N/A N/A N/A N/A $328.62 N/A N/A $191.70 N/A N/A $356.01 N/A N/A N/A N/A N/A $328.62 N/A N/A $383.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $547.70 $547.70 N/A 4409725 Pharmacy albuterol 90 mcg/inh Aer [BCH] 250 $242.77 $- $63.12 $- $- $194.22 $- N/A $63.12 N/A N/A $91.77 N/A N/A $145.66 N/A N/A $121.39 N/A N/A N/A N/A N/A $165.08 N/A N/A $150.52 N/A N/A $99.54 N/A N/A $169.94 N/A N/A $194.22 N/A N/A $133.52 N/A N/A $169.94 N/A N/A $81.33 N/A N/A N/A N/A N/A $145.66 N/A N/A $84.97 N/A N/A $157.80 N/A N/A N/A N/A N/A $145.66 N/A N/A $169.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $242.77 $242.77 N/A 4400914 Pharmacy eptifibatide 0.75 mg/mL IV Sol [BCH] J1327 258 "$1,305.72 " $- $339.49 $- $- "$1,044.58 " $- N/A $339.49 N/A N/A Not Reimbursed N/A N/A $783.43 N/A N/A $652.86 N/A N/A N/A N/A N/A $887.89 N/A N/A $809.55 N/A N/A $535.35 N/A N/A $914.00 N/A N/A "$1,044.58 " N/A N/A $718.15 N/A N/A $914.00 N/A N/A $437.42 N/A N/A N/A N/A N/A $783.43 N/A N/A $457.00 N/A N/A $848.72 N/A N/A N/A N/A N/A $783.43 N/A N/A $914.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,305.72 " "$1,305.72 " N/A 4401913 Pharmacy eptifibatide 2 mg/mL IV Sol [BCH] J1327 258 $417.22 $- $108.48 $- $- $333.78 $- N/A $108.48 N/A N/A Not Reimbursed N/A N/A $250.33 N/A N/A $208.61 N/A N/A N/A N/A N/A $283.71 N/A N/A $258.68 N/A N/A $171.06 N/A N/A $292.05 N/A N/A $333.78 N/A N/A $229.47 N/A N/A $292.05 N/A N/A $139.77 N/A N/A N/A N/A N/A $250.33 N/A N/A $146.03 N/A N/A $271.19 N/A N/A N/A N/A N/A $250.33 N/A N/A $292.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $417.22 $417.22 N/A 4408909 Pharmacy mometasone Nasal 50 mcg/inh Spry [BCH] 250 $569.44 $- $148.05 $- $- $455.55 $- N/A $148.05 N/A N/A $215.25 N/A N/A $341.66 N/A N/A $284.72 N/A N/A N/A N/A N/A $387.22 N/A N/A $353.05 N/A N/A $233.47 N/A N/A $398.61 N/A N/A $455.55 N/A N/A $313.19 N/A N/A $398.61 N/A N/A $190.76 N/A N/A N/A N/A N/A $341.66 N/A N/A $199.30 N/A N/A $370.14 N/A N/A N/A N/A N/A $341.66 N/A N/A $398.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $569.44 $569.44 N/A 91919191 Pharmacy mometasone 220 mcg/inh Aer 250 $177.50 $- $46.15 $- $- $142.00 $- N/A $46.15 N/A N/A $67.10 N/A N/A $106.50 N/A N/A $88.75 N/A N/A N/A N/A N/A $120.70 N/A N/A $110.05 N/A N/A $72.78 N/A N/A $124.25 N/A N/A $142.00 N/A N/A $97.63 N/A N/A $124.25 N/A N/A $59.46 N/A N/A N/A N/A N/A $106.50 N/A N/A $62.13 N/A N/A $115.38 N/A N/A N/A N/A N/A $106.50 N/A N/A $124.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $177.50 $177.50 N/A 4409512 Pharmacy insulin glargine 100 units/mL SubQ Sol [BCH] J1815 636 $596.42 $- $0.83 $- $- $477.14 $- N/A $155.07 N/A N/A Not Reimbursed N/A N/A $357.85 N/A N/A $298.21 N/A N/A N/A N/A N/A $405.57 N/A N/A $369.78 N/A N/A $244.53 N/A N/A $417.49 N/A N/A $477.14 N/A N/A $328.03 N/A N/A $417.49 N/A N/A $199.80 N/A N/A N/A N/A N/A $357.85 N/A N/A $208.75 N/A N/A $387.67 N/A N/A $0.83 N/A N/A $357.85 N/A N/A $417.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $596.42 $596.42 N/A 4409512 Pharmacy insulin glargine 100 units/mL Sol J1815 636 $680.53 $- $0.83 $- $- $544.43 $- N/A $176.94 N/A N/A Not Reimbursed N/A N/A $408.32 N/A N/A $340.27 N/A N/A N/A N/A N/A $462.76 N/A N/A $421.93 N/A N/A $279.02 N/A N/A $476.37 N/A N/A $544.43 N/A N/A $374.29 N/A N/A $476.37 N/A N/A $227.98 N/A N/A N/A N/A N/A $408.32 N/A N/A $238.19 N/A N/A $442.35 N/A N/A $0.83 N/A N/A $408.32 N/A N/A $476.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $680.53 $680.53 N/A 4408792 Pharmacy carvedilol 3.125 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.42 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.56 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.42 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4409455 Pharmacy busPIRone 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400969 Pharmacy busPIRone 10 mg Tab [BCH] 250 $2.69 $- $0.70 $- $- $2.15 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.61 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.10 N/A N/A $1.88 N/A N/A $2.15 N/A N/A $1.48 N/A N/A $1.88 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.61 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.61 N/A N/A $1.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.69 $2.69 N/A 4405707 Pharmacy traMADol 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400099 Pharmacy carvedilol 6.25 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.42 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.56 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.42 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4409931 Pharmacy carbidopa-levodopa 10 mg-100 mg Tab [BCH] 250 $2.09 $- $0.54 $- $- $1.67 $- N/A $0.54 N/A N/A $0.79 N/A N/A $1.25 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.42 N/A N/A $1.29 N/A N/A $0.86 N/A N/A $1.46 N/A N/A $1.67 N/A N/A $1.15 N/A N/A $1.46 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.25 N/A N/A $0.73 N/A N/A $1.36 N/A N/A N/A N/A N/A $1.25 N/A N/A $1.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.09 $2.09 N/A 4408762 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab [BCH] 250 $2.36 $- $0.61 $- $- $1.89 $- N/A $0.61 N/A N/A $0.89 N/A N/A $1.41 N/A N/A $1.18 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.46 N/A N/A $0.97 N/A N/A $1.65 N/A N/A $1.89 N/A N/A $1.30 N/A N/A $1.65 N/A N/A $0.79 N/A N/A N/A N/A N/A $1.41 N/A N/A $0.82 N/A N/A $1.53 N/A N/A N/A N/A N/A $1.41 N/A N/A $1.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.36 $2.36 N/A 4400464 Pharmacy carbidopa-levodopa 25 mg-250 mg Tab [BCH] 250 $3.00 $- $0.78 $- $- $2.40 $- N/A $0.78 N/A N/A $1.13 N/A N/A $1.80 N/A N/A $1.50 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.86 N/A N/A $1.23 N/A N/A $2.10 N/A N/A $2.40 N/A N/A $1.65 N/A N/A $2.10 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.05 N/A N/A $1.95 N/A N/A N/A N/A N/A $1.80 N/A N/A $2.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.00 $3.00 N/A 4402260 Pharmacy diltiazem 30 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400074 Pharmacy diltiazem 90 mg Tab [BCH] 250 $4.28 $- $1.11 $- $- $3.43 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.57 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.66 N/A N/A $1.76 N/A N/A $3.00 N/A N/A $3.43 N/A N/A $2.36 N/A N/A $3.00 N/A N/A $1.44 N/A N/A N/A N/A N/A $2.57 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.57 N/A N/A $3.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.28 $4.28 N/A 4400623 Pharmacy calcitriol 0.25 mcg Oral Cap [BCH] 250 $2.42 $- $0.63 $- $- $1.94 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.94 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.85 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.42 $2.42 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406543 Pharmacy atenolol 50 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405277 Pharmacy carBAMazepine 100 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409770 Pharmacy nortriptyline 25 mg Cap [BCH] 250 $2.93 $- $0.76 $- $- $2.35 $- N/A $0.76 N/A N/A $1.11 N/A N/A $1.76 N/A N/A $1.47 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.82 N/A N/A $1.20 N/A N/A $2.05 N/A N/A $2.35 N/A N/A $1.61 N/A N/A $2.05 N/A N/A $0.98 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.03 N/A N/A $1.91 N/A N/A N/A N/A N/A $1.76 N/A N/A $2.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.93 $2.93 N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402405 Pharmacy ketoconazole Top 2% Crm [BCH] 250 $104.24 $- $27.10 $- $- $83.39 $- N/A $27.10 N/A N/A $39.40 N/A N/A $62.54 N/A N/A $52.12 N/A N/A N/A N/A N/A $70.88 N/A N/A $64.63 N/A N/A $42.74 N/A N/A $72.97 N/A N/A $83.39 N/A N/A $57.33 N/A N/A $72.97 N/A N/A $34.92 N/A N/A N/A N/A N/A $62.54 N/A N/A $36.48 N/A N/A $67.76 N/A N/A N/A N/A N/A $62.54 N/A N/A $72.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $104.24 $104.24 N/A 4400758 Pharmacy busPIRone 15 mg Tab [BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.62 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4400878 Pharmacy nabumetone 500 mg Tab [BCH] 250 $2.59 $- $0.67 $- $- $2.08 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.56 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.61 N/A N/A $1.06 N/A N/A $1.82 N/A N/A $2.08 N/A N/A $1.43 N/A N/A $1.82 N/A N/A $0.87 N/A N/A N/A N/A N/A $1.56 N/A N/A $0.91 N/A N/A $1.69 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.59 $2.59 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400507 Pharmacy pioglitazone 30 mg Tab [BCH] 250 $21.44 $- $5.57 $- $- $17.15 $- N/A $5.57 N/A N/A $8.10 N/A N/A $12.86 N/A N/A $10.72 N/A N/A N/A N/A N/A $14.58 N/A N/A $13.29 N/A N/A $8.79 N/A N/A $15.01 N/A N/A $17.15 N/A N/A $11.79 N/A N/A $15.01 N/A N/A $7.18 N/A N/A N/A N/A N/A $12.86 N/A N/A $7.50 N/A N/A $13.93 N/A N/A N/A N/A N/A $12.86 N/A N/A $15.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.44 $21.44 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $14.03 $- $3.65 $- $- $11.22 $- N/A $3.65 N/A N/A $5.30 N/A N/A $8.42 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.54 N/A N/A $8.70 N/A N/A $5.75 N/A N/A $9.82 N/A N/A $11.22 N/A N/A $7.71 N/A N/A $9.82 N/A N/A $4.70 N/A N/A N/A N/A N/A $8.42 N/A N/A $4.91 N/A N/A $9.12 N/A N/A N/A N/A N/A $8.42 N/A N/A $9.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.03 $14.03 N/A 4409475 Pharmacy tolterodine 2 mg ERCap [BCH] 250 $16.07 $- $4.18 $- $- $12.86 $- N/A $4.18 N/A N/A $6.07 N/A N/A $9.64 N/A N/A $8.04 N/A N/A N/A N/A N/A $10.93 N/A N/A $9.96 N/A N/A $6.59 N/A N/A $11.25 N/A N/A $12.86 N/A N/A $8.84 N/A N/A $11.25 N/A N/A $5.38 N/A N/A N/A N/A N/A $9.64 N/A N/A $5.62 N/A N/A $10.45 N/A N/A N/A N/A N/A $9.64 N/A N/A $11.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.07 $16.07 N/A 4409385 Pharmacy cilostazol 100 mg Tab 250 $3.65 $- $0.95 $- $- $2.92 $- N/A $0.95 N/A N/A $1.38 N/A N/A $2.19 N/A N/A $1.82 N/A N/A N/A N/A N/A $2.48 N/A N/A $2.26 N/A N/A $1.50 N/A N/A $2.55 N/A N/A $2.92 N/A N/A $2.01 N/A N/A $2.55 N/A N/A $1.22 N/A N/A N/A N/A N/A $2.19 N/A N/A $1.28 N/A N/A $2.37 N/A N/A N/A N/A N/A $2.19 N/A N/A $2.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.65 $3.65 N/A 4401502 Pharmacy triamcinolone Nasal 55 mcg/inh Spry [BCH] 250 $245.36 $- $63.79 $- $- $196.29 $- N/A $63.79 N/A N/A $92.75 N/A N/A $147.22 N/A N/A $122.68 N/A N/A N/A N/A N/A $166.84 N/A N/A $152.12 N/A N/A $100.60 N/A N/A $171.75 N/A N/A $196.29 N/A N/A $134.95 N/A N/A $171.75 N/A N/A $82.20 N/A N/A N/A N/A N/A $147.22 N/A N/A $85.88 N/A N/A $159.48 N/A N/A N/A N/A N/A $147.22 N/A N/A $171.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $245.36 $245.36 N/A 4401941 Pharmacy metoclopramide 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409881 Pharmacy metoclopramide 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402252 Pharmacy sucralfate 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402252 Pharmacy sucralfate 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400834 Pharmacy amoxicillin 250 mg Chew Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400356 Pharmacy amoxicillin-clavulanate 400 mg-57 mg Tab 250 $10.78 $- $2.80 $- $- $8.62 $- N/A $2.80 N/A N/A $4.08 N/A N/A $6.47 N/A N/A $5.39 N/A N/A N/A N/A N/A $7.33 N/A N/A $6.68 N/A N/A $4.42 N/A N/A $7.55 N/A N/A $8.62 N/A N/A $5.93 N/A N/A $7.55 N/A N/A $3.61 N/A N/A N/A N/A N/A $6.47 N/A N/A $3.77 N/A N/A $7.01 N/A N/A N/A N/A N/A $6.47 N/A N/A $7.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.78 $10.78 N/A 4407927 Pharmacy cyproheptadine 4 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.71 $- N/A $0.55 N/A N/A $0.81 N/A N/A $1.28 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.88 N/A N/A $1.49 N/A N/A $1.71 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab[BCH] 250 $2.30 $- $0.60 $- $- $1.84 $- N/A $0.60 N/A N/A $0.87 N/A N/A $1.38 N/A N/A $1.15 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.42 N/A N/A $0.94 N/A N/A $1.61 N/A N/A $1.84 N/A N/A $1.26 N/A N/A $1.61 N/A N/A $0.77 N/A N/A N/A N/A N/A $1.38 N/A N/A $0.80 N/A N/A $1.49 N/A N/A N/A N/A N/A $1.38 N/A N/A $1.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.30 $2.30 N/A 4400311 Pharmacy LORazepam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403797 Pharmacy prazosin 1 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403991 Pharmacy cephalexin 250 mg/5 mL Oral Liq [BCH] 250 $103.04 $- $26.79 $- $- $82.43 $- N/A $26.79 N/A N/A $38.95 N/A N/A $61.82 N/A N/A $51.52 N/A N/A N/A N/A N/A $70.07 N/A N/A $63.88 N/A N/A $42.25 N/A N/A $72.13 N/A N/A $82.43 N/A N/A $56.67 N/A N/A $72.13 N/A N/A $34.52 N/A N/A N/A N/A N/A $61.82 N/A N/A $36.06 N/A N/A $66.98 N/A N/A N/A N/A N/A $61.82 N/A N/A $72.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $103.04 $103.04 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402112 Pharmacy bumetanide 1 mg Tab [BCH] 250 $2.75 $- $0.71 $- $- $2.20 $- N/A $0.71 N/A N/A $1.04 N/A N/A $1.65 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.70 N/A N/A $1.13 N/A N/A $1.92 N/A N/A $2.20 N/A N/A $1.51 N/A N/A $1.92 N/A N/A $0.92 N/A N/A N/A N/A N/A $1.65 N/A N/A $0.96 N/A N/A $1.79 N/A N/A N/A N/A N/A $1.65 N/A N/A $1.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.75 $2.75 N/A 4400231 Pharmacy diltiazem 240 mg/24 hours ERCap [BCH] 250 $4.10 $- $1.07 $- $- $3.28 $- N/A $1.07 N/A N/A $1.55 N/A N/A $2.46 N/A N/A $2.05 N/A N/A N/A N/A N/A $2.79 N/A N/A $2.54 N/A N/A $1.68 N/A N/A $2.87 N/A N/A $3.28 N/A N/A $2.26 N/A N/A $2.87 N/A N/A $1.37 N/A N/A N/A N/A N/A $2.46 N/A N/A $1.44 N/A N/A $2.67 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.10 $4.10 N/A 4400866 Pharmacy OLANZapine 10 mg Tab 250 $41.95 $- $10.91 $- $- $33.56 $- N/A $10.91 N/A N/A $15.86 N/A N/A $25.17 N/A N/A $20.97 N/A N/A N/A N/A N/A $28.52 N/A N/A $26.01 N/A N/A $17.20 N/A N/A $29.36 N/A N/A $33.56 N/A N/A $23.07 N/A N/A $29.36 N/A N/A $14.05 N/A N/A N/A N/A N/A $25.17 N/A N/A $14.68 N/A N/A $27.27 N/A N/A N/A N/A N/A $25.17 N/A N/A $29.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.95 $41.95 N/A 4409788 Pharmacy dutasteride 0.5 mg Cap [BCH] 250 $12.10 $- $3.15 $- $- $9.68 $- N/A $3.15 N/A N/A $4.57 N/A N/A $7.26 N/A N/A $6.05 N/A N/A N/A N/A N/A $8.23 N/A N/A $7.50 N/A N/A $4.96 N/A N/A $8.47 N/A N/A $9.68 N/A N/A $6.66 N/A N/A $8.47 N/A N/A $4.05 N/A N/A N/A N/A N/A $7.26 N/A N/A $4.24 N/A N/A $7.87 N/A N/A N/A N/A N/A $7.26 N/A N/A $8.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.10 $12.10 N/A 4409493 Pharmacy oxyCODONE 10 mg Tab [BCH] 250 $6.05 $- $1.57 $- $- $4.84 $- N/A $1.57 N/A N/A $2.29 N/A N/A $3.63 N/A N/A $3.02 N/A N/A N/A N/A N/A $4.11 N/A N/A $3.75 N/A N/A $2.48 N/A N/A $4.23 N/A N/A $4.84 N/A N/A $3.33 N/A N/A $4.23 N/A N/A $2.03 N/A N/A N/A N/A N/A $3.63 N/A N/A $2.12 N/A N/A $3.93 N/A N/A N/A N/A N/A $3.63 N/A N/A $4.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.05 $6.05 N/A 4406846 Pharmacy oxyCODONE 20 mg Tab [BCH] 250 $11.28 $- $2.93 $- $- $9.02 $- N/A $2.93 N/A N/A $4.26 N/A N/A $6.77 N/A N/A $5.64 N/A N/A N/A N/A N/A $7.67 N/A N/A $6.99 N/A N/A $4.62 N/A N/A $7.89 N/A N/A $9.02 N/A N/A $6.20 N/A N/A $7.89 N/A N/A $3.78 N/A N/A N/A N/A N/A $6.77 N/A N/A $3.95 N/A N/A $7.33 N/A N/A N/A N/A N/A $6.77 N/A N/A $7.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.28 $11.28 N/A 4400568 Pharmacy oxyCODONE 40 mg Tab [BCH] 250 $19.31 $- $5.02 $- $- $15.45 $- N/A $5.02 N/A N/A $7.30 N/A N/A $11.59 N/A N/A $9.66 N/A N/A N/A N/A N/A $13.13 N/A N/A $11.97 N/A N/A $7.92 N/A N/A $13.52 N/A N/A $15.45 N/A N/A $10.62 N/A N/A $13.52 N/A N/A $6.47 N/A N/A N/A N/A N/A $11.59 N/A N/A $6.76 N/A N/A $12.55 N/A N/A N/A N/A N/A $11.59 N/A N/A $13.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.31 $19.31 N/A 4407778 Pharmacy OLANZapine 2.5 mg Tab [BCH] 250 $22.39 $- $5.82 $- $- $17.92 $- N/A $5.82 N/A N/A $8.47 N/A N/A $13.44 N/A N/A $11.20 N/A N/A N/A N/A N/A $15.23 N/A N/A $13.88 N/A N/A $9.18 N/A N/A $15.68 N/A N/A $17.92 N/A N/A $12.32 N/A N/A $15.68 N/A N/A $7.50 N/A N/A N/A N/A N/A $13.44 N/A N/A $7.84 N/A N/A $14.56 N/A N/A N/A N/A N/A $13.44 N/A N/A $15.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.39 $22.39 N/A 4409738 Pharmacy escitalopram 10 mg Tab [BCH] 250 $8.65 $- $2.25 $- $- $6.92 $- N/A $2.25 N/A N/A $3.27 N/A N/A $5.19 N/A N/A $4.33 N/A N/A N/A N/A N/A $5.88 N/A N/A $5.36 N/A N/A $3.55 N/A N/A $6.06 N/A N/A $6.92 N/A N/A $4.76 N/A N/A $6.06 N/A N/A $2.90 N/A N/A N/A N/A N/A $5.19 N/A N/A $3.03 N/A N/A $5.62 N/A N/A N/A N/A N/A $5.19 N/A N/A $6.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.65 $8.65 N/A 4400307 Pharmacy escitalopram 20 mg Tab 250 $9.03 $- $2.35 $- $- $7.22 $- N/A $2.35 N/A N/A $3.41 N/A N/A $5.42 N/A N/A $4.51 N/A N/A N/A N/A N/A $6.14 N/A N/A $5.60 N/A N/A $3.70 N/A N/A $6.32 N/A N/A $7.22 N/A N/A $4.97 N/A N/A $6.32 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.42 N/A N/A $3.16 N/A N/A $5.87 N/A N/A N/A N/A N/A $5.42 N/A N/A $6.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.03 $9.03 N/A 4405632 Pharmacy prednisoLONE 15 mg/5 mL Oral Syrup [BCH] J7510 250 $231.14 $- $0.12 $- $- $184.91 $- N/A $60.10 N/A N/A Not Reimbursed N/A N/A $138.68 N/A N/A $115.57 N/A N/A N/A N/A N/A $157.18 N/A N/A $143.31 N/A N/A $94.77 N/A N/A $161.80 N/A N/A $184.91 N/A N/A $127.13 N/A N/A $161.80 N/A N/A $77.43 N/A N/A N/A N/A N/A $138.68 N/A N/A $80.90 N/A N/A $150.24 N/A N/A $0.12 N/A N/A $138.68 N/A N/A $161.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $231.14 $231.14 N/A 4409459 Pharmacy budesonide 0.25 mg/2 mL Inh Susp [BCH] J7626 250 $18.83 $- $1.78 $- $- $15.06 $- N/A $4.90 N/A N/A Not Reimbursed N/A N/A $11.30 N/A N/A $9.41 N/A N/A N/A N/A N/A $12.80 N/A N/A $11.67 N/A N/A $7.72 N/A N/A $13.18 N/A N/A $15.06 N/A N/A $10.36 N/A N/A $13.18 N/A N/A $6.31 N/A N/A N/A N/A N/A $11.30 N/A N/A $6.59 N/A N/A $12.24 N/A N/A $1.78 N/A N/A $11.30 N/A N/A $13.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.83 $18.83 N/A 4409460 Pharmacy budesonide 0.5 mg/2 mL Inh Susp [BCH] J7626 636 $22.16 $- $1.78 $- $- $17.73 $- N/A $5.76 N/A N/A Not Reimbursed N/A N/A $13.29 N/A N/A $11.08 N/A N/A N/A N/A N/A $15.07 N/A N/A $13.74 N/A N/A $9.08 N/A N/A $15.51 N/A N/A $17.73 N/A N/A $12.19 N/A N/A $15.51 N/A N/A $7.42 N/A N/A N/A N/A N/A $13.29 N/A N/A $7.76 N/A N/A $14.40 N/A N/A $1.78 N/A N/A $13.29 N/A N/A $15.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.16 $22.16 N/A 4400539 Pharmacy PARoxetine 40 mg Tab [BCH] 250 $5.75 $- $1.50 $- $- $4.60 $- N/A $1.50 N/A N/A $2.17 N/A N/A $3.45 N/A N/A $2.88 N/A N/A N/A N/A N/A $3.91 N/A N/A $3.57 N/A N/A $2.36 N/A N/A $4.03 N/A N/A $4.60 N/A N/A $3.16 N/A N/A $4.03 N/A N/A $1.93 N/A N/A N/A N/A N/A $3.45 N/A N/A $2.01 N/A N/A $3.74 N/A N/A N/A N/A N/A $3.45 N/A N/A $4.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.75 $5.75 N/A 4409022 Pharmacy celecoxib 100 mg Cap [BCH] 250 $9.24 $- $2.40 $- $- $7.40 $- N/A $2.40 N/A N/A $3.49 N/A N/A $5.55 N/A N/A $4.62 N/A N/A N/A N/A N/A $6.29 N/A N/A $5.73 N/A N/A $3.79 N/A N/A $6.47 N/A N/A $7.40 N/A N/A $5.08 N/A N/A $6.47 N/A N/A $3.10 N/A N/A N/A N/A N/A $5.55 N/A N/A $3.24 N/A N/A $6.01 N/A N/A N/A N/A N/A $5.55 N/A N/A $6.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.24 $9.24 N/A 4408966 Pharmacy celecoxib 200 mg Cap [BCH] 250 $15.16 $- $3.94 $- $- $12.13 $- N/A $3.94 N/A N/A $5.73 N/A N/A $9.10 N/A N/A $7.58 N/A N/A N/A N/A N/A $10.31 N/A N/A $9.40 N/A N/A $6.22 N/A N/A $10.61 N/A N/A $12.13 N/A N/A $8.34 N/A N/A $10.61 N/A N/A $5.08 N/A N/A N/A N/A N/A $9.10 N/A N/A $5.31 N/A N/A $9.86 N/A N/A N/A N/A N/A $9.10 N/A N/A $10.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.16 $15.16 N/A 4407307 Pharmacy mirtazapine 15 mg Tab [BCH] 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4409587 Pharmacy mirtazapine 30 mg Tab [BCH] 250 $5.59 $- $1.45 $- $- $4.48 $- N/A $1.45 N/A N/A $2.11 N/A N/A $3.36 N/A N/A $2.80 N/A N/A N/A N/A N/A $3.80 N/A N/A $3.47 N/A N/A $2.29 N/A N/A $3.92 N/A N/A $4.48 N/A N/A $3.08 N/A N/A $3.92 N/A N/A $1.87 N/A N/A N/A N/A N/A $3.36 N/A N/A $1.96 N/A N/A $3.64 N/A N/A N/A N/A N/A $3.36 N/A N/A $3.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.59 $5.59 N/A 4408719 Pharmacy glimepiride 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400507 Pharmacy pioglitazone 30 mg Tab [BCH] 250 $21.44 $- $5.57 $- $- $17.15 $- N/A $5.57 N/A N/A $8.10 N/A N/A $12.86 N/A N/A $10.72 N/A N/A N/A N/A N/A $14.58 N/A N/A $13.29 N/A N/A $8.79 N/A N/A $15.01 N/A N/A $17.15 N/A N/A $11.79 N/A N/A $15.01 N/A N/A $7.18 N/A N/A N/A N/A N/A $12.86 N/A N/A $7.50 N/A N/A $13.93 N/A N/A N/A N/A N/A $12.86 N/A N/A $15.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.44 $21.44 N/A 4408784 Pharmacy carvedilol 12.5 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.42 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.56 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.42 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4400351 Pharmacy meloxicam 15 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400372 Pharmacy venlafaxine 37.5 mg Tab [BCH] 250 $4.01 $- $1.04 $- $- $3.21 $- N/A $1.04 N/A N/A $1.52 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.73 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.81 N/A N/A $3.21 N/A N/A $2.20 N/A N/A $2.81 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.61 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.01 $4.01 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4405285 Pharmacy famciclovir 500 mg Tab [BCH] 250 $25.39 $- $6.60 $- $- $20.31 $- N/A $6.60 N/A N/A $9.60 N/A N/A $15.23 N/A N/A $12.69 N/A N/A N/A N/A N/A $17.26 N/A N/A $15.74 N/A N/A $10.41 N/A N/A $17.77 N/A N/A $20.31 N/A N/A $13.96 N/A N/A $17.77 N/A N/A $8.50 N/A N/A N/A N/A N/A $15.23 N/A N/A $8.89 N/A N/A $16.50 N/A N/A N/A N/A N/A $15.23 N/A N/A $17.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.39 $25.39 N/A 4406913 Pharmacy doxazosin 2 mg Tab [BCH] 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.48 N/A N/A $1.89 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4400452 Pharmacy QUEtiapine 400 mg oral tablet [BCH] 250 $39.87 $- $10.37 $- $- $31.90 $- N/A $10.37 N/A N/A $15.07 N/A N/A $23.92 N/A N/A $19.93 N/A N/A N/A N/A N/A $27.11 N/A N/A $24.72 N/A N/A $16.35 N/A N/A $27.91 N/A N/A $31.90 N/A N/A $21.93 N/A N/A $27.91 N/A N/A $13.36 N/A N/A N/A N/A N/A $23.92 N/A N/A $13.95 N/A N/A $25.92 N/A N/A N/A N/A N/A $23.92 N/A N/A $27.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.87 $39.87 N/A 4402880 Pharmacy glyBURIDE 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400952 Pharmacy mexiletine 150 mg Cap [BCH] 250 $5.07 $- $1.32 $- $- $4.06 $- N/A $1.32 N/A N/A $1.92 N/A N/A $3.04 N/A N/A $2.54 N/A N/A N/A N/A N/A $3.45 N/A N/A $3.14 N/A N/A $2.08 N/A N/A $3.55 N/A N/A $4.06 N/A N/A $2.79 N/A N/A $3.55 N/A N/A $1.70 N/A N/A N/A N/A N/A $3.04 N/A N/A $1.77 N/A N/A $3.30 N/A N/A N/A N/A N/A $3.04 N/A N/A $3.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.07 $5.07 N/A 4403761 Pharmacy acyclovir 200 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404480 Pharmacy amiodarone 200 mg Tab [BCH] 250 $6.61 $- $1.72 $- $- $5.28 $- N/A $1.72 N/A N/A $2.50 N/A N/A $3.96 N/A N/A $3.30 N/A N/A N/A N/A N/A $4.49 N/A N/A $4.10 N/A N/A $2.71 N/A N/A $4.62 N/A N/A $5.28 N/A N/A $3.63 N/A N/A $4.62 N/A N/A $2.21 N/A N/A N/A N/A N/A $3.96 N/A N/A $2.31 N/A N/A $4.29 N/A N/A N/A N/A N/A $3.96 N/A N/A $4.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.61 $6.61 N/A 4402575 Pharmacy prochlorperazine 5 mg Tab [BCH] Q0164 250 $2.09 $- $0.23 $- $- $1.68 $- N/A $0.54 N/A N/A Not Reimbursed N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.42 N/A N/A $1.30 N/A N/A $0.86 N/A N/A $1.47 N/A N/A $1.68 N/A N/A $1.15 N/A N/A $1.47 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.73 N/A N/A $1.36 N/A N/A $0.23 N/A N/A $1.26 N/A N/A $1.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.09 $2.09 N/A 4409931 Pharmacy carbidopa-levodopa 10 mg-100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404635 Pharmacy primidone 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400698 Pharmacy fenofibric acid 135 mg Cap [BCH] 250 $10.67 $- $2.77 $- $- $8.54 $- N/A $2.77 N/A N/A $4.03 N/A N/A $6.40 N/A N/A $5.34 N/A N/A N/A N/A N/A $7.26 N/A N/A $6.62 N/A N/A $4.37 N/A N/A $7.47 N/A N/A $8.54 N/A N/A $5.87 N/A N/A $7.47 N/A N/A $3.57 N/A N/A N/A N/A N/A $6.40 N/A N/A $3.73 N/A N/A $6.94 N/A N/A N/A N/A N/A $6.40 N/A N/A $7.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.67 $10.67 N/A 4400607 Pharmacy hydrOXYzine pamoate 25 mg Cap[BCH] Q0177 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409635 Pharmacy pyridostigmine 60 mg Tab [BCH] 250 $2.55 $- $0.66 $- $- $2.04 $- N/A $0.66 N/A N/A $0.96 N/A N/A $1.53 N/A N/A $1.28 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.58 N/A N/A $1.05 N/A N/A $1.79 N/A N/A $2.04 N/A N/A $1.40 N/A N/A $1.79 N/A N/A $0.85 N/A N/A N/A N/A N/A $1.53 N/A N/A $0.89 N/A N/A $1.66 N/A N/A N/A N/A N/A $1.53 N/A N/A $1.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.55 $2.55 N/A 4400492 Pharmacy midodrine 5 mg Tab [BCH] 250 $4.84 $- $1.26 $- $- $3.87 $- N/A $1.26 N/A N/A $1.83 N/A N/A $2.90 N/A N/A $2.42 N/A N/A N/A N/A N/A $3.29 N/A N/A $3.00 N/A N/A $1.98 N/A N/A $3.39 N/A N/A $3.87 N/A N/A $2.66 N/A N/A $3.39 N/A N/A $1.62 N/A N/A N/A N/A N/A $2.90 N/A N/A $1.69 N/A N/A $3.14 N/A N/A N/A N/A N/A $2.90 N/A N/A $3.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.84 $4.84 N/A 4409790 Pharmacy fenofibrate 160 mg Tab [BCH] 250 $4.75 $- $1.24 $- $- $3.80 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.85 N/A N/A $2.38 N/A N/A N/A N/A N/A $3.23 N/A N/A $2.95 N/A N/A $1.95 N/A N/A $3.33 N/A N/A $3.80 N/A N/A $2.61 N/A N/A $3.33 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.85 N/A N/A $1.66 N/A N/A $3.09 N/A N/A N/A N/A N/A $2.85 N/A N/A $3.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.75 $4.75 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours XLTab [BCH] 250 $10.43 $- $2.71 $- $- $8.34 $- N/A $2.71 N/A N/A $3.94 N/A N/A $6.26 N/A N/A $5.21 N/A N/A N/A N/A N/A $7.09 N/A N/A $6.47 N/A N/A $4.28 N/A N/A $7.30 N/A N/A $8.34 N/A N/A $5.74 N/A N/A $7.30 N/A N/A $3.49 N/A N/A N/A N/A N/A $6.26 N/A N/A $3.65 N/A N/A $6.78 N/A N/A N/A N/A N/A $6.26 N/A N/A $7.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.43 $10.43 N/A 4404125 Pharmacy fludrocortisone 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409664 Pharmacy digoxin 125 mcg (0.125 mg) Tab [BCH] 250 $2.84 $- $0.74 $- $- $2.28 $- N/A $0.74 N/A N/A $1.08 N/A N/A $1.71 N/A N/A $1.42 N/A N/A N/A N/A N/A $1.93 N/A N/A $1.76 N/A N/A $1.17 N/A N/A $1.99 N/A N/A $2.28 N/A N/A $1.56 N/A N/A $1.99 N/A N/A $0.95 N/A N/A N/A N/A N/A $1.71 N/A N/A $1.00 N/A N/A $1.85 N/A N/A N/A N/A N/A $1.71 N/A N/A $1.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.84 $2.84 N/A 4400421 Pharmacy chlorhexidine Top 0.12% Liq 480 mL [BCH] 250 $20.83 $- $5.42 $- $- $16.67 $- N/A $5.42 N/A N/A $7.87 N/A N/A $12.50 N/A N/A $10.42 N/A N/A N/A N/A N/A $14.17 N/A N/A $12.92 N/A N/A $8.54 N/A N/A $14.58 N/A N/A $16.67 N/A N/A $11.46 N/A N/A $14.58 N/A N/A $6.98 N/A N/A N/A N/A N/A $12.50 N/A N/A $7.29 N/A N/A $13.54 N/A N/A N/A N/A N/A $12.50 N/A N/A $14.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.83 $20.83 N/A 4403771 Pharmacy Milk of Mag 30ml magnesium hydroxide 8% [BCH] 250 $3.36 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.08 N/A N/A $1.38 N/A N/A $2.35 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.35 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.36 $3.36 N/A 4409567 Pharmacy acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 120 mL [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400843 Pharmacy ferrous sulfate 300 mg/5 mL Liq [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407103 Pharmacy PHENobarbital 20 mg/5 mL Oral Elix [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403959 Pharmacy docusate sodium 150 mg/15 mL Oral Liq [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400965 Pharmacy lactulose 10 g/15 mL Syr BCH] 250 $69.40 $- $18.04 $- $- $55.52 $- N/A $18.04 N/A N/A $26.23 N/A N/A $41.64 N/A N/A $34.70 N/A N/A N/A N/A N/A $47.19 N/A N/A $43.03 N/A N/A $28.45 N/A N/A $48.58 N/A N/A $55.52 N/A N/A $38.17 N/A N/A $48.58 N/A N/A $23.25 N/A N/A N/A N/A N/A $41.64 N/A N/A $24.29 N/A N/A $45.11 N/A N/A N/A N/A N/A $41.64 N/A N/A $48.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.40 $69.40 N/A 4400415 Pharmacy haloperidol 2 mg/mL Oral Conc [BCH] 250 $14.10 $- $3.67 $- $- $11.28 $- N/A $3.67 N/A N/A $5.33 N/A N/A $8.46 N/A N/A $7.05 N/A N/A N/A N/A N/A $9.59 N/A N/A $8.74 N/A N/A $5.78 N/A N/A $9.87 N/A N/A $11.28 N/A N/A $7.76 N/A N/A $9.87 N/A N/A $4.72 N/A N/A N/A N/A N/A $8.46 N/A N/A $4.94 N/A N/A $9.17 N/A N/A N/A N/A N/A $8.46 N/A N/A $9.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.10 $14.10 N/A 4404627 Pharmacy citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 15 mL [BCH] 250 $4.01 $- $1.04 $- $- $3.21 $- N/A $1.04 N/A N/A $1.52 N/A N/A $2.41 N/A N/A $2.01 N/A N/A N/A N/A N/A $2.73 N/A N/A $2.49 N/A N/A $1.64 N/A N/A $2.81 N/A N/A $3.21 N/A N/A $2.21 N/A N/A $2.81 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.41 N/A N/A $1.40 N/A N/A $2.61 N/A N/A N/A N/A N/A $2.41 N/A N/A $2.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.01 $4.01 N/A 4400784 Pharmacy citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400784 Pharmacy citric acid-sodium citrate 334 mg-500 mg/5 mL Oral Sol 30 mL [BCH] 250 $4.34 $- $1.13 $- $- $3.48 $- N/A $1.13 N/A N/A $1.64 N/A N/A $2.61 N/A N/A $2.17 N/A N/A N/A N/A N/A $2.95 N/A N/A $2.69 N/A N/A $1.78 N/A N/A $3.04 N/A N/A $3.48 N/A N/A $2.39 N/A N/A $3.04 N/A N/A $1.46 N/A N/A N/A N/A N/A $2.61 N/A N/A $1.52 N/A N/A $2.82 N/A N/A N/A N/A N/A $2.61 N/A N/A $3.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.34 $4.34 N/A 4400063 Pharmacy acetaminophen 160 mg/5 mL Oral Liq [BCH] 250 $2.86 $- $0.74 $- $- $2.29 $- N/A $0.74 N/A N/A $1.08 N/A N/A $1.72 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.95 N/A N/A $1.78 N/A N/A $1.17 N/A N/A $2.01 N/A N/A $2.29 N/A N/A $1.58 N/A N/A $2.01 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.72 N/A N/A $1.00 N/A N/A $1.86 N/A N/A N/A N/A N/A $1.72 N/A N/A $2.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.86 $2.86 N/A 4401375 Pharmacy ibuprofen 100 mg/5 mL Sus[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400063 Pharmacy acetaminophen 325 mg / 10.15 mL Liquid [BCH] 250 $2.86 $- $0.74 $- $- $2.29 $- N/A $0.74 N/A N/A $1.08 N/A N/A $1.72 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.95 N/A N/A $1.78 N/A N/A $1.17 N/A N/A $2.00 N/A N/A $2.29 N/A N/A $1.58 N/A N/A $2.00 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.72 N/A N/A $1.00 N/A N/A $1.86 N/A N/A N/A N/A N/A $1.72 N/A N/A $2.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.86 $2.86 N/A 4405301 Pharmacy potassium chloride 20 mEq/15 mL Oral Liq [BCH] 250 $10.84 $- $2.82 $- $- $8.67 $- N/A $2.82 N/A N/A $4.10 N/A N/A $6.50 N/A N/A $5.42 N/A N/A N/A N/A N/A $7.37 N/A N/A $6.72 N/A N/A $4.44 N/A N/A $7.58 N/A N/A $8.67 N/A N/A $5.96 N/A N/A $7.58 N/A N/A $3.63 N/A N/A N/A N/A N/A $6.50 N/A N/A $3.79 N/A N/A $7.04 N/A N/A N/A N/A N/A $6.50 N/A N/A $7.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.84 $10.84 N/A 4400961 Pharmacy Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg/5 mL Sus 250 $7.59 $- $1.97 $- $- $6.07 $- N/A $1.97 N/A N/A $2.87 N/A N/A $4.55 N/A N/A $3.79 N/A N/A N/A N/A N/A $5.16 N/A N/A $4.70 N/A N/A $3.11 N/A N/A $5.31 N/A N/A $6.07 N/A N/A $4.17 N/A N/A $5.31 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.55 N/A N/A $2.65 N/A N/A $4.93 N/A N/A N/A N/A N/A $4.55 N/A N/A $5.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.59 $7.59 N/A 4400735 Pharmacy Al hydroxide/Mg hydroxide/simethicone 400 mg-400 mg-40 mg/5 mL Oral Susp 30 mL [BCH] 250 $4.35 $- $1.13 $- $- $3.48 $- N/A $1.13 N/A N/A $1.64 N/A N/A $2.61 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.96 N/A N/A $2.70 N/A N/A $1.78 N/A N/A $3.05 N/A N/A $3.48 N/A N/A $2.39 N/A N/A $3.05 N/A N/A $1.46 N/A N/A N/A N/A N/A $2.61 N/A N/A $1.52 N/A N/A $2.83 N/A N/A N/A N/A N/A $2.61 N/A N/A $3.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.35 $4.35 N/A 4400721 Pharmacy lactulose 10 g/15 mL Syr [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409495 Pharmacy valproic acid 250 mg/5 mL Oral Syrup [BCH] 250 $4.32 $- $1.12 $- $- $3.46 $- N/A $1.12 N/A N/A $1.63 N/A N/A $2.59 N/A N/A $2.16 N/A N/A N/A N/A N/A $2.94 N/A N/A $2.68 N/A N/A $1.77 N/A N/A $3.02 N/A N/A $3.46 N/A N/A $2.38 N/A N/A $3.02 N/A N/A $1.45 N/A N/A N/A N/A N/A $2.59 N/A N/A $1.51 N/A N/A $2.81 N/A N/A N/A N/A N/A $2.59 N/A N/A $3.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.32 $4.32 N/A 4401375 Pharmacy ibuprofen 100 mg/5 mL Oral Susp [BCH] 250 $3.76 $- $0.98 $- $- $3.01 $- N/A $0.98 N/A N/A $1.42 N/A N/A $2.26 N/A N/A $1.88 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.33 N/A N/A $1.54 N/A N/A $2.63 N/A N/A $3.01 N/A N/A $2.07 N/A N/A $2.63 N/A N/A $1.26 N/A N/A N/A N/A N/A $2.26 N/A N/A $1.32 N/A N/A $2.44 N/A N/A N/A N/A N/A $2.26 N/A N/A $2.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.76 $3.76 N/A 4400864 Pharmacy levETIRAcetam 100 mg/mL Sol [BCH] 250 $18.69 $- $4.86 $- $- $14.95 $- N/A $4.86 N/A N/A $7.07 N/A N/A $11.22 N/A N/A $9.35 N/A N/A N/A N/A N/A $12.71 N/A N/A $11.59 N/A N/A $7.66 N/A N/A $13.08 N/A N/A $14.95 N/A N/A $10.28 N/A N/A $13.08 N/A N/A $6.26 N/A N/A N/A N/A N/A $11.22 N/A N/A $6.54 N/A N/A $12.15 N/A N/A N/A N/A N/A $11.22 N/A N/A $13.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.69 $18.69 N/A 4400864 Pharmacy levETIRAcetam 100 mg/mL Sol [BCH] 250 $18.70 $- $4.86 $- $- $14.96 $- N/A $4.86 N/A N/A $7.07 N/A N/A $11.22 N/A N/A $9.35 N/A N/A N/A N/A N/A $12.72 N/A N/A $11.59 N/A N/A $7.67 N/A N/A $13.09 N/A N/A $14.96 N/A N/A $10.29 N/A N/A $13.09 N/A N/A $6.26 N/A N/A N/A N/A N/A $11.22 N/A N/A $6.55 N/A N/A $12.16 N/A N/A N/A N/A N/A $11.22 N/A N/A $13.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.70 $18.70 N/A 4400626 Pharmacy lacosamide 50 mg Tab [BCH] 250 $17.58 $- $4.57 $- $- $14.06 $- N/A $4.57 N/A N/A $6.64 N/A N/A $10.55 N/A N/A $8.79 N/A N/A N/A N/A N/A $11.95 N/A N/A $10.90 N/A N/A $7.21 N/A N/A $12.30 N/A N/A $14.06 N/A N/A $9.67 N/A N/A $12.30 N/A N/A $5.89 N/A N/A N/A N/A N/A $10.55 N/A N/A $6.15 N/A N/A $11.42 N/A N/A N/A N/A N/A $10.55 N/A N/A $12.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.58 $17.58 N/A 4400626 Pharmacy lacosamide 50 mg Tab [BCH] 250 $28.10 $- $7.31 $- $- $22.48 $- N/A $7.31 N/A N/A $10.62 N/A N/A $16.86 N/A N/A $14.05 N/A N/A N/A N/A N/A $19.11 N/A N/A $17.42 N/A N/A $11.52 N/A N/A $19.67 N/A N/A $22.48 N/A N/A $15.45 N/A N/A $19.67 N/A N/A $9.41 N/A N/A N/A N/A N/A $16.86 N/A N/A $9.83 N/A N/A $18.26 N/A N/A N/A N/A N/A $16.86 N/A N/A $19.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.10 $28.10 N/A 4400833 Pharmacy glycerin pediatric Sup [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400189 Pharmacy mineral oil 100% Ene [BCH] 250 $4.16 $- $1.08 $- $- $3.33 $- N/A $1.08 N/A N/A $1.57 N/A N/A $2.50 N/A N/A $2.08 N/A N/A N/A N/A N/A $2.83 N/A N/A $2.58 N/A N/A $1.71 N/A N/A $2.91 N/A N/A $3.33 N/A N/A $2.29 N/A N/A $2.91 N/A N/A $1.39 N/A N/A N/A N/A N/A $2.50 N/A N/A $1.46 N/A N/A $2.70 N/A N/A N/A N/A N/A $2.50 N/A N/A $2.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.16 $4.16 N/A 4400906 Pharmacy captopril 12.5 mg Tab [BCH] 250 $3.12 $- $0.81 $- $- $2.49 $- N/A $0.81 N/A N/A $1.18 N/A N/A $1.87 N/A N/A $1.56 N/A N/A N/A N/A N/A $2.12 N/A N/A $1.93 N/A N/A $1.28 N/A N/A $2.18 N/A N/A $2.49 N/A N/A $1.71 N/A N/A $2.18 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.09 N/A N/A $2.03 N/A N/A N/A N/A N/A $1.87 N/A N/A $2.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.12 $3.12 N/A 4409748 Pharmacy trihexyphenidyl 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400708 Pharmacy isosorbide dinitrate 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402688 Pharmacy isosorbide dinitrate 20 mg Tab [BCH] 250 $2.38 $- $0.62 $- $- $1.91 $- N/A $0.62 N/A N/A $0.90 N/A N/A $1.43 N/A N/A $1.19 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.48 N/A N/A $0.98 N/A N/A $1.67 N/A N/A $1.91 N/A N/A $1.31 N/A N/A $1.67 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.43 N/A N/A $0.83 N/A N/A $1.55 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.38 $2.38 N/A 4403306 Pharmacy ceFAZolin 1 g Pow J0690 636 $28.00 $- $0.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409538 Pharmacy pantoprazole 40 mg Pow S0164 636 $15.60 $- $4.06 $- $- $12.48 $- N/A $4.06 N/A N/A Not Reimbursed N/A N/A $9.36 N/A N/A $7.80 N/A N/A N/A N/A N/A $10.61 N/A N/A $9.67 N/A N/A $6.40 N/A N/A $10.92 N/A N/A $12.48 N/A N/A $8.58 N/A N/A $10.92 N/A N/A $5.23 N/A N/A N/A N/A N/A $9.36 N/A N/A $5.46 N/A N/A $10.14 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.60 $15.60 N/A 4409538 Pharmacy pantoprazole 40 mg Pow S0164 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401771 Pharmacy etomidate 2 mg/mL Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400095 Pharmacy levoFLOXacin 250 mg/50 mL Sol [BCH] J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4401771 Pharmacy etomidate 2 mg/mL Sol [BCH] 258 $14.93 $- $3.88 $- $- $11.94 $- N/A $3.88 N/A N/A $5.64 N/A N/A $8.96 N/A N/A $7.46 N/A N/A N/A N/A N/A $10.15 N/A N/A $9.26 N/A N/A $6.12 N/A N/A $10.45 N/A N/A $11.94 N/A N/A $8.21 N/A N/A $10.45 N/A N/A $5.00 N/A N/A N/A N/A N/A $8.96 N/A N/A $5.22 N/A N/A $9.70 N/A N/A N/A N/A N/A $8.96 N/A N/A $10.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.93 $14.93 N/A 4407566 Pharmacy phentolamine 5 mg Inj [BCH] J2760 636 "$1,020.00 " $- $265.20 $- $- $816.00 $- N/A $265.20 N/A N/A Not Reimbursed N/A N/A $612.00 N/A N/A $510.00 N/A N/A N/A N/A N/A $693.60 N/A N/A $632.40 N/A N/A $418.20 N/A N/A $714.00 N/A N/A $816.00 N/A N/A $561.00 N/A N/A $714.00 N/A N/A $341.70 N/A N/A N/A N/A N/A $612.00 N/A N/A $357.00 N/A N/A $663.00 N/A N/A $374.74 N/A N/A $612.00 N/A N/A $714.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,020.00 " "$1,020.00 " N/A 4409518 Pharmacy niCARdipine 2.5 mg/mL Sol [BCH] 636 $48.34 $- $12.57 $- $- $38.67 $- N/A $12.57 N/A N/A $18.27 N/A N/A $29.00 N/A N/A $24.17 N/A N/A N/A N/A N/A $32.87 N/A N/A $29.97 N/A N/A $19.82 N/A N/A $33.84 N/A N/A $38.67 N/A N/A $26.59 N/A N/A $33.84 N/A N/A $16.19 N/A N/A N/A N/A N/A $29.00 N/A N/A $16.92 N/A N/A $31.42 N/A N/A N/A N/A N/A $29.00 N/A N/A $33.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.34 $48.34 N/A 4405855 Pharmacy labetalol 5 mg/mL Sol [BCH] 258 $17.50 $- $4.55 $- $- $14.00 $- N/A $4.55 N/A N/A $6.62 N/A N/A $10.50 N/A N/A $8.75 N/A N/A N/A N/A N/A $11.90 N/A N/A $10.85 N/A N/A $7.18 N/A N/A $12.25 N/A N/A $14.00 N/A N/A $9.63 N/A N/A $12.25 N/A N/A $5.86 N/A N/A N/A N/A N/A $10.50 N/A N/A $6.13 N/A N/A $11.38 N/A N/A N/A N/A N/A $10.50 N/A N/A $12.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.50 $17.50 N/A 4400233 Pharmacy glycopyrrolate 0.2 mg/mL Sol [BCH] J7642 636 $16.80 $- $4.37 $- $- $13.44 $- N/A $4.37 N/A N/A Not Reimbursed N/A N/A $10.08 N/A N/A $8.40 N/A N/A N/A N/A N/A $11.42 N/A N/A $10.42 N/A N/A $6.89 N/A N/A $11.76 N/A N/A $13.44 N/A N/A $9.24 N/A N/A $11.76 N/A N/A $5.63 N/A N/A N/A N/A N/A $10.08 N/A N/A $5.88 N/A N/A $10.92 N/A N/A N/A N/A N/A $10.08 N/A N/A $11.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.80 $16.80 N/A 4400233 Pharmacy glycopyrrolate 0.2 mg/mL Inj Sol [BCH] J7642 250 $31.20 $- $8.11 $- $- $24.96 $- N/A $8.11 N/A N/A Not Reimbursed N/A N/A $18.72 N/A N/A $15.60 N/A N/A N/A N/A N/A $21.22 N/A N/A $19.34 N/A N/A $12.79 N/A N/A $21.84 N/A N/A $24.96 N/A N/A $17.16 N/A N/A $21.84 N/A N/A $10.45 N/A N/A N/A N/A N/A $18.72 N/A N/A $10.92 N/A N/A $20.28 N/A N/A N/A N/A N/A $18.72 N/A N/A $21.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $31.20 $31.20 N/A 4404593 Pharmacy flumazenil 0.1 mg/mL Sol [BCH] 250 $15.60 $- $4.06 $- $- $12.48 $- N/A $4.06 N/A N/A $5.90 N/A N/A $9.36 N/A N/A $7.80 N/A N/A N/A N/A N/A $10.61 N/A N/A $9.67 N/A N/A $6.40 N/A N/A $10.92 N/A N/A $12.48 N/A N/A $8.58 N/A N/A $10.92 N/A N/A $5.23 N/A N/A N/A N/A N/A $9.36 N/A N/A $5.46 N/A N/A $10.14 N/A N/A N/A N/A N/A $9.36 N/A N/A $10.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.60 $15.60 N/A 4409518 Pharmacy niCARdipine 2.5 mg/mL Sol 10mL [BCH] 250 $48.34 $- $12.57 $- $- $38.67 $- N/A $12.57 N/A N/A $18.27 N/A N/A $29.00 N/A N/A $24.17 N/A N/A N/A N/A N/A $32.87 N/A N/A $29.97 N/A N/A $19.82 N/A N/A $33.84 N/A N/A $38.67 N/A N/A $26.59 N/A N/A $33.84 N/A N/A $16.19 N/A N/A N/A N/A N/A $29.00 N/A N/A $16.92 N/A N/A $31.42 N/A N/A N/A N/A N/A $29.00 N/A N/A $33.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.34 $48.34 N/A 4400095 Pharmacy levoFLOXacin 250 mg/50 mL Sol [BCH] J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4401136 Pharmacy benztropine 1 mg/mL Inj Sol [BCH] J0515 636 $132.00 $- $15.52 $- $- $105.60 $- N/A $34.32 N/A N/A Not Reimbursed N/A N/A $79.20 N/A N/A $66.00 N/A N/A N/A N/A N/A $89.76 N/A N/A $81.84 N/A N/A $54.12 N/A N/A $92.40 N/A N/A $105.60 N/A N/A $72.60 N/A N/A $92.40 N/A N/A $44.22 N/A N/A N/A N/A N/A $79.20 N/A N/A $46.20 N/A N/A $85.80 N/A N/A $15.52 N/A N/A $79.20 N/A N/A $92.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $132.00 $132.00 N/A 4405479 Pharmacy terbutaline 1 mg/mL Inj Sol [BCH] J3105 636 $12.00 $- $1.32 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $1.32 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404593 Pharmacy flumazenil 0.1 mg/mL IV Sol [BCH] 258 $16.26 $- $4.23 $- $- $13.01 $- N/A $4.23 N/A N/A $6.15 N/A N/A $9.76 N/A N/A $8.13 N/A N/A N/A N/A N/A $11.06 N/A N/A $10.08 N/A N/A $6.67 N/A N/A $11.38 N/A N/A $13.01 N/A N/A $8.94 N/A N/A $11.38 N/A N/A $5.45 N/A N/A N/A N/A N/A $9.76 N/A N/A $5.69 N/A N/A $10.57 N/A N/A N/A N/A N/A $9.76 N/A N/A $11.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.26 $16.26 N/A 4400052 Pharmacy enalapril 1.25 mg/mL IV Sol [BCH] 258 $14.40 $- $3.74 $- $- $11.52 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A N/A N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400052 Pharmacy enalapril 1.25 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400198 Pharmacy propranolol 1 mg/mL IV Sol [BCH] J1800 258 $20.00 $- $2.44 $- $- $16.00 $- N/A $5.20 N/A N/A Not Reimbursed N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A $12.40 N/A N/A $8.20 N/A N/A $14.00 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $14.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A $2.44 N/A N/A $12.00 N/A N/A $14.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.00 $20.00 N/A 4400693 Pharmacy metoprolol 1 mg/mL Inj Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400693 Pharmacy metoprolol 1 mg/mL Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409429 Pharmacy amiodarone 50 mg/mL IV Sol [BCH] J0280 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $7.31 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409429 Pharmacy amiodarone 50 mg/mL Sol [BCH] J0280 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $7.31 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409240 Pharmacy amoxicillin 250 mg/5 mL Pow 250 $7.53 $- $1.96 $- $- $6.02 $- N/A $1.96 N/A N/A $2.85 N/A N/A $4.52 N/A N/A $3.77 N/A N/A N/A N/A N/A $5.12 N/A N/A $4.67 N/A N/A $3.09 N/A N/A $5.27 N/A N/A $6.02 N/A N/A $4.14 N/A N/A $5.27 N/A N/A $2.52 N/A N/A N/A N/A N/A $4.52 N/A N/A $2.64 N/A N/A $4.89 N/A N/A N/A N/A N/A $4.52 N/A N/A $5.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.53 $7.53 N/A 4409240 Pharmacy amoxicillin 250 mg/5 mL Pow [BCH] 250 $10.62 $- $2.76 $- $- $8.50 $- N/A $2.76 N/A N/A $4.01 N/A N/A $6.37 N/A N/A $5.31 N/A N/A N/A N/A N/A $7.22 N/A N/A $6.58 N/A N/A $4.35 N/A N/A $7.43 N/A N/A $8.50 N/A N/A $5.84 N/A N/A $7.43 N/A N/A $3.56 N/A N/A N/A N/A N/A $6.37 N/A N/A $3.72 N/A N/A $6.90 N/A N/A N/A N/A N/A $6.37 N/A N/A $7.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.62 $10.62 N/A 4403045 Pharmacy cephalexin 500 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403306 Pharmacy ceFAZolin 1 g Inj [BCH] J0690 636 $28.00 $- $0.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4403028 Pharmacy ciprofloxacin 250 mg Tab[BCH] 250 $9.19 $- $2.39 $- $- $7.35 $- N/A $2.39 N/A N/A $3.47 N/A N/A $5.51 N/A N/A $4.59 N/A N/A N/A N/A N/A $6.25 N/A N/A $5.70 N/A N/A $3.77 N/A N/A $6.43 N/A N/A $7.35 N/A N/A $5.05 N/A N/A $6.43 N/A N/A $3.08 N/A N/A N/A N/A N/A $5.51 N/A N/A $3.22 N/A N/A $5.97 N/A N/A N/A N/A N/A $5.51 N/A N/A $6.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.19 $9.19 N/A 4400994 Pharmacy triamcinolone topical 0.025% Cre [BCH] 250 $8.92 $- $2.32 $- $- $7.14 $- N/A $2.32 N/A N/A $3.37 N/A N/A $5.35 N/A N/A $4.46 N/A N/A N/A N/A N/A $6.07 N/A N/A $5.53 N/A N/A $3.66 N/A N/A $6.24 N/A N/A $7.14 N/A N/A $4.91 N/A N/A $6.24 N/A N/A $2.99 N/A N/A N/A N/A N/A $5.35 N/A N/A $3.12 N/A N/A $5.80 N/A N/A N/A N/A N/A $5.35 N/A N/A $6.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.92 $8.92 N/A 4409472 Pharmacy triamcinolone Top 0.1% Crm [BCH] 250 $11.16 $- $2.90 $- $- $8.93 $- N/A $2.90 N/A N/A $4.22 N/A N/A $6.70 N/A N/A $5.58 N/A N/A N/A N/A N/A $7.59 N/A N/A $6.92 N/A N/A $4.58 N/A N/A $7.81 N/A N/A $8.93 N/A N/A $6.14 N/A N/A $7.81 N/A N/A $3.74 N/A N/A N/A N/A N/A $6.70 N/A N/A $3.91 N/A N/A $7.25 N/A N/A N/A N/A N/A $6.70 N/A N/A $7.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.16 $11.16 N/A 4400247 Pharmacy triamcinolone Top 0.1% Crm [BCH] 250 $27.89 $- $7.25 $- $- $22.31 $- N/A $7.25 N/A N/A $10.54 N/A N/A $16.73 N/A N/A $13.94 N/A N/A N/A N/A N/A $18.96 N/A N/A $17.29 N/A N/A $11.43 N/A N/A $19.52 N/A N/A $22.31 N/A N/A $15.34 N/A N/A $19.52 N/A N/A $9.34 N/A N/A N/A N/A N/A $16.73 N/A N/A $9.76 N/A N/A $18.13 N/A N/A N/A N/A N/A $16.73 N/A N/A $19.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.89 $27.89 N/A 4400188 Pharmacy triamcinolone Top 0.1% Oint [BCH] 250 $11.16 $- $2.90 $- $- $8.93 $- N/A $2.90 N/A N/A $4.22 N/A N/A $6.70 N/A N/A $5.58 N/A N/A N/A N/A N/A $7.59 N/A N/A $6.92 N/A N/A $4.58 N/A N/A $7.81 N/A N/A $8.93 N/A N/A $6.14 N/A N/A $7.81 N/A N/A $3.74 N/A N/A N/A N/A N/A $6.70 N/A N/A $3.91 N/A N/A $7.25 N/A N/A N/A N/A N/A $6.70 N/A N/A $7.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.16 $11.16 N/A 4401957 Pharmacy bacitracin topical zinc 500 units/g Oin [BCH] 250 $7.40 $- $1.92 $- $- $5.92 $- N/A $1.92 N/A N/A $2.80 N/A N/A $4.44 N/A N/A $3.70 N/A N/A N/A N/A N/A $5.03 N/A N/A $4.59 N/A N/A $3.03 N/A N/A $5.18 N/A N/A $5.92 N/A N/A $4.07 N/A N/A $5.18 N/A N/A $2.48 N/A N/A N/A N/A N/A $4.44 N/A N/A $2.59 N/A N/A $4.81 N/A N/A N/A N/A N/A $4.44 N/A N/A $5.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.40 $7.40 N/A 4400091 Pharmacy vitamin A & D Top Oint [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400381 Pharmacy petrolatum topical 100% Oin [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400381 Pharmacy petrolatum Top 100% Oint [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400682 Pharmacy zinc oxide Top 20% Oint [BCH] 250 $9.96 $- $2.59 $- $- $7.97 $- N/A $2.59 N/A N/A $3.76 N/A N/A $5.98 N/A N/A $4.98 N/A N/A N/A N/A N/A $6.77 N/A N/A $6.18 N/A N/A $4.08 N/A N/A $6.97 N/A N/A $7.97 N/A N/A $5.48 N/A N/A $6.97 N/A N/A $3.34 N/A N/A N/A N/A N/A $5.98 N/A N/A $3.49 N/A N/A $6.47 N/A N/A N/A N/A N/A $5.98 N/A N/A $6.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.96 $9.96 N/A 4400488 Pharmacy hydrocortisone Top 2.5% Crm [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4402405 Pharmacy ketoconazole Top 2% Crm [BCH] 250 $104.22 $- $27.10 $- $- $83.38 $- N/A $27.10 N/A N/A $39.40 N/A N/A $62.53 N/A N/A $52.11 N/A N/A N/A N/A N/A $70.87 N/A N/A $64.62 N/A N/A $42.73 N/A N/A $72.95 N/A N/A $83.38 N/A N/A $57.32 N/A N/A $72.95 N/A N/A $34.91 N/A N/A N/A N/A N/A $62.53 N/A N/A $36.48 N/A N/A $67.74 N/A N/A N/A N/A N/A $62.53 N/A N/A $72.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $104.22 $104.22 N/A 4400815 Pharmacy metroNIDAZOLE topical 0.75% Cre [BCH] 250 $364.32 $- $94.72 $- $- $291.46 $- N/A $94.72 N/A N/A $137.71 N/A N/A $218.59 N/A N/A $182.16 N/A N/A N/A N/A N/A $247.74 N/A N/A $225.88 N/A N/A $149.37 N/A N/A $255.02 N/A N/A $291.46 N/A N/A $200.38 N/A N/A $255.02 N/A N/A $122.05 N/A N/A N/A N/A N/A $218.59 N/A N/A $127.51 N/A N/A $236.81 N/A N/A N/A N/A N/A $218.59 N/A N/A $255.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $364.32 $364.32 N/A 4409736 Pharmacy lidocaine-prilocaine Top 2.5%-2.5% Crm [BCH] 250 $19.83 $- $5.16 $- $- $15.87 $- N/A $5.16 N/A N/A $7.50 N/A N/A $11.90 N/A N/A $9.92 N/A N/A N/A N/A N/A $13.49 N/A N/A $12.30 N/A N/A $8.13 N/A N/A $13.88 N/A N/A $15.87 N/A N/A $10.91 N/A N/A $13.88 N/A N/A $6.64 N/A N/A N/A N/A N/A $11.90 N/A N/A $6.94 N/A N/A $12.89 N/A N/A N/A N/A N/A $11.90 N/A N/A $13.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.83 $19.83 N/A 4402597 Pharmacy insulin isophane-insulin regular human recombinant 70 units-30 units/mL SubQ Inj 10 mL [BCH] J1815 636 $306.24 $- $0.83 $- $- $244.99 $- N/A $79.62 N/A N/A Not Reimbursed N/A N/A $183.74 N/A N/A $153.12 N/A N/A N/A N/A N/A $208.24 N/A N/A $189.87 N/A N/A $125.56 N/A N/A $214.37 N/A N/A $244.99 N/A N/A $168.43 N/A N/A $214.37 N/A N/A $102.59 N/A N/A N/A N/A N/A $183.74 N/A N/A $107.18 N/A N/A $199.06 N/A N/A $0.83 N/A N/A $183.74 N/A N/A $214.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $306.24 $306.24 N/A 4400250 Pharmacy insulin aspart-insulin aspart protamine 30 units-70 units/mL SubQ Susp 10 mL [BCH] J1815 636 $589.20 $- $0.83 $- $- $471.36 $- N/A $153.19 N/A N/A Not Reimbursed N/A N/A $353.52 N/A N/A $294.60 N/A N/A N/A N/A N/A $400.66 N/A N/A $365.30 N/A N/A $241.57 N/A N/A $412.44 N/A N/A $471.36 N/A N/A $324.06 N/A N/A $412.44 N/A N/A $197.38 N/A N/A N/A N/A N/A $353.52 N/A N/A $206.22 N/A N/A $382.98 N/A N/A $0.83 N/A N/A $353.52 N/A N/A $412.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $589.20 $589.20 N/A 4400417 Pharmacy insulin detemir 100 units/mL SC Sol [BCH] J1815 636 $645.60 $- $0.83 $- $- $516.48 $- N/A $167.86 N/A N/A Not Reimbursed N/A N/A $387.36 N/A N/A $322.80 N/A N/A N/A N/A N/A $439.01 N/A N/A $400.27 N/A N/A $264.70 N/A N/A $451.92 N/A N/A $516.48 N/A N/A $355.08 N/A N/A $451.92 N/A N/A $216.28 N/A N/A N/A N/A N/A $387.36 N/A N/A $225.96 N/A N/A $419.64 N/A N/A $0.83 N/A N/A $387.36 N/A N/A $451.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $645.60 $645.60 N/A 4404778 Pharmacy hydrochlorothiazide 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.11 $- $0.55 $- $- $1.68 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.31 N/A N/A $0.86 N/A N/A $1.47 N/A N/A $1.68 N/A N/A $1.16 N/A N/A $1.47 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.74 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.26 N/A N/A $1.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.11 $2.11 N/A 4408101 Pharmacy diazepam 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400730 Pharmacy fluconazole 150 mg Tab [BCH] 250 $27.87 $- $7.24 $- $- $22.29 $- N/A $7.24 N/A N/A $10.53 N/A N/A $16.72 N/A N/A $13.93 N/A N/A N/A N/A N/A $18.95 N/A N/A $17.28 N/A N/A $11.42 N/A N/A $19.51 N/A N/A $22.29 N/A N/A $15.33 N/A N/A $19.51 N/A N/A $9.33 N/A N/A N/A N/A N/A $16.72 N/A N/A $9.75 N/A N/A $18.11 N/A N/A N/A N/A N/A $16.72 N/A N/A $19.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.87 $27.87 N/A 4401253 Pharmacy famotidine 20 mg Tab [BCH] 250 $4.84 $- $1.26 $- $- $3.88 $- N/A $1.26 N/A N/A $1.83 N/A N/A $2.91 N/A N/A $2.42 N/A N/A N/A N/A N/A $3.29 N/A N/A $3.00 N/A N/A $1.99 N/A N/A $3.39 N/A N/A $3.88 N/A N/A $2.66 N/A N/A $3.39 N/A N/A $1.62 N/A N/A N/A N/A N/A $2.91 N/A N/A $1.70 N/A N/A $3.15 N/A N/A N/A N/A N/A $2.91 N/A N/A $3.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.84 $4.84 N/A 4409725 Pharmacy albuterol 90 mcg/inh Aer 250 $62.74 $- $16.31 $- $- $50.19 $- N/A $16.31 N/A N/A $23.72 N/A N/A $37.64 N/A N/A $31.37 N/A N/A N/A N/A N/A $42.66 N/A N/A $38.90 N/A N/A $25.72 N/A N/A $43.92 N/A N/A $50.19 N/A N/A $34.51 N/A N/A $43.92 N/A N/A $21.02 N/A N/A N/A N/A N/A $37.64 N/A N/A $21.96 N/A N/A $40.78 N/A N/A N/A N/A N/A $37.64 N/A N/A $43.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $62.74 $62.74 N/A 4409725 Pharmacy albuterol 90 mcg/inh Aer [BCH] 250 $49.67 $- $12.91 $- $- $39.73 $- N/A $12.91 N/A N/A $18.77 N/A N/A $29.80 N/A N/A $24.83 N/A N/A N/A N/A N/A $33.77 N/A N/A $30.79 N/A N/A $20.36 N/A N/A $34.77 N/A N/A $39.73 N/A N/A $27.32 N/A N/A $34.77 N/A N/A $16.64 N/A N/A N/A N/A N/A $29.80 N/A N/A $17.38 N/A N/A $32.28 N/A N/A N/A N/A N/A $29.80 N/A N/A $34.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.67 $49.67 N/A 4409602 Pharmacy fluticasone-salmeterol 100 mcg-50 mcg Inh Pwdr [BCH] 250 $309.34 $- $80.43 $- $- $247.47 $- N/A $80.43 N/A N/A $116.93 N/A N/A $185.60 N/A N/A $154.67 N/A N/A N/A N/A N/A $210.35 N/A N/A $191.79 N/A N/A $126.83 N/A N/A $216.54 N/A N/A $247.47 N/A N/A $170.14 N/A N/A $216.54 N/A N/A $103.63 N/A N/A N/A N/A N/A $185.60 N/A N/A $108.27 N/A N/A $201.07 N/A N/A N/A N/A N/A $185.60 N/A N/A $216.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $309.34 $309.34 N/A 4409558 Pharmacy fluticasone-salmeterol 250 mcg-50 mcg Pow [BCH] 250 $15.76 $- $4.10 $- $- $12.61 $- N/A $4.10 N/A N/A $5.96 N/A N/A $9.45 N/A N/A $7.88 N/A N/A N/A N/A N/A $10.71 N/A N/A $9.77 N/A N/A $6.46 N/A N/A $11.03 N/A N/A $12.61 N/A N/A $8.67 N/A N/A $11.03 N/A N/A $5.28 N/A N/A N/A N/A N/A $9.45 N/A N/A $5.52 N/A N/A $10.24 N/A N/A N/A N/A N/A $9.45 N/A N/A $11.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.76 $15.76 N/A 4409558 Pharmacy fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr [BCH] 250 $309.34 $- $80.43 $- $- $247.47 $- N/A $80.43 N/A N/A $116.93 N/A N/A $185.60 N/A N/A $154.67 N/A N/A N/A N/A N/A $210.35 N/A N/A $191.79 N/A N/A $126.83 N/A N/A $216.54 N/A N/A $247.47 N/A N/A $170.14 N/A N/A $216.54 N/A N/A $103.63 N/A N/A N/A N/A N/A $185.60 N/A N/A $108.27 N/A N/A $201.07 N/A N/A N/A N/A N/A $185.60 N/A N/A $216.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $309.34 $309.34 N/A 4409600 Pharmacy fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr [BCH] 250 $504.16 $- $131.08 $- $- $403.33 $- N/A $131.08 N/A N/A $190.57 N/A N/A $302.50 N/A N/A $252.08 N/A N/A N/A N/A N/A $342.83 N/A N/A $312.58 N/A N/A $206.71 N/A N/A $352.91 N/A N/A $403.33 N/A N/A $277.29 N/A N/A $352.91 N/A N/A $168.89 N/A N/A N/A N/A N/A $302.50 N/A N/A $176.46 N/A N/A $327.70 N/A N/A N/A N/A N/A $302.50 N/A N/A $352.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $504.16 $504.16 N/A 4409788 Pharmacy dutasteride 0.5 mg Cap [BCH] 250 $13.44 $- $3.50 $- $- $10.76 $- N/A $3.50 N/A N/A $5.08 N/A N/A $8.07 N/A N/A $6.72 N/A N/A N/A N/A N/A $9.14 N/A N/A $8.34 N/A N/A $5.51 N/A N/A $9.41 N/A N/A $10.76 N/A N/A $7.39 N/A N/A $9.41 N/A N/A $4.50 N/A N/A N/A N/A N/A $8.07 N/A N/A $4.71 N/A N/A $8.74 N/A N/A N/A N/A N/A $8.07 N/A N/A $9.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.44 $13.44 N/A 4408974 Pharmacy fluticasone CFC free 44 mcg/inh Inh Aer w/adapter [BCH] 250 $380.98 $- $99.06 $- $- $304.78 $- N/A $99.06 N/A N/A $144.01 N/A N/A $228.59 N/A N/A $190.49 N/A N/A N/A N/A N/A $259.07 N/A N/A $236.21 N/A N/A $156.20 N/A N/A $266.69 N/A N/A $304.78 N/A N/A $209.54 N/A N/A $266.69 N/A N/A $127.63 N/A N/A N/A N/A N/A $228.59 N/A N/A $133.34 N/A N/A $247.64 N/A N/A N/A N/A N/A $228.59 N/A N/A $266.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $380.98 $380.98 N/A 4409442 Pharmacy fluticasone CFC free 110 mcg/inh Inh Aer w/adapter [BCH] 250 $510.04 $- $132.61 $- $- $408.03 $- N/A $132.61 N/A N/A $192.80 N/A N/A $306.02 N/A N/A $255.02 N/A N/A N/A N/A N/A $346.83 N/A N/A $316.23 N/A N/A $209.12 N/A N/A $357.03 N/A N/A $408.03 N/A N/A $280.52 N/A N/A $357.03 N/A N/A $170.86 N/A N/A N/A N/A N/A $306.02 N/A N/A $178.51 N/A N/A $331.53 N/A N/A N/A N/A N/A $306.02 N/A N/A $357.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $510.04 $510.04 N/A 4407687 Pharmacy fluticasone CFC free 220 mcg/inh Inh Aer w/adapter [BCH] 250 $792.22 $- $205.98 $- $- $633.78 $- N/A $205.98 N/A N/A $299.46 N/A N/A $475.33 N/A N/A $396.11 N/A N/A N/A N/A N/A $538.71 N/A N/A $491.18 N/A N/A $324.81 N/A N/A $554.55 N/A N/A $633.78 N/A N/A $435.72 N/A N/A $554.55 N/A N/A $265.39 N/A N/A N/A N/A N/A $475.33 N/A N/A $277.28 N/A N/A $514.94 N/A N/A N/A N/A N/A $475.33 N/A N/A $554.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $792.22 $792.22 N/A 7000004 Pharmacy sotrovimab 500 mg Injection 636 $- $- $- $- $- $- $- N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400292 Pharmacy lovastatin 40 mg Tab [BCH] 250 $8.54 $- $2.22 $- $- $6.83 $- N/A $2.22 N/A N/A $3.23 N/A N/A $5.13 N/A N/A $4.27 N/A N/A N/A N/A N/A $5.81 N/A N/A $5.30 N/A N/A $3.50 N/A N/A $5.98 N/A N/A $6.83 N/A N/A $4.70 N/A N/A $5.98 N/A N/A $2.86 N/A N/A N/A N/A N/A $5.13 N/A N/A $2.99 N/A N/A $5.55 N/A N/A N/A N/A N/A $5.13 N/A N/A $5.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.54 $8.54 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.01 $- $0.52 $- $- $1.61 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.21 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.25 N/A N/A $0.82 N/A N/A $1.41 N/A N/A $1.61 N/A N/A $1.10 N/A N/A $1.41 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.21 N/A N/A $0.70 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.21 N/A N/A $1.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.01 $2.01 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404480 Pharmacy amiodarone 200 mg Tab [BCH] 250 $6.76 $- $1.76 $- $- $5.41 $- N/A $1.76 N/A N/A $2.56 N/A N/A $4.06 N/A N/A $3.38 N/A N/A N/A N/A N/A $4.60 N/A N/A $4.19 N/A N/A $2.77 N/A N/A $4.73 N/A N/A $5.41 N/A N/A $3.72 N/A N/A $4.73 N/A N/A $2.27 N/A N/A N/A N/A N/A $4.06 N/A N/A $2.37 N/A N/A $4.40 N/A N/A N/A N/A N/A $4.06 N/A N/A $4.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.76 $6.76 N/A 4400759 Pharmacy methimazole 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409385 Pharmacy cilostazol 100 mg Tab [BCH] 250 $3.65 $- $0.95 $- $- $2.92 $- N/A $0.95 N/A N/A $1.38 N/A N/A $2.19 N/A N/A $1.82 N/A N/A N/A N/A N/A $2.48 N/A N/A $2.26 N/A N/A $1.50 N/A N/A $2.55 N/A N/A $2.92 N/A N/A $2.01 N/A N/A $2.55 N/A N/A $1.22 N/A N/A N/A N/A N/A $2.19 N/A N/A $1.28 N/A N/A $2.37 N/A N/A N/A N/A N/A $2.19 N/A N/A $2.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.65 $3.65 N/A 4400129 Pharmacy buPROPion 100 mg ER Tab [BCH] 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.20 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4409329 Pharmacy buPROPion 150 mg ER Tab [BCH] 250 $3.89 $- $1.01 $- $- $3.11 $- N/A $1.01 N/A N/A $1.47 N/A N/A $2.33 N/A N/A $1.94 N/A N/A N/A N/A N/A $2.64 N/A N/A $2.41 N/A N/A $1.59 N/A N/A $2.72 N/A N/A $3.11 N/A N/A $2.14 N/A N/A $2.72 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.33 N/A N/A $1.36 N/A N/A $2.53 N/A N/A N/A N/A N/A $2.33 N/A N/A $2.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.89 $3.89 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.01 $- $0.52 $- $- $1.61 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.21 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.25 N/A N/A $0.82 N/A N/A $1.41 N/A N/A $1.61 N/A N/A $1.10 N/A N/A $1.41 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.21 N/A N/A $0.70 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.21 N/A N/A $1.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.01 $2.01 N/A 4400607 Pharmacy hydrOXYzine pamoate 25 mg Cap [BCH] Q0177 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.51 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.51 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4400607 Pharmacy hydrOXYzine pamoate 25 mg Cap [BCH] Q0177 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400931 Pharmacy quiNIDine 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400405 Pharmacy metOLazone 2.5 mg Tab[BCH] 250 $4.15 $- $1.08 $- $- $3.32 $- N/A $1.08 N/A N/A $1.57 N/A N/A $2.49 N/A N/A $2.07 N/A N/A N/A N/A N/A $2.82 N/A N/A $2.57 N/A N/A $1.70 N/A N/A $2.90 N/A N/A $3.32 N/A N/A $2.28 N/A N/A $2.90 N/A N/A $1.39 N/A N/A N/A N/A N/A $2.49 N/A N/A $1.45 N/A N/A $2.70 N/A N/A N/A N/A N/A $2.49 N/A N/A $2.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.15 $4.15 N/A 4400609 Pharmacy budesonide-formoterol 160 mcg-4.5 mcg/inh Inh Aer w/adapter [BCH] 250 $474.92 $- $123.48 $- $- $379.94 $- N/A $123.48 N/A N/A $179.52 N/A N/A $284.95 N/A N/A $237.46 N/A N/A N/A N/A N/A $322.95 N/A N/A $294.45 N/A N/A $194.72 N/A N/A $332.44 N/A N/A $379.94 N/A N/A $261.21 N/A N/A $332.44 N/A N/A $159.10 N/A N/A N/A N/A N/A $284.95 N/A N/A $166.22 N/A N/A $308.70 N/A N/A N/A N/A N/A $284.95 N/A N/A $332.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $474.92 $474.92 N/A 4400734 Pharmacy budesonide-formoterol 80 mcg-4.5 mcg/inh Aer [BCH] 250 $412.86 $- $107.34 $- $- $330.29 $- N/A $107.34 N/A N/A $156.06 N/A N/A $247.72 N/A N/A $206.43 N/A N/A N/A N/A N/A $280.74 N/A N/A $255.97 N/A N/A $169.27 N/A N/A $289.00 N/A N/A $330.29 N/A N/A $227.07 N/A N/A $289.00 N/A N/A $138.31 N/A N/A N/A N/A N/A $247.72 N/A N/A $144.50 N/A N/A $268.36 N/A N/A N/A N/A N/A $247.72 N/A N/A $289.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $412.86 $412.86 N/A 4400597 Pharmacy ticagrelor 90 mg Tab [BCH] 250 $12.33 $- $3.21 $- $- $9.87 $- N/A $3.21 N/A N/A $4.66 N/A N/A $7.40 N/A N/A $6.17 N/A N/A N/A N/A N/A $8.39 N/A N/A $7.65 N/A N/A $5.06 N/A N/A $8.63 N/A N/A $9.87 N/A N/A $6.78 N/A N/A $8.63 N/A N/A $4.13 N/A N/A N/A N/A N/A $7.40 N/A N/A $4.32 N/A N/A $8.02 N/A N/A N/A N/A N/A $7.40 N/A N/A $8.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.33 $12.33 N/A 4400014 Pharmacy budesonide 180 mcg/inh Inh Pwdr [BCH] 250 $481.12 $- $125.09 $- $- $384.90 $- N/A $125.09 N/A N/A $181.86 N/A N/A $288.67 N/A N/A $240.56 N/A N/A N/A N/A N/A $327.16 N/A N/A $298.29 N/A N/A $197.26 N/A N/A $336.78 N/A N/A $384.90 N/A N/A $264.62 N/A N/A $336.78 N/A N/A $161.18 N/A N/A N/A N/A N/A $288.67 N/A N/A $168.39 N/A N/A $312.73 N/A N/A N/A N/A N/A $288.67 N/A N/A $336.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $481.12 $481.12 N/A 4409459 Pharmacy budesonide 0.25 mg/2 mL Inh Susp [BCH] J7626 636 $20.92 $- $1.78 $- $- $16.73 $- N/A $5.44 N/A N/A Not Reimbursed N/A N/A $12.55 N/A N/A $10.46 N/A N/A N/A N/A N/A $14.22 N/A N/A $12.97 N/A N/A $8.58 N/A N/A $14.64 N/A N/A $16.73 N/A N/A $11.50 N/A N/A $14.64 N/A N/A $7.01 N/A N/A N/A N/A N/A $12.55 N/A N/A $7.32 N/A N/A $13.60 N/A N/A $1.78 N/A N/A $12.55 N/A N/A $14.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.92 $20.92 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours XLTab [BCH] 250 $94.32 $- $24.52 $- $- $75.45 $- N/A $24.52 N/A N/A $35.65 N/A N/A $56.59 N/A N/A $47.16 N/A N/A N/A N/A N/A $64.13 N/A N/A $58.48 N/A N/A $38.67 N/A N/A $66.02 N/A N/A $75.45 N/A N/A $51.87 N/A N/A $66.02 N/A N/A $31.60 N/A N/A N/A N/A N/A $56.59 N/A N/A $33.01 N/A N/A $61.31 N/A N/A N/A N/A N/A $56.59 N/A N/A $66.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $94.32 $94.32 N/A 4404957 Pharmacy phytonadione 5 mg Tab [BCH] 250 $141.02 $- $36.67 $- $- $112.82 $- N/A $36.67 N/A N/A $53.31 N/A N/A $84.61 N/A N/A $70.51 N/A N/A N/A N/A N/A $95.90 N/A N/A $87.44 N/A N/A $57.82 N/A N/A $98.72 N/A N/A $112.82 N/A N/A $77.56 N/A N/A $98.72 N/A N/A $47.24 N/A N/A N/A N/A N/A $84.61 N/A N/A $49.36 N/A N/A $91.67 N/A N/A N/A N/A N/A $84.61 N/A N/A $98.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $141.02 $141.02 N/A 4409647 Pharmacy piperacillin-tazobactam 2 g-0.25 g IV Inj [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g IV Inj [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409162 Pharmacy piperacillin-tazobactam 4 g-0.5 g IV Inj [BCH] J2543 636 $33.60 $- $1.68 $- $- $26.88 $- N/A $8.74 N/A N/A Not Reimbursed N/A N/A $20.16 N/A N/A $16.80 N/A N/A N/A N/A N/A $22.85 N/A N/A $20.83 N/A N/A $13.78 N/A N/A $23.52 N/A N/A $26.88 N/A N/A $18.48 N/A N/A $23.52 N/A N/A $11.26 N/A N/A N/A N/A N/A $20.16 N/A N/A $11.76 N/A N/A $21.84 N/A N/A $1.68 N/A N/A $20.16 N/A N/A $23.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.60 $33.60 N/A 4400335 Pharmacy sodium chloride 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400335 Pharmacy sodium chloride 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400689 Pharmacy sodium chloride nasal 0.65% Gel [BCH] 250 $6.16 $- $1.60 $- $- $4.93 $- N/A $1.60 N/A N/A $2.33 N/A N/A $3.70 N/A N/A $3.08 N/A N/A N/A N/A N/A $4.19 N/A N/A $3.82 N/A N/A $2.53 N/A N/A $4.31 N/A N/A $4.93 N/A N/A $3.39 N/A N/A $4.31 N/A N/A $2.06 N/A N/A N/A N/A N/A $3.70 N/A N/A $2.16 N/A N/A $4.00 N/A N/A N/A N/A N/A $3.70 N/A N/A $4.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.16 $6.16 N/A 4400363 Pharmacy phenylephrine nasal 0.25% Spr [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4400160 Pharmacy phenylephrine nasal 0.5% Spr [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404577 Pharmacy ALPRAZolam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401006 Pharmacy oxazepam 10 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400540 Pharmacy propylthiouracil 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409931 Pharmacy carbidopa-levodopa 10 mg-100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408762 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400464 Pharmacy carbidopa-levodopa 25 mg-250 mg Tab [BCH] 250 $2.22 $- $0.58 $- $- $1.78 $- N/A $0.58 N/A N/A $0.84 N/A N/A $1.33 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.51 N/A N/A $1.38 N/A N/A $0.91 N/A N/A $1.56 N/A N/A $1.78 N/A N/A $1.22 N/A N/A $1.56 N/A N/A $0.74 N/A N/A N/A N/A N/A $1.33 N/A N/A $0.78 N/A N/A $1.44 N/A N/A N/A N/A N/A $1.33 N/A N/A $1.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.22 $2.22 N/A 4403342 Pharmacy indapamide 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401338 Pharmacy spironolactone 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400610 Pharmacy oxyCODONE 15 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4400680 Pharmacy DULoxetine 60 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4409204 Pharmacy tamsulosin 0.4 mg Oral Cap [BCH] 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.22 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.63 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400727 Pharmacy amphetamine-dextroamphetamine 30 mg Cap [BCH] 250 $14.10 $- $3.67 $- $- $11.28 $- N/A $3.67 N/A N/A $5.33 N/A N/A $8.46 N/A N/A $7.05 N/A N/A N/A N/A N/A $9.59 N/A N/A $8.74 N/A N/A $5.78 N/A N/A $9.87 N/A N/A $11.28 N/A N/A $7.75 N/A N/A $9.87 N/A N/A $4.72 N/A N/A N/A N/A N/A $8.46 N/A N/A $4.93 N/A N/A $9.16 N/A N/A N/A N/A N/A $8.46 N/A N/A $9.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.10 $14.10 N/A 4400793 Pharmacy oxymorphone 40 mg oral ER Tab [BCH] 250 $23.20 $- $6.03 $- $- $18.56 $- N/A $6.03 N/A N/A $8.77 N/A N/A $13.92 N/A N/A $11.60 N/A N/A N/A N/A N/A $15.77 N/A N/A $14.38 N/A N/A $9.51 N/A N/A $16.24 N/A N/A $18.56 N/A N/A $12.76 N/A N/A $16.24 N/A N/A $7.77 N/A N/A N/A N/A N/A $13.92 N/A N/A $8.12 N/A N/A $15.08 N/A N/A N/A N/A N/A $13.92 N/A N/A $16.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.20 $23.20 N/A 4407455 Pharmacy cholestyramine 4 g/5.5 g Pow UD [BCH] 250 $10.21 $- $2.66 $- $- $8.17 $- N/A $2.66 N/A N/A $3.86 N/A N/A $6.13 N/A N/A $5.11 N/A N/A N/A N/A N/A $6.95 N/A N/A $6.33 N/A N/A $4.19 N/A N/A $7.15 N/A N/A $8.17 N/A N/A $5.62 N/A N/A $7.15 N/A N/A $3.42 N/A N/A N/A N/A N/A $6.13 N/A N/A $3.58 N/A N/A $6.64 N/A N/A N/A N/A N/A $6.13 N/A N/A $7.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.21 $10.21 N/A 4404480 Pharmacy amiodarone 200 mg Tab [BCH] 250 $15.89 $- $4.13 $- $- $12.71 $- N/A $4.13 N/A N/A $6.01 N/A N/A $9.53 N/A N/A $7.94 N/A N/A N/A N/A N/A $10.80 N/A N/A $9.85 N/A N/A $6.51 N/A N/A $11.12 N/A N/A $12.71 N/A N/A $8.74 N/A N/A $11.12 N/A N/A $5.32 N/A N/A N/A N/A N/A $9.53 N/A N/A $5.56 N/A N/A $10.33 N/A N/A N/A N/A N/A $9.53 N/A N/A $11.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.89 $15.89 N/A 4400492 Pharmacy midodrine 5 mg Tab 250 $8.98 $- $2.33 $- $- $7.18 $- N/A $2.33 N/A N/A $3.39 N/A N/A $5.39 N/A N/A $4.49 N/A N/A N/A N/A N/A $6.10 N/A N/A $5.56 N/A N/A $3.68 N/A N/A $6.28 N/A N/A $7.18 N/A N/A $4.94 N/A N/A $6.28 N/A N/A $3.01 N/A N/A N/A N/A N/A $5.39 N/A N/A $3.14 N/A N/A $5.83 N/A N/A N/A N/A N/A $5.39 N/A N/A $6.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.98 $8.98 N/A 4400492 Pharmacy midodrine 5 mg Tab [BCH] 250 $8.31 $- $2.16 $- $- $6.65 $- N/A $2.16 N/A N/A $3.14 N/A N/A $4.99 N/A N/A $4.16 N/A N/A N/A N/A N/A $5.65 N/A N/A $5.15 N/A N/A $3.41 N/A N/A $5.82 N/A N/A $6.65 N/A N/A $4.57 N/A N/A $5.82 N/A N/A $2.78 N/A N/A N/A N/A N/A $4.99 N/A N/A $2.91 N/A N/A $5.40 N/A N/A N/A N/A N/A $4.99 N/A N/A $5.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.31 $8.31 N/A 4400954 Pharmacy midodrine 10 mg Tab 250 $19.44 $- $5.05 $- $- $15.55 $- N/A $5.05 N/A N/A $7.35 N/A N/A $11.66 N/A N/A $9.72 N/A N/A N/A N/A N/A $13.22 N/A N/A $12.05 N/A N/A $7.97 N/A N/A $13.61 N/A N/A $15.55 N/A N/A $10.69 N/A N/A $13.61 N/A N/A $6.51 N/A N/A N/A N/A N/A $11.66 N/A N/A $6.80 N/A N/A $12.64 N/A N/A N/A N/A N/A $11.66 N/A N/A $13.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.44 $19.44 N/A 4400925 Pharmacy potassium chloride 20 mEq Pow 250 $21.48 $- $5.58 $- $- $17.18 $- N/A $5.58 N/A N/A $8.12 N/A N/A $12.89 N/A N/A $10.74 N/A N/A N/A N/A N/A $14.61 N/A N/A $13.32 N/A N/A $8.81 N/A N/A $15.04 N/A N/A $17.18 N/A N/A $11.81 N/A N/A $15.04 N/A N/A $7.20 N/A N/A N/A N/A N/A $12.89 N/A N/A $7.52 N/A N/A $13.96 N/A N/A N/A N/A N/A $12.89 N/A N/A $15.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.48 $21.48 N/A 4400053 Pharmacy metroNIDAZOLE 0.75% Vag Gel w/Appl [BCH] 250 $326.07 $- $84.78 $- $- $260.86 $- N/A $84.78 N/A N/A $123.26 N/A N/A $195.64 N/A N/A $163.04 N/A N/A N/A N/A N/A $221.73 N/A N/A $202.17 N/A N/A $133.69 N/A N/A $228.25 N/A N/A $260.86 N/A N/A $179.34 N/A N/A $228.25 N/A N/A $109.23 N/A N/A N/A N/A N/A $195.64 N/A N/A $114.13 N/A N/A $211.95 N/A N/A N/A N/A N/A $195.64 N/A N/A $228.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $326.07 $326.07 N/A 4407522 Pharmacy hetastarch 60 mg/mL-NaCl 0.9% Sol [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400970 Pharmacy ceFAZolin 1 g Pow [BCH] J0690 636 $75.00 $- $0.77 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.77 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409059 Pharmacy metroNIDAZOLE 500 mg/100 mL IV Sol [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404156 Pharmacy Dextrose 5% with 0.2% NaCl IV Sol 1000 mL [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400428 Pharmacy Sodium Chloride 0.9% IV Sol 500 mL [BCH] J7040 258 $75.00 $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404297 Pharmacy Sodium Chloride 0.9% IV Sol 250 mL [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400614 Pharmacy Sodium Chloride 3% IV Sol 500 mL [BCH] J7131 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400958 Pharmacy iopamidol 61% Sol Q9967 250 $12.00 $- $0.11 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.11 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400959 Pharmacy iopamidol 76% Sol [BCH] Q9967 636 $234.62 $- $0.11 $- $- $187.70 $- N/A $61.00 N/A N/A Not Reimbursed N/A N/A $140.77 N/A N/A $117.31 N/A N/A N/A N/A N/A $159.54 N/A N/A $145.46 N/A N/A $96.19 N/A N/A $164.23 N/A N/A $187.70 N/A N/A $129.04 N/A N/A $164.23 N/A N/A $78.60 N/A N/A N/A N/A N/A $140.77 N/A N/A $82.12 N/A N/A $152.50 N/A N/A $0.11 N/A N/A $140.77 N/A N/A $164.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $234.62 $234.62 N/A 4400426 Pharmacy "emollients, Top Gel [BCH]" 250 $3.96 $- $1.03 $- $- $3.17 $- N/A $1.03 N/A N/A $1.50 N/A N/A $2.37 N/A N/A $1.98 N/A N/A N/A N/A N/A $2.69 N/A N/A $2.45 N/A N/A $1.62 N/A N/A $2.77 N/A N/A $3.17 N/A N/A $2.18 N/A N/A $2.77 N/A N/A $1.33 N/A N/A N/A N/A N/A $2.37 N/A N/A $1.38 N/A N/A $2.57 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.96 $3.96 N/A 4405825 Pharmacy nitroglycerin 2% Oin [BCH] 250 $5.01 $- $1.30 $- $- $4.01 $- N/A $1.30 N/A N/A $1.90 N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.06 N/A N/A $3.51 N/A N/A $4.01 N/A N/A $2.76 N/A N/A $3.51 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.75 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4401334 Pharmacy benzocaine Top 20% mucous membrane spray [BCH] 250 $- $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400816 Pharmacy benzocaine topical 20% Gel [BCH] 250 $8.65 $- $2.25 $- $- $6.92 $- N/A $2.25 N/A N/A $3.27 N/A N/A $5.19 N/A N/A $4.32 N/A N/A N/A N/A N/A $5.88 N/A N/A $5.36 N/A N/A $3.55 N/A N/A $6.05 N/A N/A $6.92 N/A N/A $4.76 N/A N/A $6.05 N/A N/A $2.90 N/A N/A N/A N/A N/A $5.19 N/A N/A $3.03 N/A N/A $5.62 N/A N/A N/A N/A N/A $5.19 N/A N/A $6.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.65 $8.65 N/A 4400699 Pharmacy "emollients, Top Crm [BCH]" 250 $13.20 $- $3.43 $- $- $10.56 $- N/A $3.43 N/A N/A $4.99 N/A N/A $7.92 N/A N/A $6.60 N/A N/A N/A N/A N/A $8.98 N/A N/A $8.18 N/A N/A $5.41 N/A N/A $9.24 N/A N/A $10.56 N/A N/A $7.26 N/A N/A $9.24 N/A N/A $4.42 N/A N/A N/A N/A N/A $7.92 N/A N/A $4.62 N/A N/A $8.58 N/A N/A N/A N/A N/A $7.92 N/A N/A $9.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.20 $13.20 N/A 4400452 Pharmacy QUEtiapine 400 mg oral tablet [BCH] 250 $44.30 $- $11.52 $- $- $35.44 $- N/A $11.52 N/A N/A $16.75 N/A N/A $26.58 N/A N/A $22.15 N/A N/A N/A N/A N/A $30.12 N/A N/A $27.47 N/A N/A $18.16 N/A N/A $31.01 N/A N/A $35.44 N/A N/A $24.36 N/A N/A $31.01 N/A N/A $14.84 N/A N/A N/A N/A N/A $26.58 N/A N/A $15.50 N/A N/A $28.79 N/A N/A N/A N/A N/A $26.58 N/A N/A $31.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.30 $44.30 N/A 4400754 Pharmacy QUEtiapine 50 mg Tab [BCH] 250 $19.71 $- $5.12 $- $- $15.77 $- N/A $5.12 N/A N/A $7.45 N/A N/A $11.83 N/A N/A $9.85 N/A N/A N/A N/A N/A $13.40 N/A N/A $12.22 N/A N/A $8.08 N/A N/A $13.80 N/A N/A $15.77 N/A N/A $10.84 N/A N/A $13.80 N/A N/A $6.60 N/A N/A N/A N/A N/A $11.83 N/A N/A $6.90 N/A N/A $12.81 N/A N/A N/A N/A N/A $11.83 N/A N/A $13.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.71 $19.71 N/A 4400882 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 $38.95 $- $10.13 $- $- $31.16 $- N/A $10.13 N/A N/A $14.72 N/A N/A $23.37 N/A N/A $19.48 N/A N/A N/A N/A N/A $26.49 N/A N/A $24.15 N/A N/A $15.97 N/A N/A $27.27 N/A N/A $31.16 N/A N/A $21.42 N/A N/A $27.27 N/A N/A $13.05 N/A N/A N/A N/A N/A $23.37 N/A N/A $13.63 N/A N/A $25.32 N/A N/A N/A N/A N/A $23.37 N/A N/A $27.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.95 $38.95 N/A 4400869 Pharmacy QUEtiapine 300 mg Tab [BCH] 250 $51.07 $- $13.28 $- $- $40.86 $- N/A $13.28 N/A N/A $19.30 N/A N/A $30.64 N/A N/A $25.54 N/A N/A N/A N/A N/A $34.73 N/A N/A $31.66 N/A N/A $20.94 N/A N/A $35.75 N/A N/A $40.86 N/A N/A $28.09 N/A N/A $35.75 N/A N/A $17.11 N/A N/A N/A N/A N/A $30.64 N/A N/A $17.87 N/A N/A $33.20 N/A N/A N/A N/A N/A $30.64 N/A N/A $35.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $51.07 $51.07 N/A 4404297 Pharmacy Sodium Chloride 0.9% IV Sol 250 mL [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400428 Pharmacy LVP solution Sodium Chloride 0.9% Sol [BCH] J7040 636 $75.00 $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404693 Pharmacy LVP solution Sodium Chloride 0.9% Sol [BCH] J7050 636 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400614 Pharmacy Sodium Chloride 3% IV Sol 500 mL [BCH] J7131 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400871 Pharmacy LVP solution Lactated Ringers 500ml Injection Sol [BCH] J7120 636 $200.00 $- $2.34 $- $- $160.00 $- N/A $52.00 N/A N/A Not Reimbursed N/A N/A $120.00 N/A N/A $100.00 N/A N/A N/A N/A N/A $136.00 N/A N/A $124.00 N/A N/A $82.00 N/A N/A $140.00 N/A N/A $160.00 N/A N/A $110.00 N/A N/A $140.00 N/A N/A $67.00 N/A N/A N/A N/A N/A $120.00 N/A N/A $70.00 N/A N/A $130.00 N/A N/A $2.34 N/A N/A $120.00 N/A N/A $140.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $200.00 $200.00 N/A 4407597 Pharmacy lidocaine 5%-0.4% Sol [BCH] J2001 636 $75.00 $- $0.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400738 Pharmacy Intralipids 20% 500mL [BCH] 250 $90.94 $- $23.64 $- $- $72.75 $- N/A $23.64 N/A N/A $34.38 N/A N/A $54.56 N/A N/A $45.47 N/A N/A N/A N/A N/A $61.84 N/A N/A $56.38 N/A N/A $37.29 N/A N/A $63.66 N/A N/A $72.75 N/A N/A $50.02 N/A N/A $63.66 N/A N/A $30.46 N/A N/A N/A N/A N/A $54.56 N/A N/A $31.83 N/A N/A $59.11 N/A N/A N/A N/A N/A $54.56 N/A N/A $63.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.94 $90.94 N/A 4404693 Pharmacy Sodium Chloride 0.9% IV Sol 50 mL [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403496 Pharmacy Sodium Chloride 0.9% IV Sol 100 mL [BCH] J7040 258 $- $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400576 Pharmacy LVP solution with potassium Sodium Chloride 0.45% with KCl 20 mEq/L Sol [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400565 Pharmacy potassium chloride 20 mEq/100 mL Sol J3480 250 $75.00 $- $0.18 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.18 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400575 Pharmacy potassium chloride 10 mEq/100 mL Sol [BCH] J3480 250 $75.00 $- $0.18 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.18 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403322 Pharmacy DOPamine 400 mg/250 mL-D5% Sol [BCH] J1265 636 $75.00 $- $0.68 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.68 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400472 Pharmacy nitroglycerin 25 mg/250 mL-D5% Sol [BCH] 250 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409059 Pharmacy metroNIDAZOLE 500 mg/100 mL Sol 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4405368 Pharmacy DOBUTamine 1 mg/mL-D5% Sol J1250 636 $75.00 $- $5.96 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $5.96 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400755 Pharmacy Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) intravenous solution Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) Sol [BCH] 258 $90.00 $- $23.40 $- $- $72.00 $- N/A $23.40 N/A N/A $34.02 N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A N/A N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400402 Pharmacy Amino Acids 4.25% with 5% Dextrose & Electrolytes (Clinimix E Sulfite-Free) 1000 mL [BCH] 250 $75.68 $- $19.68 $- $- $60.54 $- N/A $19.68 N/A N/A $28.61 N/A N/A $45.41 N/A N/A $37.84 N/A N/A N/A N/A N/A $51.46 N/A N/A $46.92 N/A N/A $31.03 N/A N/A $52.98 N/A N/A $60.54 N/A N/A $41.62 N/A N/A $52.98 N/A N/A $25.35 N/A N/A N/A N/A N/A $45.41 N/A N/A $26.49 N/A N/A $49.19 N/A N/A N/A N/A N/A $45.41 N/A N/A $52.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.68 $75.68 N/A 4408937 Pharmacy Amino Acids 5% with 15% Dextrose and Electrolytes (Clinimix E Sulfite-Free) IV Sol 1000 mL [BCH] 250 $85.20 $- $22.15 $- $- $68.16 $- N/A $22.15 N/A N/A $32.21 N/A N/A $51.12 N/A N/A $42.60 N/A N/A N/A N/A N/A $57.94 N/A N/A $52.82 N/A N/A $34.93 N/A N/A $59.64 N/A N/A $68.16 N/A N/A $46.86 N/A N/A $59.64 N/A N/A $28.54 N/A N/A N/A N/A N/A $51.12 N/A N/A $29.82 N/A N/A $55.38 N/A N/A N/A N/A N/A $51.12 N/A N/A $59.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $85.20 $85.20 N/A 7000005 Pharmacy clindamycin 600 mg/50 mL-NaCl 0.9% Sol [BCH] 636 $- $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409931 Pharmacy carbidopa-levodopa 10 mg-100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403342 Pharmacy indapamide 2.5 mg Tab [BCH] 250 $3.10 $- $0.81 $- $- $2.48 $- N/A $0.81 N/A N/A $1.17 N/A N/A $1.86 N/A N/A $1.55 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.92 N/A N/A $1.27 N/A N/A $2.17 N/A N/A $2.48 N/A N/A $1.70 N/A N/A $2.17 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.86 N/A N/A $1.08 N/A N/A $2.01 N/A N/A N/A N/A N/A $1.86 N/A N/A $2.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.10 $3.10 N/A 4408762 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400074 Pharmacy diltiazem 90 mg Tab [BCH] 250 $4.28 $- $1.11 $- $- $3.43 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.57 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.66 N/A N/A $1.76 N/A N/A $3.00 N/A N/A $3.43 N/A N/A $2.36 N/A N/A $3.00 N/A N/A $1.44 N/A N/A N/A N/A N/A $2.57 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.57 N/A N/A $3.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.28 $4.28 N/A 4404387 Pharmacy propranolol 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403110 Pharmacy furosemide 20 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408941 Pharmacy chlorthalidone 25 mg Tab [BCH] 250 $2.41 $- $0.63 $- $- $1.93 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.93 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.84 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4402939 Pharmacy haloperidol 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404936 Pharmacy haloperidol 5 mg Tab [BCH] 250 $2.05 $- $0.53 $- $- $1.64 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.23 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.27 N/A N/A $0.84 N/A N/A $1.43 N/A N/A $1.64 N/A N/A $1.13 N/A N/A $1.43 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.23 N/A N/A $0.72 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.23 N/A N/A $1.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.05 $2.05 N/A 4403284 Pharmacy atropine-diphenoxylate 0.025 mg-2.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406120 Pharmacy cloNIDine 0.1 mg/24 hr Transderm ER Film [BCH] 250 $66.25 $- $17.22 $- $- $53.00 $- N/A $17.22 N/A N/A $25.04 N/A N/A $39.75 N/A N/A $33.12 N/A N/A N/A N/A N/A $45.05 N/A N/A $41.07 N/A N/A $27.16 N/A N/A $46.37 N/A N/A $53.00 N/A N/A $36.43 N/A N/A $46.37 N/A N/A $22.19 N/A N/A N/A N/A N/A $39.75 N/A N/A $23.19 N/A N/A $43.06 N/A N/A N/A N/A N/A $39.75 N/A N/A $46.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $66.25 $66.25 N/A 4403797 Pharmacy prazosin 1 mg Cap[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400921 Pharmacy memantine 10 mg Tab [BCH] 250 $12.19 $- $3.17 $- $- $9.75 $- N/A $3.17 N/A N/A $4.61 N/A N/A $7.32 N/A N/A $6.10 N/A N/A N/A N/A N/A $8.29 N/A N/A $7.56 N/A N/A $5.00 N/A N/A $8.53 N/A N/A $9.75 N/A N/A $6.71 N/A N/A $8.53 N/A N/A $4.08 N/A N/A N/A N/A N/A $7.32 N/A N/A $4.27 N/A N/A $7.93 N/A N/A N/A N/A N/A $7.32 N/A N/A $8.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.19 $12.19 N/A 4400464 Pharmacy carbidopa-levodopa 25 mg-250 mg Tab [BCH] 250 $2.22 $- $0.58 $- $- $1.78 $- N/A $0.58 N/A N/A $0.84 N/A N/A $1.33 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.51 N/A N/A $1.38 N/A N/A $0.91 N/A N/A $1.56 N/A N/A $1.78 N/A N/A $1.22 N/A N/A $1.56 N/A N/A $0.74 N/A N/A N/A N/A N/A $1.33 N/A N/A $0.78 N/A N/A $1.44 N/A N/A N/A N/A N/A $1.33 N/A N/A $1.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.22 $2.22 N/A 4409455 Pharmacy busPIRone 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400758 Pharmacy busPIRone 15 mg Tab [BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.62 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4400909 Pharmacy estradiol 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405965 Pharmacy phenytoin 100 mg ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400618 Pharmacy dicyclomine 10 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403090 Pharmacy levothyroxine 50 mcg (0.05 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403090 Pharmacy levothyroxine 50 mcg (0.05 mg) Tab [BCH} 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404759 Pharmacy levothyroxine 75 mcg (0.075 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404759 Pharmacy levothyroxine 75 mcg (0.075 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400392 Pharmacy levothyroxine 88 mcg (0.088 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400392 Pharmacy levothyroxine 88 mcg (0.088 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401945 Pharmacy levothyroxine 100 mcg (0.1 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401945 Pharmacy levothyroxine 100 mcg (0.1 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400350 Pharmacy levothyroxine 112 mcg (0.112 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402712 Pharmacy levothyroxine 125 mcg (0.125 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402712 Pharmacy levothyroxine 125 mcg (0.125 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405343 Pharmacy levothyroxine 150 mcg (0.15 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405343 Pharmacy levothyroxine 150 mcg (0.15 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409561 Pharmacy levothyroxine 137 mcg (0.137 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400295 Pharmacy atenolol-chlorthalidone 50 mg-25 mg Tab [BCH] 250 $3.77 $- $0.98 $- $- $3.01 $- N/A $0.98 N/A N/A $1.42 N/A N/A $2.26 N/A N/A $1.88 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.34 N/A N/A $1.54 N/A N/A $2.64 N/A N/A $3.01 N/A N/A $2.07 N/A N/A $2.64 N/A N/A $1.26 N/A N/A N/A N/A N/A $2.26 N/A N/A $1.32 N/A N/A $2.45 N/A N/A N/A N/A N/A $2.26 N/A N/A $2.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.77 $3.77 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.70 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.28 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.87 N/A N/A $1.49 N/A N/A $1.70 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4400929 Pharmacy loperamide 2 mg Cap [BCH] 250 $2.10 $- $0.55 $- $- $1.68 $- N/A $0.55 N/A N/A $0.79 N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.30 N/A N/A $0.86 N/A N/A $1.47 N/A N/A $1.68 N/A N/A $1.15 N/A N/A $1.47 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.73 N/A N/A $1.36 N/A N/A N/A N/A N/A $1.26 N/A N/A $1.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.10 $2.10 N/A 4400156 Pharmacy nisoldipine 20 mg ER Tab [BCH] 250 $32.90 $- $8.56 $- $- $26.32 $- N/A $8.56 N/A N/A $12.44 N/A N/A $19.74 N/A N/A $16.45 N/A N/A N/A N/A N/A $22.37 N/A N/A $20.40 N/A N/A $13.49 N/A N/A $23.03 N/A N/A $26.32 N/A N/A $18.10 N/A N/A $23.03 N/A N/A $11.02 N/A N/A N/A N/A N/A $19.74 N/A N/A $11.52 N/A N/A $21.39 N/A N/A N/A N/A N/A $19.74 N/A N/A $23.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.90 $32.90 N/A 4405013 Pharmacy LORazepam 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409204 Pharmacy tamsulosin 0.4 mg Oral Cap [BCH] 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.22 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.64 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4400906 Pharmacy captopril 12.5 mg Tab [BCH] 250 $3.12 $- $0.81 $- $- $2.49 $- N/A $0.81 N/A N/A $1.18 N/A N/A $1.87 N/A N/A $1.56 N/A N/A N/A N/A N/A $2.12 N/A N/A $1.93 N/A N/A $1.28 N/A N/A $2.18 N/A N/A $2.49 N/A N/A $1.71 N/A N/A $2.18 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.09 N/A N/A $2.03 N/A N/A N/A N/A N/A $1.87 N/A N/A $2.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.12 $3.12 N/A 4400166 Pharmacy fenofibrate 48 mg Tab [BCH] 250 $3.82 $- $0.99 $- $- $3.06 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.29 N/A N/A $1.91 N/A N/A N/A N/A N/A $2.60 N/A N/A $2.37 N/A N/A $1.57 N/A N/A $2.67 N/A N/A $3.06 N/A N/A $2.10 N/A N/A $2.67 N/A N/A $1.28 N/A N/A N/A N/A N/A $2.29 N/A N/A $1.34 N/A N/A $2.48 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.82 $3.82 N/A 4400867 Pharmacy fenofibrate 145 mg Tab [BCH] 250 $11.46 $- $2.98 $- $- $9.17 $- N/A $2.98 N/A N/A $4.33 N/A N/A $6.87 N/A N/A $5.73 N/A N/A N/A N/A N/A $7.79 N/A N/A $7.10 N/A N/A $4.70 N/A N/A $8.02 N/A N/A $9.17 N/A N/A $6.30 N/A N/A $8.02 N/A N/A $3.84 N/A N/A N/A N/A N/A $6.87 N/A N/A $4.01 N/A N/A $7.45 N/A N/A N/A N/A N/A $6.87 N/A N/A $8.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.46 $11.46 N/A 4400657 Pharmacy doxepin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405798 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $9.08 $- $2.36 $- $- $7.27 $- N/A $2.36 N/A N/A $3.43 N/A N/A $5.45 N/A N/A $4.54 N/A N/A N/A N/A N/A $6.18 N/A N/A $5.63 N/A N/A $3.72 N/A N/A $6.36 N/A N/A $7.27 N/A N/A $5.00 N/A N/A $6.36 N/A N/A $3.04 N/A N/A N/A N/A N/A $5.45 N/A N/A $3.18 N/A N/A $5.90 N/A N/A N/A N/A N/A $5.45 N/A N/A $6.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.08 $9.08 N/A 4400316 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $15.18 $- $3.95 $- $- $12.14 $- N/A $3.95 N/A N/A $5.74 N/A N/A $9.11 N/A N/A $7.59 N/A N/A N/A N/A N/A $10.32 N/A N/A $9.41 N/A N/A $6.22 N/A N/A $10.63 N/A N/A $12.14 N/A N/A $8.35 N/A N/A $10.63 N/A N/A $5.09 N/A N/A N/A N/A N/A $9.11 N/A N/A $5.31 N/A N/A $9.87 N/A N/A N/A N/A N/A $9.11 N/A N/A $10.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.18 $15.18 N/A 4408784 Pharmacy carvedilol 12.5 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4400860 Pharmacy paliperidone 3 mg Tab [BCH] 250 $61.12 $- $15.89 $- $- $48.90 $- N/A $15.89 N/A N/A $23.10 N/A N/A $36.67 N/A N/A $30.56 N/A N/A N/A N/A N/A $41.56 N/A N/A $37.90 N/A N/A $25.06 N/A N/A $42.79 N/A N/A $48.90 N/A N/A $33.62 N/A N/A $42.79 N/A N/A $20.48 N/A N/A N/A N/A N/A $36.67 N/A N/A $21.39 N/A N/A $39.73 N/A N/A N/A N/A N/A $36.67 N/A N/A $42.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $61.12 $61.12 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400671 Pharmacy rOPINIRole 2 mg Tab [BCH] 250 $5.47 $- $1.42 $- $- $4.38 $- N/A $1.42 N/A N/A $2.07 N/A N/A $3.28 N/A N/A $2.74 N/A N/A N/A N/A N/A $3.72 N/A N/A $3.39 N/A N/A $2.24 N/A N/A $3.83 N/A N/A $4.38 N/A N/A $3.01 N/A N/A $3.83 N/A N/A $1.83 N/A N/A N/A N/A N/A $3.28 N/A N/A $1.91 N/A N/A $3.56 N/A N/A N/A N/A N/A $3.28 N/A N/A $3.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.47 $5.47 N/A 4405707 Pharmacy traMADol 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400372 Pharmacy venlafaxine 37.5 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400410 Pharmacy carbidopa-levodopa 25 mg-100 mg Dis Tab [BCH] 250 $2.74 $- $0.71 $- $- $2.19 $- N/A $0.71 N/A N/A $1.04 N/A N/A $1.65 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.70 N/A N/A $1.12 N/A N/A $1.92 N/A N/A $2.19 N/A N/A $1.51 N/A N/A $1.92 N/A N/A $0.92 N/A N/A N/A N/A N/A $1.65 N/A N/A $0.96 N/A N/A $1.78 N/A N/A N/A N/A N/A $1.65 N/A N/A $1.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.74 $2.74 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.75 $- $1.23 $- $- $3.80 $- N/A $1.23 N/A N/A $1.79 N/A N/A $2.85 N/A N/A $2.37 N/A N/A N/A N/A N/A $3.23 N/A N/A $2.94 N/A N/A $1.95 N/A N/A $3.32 N/A N/A $3.80 N/A N/A $2.61 N/A N/A $3.32 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.85 N/A N/A $1.66 N/A N/A $3.09 N/A N/A N/A N/A N/A $2.85 N/A N/A $3.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.75 $4.75 N/A 4400137 Pharmacy modafinil 100 mg Tab [BCH] 250 $52.76 $- $13.72 $- $- $42.21 $- N/A $13.72 N/A N/A $19.94 N/A N/A $31.66 N/A N/A $26.38 N/A N/A N/A N/A N/A $35.88 N/A N/A $32.71 N/A N/A $21.63 N/A N/A $36.93 N/A N/A $42.21 N/A N/A $29.02 N/A N/A $36.93 N/A N/A $17.67 N/A N/A N/A N/A N/A $31.66 N/A N/A $18.47 N/A N/A $34.29 N/A N/A N/A N/A N/A $31.66 N/A N/A $36.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.76 $52.76 N/A 4409447 Pharmacy SUMAtriptan 50 mg Tab [BCH] 250 $50.29 $- $13.07 $- $- $40.23 $- N/A $13.07 N/A N/A $19.01 N/A N/A $30.17 N/A N/A $25.14 N/A N/A N/A N/A N/A $34.19 N/A N/A $31.18 N/A N/A $20.62 N/A N/A $35.20 N/A N/A $40.23 N/A N/A $27.66 N/A N/A $35.20 N/A N/A $16.85 N/A N/A N/A N/A N/A $30.17 N/A N/A $17.60 N/A N/A $32.69 N/A N/A N/A N/A N/A $30.17 N/A N/A $35.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.29 $50.29 N/A 4400846 Pharmacy fluPHENAZine 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400747 Pharmacy risperiDONE 0.25 mg Tab [BCH] 250 $9.60 $- $2.50 $- $- $7.68 $- N/A $2.50 N/A N/A $3.63 N/A N/A $5.76 N/A N/A $4.80 N/A N/A N/A N/A N/A $6.53 N/A N/A $5.95 N/A N/A $3.94 N/A N/A $6.72 N/A N/A $7.68 N/A N/A $5.28 N/A N/A $6.72 N/A N/A $3.22 N/A N/A N/A N/A N/A $5.76 N/A N/A $3.36 N/A N/A $6.24 N/A N/A N/A N/A N/A $5.76 N/A N/A $6.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.60 $9.60 N/A 4400757 Pharmacy risperiDONE 3 mg oral Dis Tab [BCH] 250 $23.56 $- $6.13 $- $- $18.85 $- N/A $6.13 N/A N/A $8.91 N/A N/A $14.14 N/A N/A $11.78 N/A N/A N/A N/A N/A $16.02 N/A N/A $14.61 N/A N/A $9.66 N/A N/A $16.49 N/A N/A $18.85 N/A N/A $12.96 N/A N/A $16.49 N/A N/A $7.89 N/A N/A N/A N/A N/A $14.14 N/A N/A $8.25 N/A N/A $15.32 N/A N/A N/A N/A N/A $14.14 N/A N/A $16.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.56 $23.56 N/A 4400691 Pharmacy fluPHENAZine 5 mg Tab [BCH] 250 $2.44 $- $0.63 $- $- $1.95 $- N/A $0.63 N/A N/A $0.92 N/A N/A $1.46 N/A N/A $1.22 N/A N/A N/A N/A N/A $1.66 N/A N/A $1.51 N/A N/A $1.00 N/A N/A $1.71 N/A N/A $1.95 N/A N/A $1.34 N/A N/A $1.71 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.46 N/A N/A $0.85 N/A N/A $1.58 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.44 $2.44 N/A 4400405 Pharmacy metolazone 2.5 mg Tab [BCH] 250 $4.74 $- $1.23 $- $- $3.79 $- N/A $1.23 N/A N/A $1.79 N/A N/A $2.84 N/A N/A $2.37 N/A N/A N/A N/A N/A $3.22 N/A N/A $2.94 N/A N/A $1.94 N/A N/A $3.32 N/A N/A $3.79 N/A N/A $2.61 N/A N/A $3.32 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.84 N/A N/A $1.66 N/A N/A $3.08 N/A N/A N/A N/A N/A $2.84 N/A N/A $3.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.74 $4.74 N/A 4400753 Pharmacy doxepin 100 mg Cap [BCH] 250 $3.94 $- $1.03 $- $- $3.16 $- N/A $1.03 N/A N/A $1.49 N/A N/A $2.37 N/A N/A $1.97 N/A N/A N/A N/A N/A $2.68 N/A N/A $2.45 N/A N/A $1.62 N/A N/A $2.76 N/A N/A $3.16 N/A N/A $2.17 N/A N/A $2.76 N/A N/A $1.32 N/A N/A N/A N/A N/A $2.37 N/A N/A $1.38 N/A N/A $2.56 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.94 $3.94 N/A 4409594 Pharmacy pantoprazole 40 mg Tab [BCH] 250 $10.53 $- $2.74 $- $- $8.43 $- N/A $2.74 N/A N/A $3.98 N/A N/A $6.32 N/A N/A $5.27 N/A N/A N/A N/A N/A $7.16 N/A N/A $6.53 N/A N/A $4.32 N/A N/A $7.37 N/A N/A $8.43 N/A N/A $5.79 N/A N/A $7.37 N/A N/A $3.53 N/A N/A N/A N/A N/A $6.32 N/A N/A $3.69 N/A N/A $6.85 N/A N/A N/A N/A N/A $6.32 N/A N/A $7.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.53 $10.53 N/A 4400811 Pharmacy sodium chloride 0.9% Sol UD 15 mL [BCH] 258 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409776 Pharmacy acetaminophen-oxyCODONE 325 mg-7.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404619 Pharmacy ipratropium 500 mcg/2.5 mL Sol [BCH] J7644 636 $5.00 $- $0.21 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.21 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401905 Pharmacy acyclovir Top 5% Oint [BCH] 250 $997.00 $- $259.22 $- $- $797.60 $- N/A $259.22 N/A N/A $376.87 N/A N/A $598.20 N/A N/A $498.50 N/A N/A N/A N/A N/A $677.96 N/A N/A $618.14 N/A N/A $408.77 N/A N/A $697.90 N/A N/A $797.60 N/A N/A $548.35 N/A N/A $697.90 N/A N/A $333.99 N/A N/A N/A N/A N/A $598.20 N/A N/A $348.95 N/A N/A $648.05 N/A N/A N/A N/A N/A $598.20 N/A N/A $697.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $997.00 $997.00 N/A 4409666 Pharmacy lidocaine Top 5% film [BCH] 250 $20.55 $- $5.34 $- $- $16.44 $- N/A $5.34 N/A N/A $7.77 N/A N/A $12.33 N/A N/A $10.28 N/A N/A N/A N/A N/A $13.97 N/A N/A $12.74 N/A N/A $8.43 N/A N/A $14.39 N/A N/A $16.44 N/A N/A $11.30 N/A N/A $14.39 N/A N/A $6.88 N/A N/A N/A N/A N/A $12.33 N/A N/A $7.19 N/A N/A $13.36 N/A N/A N/A N/A N/A $12.33 N/A N/A $14.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.55 $20.55 N/A 4401527 Pharmacy entacapone 200 mg Tab [BCH] 250 $7.91 $- $2.06 $- $- $6.33 $- N/A $2.06 N/A N/A $2.99 N/A N/A $4.75 N/A N/A $3.95 N/A N/A N/A N/A N/A $5.38 N/A N/A $4.90 N/A N/A $3.24 N/A N/A $5.54 N/A N/A $6.33 N/A N/A $4.35 N/A N/A $5.54 N/A N/A $2.65 N/A N/A N/A N/A N/A $4.75 N/A N/A $2.77 N/A N/A $5.14 N/A N/A N/A N/A N/A $4.75 N/A N/A $5.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.91 $7.91 N/A 4401725 Pharmacy nitroglycerin 0.1 mg/hr Fil [BCH] 250 $3.72 $- $0.97 $- $- $2.97 $- N/A $0.97 N/A N/A $1.41 N/A N/A $2.23 N/A N/A $1.86 N/A N/A N/A N/A N/A $2.53 N/A N/A $2.30 N/A N/A $1.52 N/A N/A $2.60 N/A N/A $2.97 N/A N/A $2.04 N/A N/A $2.60 N/A N/A $1.25 N/A N/A N/A N/A N/A $2.23 N/A N/A $1.30 N/A N/A $2.42 N/A N/A N/A N/A N/A $2.23 N/A N/A $2.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.72 $3.72 N/A 4401929 Pharmacy nitroglycerin 0.2 mg/hr Fil [BCH] 250 $3.80 $- $0.99 $- $- $3.04 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.28 N/A N/A $1.90 N/A N/A N/A N/A N/A $2.59 N/A N/A $2.36 N/A N/A $1.56 N/A N/A $2.66 N/A N/A $3.04 N/A N/A $2.09 N/A N/A $2.66 N/A N/A $1.27 N/A N/A N/A N/A N/A $2.28 N/A N/A $1.33 N/A N/A $2.47 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.80 $3.80 N/A 4401326 Pharmacy fentaNYL 25 mcg/hr Fil 250 $28.84 $- $7.50 $- $- $23.07 $- N/A $7.50 N/A N/A $10.90 N/A N/A $17.30 N/A N/A $14.42 N/A N/A N/A N/A N/A $19.61 N/A N/A $17.88 N/A N/A $11.82 N/A N/A $20.19 N/A N/A $23.07 N/A N/A $15.86 N/A N/A $20.19 N/A N/A $9.66 N/A N/A N/A N/A N/A $17.30 N/A N/A $10.09 N/A N/A $18.75 N/A N/A N/A N/A N/A $17.30 N/A N/A $20.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.84 $28.84 N/A 4409671 Pharmacy levalbuterol 0.31 mg/3 mL Inh Sol [BCH] J7614 636 $13.41 $- $0.06 $- $- $10.73 $- N/A $3.49 N/A N/A Not Reimbursed N/A N/A $8.05 N/A N/A $6.71 N/A N/A N/A N/A N/A $9.12 N/A N/A $8.32 N/A N/A $5.50 N/A N/A $9.39 N/A N/A $10.73 N/A N/A $7.38 N/A N/A $9.39 N/A N/A $4.49 N/A N/A N/A N/A N/A $8.05 N/A N/A $4.69 N/A N/A $8.72 N/A N/A $0.06 N/A N/A $8.05 N/A N/A $9.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.41 $13.41 N/A 4409873 Pharmacy levalbuterol 0.63 mg/3 mL Inh Sol [BCH] J7614 636 $13.41 $- $0.06 $- $- $10.73 $- N/A $3.49 N/A N/A Not Reimbursed N/A N/A $8.05 N/A N/A $6.71 N/A N/A N/A N/A N/A $9.12 N/A N/A $8.32 N/A N/A $5.50 N/A N/A $9.39 N/A N/A $10.73 N/A N/A $7.38 N/A N/A $9.39 N/A N/A $4.49 N/A N/A N/A N/A N/A $8.05 N/A N/A $4.69 N/A N/A $8.72 N/A N/A $0.06 N/A N/A $8.05 N/A N/A $9.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.41 $13.41 N/A 4401954 Pharmacy levalbuterol 1.25 mg/3 mL Inh Sol [BCH] J7614 636 $13.41 $- $0.06 $- $- $10.73 $- N/A $3.49 N/A N/A Not Reimbursed N/A N/A $8.05 N/A N/A $6.71 N/A N/A N/A N/A N/A $9.12 N/A N/A $8.32 N/A N/A $5.50 N/A N/A $9.39 N/A N/A $10.73 N/A N/A $7.38 N/A N/A $9.39 N/A N/A $4.49 N/A N/A N/A N/A N/A $8.05 N/A N/A $4.69 N/A N/A $8.72 N/A N/A $0.06 N/A N/A $8.05 N/A N/A $9.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.41 $13.41 N/A 4409873 Pharmacy levalbuterol 0.63 mg/3 mL Sol J7614 636 $13.41 $- $0.06 $- $- $10.73 $- N/A $3.49 N/A N/A Not Reimbursed N/A N/A $8.05 N/A N/A $6.71 N/A N/A N/A N/A N/A $9.12 N/A N/A $8.32 N/A N/A $5.50 N/A N/A $9.39 N/A N/A $10.73 N/A N/A $7.38 N/A N/A $9.39 N/A N/A $4.49 N/A N/A N/A N/A N/A $8.05 N/A N/A $4.70 N/A N/A $8.72 N/A N/A $0.06 N/A N/A $8.05 N/A N/A $9.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.41 $13.41 N/A 4402258 Pharmacy ethyl chloride Top 100% Spry [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400010 Pharmacy calamine Top 8% Lotion [BCH] 250 $7.46 $- $1.94 $- $- $5.97 $- N/A $1.94 N/A N/A $2.82 N/A N/A $4.48 N/A N/A $3.73 N/A N/A N/A N/A N/A $5.07 N/A N/A $4.62 N/A N/A $3.06 N/A N/A $5.22 N/A N/A $5.97 N/A N/A $4.10 N/A N/A $5.22 N/A N/A $2.50 N/A N/A N/A N/A N/A $4.48 N/A N/A $2.61 N/A N/A $4.85 N/A N/A N/A N/A N/A $4.48 N/A N/A $5.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.46 $7.46 N/A 4409006 Pharmacy iodine-potassium iodide 5%-10% oral Sol 473 mL [BCH] 250 $149.50 $- $38.87 $- $- $119.60 $- N/A $38.87 N/A N/A $56.51 N/A N/A $89.70 N/A N/A $74.75 N/A N/A N/A N/A N/A $101.66 N/A N/A $92.69 N/A N/A $61.29 N/A N/A $104.65 N/A N/A $119.60 N/A N/A $82.22 N/A N/A $104.65 N/A N/A $50.08 N/A N/A N/A N/A N/A $89.70 N/A N/A $52.32 N/A N/A $97.17 N/A N/A N/A N/A N/A $89.70 N/A N/A $104.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $149.50 $149.50 N/A 4400227 Pharmacy acetaminophen-HYDROcodone 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400227 Pharmacy acetaminophen-HYDROcodone 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400227 Pharmacy acetaminophen-hydrocodone 325 mg-5 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400229 Pharmacy acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400228 Pharmacy acetaminophen-HYDROcodone 325 mg-10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400228 Pharmacy acetaminophen-hydrocodone 325 mg-10 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400227 Pharmacy acetaminophen-HYDROcodone 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408002 Pharmacy acetaminophen-codeine 300 mg-30 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406360 Pharmacy acetaminophen-oxyCODONE 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409776 Pharmacy acetaminophen-oxycodone 325 mg-7.5 mg Tab [BCH] 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4409776 Pharmacy acetaminophen-oxycodone 325 mg-7.5 mg Tab 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4400062 Pharmacy acetaminophen-oxycodone 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409540 Pharmacy HYDROmorphone 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409613 Pharmacy methadone 5 mg Tab [BCH] S0109 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400904 Pharmacy methadone 10 mg Tab [BCH] S0109 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403812 Pharmacy morphine 20 mg/mL Con 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401920 Pharmacy morphine 15 mg ER Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405817 Pharmacy morphine 30 mg ER Tab [BCH] 250 $6.34 $- $1.65 $- $- $5.08 $- N/A $1.65 N/A N/A $2.40 N/A N/A $3.81 N/A N/A $3.17 N/A N/A N/A N/A N/A $4.31 N/A N/A $3.93 N/A N/A $2.60 N/A N/A $4.44 N/A N/A $5.08 N/A N/A $3.49 N/A N/A $4.44 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.81 N/A N/A $2.22 N/A N/A $4.12 N/A N/A N/A N/A N/A $3.81 N/A N/A $4.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.34 $6.34 N/A 4400610 Pharmacy oxyCODONE 15 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400610 Pharmacy oxyCODONE 15 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409026 Pharmacy fentaNYL 100 mcg/hr Fil 250 $106.72 $- $27.75 $- $- $85.38 $- N/A $27.75 N/A N/A $40.34 N/A N/A $64.03 N/A N/A $53.36 N/A N/A N/A N/A N/A $72.57 N/A N/A $66.17 N/A N/A $43.76 N/A N/A $74.70 N/A N/A $85.38 N/A N/A $58.70 N/A N/A $74.70 N/A N/A $35.75 N/A N/A N/A N/A N/A $64.03 N/A N/A $37.35 N/A N/A $69.37 N/A N/A N/A N/A N/A $64.03 N/A N/A $74.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $106.72 $106.72 N/A 4401474 Pharmacy fentaNYL 50 mcg/hr Fil[BCH] 250 $52.72 $- $13.71 $- $- $42.18 $- N/A $13.71 N/A N/A $19.93 N/A N/A $31.63 N/A N/A $26.36 N/A N/A N/A N/A N/A $35.85 N/A N/A $32.69 N/A N/A $21.62 N/A N/A $36.90 N/A N/A $42.18 N/A N/A $29.00 N/A N/A $36.90 N/A N/A $17.66 N/A N/A N/A N/A N/A $31.63 N/A N/A $18.45 N/A N/A $34.27 N/A N/A N/A N/A N/A $31.63 N/A N/A $36.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.72 $52.72 N/A 4409026 Pharmacy fentaNYL 100 mcg/hr Fil [BCH] 250 $106.72 $- $27.75 $- $- $85.38 $- N/A $27.75 N/A N/A $40.34 N/A N/A $64.03 N/A N/A $53.36 N/A N/A N/A N/A N/A $72.57 N/A N/A $66.17 N/A N/A $43.76 N/A N/A $74.70 N/A N/A $85.38 N/A N/A $58.70 N/A N/A $74.70 N/A N/A $35.75 N/A N/A N/A N/A N/A $64.03 N/A N/A $37.35 N/A N/A $69.37 N/A N/A N/A N/A N/A $64.03 N/A N/A $74.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $106.72 $106.72 N/A 4400060 Pharmacy temazepam 7.5 mg Cap [BCH] 250 $19.88 $- $5.17 $- $- $15.90 $- N/A $5.17 N/A N/A $7.51 N/A N/A $11.93 N/A N/A $9.94 N/A N/A N/A N/A N/A $13.52 N/A N/A $12.33 N/A N/A $8.15 N/A N/A $13.92 N/A N/A $15.90 N/A N/A $10.93 N/A N/A $13.92 N/A N/A $6.66 N/A N/A N/A N/A N/A $11.93 N/A N/A $6.96 N/A N/A $12.92 N/A N/A N/A N/A N/A $11.93 N/A N/A $13.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.88 $19.88 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409821 Pharmacy DAPTOmycin 500 mg Pow [BCH] J0878 636 "$1,069.06 " $- $0.14 $- $- $855.25 $- N/A $277.96 N/A N/A Not Reimbursed N/A N/A $641.44 N/A N/A $534.53 N/A N/A N/A N/A N/A $726.96 N/A N/A $662.82 N/A N/A $438.31 N/A N/A $748.34 N/A N/A $855.25 N/A N/A $587.98 N/A N/A $748.34 N/A N/A $358.14 N/A N/A N/A N/A N/A $641.44 N/A N/A $374.17 N/A N/A $694.89 N/A N/A $0.14 N/A N/A $641.44 N/A N/A $748.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,069.06 " "$1,069.06 " N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $28.00 $- $1.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4403306 Pharmacy ceFAZolin 1 g Inj [BCH] J0690 636 $28.00 $- $0.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400780 Pharmacy atracurium 10 mg/mL IV Sol [BCH] 258 $18.85 $- $4.90 $- $- $15.08 $- N/A $4.90 N/A N/A $7.13 N/A N/A $11.31 N/A N/A $9.43 N/A N/A N/A N/A N/A $12.82 N/A N/A $11.69 N/A N/A $7.73 N/A N/A $13.20 N/A N/A $15.08 N/A N/A $10.37 N/A N/A $13.20 N/A N/A $6.32 N/A N/A N/A N/A N/A $11.31 N/A N/A $6.60 N/A N/A $12.25 N/A N/A N/A N/A N/A $11.31 N/A N/A $13.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.85 $18.85 N/A 4402186 Pharmacy verapamil 2.5 mg/mL Sol 258 $34.93 $- $9.08 $- $- $27.95 $- N/A $9.08 N/A N/A $13.20 N/A N/A $20.96 N/A N/A $17.47 N/A N/A N/A N/A N/A $23.75 N/A N/A $21.66 N/A N/A $14.32 N/A N/A $24.45 N/A N/A $27.95 N/A N/A $19.21 N/A N/A $24.45 N/A N/A $11.70 N/A N/A N/A N/A N/A $20.96 N/A N/A $12.23 N/A N/A $22.71 N/A N/A N/A N/A N/A $20.96 N/A N/A $24.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.93 $34.93 N/A 4402186 Pharmacy verapamil 2.5 mg/mL IV Sol [BCH] 258 $76.39 $- $19.86 $- $- $61.11 $- N/A $19.86 N/A N/A $28.88 N/A N/A $45.84 N/A N/A $38.20 N/A N/A N/A N/A N/A $51.95 N/A N/A $47.36 N/A N/A $31.32 N/A N/A $53.47 N/A N/A $61.11 N/A N/A $42.02 N/A N/A $53.47 N/A N/A $25.59 N/A N/A N/A N/A N/A $45.84 N/A N/A $26.74 N/A N/A $49.65 N/A N/A N/A N/A N/A $45.84 N/A N/A $53.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $76.39 $76.39 N/A 4402186 Pharmacy verapamil 2.5 mg/mL Sol [BCH] 636 $69.46 $- $18.06 $- $- $55.56 $- N/A $18.06 N/A N/A $26.25 N/A N/A $41.67 N/A N/A $34.73 N/A N/A N/A N/A N/A $47.23 N/A N/A $43.06 N/A N/A $28.48 N/A N/A $48.62 N/A N/A $55.56 N/A N/A $38.20 N/A N/A $48.62 N/A N/A $23.27 N/A N/A N/A N/A N/A $41.67 N/A N/A $24.31 N/A N/A $45.15 N/A N/A N/A N/A N/A $41.67 N/A N/A $48.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.46 $69.46 N/A 4400265 Pharmacy bupivacaine 0.25% preservative-free Sol 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400549 Pharmacy bupivacaine 0.25% PF Inj Sol 30 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400267 Pharmacy bupivacaine 0.5% preservative-free Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403223 Pharmacy bupivacaine 0.5% PF Inj Sol 30 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409402 Pharmacy diltiazem 5 mg/mL 5ml IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400787 Pharmacy diltiazem 5 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409794 Pharmacy droperidol 2.5 mg/mL Inj Sol [BCH] J1790 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402285 Pharmacy naloxone 0.4 mg/mL Inj Sol [BCH] J2310 636 $37.99 $- $9.88 $- $- $30.39 $- N/A $9.88 N/A N/A Not Reimbursed N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.83 N/A N/A $23.56 N/A N/A $15.58 N/A N/A $26.59 N/A N/A $30.39 N/A N/A $20.90 N/A N/A $26.59 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.69 N/A N/A $14.22 N/A N/A $22.80 N/A N/A $26.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.99 $37.99 N/A 4401010 Pharmacy Naloxone 0.4 mg/mL Injection J2310 636 $379.92 $- $14.22 $- $- $303.94 $- N/A $98.78 N/A N/A Not Reimbursed N/A N/A $227.95 N/A N/A $189.96 N/A N/A N/A N/A N/A $258.35 N/A N/A $235.55 N/A N/A $155.77 N/A N/A $265.94 N/A N/A $303.94 N/A N/A $208.96 N/A N/A $265.94 N/A N/A $127.27 N/A N/A N/A N/A N/A $227.95 N/A N/A $132.97 N/A N/A $246.95 N/A N/A $14.22 N/A N/A $227.95 N/A N/A $265.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $379.92 $379.92 N/A 4409809 Pharmacy diazepam 5 mg/mL Inj Sol [BCH] J3360 636 $54.95 $- $6.34 $- $- $43.96 $- N/A $14.29 N/A N/A Not Reimbursed N/A N/A $32.97 N/A N/A $27.47 N/A N/A N/A N/A N/A $37.37 N/A N/A $34.07 N/A N/A $22.53 N/A N/A $38.46 N/A N/A $43.96 N/A N/A $30.22 N/A N/A $38.46 N/A N/A $18.41 N/A N/A N/A N/A N/A $32.97 N/A N/A $19.23 N/A N/A $35.72 N/A N/A $6.34 N/A N/A $32.97 N/A N/A $38.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $54.95 $54.95 N/A 4400604 Pharmacy HYDROmorphone 1 mg/mL Sol J1170 636 $22.00 $- $3.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4403227 Pharmacy lidocaine 2% preservative-free Sol [BCH] J2001 636 $15.00 $- $0.02 $- $- $12.00 $- N/A $3.90 N/A N/A Not Reimbursed N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $0.02 N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4400782 Pharmacy bumetanide 0.25 mg/mL Inj Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404191 Pharmacy nalbuphine 20 mg/mL Inj Sol [BCH] J2300 636 $12.48 $- $2.37 $- $- $9.98 $- N/A $3.24 N/A N/A Not Reimbursed N/A N/A $7.49 N/A N/A $6.24 N/A N/A N/A N/A N/A $8.49 N/A N/A $7.74 N/A N/A $5.12 N/A N/A $8.74 N/A N/A $9.98 N/A N/A $6.86 N/A N/A $8.74 N/A N/A $4.18 N/A N/A N/A N/A N/A $7.49 N/A N/A $4.37 N/A N/A $8.11 N/A N/A $2.37 N/A N/A $7.49 N/A N/A $8.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.48 $12.48 N/A 4400265 Pharmacy bupivacaine 0.25% PF Inj Sol 10 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403207 Pharmacy bupivacaine 0.25% PF Inj Sol 30 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400549 Pharmacy bupivacaine 0.25% PF Inj Sol 30 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400267 Pharmacy bupivacaine 0.5% PF Inj Sol 10 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400270 Pharmacy bupivacaine 0.75% PF Inj Sol 10 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403231 Pharmacy bupivacaine 0.75% PF Inj Sol 30 mL [BCH] 250 $13.30 $- $3.46 $- $- $10.64 $- N/A $3.46 N/A N/A $5.03 N/A N/A $7.98 N/A N/A $6.65 N/A N/A N/A N/A N/A $9.04 N/A N/A $8.24 N/A N/A $5.45 N/A N/A $9.31 N/A N/A $10.64 N/A N/A $7.31 N/A N/A $9.31 N/A N/A $4.45 N/A N/A N/A N/A N/A $7.98 N/A N/A $4.65 N/A N/A $8.64 N/A N/A N/A N/A N/A $7.98 N/A N/A $9.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.30 $13.30 N/A 4409680 Pharmacy vecuronium 10 mg Pow [BCH] 250 $12.43 $- $3.23 $- $- $9.95 $- N/A $3.23 N/A N/A $4.70 N/A N/A $7.46 N/A N/A $6.22 N/A N/A N/A N/A N/A $8.45 N/A N/A $7.71 N/A N/A $5.10 N/A N/A $8.70 N/A N/A $9.95 N/A N/A $6.84 N/A N/A $8.70 N/A N/A $4.16 N/A N/A N/A N/A N/A $7.46 N/A N/A $4.35 N/A N/A $8.08 N/A N/A N/A N/A N/A $7.46 N/A N/A $8.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.43 $12.43 N/A 4403199 Pharmacy "bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 30 mL [BCH]" 250 $22.27 $- $5.79 $- $- $17.82 $- N/A $5.79 N/A N/A $8.42 N/A N/A $13.36 N/A N/A $11.14 N/A N/A N/A N/A N/A $15.15 N/A N/A $13.81 N/A N/A $9.13 N/A N/A $15.59 N/A N/A $17.82 N/A N/A $12.25 N/A N/A $15.59 N/A N/A $7.46 N/A N/A N/A N/A N/A $13.36 N/A N/A $7.80 N/A N/A $14.48 N/A N/A N/A N/A N/A $13.36 N/A N/A $15.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.27 $22.27 N/A 4403215 Pharmacy "bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Sol 30 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407133 Pharmacy glucose 25% Sol[BCH] 258 $17.50 $- $4.55 $- $- $14.00 $- N/A $4.55 N/A N/A $6.61 N/A N/A $10.50 N/A N/A $8.75 N/A N/A N/A N/A N/A $11.90 N/A N/A $10.85 N/A N/A $7.17 N/A N/A $12.25 N/A N/A $14.00 N/A N/A $9.62 N/A N/A $12.25 N/A N/A $5.86 N/A N/A N/A N/A N/A $10.50 N/A N/A $6.12 N/A N/A $11.37 N/A N/A N/A N/A N/A $10.50 N/A N/A $12.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.50 $17.50 N/A 4400693 Pharmacy metoprolol 1 mg/mL Inj Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407442 Pharmacy procainamide 500 mg/mL Inj Sol [BCH] J2690 636 $131.33 $- $34.15 $- $- $105.06 $- N/A $34.15 N/A N/A Not Reimbursed N/A N/A $78.80 N/A N/A $65.66 N/A N/A N/A N/A N/A $89.30 N/A N/A $81.42 N/A N/A $53.84 N/A N/A $91.93 N/A N/A $105.06 N/A N/A $72.23 N/A N/A $91.93 N/A N/A $43.99 N/A N/A N/A N/A N/A $78.80 N/A N/A $45.96 N/A N/A $85.36 N/A N/A $90.52 N/A N/A $78.80 N/A N/A $91.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $131.33 $131.33 N/A 4400889 Pharmacy ketamine 100 mg/mL Sol [BCH] 250 $23.74 $- $6.17 $- $- $18.99 $- N/A $6.17 N/A N/A $8.97 N/A N/A $14.24 N/A N/A $11.87 N/A N/A N/A N/A N/A $16.14 N/A N/A $14.72 N/A N/A $9.73 N/A N/A $16.62 N/A N/A $18.99 N/A N/A $13.05 N/A N/A $16.62 N/A N/A $7.95 N/A N/A N/A N/A N/A $14.24 N/A N/A $8.31 N/A N/A $15.43 N/A N/A N/A N/A N/A $14.24 N/A N/A $16.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.74 $23.74 N/A 4400052 Pharmacy enalapril 1.25 mg/mL Sol 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400112 Pharmacy alfentanil 0.5 mg/mL Inj Sol [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4405855 Pharmacy labetalol 5 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409376 Pharmacy midazolam 1 mg/mL preservative-free Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4408218 Pharmacy midazolam 5 mg/mL 2ml preservative-free Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400126 Pharmacy midazolam 10 mg Injection 636 $26.66 $- $6.93 $- $- $21.33 $- N/A $6.93 N/A N/A $10.08 N/A N/A $16.00 N/A N/A $13.33 N/A N/A N/A N/A N/A $18.13 N/A N/A $16.53 N/A N/A $10.93 N/A N/A $18.66 N/A N/A $21.33 N/A N/A $14.66 N/A N/A $18.66 N/A N/A $8.93 N/A N/A N/A N/A N/A $16.00 N/A N/A $9.33 N/A N/A $17.33 N/A N/A N/A N/A N/A $16.00 N/A N/A $18.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.66 $26.66 N/A 4400547 Pharmacy deferoxamine 500 mg Inj [BCH] J0895 636 $22.59 $- $5.87 $- $- $18.07 $- N/A $5.87 N/A N/A Not Reimbursed N/A N/A $13.55 N/A N/A $11.29 N/A N/A N/A N/A N/A $15.36 N/A N/A $14.00 N/A N/A $9.26 N/A N/A $15.81 N/A N/A $18.07 N/A N/A $12.42 N/A N/A $15.81 N/A N/A $7.57 N/A N/A N/A N/A N/A $13.55 N/A N/A $7.90 N/A N/A $14.68 N/A N/A $8.03 N/A N/A $13.55 N/A N/A $15.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.59 $22.59 N/A 4405855 Pharmacy labetalol 5 mg/mL Sol [BCH] 258 $324.48 $- $84.36 $- $- $259.58 $- N/A $84.36 N/A N/A $122.65 N/A N/A $194.69 N/A N/A $162.24 N/A N/A N/A N/A N/A $220.65 N/A N/A $201.18 N/A N/A $133.04 N/A N/A $227.14 N/A N/A $259.58 N/A N/A $178.46 N/A N/A $227.14 N/A N/A $108.70 N/A N/A N/A N/A N/A $194.69 N/A N/A $113.57 N/A N/A $210.91 N/A N/A N/A N/A N/A $194.69 N/A N/A $227.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $324.48 $324.48 N/A 4404282 Pharmacy DOBUTamine 12.5 mg/mL Sol[BCH] J1250 636 $14.36 $- $3.73 $- $- $11.49 $- N/A $3.73 N/A N/A Not Reimbursed N/A N/A $8.62 N/A N/A $7.18 N/A N/A N/A N/A N/A $9.76 N/A N/A $8.90 N/A N/A $5.89 N/A N/A $10.05 N/A N/A $11.49 N/A N/A $7.90 N/A N/A $10.05 N/A N/A $4.81 N/A N/A N/A N/A N/A $8.62 N/A N/A $5.03 N/A N/A $9.33 N/A N/A $5.96 N/A N/A $8.62 N/A N/A $10.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.36 $14.36 N/A 4404282 Pharmacy DOBUTamine 12.5 mg/mL IV Sol [BCH] J1250 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $5.96 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404282 Pharmacy DOBUTamine 12.5 mg/mL Sol [BCH] J1250 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $5.96 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405368 Pharmacy DOBUTamine 1 mg/mL-D5W intravenous solution [BCH] J1250 636 $75.00 $- $5.96 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $5.96 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400604 Pharmacy HYDROmorphone 1 mg/mL Inj Sol [BCH] J1170 636 $22.00 $- $3.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400172 Pharmacy heparin 1000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400724 Pharmacy heparin 1000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405016 Pharmacy heparin 5000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408382 Pharmacy "EPINEPHrine-lidocaine 1:200,000-0.5% Inj Sol 50 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409998 Pharmacy "EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409117 Pharmacy "EPINEPHrine-lidocaine 1:100,000-2% Inj Sol 20 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409117 Pharmacy epinephrine-lidocaine 1:100000-2% Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400985 Pharmacy "epinephrine-lidocaine 1:200,000-2% preservative-free Sol [BCH]" 630 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409809 Pharmacy diazePAM 5 mg/mL Sol [BCH] J3360 636 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $6.34 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4407323 Pharmacy acetylcysteine 20% Inh Sol 30 mL [BCH] J7608 636 $24.55 $- $5.48 $- $- $19.64 $- N/A $6.38 N/A N/A Not Reimbursed N/A N/A $14.73 N/A N/A $12.28 N/A N/A N/A N/A N/A $16.70 N/A N/A $15.22 N/A N/A $10.07 N/A N/A $17.19 N/A N/A $19.64 N/A N/A $13.50 N/A N/A $17.19 N/A N/A $8.23 N/A N/A N/A N/A N/A $14.73 N/A N/A $8.59 N/A N/A $15.96 N/A N/A $5.48 N/A N/A $14.73 N/A N/A $17.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.55 $24.55 N/A 4400071 Pharmacy HYDROmorphone 2 mg/mL Sol [BCH] J1170 636 $- $- $3.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4403151 Pharmacy norepinephrine 1 mg/mL Sol [BCH] 258 $45.50 $- $11.83 $- $- $36.40 $- N/A $11.83 N/A N/A $17.20 N/A N/A $27.30 N/A N/A $22.75 N/A N/A N/A N/A N/A $30.94 N/A N/A $28.21 N/A N/A $18.66 N/A N/A $31.85 N/A N/A $36.40 N/A N/A $25.03 N/A N/A $31.85 N/A N/A $15.24 N/A N/A N/A N/A N/A $27.30 N/A N/A $15.93 N/A N/A $29.58 N/A N/A N/A N/A N/A $27.30 N/A N/A $31.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.50 $45.50 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g IV Inj [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409162 Pharmacy piperacillin-tazobactam 4 g-0.5 g IV Inj [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4407608 Pharmacy metoclopramide 5 mg/mL Inj Sol [BCH] J2765 636 $12.00 $- $1.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $1.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400714 Pharmacy meropenem 1 g IV Inj [BCH] J2185 636 $69.94 $- $0.79 $- $- $55.95 $- N/A $18.18 N/A N/A Not Reimbursed N/A N/A $41.96 N/A N/A $34.97 N/A N/A N/A N/A N/A $47.56 N/A N/A $43.36 N/A N/A $28.67 N/A N/A $48.96 N/A N/A $55.95 N/A N/A $38.46 N/A N/A $48.96 N/A N/A $23.43 N/A N/A N/A N/A N/A $41.96 N/A N/A $24.48 N/A N/A $45.46 N/A N/A $0.79 N/A N/A $41.96 N/A N/A $48.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.94 $69.94 N/A 4400271 Pharmacy bupivacaine 0.75% intrathecal Sol 2 mL [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405874 Pharmacy ketorolac 30 mg/mL Inj Sol [BCH] J1885 636 $13.80 $- $0.58 $- $- $11.04 $- N/A $3.59 N/A N/A Not Reimbursed N/A N/A $8.28 N/A N/A $6.90 N/A N/A N/A N/A N/A $9.38 N/A N/A $8.56 N/A N/A $5.66 N/A N/A $9.66 N/A N/A $11.04 N/A N/A $7.59 N/A N/A $9.66 N/A N/A $4.62 N/A N/A N/A N/A N/A $8.28 N/A N/A $4.83 N/A N/A $8.97 N/A N/A $0.58 N/A N/A $8.28 N/A N/A $9.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.80 $13.80 N/A 4400075 Pharmacy lidocaine 1% Sol [BCH] J2001 636 $12.00 $- $0.02 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.02 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400075 Pharmacy lidocaine 1% Sol [BCH] J2001 636 $12.00 $- $0.02 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.02 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402746 Pharmacy lidocaine 2% Sol[BCH] J2001 636 $12.00 $- $0.02 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.02 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408610 Pharmacy vancomycin 500 mg IV Inj [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405582 Pharmacy pancuronium 1 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409915 Pharmacy propofol 10 mg/mL IV 100ml Emul [BCH] S0144 258 $82.80 $- $21.53 $- $- $66.24 $- N/A $21.53 N/A N/A Not Reimbursed N/A N/A $49.68 N/A N/A $41.40 N/A N/A N/A N/A N/A $56.30 N/A N/A $51.34 N/A N/A $33.95 N/A N/A $57.96 N/A N/A $66.24 N/A N/A $45.54 N/A N/A $57.96 N/A N/A $27.74 N/A N/A N/A N/A N/A $49.68 N/A N/A $28.98 N/A N/A $53.82 N/A N/A N/A N/A N/A $49.68 N/A N/A $57.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $82.80 $82.80 N/A 4405395 Pharmacy propofol 10 mg/mL IV 20ml Emul [BCH] S0144 636 $16.56 $- $4.31 $- $- $13.25 $- N/A $4.31 N/A N/A Not Reimbursed N/A N/A $9.94 N/A N/A $8.28 N/A N/A N/A N/A N/A $11.26 N/A N/A $10.27 N/A N/A $6.79 N/A N/A $11.59 N/A N/A $13.25 N/A N/A $9.11 N/A N/A $11.59 N/A N/A $5.55 N/A N/A N/A N/A N/A $9.94 N/A N/A $5.80 N/A N/A $10.76 N/A N/A N/A N/A N/A $9.94 N/A N/A $11.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.56 $16.56 N/A 4401250 Pharmacy ondansetron 2 mg/mL Inj Sol [BCH] J2405 636 $12.00 $- $0.10 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.10 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409535 Pharmacy linezolid 2 mg/mL IV Sol [BCH] J2020 258 $194.52 $- $6.46 $- $- $155.62 $- N/A $50.58 N/A N/A Not Reimbursed N/A N/A $116.71 N/A N/A $97.26 N/A N/A N/A N/A N/A $132.27 N/A N/A $120.60 N/A N/A $79.75 N/A N/A $136.16 N/A N/A $155.62 N/A N/A $106.99 N/A N/A $136.16 N/A N/A $65.16 N/A N/A N/A N/A N/A $116.71 N/A N/A $68.08 N/A N/A $126.44 N/A N/A $6.46 N/A N/A $116.71 N/A N/A $136.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $194.52 $194.52 N/A 4400813 Pharmacy sterile water Inj Sol [BCH] A4217 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400812 Pharmacy sterile water Inj Sol [BCH] A4217 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400559 Pharmacy sodium chloride 0.9% Inj Sol 10 mL [BCH] 258 $- $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400823 Pharmacy sodium chloride 0.9% Inj Sol 10 mL [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402864 Pharmacy glucose 50% IV Sol 50 mL [BCH] 258 $19.13 $- $4.97 $- $- $15.30 $- N/A $4.97 N/A N/A $7.23 N/A N/A $11.48 N/A N/A $9.57 N/A N/A N/A N/A N/A $13.01 N/A N/A $11.86 N/A N/A $7.84 N/A N/A $13.39 N/A N/A $15.30 N/A N/A $10.52 N/A N/A $13.39 N/A N/A $6.41 N/A N/A N/A N/A N/A $11.48 N/A N/A $6.70 N/A N/A $12.43 N/A N/A N/A N/A N/A $11.48 N/A N/A $13.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.13 $19.13 N/A 4401858 Pharmacy atropine 0.1 mg/mL Inj Sol [BCH] J0461 636 $22.20 $- $0.06 $- $- $17.76 $- N/A $5.77 N/A N/A Not Reimbursed N/A N/A $13.32 N/A N/A $11.10 N/A N/A N/A N/A N/A $15.10 N/A N/A $13.76 N/A N/A $9.10 N/A N/A $15.54 N/A N/A $17.76 N/A N/A $12.21 N/A N/A $15.54 N/A N/A $7.44 N/A N/A N/A N/A N/A $13.32 N/A N/A $7.77 N/A N/A $14.43 N/A N/A $0.06 N/A N/A $13.32 N/A N/A $15.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.20 $22.20 N/A 4400999 Pharmacy sodium bicarbonate 7.5% Sol [BCH] 636 $35.11 $- $9.13 $- $- $28.09 $- N/A $9.13 N/A N/A $13.27 N/A N/A $21.07 N/A N/A $17.56 N/A N/A N/A N/A N/A $23.88 N/A N/A $21.77 N/A N/A $14.40 N/A N/A $24.58 N/A N/A $28.09 N/A N/A $19.31 N/A N/A $24.58 N/A N/A $11.76 N/A N/A N/A N/A N/A $21.07 N/A N/A $12.29 N/A N/A $22.82 N/A N/A N/A N/A N/A $21.07 N/A N/A $24.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.11 $35.11 N/A 4400511 Pharmacy EPINEPHrine 0.1 mg/mL Inj Sol [BCH] J0171 636 $12.00 $- $0.91 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.91 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400199 Pharmacy calcium chloride 100 mg/mL Sol [BCH] 636 $23.16 $- $6.02 $- $- $18.53 $- N/A $6.02 N/A N/A $8.75 N/A N/A $13.90 N/A N/A $11.58 N/A N/A N/A N/A N/A $15.75 N/A N/A $14.36 N/A N/A $9.50 N/A N/A $16.21 N/A N/A $18.53 N/A N/A $12.74 N/A N/A $16.21 N/A N/A $7.76 N/A N/A N/A N/A N/A $13.90 N/A N/A $8.11 N/A N/A $15.05 N/A N/A N/A N/A N/A $13.90 N/A N/A $16.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.16 $23.16 N/A 4405537 Pharmacy cefTAZidime 1 g Inj [BCH] J0713 636 $28.00 $- $1.99 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.99 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400484 Pharmacy sodium bicarbonate 4.2% Sol[BCH] 636 $29.97 $- $7.79 $- $- $23.97 $- N/A $7.79 N/A N/A $11.33 N/A N/A $17.98 N/A N/A $14.98 N/A N/A N/A N/A N/A $20.38 N/A N/A $18.58 N/A N/A $12.29 N/A N/A $20.98 N/A N/A $23.97 N/A N/A $16.48 N/A N/A $20.98 N/A N/A $10.04 N/A N/A N/A N/A N/A $17.98 N/A N/A $10.49 N/A N/A $19.48 N/A N/A N/A N/A N/A $17.98 N/A N/A $20.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.97 $29.97 N/A 4400484 Pharmacy sodium bicarbonate 4.2% IV Sol 10 mL [BCH] 258 $25.94 $- $6.75 $- $- $20.76 $- N/A $6.75 N/A N/A $9.81 N/A N/A $15.57 N/A N/A $12.97 N/A N/A N/A N/A N/A $17.64 N/A N/A $16.09 N/A N/A $10.64 N/A N/A $18.16 N/A N/A $20.76 N/A N/A $14.27 N/A N/A $18.16 N/A N/A $8.69 N/A N/A N/A N/A N/A $15.57 N/A N/A $9.08 N/A N/A $16.86 N/A N/A N/A N/A N/A $15.57 N/A N/A $18.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.94 $25.94 N/A 4400944 Pharmacy DOPamine 40 mg/mL Sol [BCH] J1265 636 $12.00 $- $0.68 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.68 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400494 Pharmacy aminophylline 25 mg/mL IV Sol [BCH] J0280 636 $25.01 $- $6.50 $- $- $20.01 $- N/A $6.50 N/A N/A Not Reimbursed N/A N/A $15.00 N/A N/A $12.50 N/A N/A N/A N/A N/A $17.01 N/A N/A $15.50 N/A N/A $10.25 N/A N/A $17.51 N/A N/A $20.01 N/A N/A $13.75 N/A N/A $17.51 N/A N/A $8.38 N/A N/A N/A N/A N/A $15.00 N/A N/A $8.75 N/A N/A $16.26 N/A N/A $7.31 N/A N/A $15.00 N/A N/A $17.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.01 $25.01 N/A 4400437 Pharmacy furosemide 10 mg/mL Inj Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403102 Pharmacy furosemide 10 mg/mL Inj Sol [BCH] J1940 636 $12.17 $- $0.60 $- $- $9.73 $- N/A $3.16 N/A N/A Not Reimbursed N/A N/A $7.30 N/A N/A $6.08 N/A N/A N/A N/A N/A $8.27 N/A N/A $7.54 N/A N/A $4.99 N/A N/A $8.52 N/A N/A $9.73 N/A N/A $6.69 N/A N/A $8.52 N/A N/A $4.08 N/A N/A N/A N/A N/A $7.30 N/A N/A $4.26 N/A N/A $7.91 N/A N/A $0.60 N/A N/A $7.30 N/A N/A $8.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.17 $12.17 N/A 4400685 Pharmacy furosemide 10 mg/mL Inj Sol [BCH] J1940 636 $13.80 $- $0.60 $- $- $11.04 $- N/A $3.59 N/A N/A Not Reimbursed N/A N/A $8.28 N/A N/A $6.90 N/A N/A N/A N/A N/A $9.38 N/A N/A $8.56 N/A N/A $5.66 N/A N/A $9.66 N/A N/A $11.04 N/A N/A $7.59 N/A N/A $9.66 N/A N/A $4.62 N/A N/A N/A N/A N/A $8.28 N/A N/A $4.83 N/A N/A $8.97 N/A N/A $0.60 N/A N/A $8.28 N/A N/A $9.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.80 $13.80 N/A 4400437 Pharmacy furosemide 10 mg/mL Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403102 Pharmacy furosemide 10 mg/mL Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401007 Pharmacy Furosemide 20 mg / 2 mL Vial J1940 636 $404.40 $- $0.60 $- $- $323.52 $- N/A $105.14 N/A N/A Not Reimbursed N/A N/A $242.64 N/A N/A $202.20 N/A N/A N/A N/A N/A $274.99 N/A N/A $250.73 N/A N/A $165.80 N/A N/A $283.08 N/A N/A $323.52 N/A N/A $222.42 N/A N/A $283.08 N/A N/A $135.47 N/A N/A N/A N/A N/A $242.64 N/A N/A $141.54 N/A N/A $262.86 N/A N/A $0.60 N/A N/A $242.64 N/A N/A $283.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $404.40 $404.40 N/A 4409812 Pharmacy erythromycin lactobionate 500 mg Inj [BCH] J1364 636 $150.07 $- $39.02 $- $- $120.06 $- N/A $39.02 N/A N/A Not Reimbursed N/A N/A $90.04 N/A N/A $75.04 N/A N/A N/A N/A N/A $102.05 N/A N/A $93.04 N/A N/A $61.53 N/A N/A $105.05 N/A N/A $120.06 N/A N/A $82.54 N/A N/A $105.05 N/A N/A $50.27 N/A N/A N/A N/A N/A $90.04 N/A N/A $52.53 N/A N/A $97.55 N/A N/A $79.08 N/A N/A $90.04 N/A N/A $105.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $150.07 $150.07 N/A 4400387 Pharmacy vancomycin 750 mg Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405346 Pharmacy vancomycin 1 g IV Inj [BCH] J3370 636 $38.50 $- $2.77 $- $- $30.80 $- N/A $10.01 N/A N/A Not Reimbursed N/A N/A $23.10 N/A N/A $19.25 N/A N/A N/A N/A N/A $26.18 N/A N/A $23.87 N/A N/A $15.78 N/A N/A $26.95 N/A N/A $30.80 N/A N/A $21.17 N/A N/A $26.95 N/A N/A $12.90 N/A N/A N/A N/A N/A $23.10 N/A N/A $13.47 N/A N/A $25.02 N/A N/A $2.77 N/A N/A $23.10 N/A N/A $26.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.50 $38.50 N/A 4405346 Pharmacy vancomycin 1 g Pow [BCH] J3370 636 $38.69 $- $2.77 $- $- $30.95 $- N/A $10.06 N/A N/A Not Reimbursed N/A N/A $23.21 N/A N/A $19.34 N/A N/A N/A N/A N/A $26.31 N/A N/A $23.99 N/A N/A $15.86 N/A N/A $27.08 N/A N/A $30.95 N/A N/A $21.28 N/A N/A $27.08 N/A N/A $12.96 N/A N/A N/A N/A N/A $23.21 N/A N/A $13.54 N/A N/A $25.15 N/A N/A $2.77 N/A N/A $23.21 N/A N/A $27.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.69 $38.69 N/A 4405346 Pharmacy vancomycin 1 g Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405346 Pharmacy vancomycin 1 g Pow J3370 636 $38.50 $- $2.77 $- $- $30.80 $- N/A $10.01 N/A N/A Not Reimbursed N/A N/A $23.10 N/A N/A $19.25 N/A N/A N/A N/A N/A $26.18 N/A N/A $23.87 N/A N/A $15.78 N/A N/A $26.95 N/A N/A $30.80 N/A N/A $21.17 N/A N/A $26.95 N/A N/A $12.90 N/A N/A N/A N/A N/A $23.10 N/A N/A $13.47 N/A N/A $25.02 N/A N/A $2.77 N/A N/A $23.10 N/A N/A $26.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.50 $38.50 N/A 4404932 Pharmacy sodium bicarbonate 8.4% IV Sol 50 mL [BCH] 258 $23.26 $- $6.05 $- $- $18.61 $- N/A $6.05 N/A N/A $8.79 N/A N/A $13.96 N/A N/A $11.63 N/A N/A N/A N/A N/A $15.82 N/A N/A $14.42 N/A N/A $9.54 N/A N/A $16.28 N/A N/A $18.61 N/A N/A $12.79 N/A N/A $16.28 N/A N/A $7.79 N/A N/A N/A N/A N/A $13.96 N/A N/A $8.14 N/A N/A $15.12 N/A N/A N/A N/A N/A $13.96 N/A N/A $16.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.26 $23.26 N/A 4409392 Pharmacy succinylcholine 20 mg/mL Sol J0330 636 $64.06 $- $16.65 $- $- $51.24 $- N/A $16.65 N/A N/A Not Reimbursed N/A N/A $38.43 N/A N/A $32.03 N/A N/A N/A N/A N/A $43.56 N/A N/A $39.71 N/A N/A $26.26 N/A N/A $44.84 N/A N/A $51.24 N/A N/A $35.23 N/A N/A $44.84 N/A N/A $21.46 N/A N/A N/A N/A N/A $38.43 N/A N/A $22.42 N/A N/A $41.64 N/A N/A N/A N/A N/A $38.43 N/A N/A $44.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.06 $64.06 N/A 4404932 Pharmacy sodium bicarbonate 8.4% Sol [BCH] 250 $25.34 $- $6.59 $- $- $20.28 $- N/A $6.59 N/A N/A $9.58 N/A N/A $15.21 N/A N/A $12.67 N/A N/A N/A N/A N/A $17.23 N/A N/A $15.71 N/A N/A $10.39 N/A N/A $17.74 N/A N/A $20.28 N/A N/A $13.94 N/A N/A $17.74 N/A N/A $8.49 N/A N/A N/A N/A N/A $15.21 N/A N/A $8.87 N/A N/A $16.47 N/A N/A N/A N/A N/A $15.21 N/A N/A $17.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.34 $25.34 N/A 4402864 Pharmacy glucose 50% IV Sol 50 mL [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407285 Pharmacy potassium chloride 2 mEq/mL IV Sol [BCH] J3480 250 $12.00 $- $0.18 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.18 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401771 Pharmacy etomidate 2 mg/mL IV Sol [BCH] 258 $13.34 $- $3.47 $- $- $10.67 $- N/A $3.47 N/A N/A $5.04 N/A N/A $8.00 N/A N/A $6.67 N/A N/A N/A N/A N/A $9.07 N/A N/A $8.27 N/A N/A $5.47 N/A N/A $9.34 N/A N/A $10.67 N/A N/A $7.34 N/A N/A $9.34 N/A N/A $4.47 N/A N/A N/A N/A N/A $8.00 N/A N/A $4.67 N/A N/A $8.67 N/A N/A N/A N/A N/A $8.00 N/A N/A $9.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.34 $13.34 N/A 4408951 Pharmacy magnesium sulfate 10 mg/mL-D5W intravenous solution [BCH] J3475 636 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400564 Pharmacy magnesium sulfate 40 mg/mL Inj Sol [BCH] J3475 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400740 Pharmacy LORazepam 2 mg/mL Inj Sol [BCH] J2060 636 $22.00 $- $0.69 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.69 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400575 Pharmacy potassium chloride 10 mEq/100 mL IV Sol [BCH] J3480 250 $75.00 $- $0.18 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.18 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400565 Pharmacy potassium chloride 20 mEq/100 mL IV Sol [BCH] J3480 250 $638.42 $- $0.18 $- $- $510.73 $- N/A $165.99 N/A N/A Not Reimbursed N/A N/A $383.05 N/A N/A $319.21 N/A N/A N/A N/A N/A $434.12 N/A N/A $395.82 N/A N/A $261.75 N/A N/A $446.89 N/A N/A $510.73 N/A N/A $351.13 N/A N/A $446.89 N/A N/A $213.87 N/A N/A N/A N/A N/A $383.05 N/A N/A $223.45 N/A N/A $414.97 N/A N/A $0.18 N/A N/A $383.05 N/A N/A $446.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $638.42 $638.42 N/A 4409544 Pharmacy Sodium Chloride 0.9% with KCl 20 mEq/l IV Sol 1000 mL [BCH] J3480 258 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400524 Pharmacy Sodium Chloride 0.9% with KCl 40 mEq/l IV Sol 1000 mL [BCH] J3480 258 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4404548 Pharmacy EPINEPHrine 1 mg/mL Inj Sol [BCH] J0171 636 $12.00 $- $0.91 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.91 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407522 Pharmacy hetastarch 60 mg/mL-NaCl 0.9% Sol [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4407293 Pharmacy potassium phosphate 3 mmol/mL IV Sol [BCH] 250 $35.14 $- $9.14 $- $- $28.11 $- N/A $9.14 N/A N/A $13.28 N/A N/A $21.09 N/A N/A $17.57 N/A N/A N/A N/A N/A $23.90 N/A N/A $21.79 N/A N/A $14.41 N/A N/A $24.60 N/A N/A $28.11 N/A N/A $19.33 N/A N/A $24.60 N/A N/A $11.77 N/A N/A N/A N/A N/A $21.09 N/A N/A $12.30 N/A N/A $22.84 N/A N/A N/A N/A N/A $21.09 N/A N/A $24.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.14 $35.14 N/A 4403066 Pharmacy sodium acetate 2 mEq/mL Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403066 Pharmacy sodium acetate 2 mEq/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400880 Pharmacy cefTRIAXone 1 g Inj [BCH] J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400880 Pharmacy cefTRIAXone 1 g Pow J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400650 Pharmacy cefTRIAXone 2 g Inj [BCH] J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400650 Pharmacy cefTRIAXone 2 g Pow J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4407723 Pharmacy cefTRIAXone 250 mg Inj [BCH] J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4407723 Pharmacy cefTRIAXone 250 mg Pow J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4402864 Pharmacy glucose 50% IV Sol 50 mL [BCH] 258 $15.05 $- $3.91 $- $- $12.04 $- N/A $3.91 N/A N/A $5.69 N/A N/A $9.03 N/A N/A $7.53 N/A N/A N/A N/A N/A $10.23 N/A N/A $9.33 N/A N/A $6.17 N/A N/A $10.54 N/A N/A $12.04 N/A N/A $8.28 N/A N/A $10.54 N/A N/A $5.04 N/A N/A N/A N/A N/A $9.03 N/A N/A $5.27 N/A N/A $9.78 N/A N/A N/A N/A N/A $9.03 N/A N/A $10.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.05 $15.05 N/A 4403508 Pharmacy mannitol 20% IV Sol 500 mL [BCH] J2150 636 $75.00 $- $1.94 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.94 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409059 Pharmacy metroNIDAZOLE 500 mg/100 mL Sol 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409059 Pharmacy metroNIDAZOLE 500 mg/100 mL IV Sol [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4407548 Pharmacy Dextrose 5% with 0.45% NaCl and KCl 20 mEq/l IV Sol 1000 mL [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400523 Pharmacy Dextrose 5% with 0.45% NaCl and KCl 40 mEq/l IV Sol 1000 mL [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4404230 Pharmacy Dextrose 5% in Water IV Sol 250 mL [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404131 Pharmacy Dextrose 5% in Water IV Sol 1000 mL [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404701 Pharmacy Dextrose 5% in Water IV Sol 50 mL [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404248 Pharmacy Dextrose 5% in Water IV Sol 100 mL [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400786 Pharmacy Dextrose 5% with 0.45% NaCl IV Sol 500 mL [BCH] J7042 636 $75.00 $- $1.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404164 Pharmacy Dextrose 5% with 0.45% NaCl IV Sol 1000 mL [BCH] J7042 258 $75.00 $- $1.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400056 Pharmacy Dextrose 5% in Lactated Ringers IV Sol 1000 mL [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400211 Pharmacy Dextrose 10% in Water IV Sol 1000 mL [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4407597 Pharmacy lidocaine 5%-0.4% Sol [BCH] J2001 636 $75.00 $- $0.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400055 Pharmacy Dextrose 5% with NS IV Sol 1000 mL [BCH] J7042 636 $75.00 $- $1.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400871 Pharmacy LVP solution Lactated Ringers 500ml Injection Sol [BCH] J7120 636 $75.00 $- $2.34 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.34 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404255 Pharmacy LVP solution Lactated Ringers Injection Sol J7120 636 $75.00 $- $2.34 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.34 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404255 Pharmacy Lactated Ringers IV Sol 1000 mL [BCH] J7120 258 $75.00 $- $2.34 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.34 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404297 Pharmacy Sodium Chloride 0.9% IV Sol 250 mL [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400428 Pharmacy Sodium Chloride 0.9% IV Sol 500 mL [BCH] J7040 636 $75.00 $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404271 Pharmacy Sodium Chloride 0.9% IV Sol 1000 mL [BCH] J7030 258 $75.00 $- $2.55 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.55 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404693 Pharmacy Sodium Chloride 0.9% IV Sol 50 mL [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403496 Pharmacy Sodium Chloride 0.9% IV Sol 100 mL [BCH] J7040 258 $- $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4404370 Pharmacy Sodium Chloride 0.45% IV Sol 1000 mL [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400266 Pharmacy "bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 10 mL [BC" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400268 Pharmacy "bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Sol 10 mL [BCH" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400926 Pharmacy "bupivacaine-epinephrine 0.5%-1:200,000 Sol [BCH]" 636 $13.61 $- $3.54 $- $- $10.89 $- N/A $3.54 N/A N/A $5.14 N/A N/A $8.16 N/A N/A $6.80 N/A N/A N/A N/A N/A $9.25 N/A N/A $8.44 N/A N/A $5.58 N/A N/A $9.53 N/A N/A $10.89 N/A N/A $7.48 N/A N/A $9.53 N/A N/A $4.56 N/A N/A N/A N/A N/A $8.16 N/A N/A $4.76 N/A N/A $8.85 N/A N/A N/A N/A N/A $8.16 N/A N/A $9.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.61 $13.61 N/A 4405155 Pharmacy fentaNYL 0.05 mg/mL Inj Sol [BCH] J3010 636 $22.00 $- $0.91 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.91 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4409517 Pharmacy fentaNYL 0.05 mg/mL Inj Sol [BCH] J3010 636 $22.00 $- $0.91 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.91 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400132 Pharmacy phytonadione 10 mg/mL Inj Sol [BCH] J3430 636 $90.65 $- $4.06 $- $- $72.52 $- N/A $23.57 N/A N/A Not Reimbursed N/A N/A $54.39 N/A N/A $45.32 N/A N/A N/A N/A N/A $61.64 N/A N/A $56.20 N/A N/A $37.17 N/A N/A $63.45 N/A N/A $72.52 N/A N/A $49.86 N/A N/A $63.45 N/A N/A $30.37 N/A N/A N/A N/A N/A $54.39 N/A N/A $31.73 N/A N/A $58.92 N/A N/A $4.06 N/A N/A $54.39 N/A N/A $63.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.65 $90.65 N/A 4400576 Pharmacy Sodium Chloride 0.45% with KCl 20 mEq/l IV Sol 1000 mL [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4404650 Pharmacy rocuronium 10 mg/mL Sol [BCH] 636 $24.80 $- $6.45 $- $- $19.84 $- N/A $6.45 N/A N/A $9.37 N/A N/A $14.88 N/A N/A $12.40 N/A N/A N/A N/A N/A $16.86 N/A N/A $15.38 N/A N/A $10.17 N/A N/A $17.36 N/A N/A $19.84 N/A N/A $13.64 N/A N/A $17.36 N/A N/A $8.31 N/A N/A N/A N/A N/A $14.88 N/A N/A $8.68 N/A N/A $16.12 N/A N/A N/A N/A N/A $14.88 N/A N/A $17.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.80 $24.80 N/A 4404650 Pharmacy rocuronium 10 mg/mL Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409643 Pharmacy risedronate 35 mg Tab [BCH] 250 $148.69 $- $38.66 $- $- $118.95 $- N/A $38.66 N/A N/A $56.20 N/A N/A $89.21 N/A N/A $74.34 N/A N/A N/A N/A N/A $101.11 N/A N/A $92.18 N/A N/A $60.96 N/A N/A $104.08 N/A N/A $118.95 N/A N/A $81.78 N/A N/A $104.08 N/A N/A $49.81 N/A N/A N/A N/A N/A $89.21 N/A N/A $52.04 N/A N/A $96.65 N/A N/A N/A N/A N/A $89.21 N/A N/A $104.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $148.69 $148.69 N/A 4408727 Pharmacy mesalamine 400 mg Oral EC Tab [BCH] 250 $5.05 $- $1.31 $- $- $4.04 $- N/A $1.31 N/A N/A $1.91 N/A N/A $3.03 N/A N/A $2.52 N/A N/A N/A N/A N/A $3.43 N/A N/A $3.13 N/A N/A $2.07 N/A N/A $3.53 N/A N/A $4.04 N/A N/A $2.78 N/A N/A $3.53 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.03 N/A N/A $1.77 N/A N/A $3.28 N/A N/A N/A N/A N/A $3.03 N/A N/A $3.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.05 $5.05 N/A 4400862 Pharmacy mesalamine 400 mg Cap [BCH] 250 $7.12 $- $1.85 $- $- $5.70 $- N/A $1.85 N/A N/A $2.69 N/A N/A $4.27 N/A N/A $3.56 N/A N/A N/A N/A N/A $4.84 N/A N/A $4.42 N/A N/A $2.92 N/A N/A $4.99 N/A N/A $5.70 N/A N/A $3.92 N/A N/A $4.99 N/A N/A $2.39 N/A N/A N/A N/A N/A $4.27 N/A N/A $2.49 N/A N/A $4.63 N/A N/A N/A N/A N/A $4.27 N/A N/A $4.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.12 $7.12 N/A 4400636 Pharmacy sodium hypochlorite Top 0.25% Sol [BCH] 250 $22.70 $- $5.90 $- $- $18.16 $- N/A $5.90 N/A N/A $8.58 N/A N/A $13.62 N/A N/A $11.35 N/A N/A N/A N/A N/A $15.44 N/A N/A $14.08 N/A N/A $9.31 N/A N/A $15.89 N/A N/A $18.16 N/A N/A $12.49 N/A N/A $15.89 N/A N/A $7.61 N/A N/A N/A N/A N/A $13.62 N/A N/A $7.95 N/A N/A $14.76 N/A N/A N/A N/A N/A $13.62 N/A N/A $15.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.70 $22.70 N/A 4400817 Pharmacy ceftaroline 400 mg Pow [BCH] J0712 636 $366.24 $- $3.33 $- $- $292.99 $- N/A $95.22 N/A N/A Not Reimbursed N/A N/A $219.75 N/A N/A $183.12 N/A N/A N/A N/A N/A $249.04 N/A N/A $227.07 N/A N/A $150.16 N/A N/A $256.37 N/A N/A $292.99 N/A N/A $201.43 N/A N/A $256.37 N/A N/A $122.69 N/A N/A N/A N/A N/A $219.75 N/A N/A $128.18 N/A N/A $238.06 N/A N/A $3.33 N/A N/A $219.75 N/A N/A $256.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $366.24 $366.24 N/A 4406758 Pharmacy thyroid desiccated 60 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400818 Pharmacy ceftaroline 600 mg Pow [BCH] J0712 636 $384.55 $- $3.33 $- $- $307.64 $- N/A $99.98 N/A N/A Not Reimbursed N/A N/A $230.73 N/A N/A $192.28 N/A N/A N/A N/A N/A $261.50 N/A N/A $238.42 N/A N/A $157.67 N/A N/A $269.19 N/A N/A $307.64 N/A N/A $211.50 N/A N/A $269.19 N/A N/A $128.83 N/A N/A N/A N/A N/A $230.73 N/A N/A $134.59 N/A N/A $249.96 N/A N/A $3.33 N/A N/A $230.73 N/A N/A $269.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $384.55 $384.55 N/A 4400646 Pharmacy vilazodone 20 mg Tab [BCH] 250 $16.66 $- $4.33 $- $- $13.33 $- N/A $4.33 N/A N/A $6.30 N/A N/A $10.00 N/A N/A $8.33 N/A N/A N/A N/A N/A $11.33 N/A N/A $10.33 N/A N/A $6.83 N/A N/A $11.66 N/A N/A $13.33 N/A N/A $9.17 N/A N/A $11.66 N/A N/A $5.58 N/A N/A N/A N/A N/A $10.00 N/A N/A $5.83 N/A N/A $10.83 N/A N/A N/A N/A N/A $10.00 N/A N/A $11.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.66 $16.66 N/A 4400681 Pharmacy linaclotide 290 mcg Cap [BCH] 250 $28.28 $- $7.35 $- $- $22.62 $- N/A $7.35 N/A N/A $10.69 N/A N/A $16.97 N/A N/A $14.14 N/A N/A N/A N/A N/A $19.23 N/A N/A $17.53 N/A N/A $11.59 N/A N/A $19.80 N/A N/A $22.62 N/A N/A $15.55 N/A N/A $19.80 N/A N/A $9.47 N/A N/A N/A N/A N/A $16.97 N/A N/A $9.90 N/A N/A $18.38 N/A N/A N/A N/A N/A $16.97 N/A N/A $19.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.28 $28.28 N/A 4400448 Pharmacy nebivolol 2.5 mg Tab [BCH] 250 $8.77 $- $2.28 $- $- $7.01 $- N/A $2.28 N/A N/A $3.31 N/A N/A $5.26 N/A N/A $4.38 N/A N/A N/A N/A N/A $5.96 N/A N/A $5.44 N/A N/A $3.59 N/A N/A $6.14 N/A N/A $7.01 N/A N/A $4.82 N/A N/A $6.14 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.26 N/A N/A $3.07 N/A N/A $5.70 N/A N/A N/A N/A N/A $5.26 N/A N/A $6.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.77 $8.77 N/A 4400639 Pharmacy nebivolol 10 mg Tab [BCH] 250 $6.83 $- $1.78 $- $- $5.47 $- N/A $1.78 N/A N/A $2.58 N/A N/A $4.10 N/A N/A $3.42 N/A N/A N/A N/A N/A $4.65 N/A N/A $4.24 N/A N/A $2.80 N/A N/A $4.78 N/A N/A $5.47 N/A N/A $3.76 N/A N/A $4.78 N/A N/A $2.29 N/A N/A N/A N/A N/A $4.10 N/A N/A $2.39 N/A N/A $4.44 N/A N/A N/A N/A N/A $4.10 N/A N/A $4.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.83 $6.83 N/A 4400639 Pharmacy nebivolol 10 mg Tab [BCH] 250 $8.77 $- $2.28 $- $- $7.01 $- N/A $2.28 N/A N/A $3.31 N/A N/A $5.26 N/A N/A $4.38 N/A N/A N/A N/A N/A $5.96 N/A N/A $5.44 N/A N/A $3.59 N/A N/A $6.14 N/A N/A $7.01 N/A N/A $4.82 N/A N/A $6.14 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.26 N/A N/A $3.07 N/A N/A $5.70 N/A N/A N/A N/A N/A $5.26 N/A N/A $6.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.77 $8.77 N/A 4400702 Pharmacy memantine 7 mg Cap [BCH] 250 $28.32 $- $7.36 $- $- $22.66 $- N/A $7.36 N/A N/A $10.70 N/A N/A $16.99 N/A N/A $14.16 N/A N/A N/A N/A N/A $19.26 N/A N/A $17.56 N/A N/A $11.61 N/A N/A $19.82 N/A N/A $22.66 N/A N/A $15.58 N/A N/A $19.82 N/A N/A $9.49 N/A N/A N/A N/A N/A $16.99 N/A N/A $9.91 N/A N/A $18.41 N/A N/A N/A N/A N/A $16.99 N/A N/A $19.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.32 $28.32 N/A 4400701 Pharmacy memantine 14 mg Cap [BCH] 250 $28.32 $- $7.36 $- $- $22.66 $- N/A $7.36 N/A N/A $10.70 N/A N/A $16.99 N/A N/A $14.16 N/A N/A N/A N/A N/A $19.26 N/A N/A $17.56 N/A N/A $11.61 N/A N/A $19.82 N/A N/A $22.66 N/A N/A $15.58 N/A N/A $19.82 N/A N/A $9.49 N/A N/A N/A N/A N/A $16.99 N/A N/A $9.91 N/A N/A $18.41 N/A N/A N/A N/A N/A $16.99 N/A N/A $19.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.32 $28.32 N/A 4400796 Pharmacy memantine 21 mg Cap [BCH] 250 $28.32 $- $7.36 $- $- $22.66 $- N/A $7.36 N/A N/A $10.70 N/A N/A $16.99 N/A N/A $14.16 N/A N/A N/A N/A N/A $19.26 N/A N/A $17.56 N/A N/A $11.61 N/A N/A $19.82 N/A N/A $22.66 N/A N/A $15.58 N/A N/A $19.82 N/A N/A $9.49 N/A N/A N/A N/A N/A $16.99 N/A N/A $9.91 N/A N/A $18.41 N/A N/A N/A N/A N/A $16.99 N/A N/A $19.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.32 $28.32 N/A 4400703 Pharmacy memantine 28 mg Cap [BCH] 250 $28.32 $- $7.36 $- $- $22.66 $- N/A $7.36 N/A N/A $10.70 N/A N/A $16.99 N/A N/A $14.16 N/A N/A N/A N/A N/A $19.26 N/A N/A $17.56 N/A N/A $11.61 N/A N/A $19.82 N/A N/A $22.66 N/A N/A $15.58 N/A N/A $19.82 N/A N/A $9.49 N/A N/A N/A N/A N/A $16.99 N/A N/A $9.91 N/A N/A $18.41 N/A N/A N/A N/A N/A $16.99 N/A N/A $19.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.32 $28.32 N/A 4400663 Pharmacy micafungin 100 mg IV Inj [BCH] J2248 636 $448.80 $- $1.05 $- $- $359.04 $- N/A $116.69 N/A N/A Not Reimbursed N/A N/A $269.28 N/A N/A $224.40 N/A N/A N/A N/A N/A $305.18 N/A N/A $278.26 N/A N/A $184.01 N/A N/A $314.16 N/A N/A $359.04 N/A N/A $246.84 N/A N/A $314.16 N/A N/A $150.35 N/A N/A N/A N/A N/A $269.28 N/A N/A $157.08 N/A N/A $291.72 N/A N/A $1.05 N/A N/A $269.28 N/A N/A $314.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $448.80 $448.80 N/A 4400435 Pharmacy regadenoson 0.4 mg/5 mL IV Sol [BCH] J2785 636 $555.00 $- $59.18 $- $- $444.00 $- N/A $144.30 N/A N/A Not Reimbursed N/A N/A $333.00 N/A N/A $277.50 N/A N/A N/A N/A N/A $377.40 N/A N/A $344.10 N/A N/A $227.55 N/A N/A $388.50 N/A N/A $444.00 N/A N/A $305.25 N/A N/A $388.50 N/A N/A $185.93 N/A N/A N/A N/A N/A $333.00 N/A N/A $194.25 N/A N/A $360.75 N/A N/A $59.18 N/A N/A $333.00 N/A N/A $388.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $555.00 $555.00 N/A 4402394 Pharmacy adenosine 3 mg/mL IV Sol vl[BCH] J0150 636 $86.48 $- $22.48 $- $- $69.18 $- N/A $22.48 N/A N/A Not Reimbursed N/A N/A $51.89 N/A N/A $43.24 N/A N/A N/A N/A N/A $58.81 N/A N/A $53.62 N/A N/A $35.46 N/A N/A $60.54 N/A N/A $69.18 N/A N/A $47.56 N/A N/A $60.54 N/A N/A $28.97 N/A N/A N/A N/A N/A $51.89 N/A N/A $30.27 N/A N/A $56.21 N/A N/A N/A N/A N/A $51.89 N/A N/A $60.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $86.48 $86.48 N/A 4407760 Pharmacy "nystatin Top 100,000 units/g Crm [BCH]" 250 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A $21.70 N/A N/A $14.35 N/A N/A $24.50 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $24.50 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A N/A N/A N/A $21.00 N/A N/A $24.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.00 $35.00 N/A 4400488 Pharmacy hydrocortisone topical 2.5% Cre 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4406309 Pharmacy hydrocortisone Top 1% Crm [BCH] 250 $6.96 $- $1.81 $- $- $5.57 $- N/A $1.81 N/A N/A $2.63 N/A N/A $4.18 N/A N/A $3.48 N/A N/A N/A N/A N/A $4.73 N/A N/A $4.32 N/A N/A $2.85 N/A N/A $4.87 N/A N/A $5.57 N/A N/A $3.83 N/A N/A $4.87 N/A N/A $2.33 N/A N/A N/A N/A N/A $4.18 N/A N/A $2.44 N/A N/A $4.52 N/A N/A N/A N/A N/A $4.18 N/A N/A $4.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.96 $6.96 N/A 4402269 Pharmacy miconazole Top 2% Crm [BCH] 250 $4.72 $- $1.23 $- $- $3.78 $- N/A $1.23 N/A N/A $1.78 N/A N/A $2.83 N/A N/A $2.36 N/A N/A N/A N/A N/A $3.21 N/A N/A $2.93 N/A N/A $1.94 N/A N/A $3.30 N/A N/A $3.78 N/A N/A $2.60 N/A N/A $3.30 N/A N/A $1.58 N/A N/A N/A N/A N/A $2.83 N/A N/A $1.65 N/A N/A $3.07 N/A N/A N/A N/A N/A $2.83 N/A N/A $3.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.72 $4.72 N/A 4402269 Pharmacy miconazole Top 2% Crm [BCH] 250 $3.25 $- $0.85 $- $- $2.60 $- N/A $0.85 N/A N/A $1.23 N/A N/A $1.95 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.21 N/A N/A $2.02 N/A N/A $1.33 N/A N/A $2.28 N/A N/A $2.60 N/A N/A $1.79 N/A N/A $2.28 N/A N/A $1.09 N/A N/A N/A N/A N/A $1.95 N/A N/A $1.14 N/A N/A $2.11 N/A N/A N/A N/A N/A $1.95 N/A N/A $2.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.25 $3.25 N/A 4401957 Pharmacy bacitracin topical zinc 500 units/g Oin [BCH] 250 $9.09 $- $2.36 $- $- $7.27 $- N/A $2.36 N/A N/A $3.43 N/A N/A $5.45 N/A N/A $4.54 N/A N/A N/A N/A N/A $6.18 N/A N/A $5.63 N/A N/A $3.73 N/A N/A $6.36 N/A N/A $7.27 N/A N/A $5.00 N/A N/A $6.36 N/A N/A $3.04 N/A N/A N/A N/A N/A $5.45 N/A N/A $3.18 N/A N/A $5.91 N/A N/A N/A N/A N/A $5.45 N/A N/A $6.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.09 $9.09 N/A 4403850 Pharmacy codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400138 Pharmacy potassium acid phosphate 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408743 Pharmacy albuterol-ipratropium Inh Sol 3 mL [BCH] J7620 250 $5.00 $- $0.13 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.13 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401956 Pharmacy racepinephrine 2.25% Sol UD [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405996 Pharmacy sodium chloride 0.9% Inh Sol 3 mL [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400365 Pharmacy albuterol 2.5 mg/3 mL (0.083%) Sol [BCH] J7611 636 $5.00 $- $0.24 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.24 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400365 Pharmacy albuterol 0.083% Inh Sol 3 mL [BCH] J7611 250 $5.00 $- $0.24 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.24 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409460 Pharmacy budesonide 0.5 mg/2 mL Sus [BCH] J7626 636 $22.33 $- $1.78 $- $- $17.87 $- N/A $5.81 N/A N/A Not Reimbursed N/A N/A $13.40 N/A N/A $11.17 N/A N/A N/A N/A N/A $15.19 N/A N/A $13.85 N/A N/A $9.16 N/A N/A $15.63 N/A N/A $17.87 N/A N/A $12.28 N/A N/A $15.63 N/A N/A $7.48 N/A N/A N/A N/A N/A $13.40 N/A N/A $7.82 N/A N/A $14.52 N/A N/A $1.78 N/A N/A $13.40 N/A N/A $15.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.33 $22.33 N/A 4404619 Pharmacy ipratropium 0.02% Inh Sol 2 mL [BCH] J7644 636 $5.00 $- $0.21 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.21 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405172 Pharmacy iron dextran 50 mg/mL Inj Sol [BCH] J1750 636 $90.00 $- $15.02 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $15.02 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4403730 Pharmacy methylene blue 10 mg/mL Inj Sol [BCH] 250 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A $5.67 N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A N/A N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4400157 Pharmacy atropine 0.4 mg/mL Inj Sol [BCH] J0461 636 $12.00 $- $0.06 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.06 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400987 Pharmacy ferric carboxymaltose (as elemental iron) 50 mg/mL Sol [BCH] J1439 636 "$2,685.62 " $- $1.12 $- $- "$2,148.50 " $- N/A $698.26 N/A N/A Not Reimbursed N/A N/A "$1,611.37 " N/A N/A "$1,342.81 " N/A N/A N/A N/A N/A "$1,826.22 " N/A N/A "$1,665.08 " N/A N/A "$1,101.10 " N/A N/A "$1,879.93 " N/A N/A "$2,148.50 " N/A N/A "$1,477.09 " N/A N/A "$1,879.93 " N/A N/A $899.68 N/A N/A N/A N/A N/A "$1,611.37 " N/A N/A $939.97 N/A N/A "$1,745.65 " N/A N/A $1.12 N/A N/A "$1,611.37 " N/A N/A "$1,879.93 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,685.62 " "$2,685.62 " N/A 4400873 Pharmacy betamethasone 6 mg/mL Sus [BCH] J0702 636 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A Not Reimbursed N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A $9.92 N/A N/A $6.56 N/A N/A $11.20 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $11.20 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A $7.41 N/A N/A $9.60 N/A N/A $11.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.00 $16.00 N/A 4409394 Pharmacy latanoprost Ophth 0.005% Sol [BCH] 250 $30.00 $- $7.80 $- $- $24.00 $- N/A $7.80 N/A N/A $11.34 N/A N/A $18.00 N/A N/A $15.00 N/A N/A N/A N/A N/A $20.40 N/A N/A $18.60 N/A N/A $12.30 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A N/A N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A N/A N/A N/A $18.00 N/A N/A $21.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.00 $30.00 N/A 4400694 Pharmacy OLANZapine 10 mg IM Inj [BCH] 250 $82.50 $- $21.45 $- $- $66.00 $- N/A $21.45 N/A N/A $31.19 N/A N/A $49.50 N/A N/A $41.25 N/A N/A N/A N/A N/A $56.10 N/A N/A $51.15 N/A N/A $33.83 N/A N/A $57.75 N/A N/A $66.00 N/A N/A $45.38 N/A N/A $57.75 N/A N/A $27.64 N/A N/A N/A N/A N/A $49.50 N/A N/A $28.88 N/A N/A $53.63 N/A N/A N/A N/A N/A $49.50 N/A N/A $57.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $82.50 $82.50 N/A 4400872 Pharmacy atropine 1 mg/mL Inj Sol [BCH] J0461 636 $13.75 $- $0.06 $- $- $11.00 $- N/A $3.58 N/A N/A Not Reimbursed N/A N/A $8.25 N/A N/A $6.88 N/A N/A N/A N/A N/A $9.35 N/A N/A $8.53 N/A N/A $5.64 N/A N/A $9.63 N/A N/A $11.00 N/A N/A $7.56 N/A N/A $9.63 N/A N/A $4.61 N/A N/A N/A N/A N/A $8.25 N/A N/A $4.81 N/A N/A $8.94 N/A N/A $0.06 N/A N/A $8.25 N/A N/A $9.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.75 $13.75 N/A 4407673 Pharmacy methocarbamol 100 mg/mL Sol J2800 636 $50.18 $- $6.28 $- $- $40.15 $- N/A $13.05 N/A N/A Not Reimbursed N/A N/A $30.11 N/A N/A $25.09 N/A N/A N/A N/A N/A $34.12 N/A N/A $31.11 N/A N/A $20.57 N/A N/A $35.13 N/A N/A $40.15 N/A N/A $27.60 N/A N/A $35.13 N/A N/A $16.81 N/A N/A N/A N/A N/A $30.11 N/A N/A $17.56 N/A N/A $32.62 N/A N/A $6.28 N/A N/A $30.11 N/A N/A $35.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.18 $50.18 N/A 4402013 Pharmacy dicyclomine 10 mg/mL Sol [BCH] J0500 636 $97.50 $- $25.35 $- $- $78.00 $- N/A $25.35 N/A N/A Not Reimbursed N/A N/A $58.50 N/A N/A $48.75 N/A N/A N/A N/A N/A $66.30 N/A N/A $60.45 N/A N/A $39.98 N/A N/A $68.25 N/A N/A $78.00 N/A N/A $53.63 N/A N/A $68.25 N/A N/A $32.66 N/A N/A N/A N/A N/A $58.50 N/A N/A $34.13 N/A N/A $63.38 N/A N/A $40.65 N/A N/A $58.50 N/A N/A $68.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $97.50 $97.50 N/A 4400465 Pharmacy iron sucrose 20 mg/mL IV Sol [BCH] J1756 636 $240.00 $- $0.21 $- $- $192.00 $- N/A $62.40 N/A N/A Not Reimbursed N/A N/A $144.00 N/A N/A $120.00 N/A N/A N/A N/A N/A $163.20 N/A N/A $148.80 N/A N/A $98.40 N/A N/A $168.00 N/A N/A $192.00 N/A N/A $132.00 N/A N/A $168.00 N/A N/A $80.40 N/A N/A N/A N/A N/A $144.00 N/A N/A $84.00 N/A N/A $156.00 N/A N/A $0.21 N/A N/A $144.00 N/A N/A $168.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $240.00 $240.00 N/A 4400821 Pharmacy hydrOXYzine hydrochloride 25 mg/mL Sol [BCH] J3410 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $6.98 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400961 Pharmacy hydrOXYzine hydrochloride 50 mg/mL Sol [BCH] J3410 636 $53.40 $- $6.98 $- $- $42.72 $- N/A $13.88 N/A N/A Not Reimbursed N/A N/A $32.04 N/A N/A $26.70 N/A N/A N/A N/A N/A $36.31 N/A N/A $33.11 N/A N/A $21.89 N/A N/A $37.38 N/A N/A $42.72 N/A N/A $29.37 N/A N/A $37.38 N/A N/A $17.89 N/A N/A N/A N/A N/A $32.04 N/A N/A $18.69 N/A N/A $34.71 N/A N/A $6.98 N/A N/A $32.04 N/A N/A $37.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $53.40 $53.40 N/A 4409794 Pharmacy droperidol 2.5 mg/mL Inj Sol [BCH] J1790 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400618 Pharmacy dicyclomine 10 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400603 Pharmacy acetaZOLAMIDE 250 mg Tab [BCH] 250 $6.59 $- $1.71 $- $- $5.27 $- N/A $1.71 N/A N/A $2.49 N/A N/A $3.95 N/A N/A $3.30 N/A N/A N/A N/A N/A $4.48 N/A N/A $4.09 N/A N/A $2.70 N/A N/A $4.61 N/A N/A $5.27 N/A N/A $3.62 N/A N/A $4.61 N/A N/A $2.21 N/A N/A N/A N/A N/A $3.95 N/A N/A $2.31 N/A N/A $4.28 N/A N/A N/A N/A N/A $3.95 N/A N/A $4.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.59 $6.59 N/A 4400897 Pharmacy rifAMPin 300 mg Cap 250 $9.18 $- $2.39 $- $- $7.35 $- N/A $2.39 N/A N/A $3.47 N/A N/A $5.51 N/A N/A $4.59 N/A N/A N/A N/A N/A $6.24 N/A N/A $5.69 N/A N/A $3.77 N/A N/A $6.43 N/A N/A $7.35 N/A N/A $5.05 N/A N/A $6.43 N/A N/A $3.08 N/A N/A N/A N/A N/A $5.51 N/A N/A $3.21 N/A N/A $5.97 N/A N/A N/A N/A N/A $5.51 N/A N/A $6.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.18 $9.18 N/A 4409664 Pharmacy digoxin 125 mcg (0.125 mg) Tab [BCH] 250 $4.60 $- $1.20 $- $- $3.68 $- N/A $1.20 N/A N/A $1.74 N/A N/A $2.76 N/A N/A $2.30 N/A N/A N/A N/A N/A $3.13 N/A N/A $2.85 N/A N/A $1.89 N/A N/A $3.22 N/A N/A $3.68 N/A N/A $2.53 N/A N/A $3.22 N/A N/A $1.54 N/A N/A N/A N/A N/A $2.76 N/A N/A $1.61 N/A N/A $2.99 N/A N/A N/A N/A N/A $2.76 N/A N/A $3.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.60 $4.60 N/A 4400462 Pharmacy ursodiol 300 mg Cap [BCH] 250 $14.70 $- $3.82 $- $- $11.76 $- N/A $3.82 N/A N/A $5.56 N/A N/A $8.82 N/A N/A $7.35 N/A N/A N/A N/A N/A $10.00 N/A N/A $9.12 N/A N/A $6.03 N/A N/A $10.29 N/A N/A $11.76 N/A N/A $8.09 N/A N/A $10.29 N/A N/A $4.93 N/A N/A N/A N/A N/A $8.82 N/A N/A $5.15 N/A N/A $9.56 N/A N/A N/A N/A N/A $8.82 N/A N/A $10.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.70 $14.70 N/A 4407463 Pharmacy clindamycin 150 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400859 Pharmacy loxapine 25 mg Cap [BCH] 250 $3.85 $- $1.00 $- $- $3.08 $- N/A $1.00 N/A N/A $1.45 N/A N/A $2.31 N/A N/A $1.92 N/A N/A N/A N/A N/A $2.62 N/A N/A $2.39 N/A N/A $1.58 N/A N/A $2.69 N/A N/A $3.08 N/A N/A $2.12 N/A N/A $2.69 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.31 N/A N/A $1.35 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.85 $3.85 N/A 4400846 Pharmacy fluPHENAZine 1 mg Tab [BCH] 250 $8.78 $- $2.28 $- $- $7.03 $- N/A $2.28 N/A N/A $3.32 N/A N/A $5.27 N/A N/A $4.39 N/A N/A N/A N/A N/A $5.97 N/A N/A $5.45 N/A N/A $3.60 N/A N/A $6.15 N/A N/A $7.03 N/A N/A $4.83 N/A N/A $6.15 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.27 N/A N/A $3.07 N/A N/A $5.71 N/A N/A N/A N/A N/A $5.27 N/A N/A $6.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.78 $8.78 N/A 4400691 Pharmacy fluPHENAZine 5 mg Tab [BCH] 250 $18.40 $- $4.78 $- $- $14.72 $- N/A $4.78 N/A N/A $6.96 N/A N/A $11.04 N/A N/A $9.20 N/A N/A N/A N/A N/A $12.51 N/A N/A $11.41 N/A N/A $7.54 N/A N/A $12.88 N/A N/A $14.72 N/A N/A $10.12 N/A N/A $12.88 N/A N/A $6.16 N/A N/A N/A N/A N/A $11.04 N/A N/A $6.44 N/A N/A $11.96 N/A N/A N/A N/A N/A $11.04 N/A N/A $12.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.40 $18.40 N/A 4400405 Pharmacy metOLazone 2.5 mg Tab [BCH] 250 $4.90 $- $1.27 $- $- $3.92 $- N/A $1.27 N/A N/A $1.85 N/A N/A $2.94 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.33 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.43 N/A N/A $3.92 N/A N/A $2.69 N/A N/A $3.43 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.94 N/A N/A $1.71 N/A N/A $3.18 N/A N/A N/A N/A N/A $2.94 N/A N/A $3.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.90 $4.90 N/A 4409950 Pharmacy lidocaine topical 4% Sol [BCH] 250 $129.28 $- $33.61 $- $- $103.42 $- N/A $33.61 N/A N/A $48.87 N/A N/A $77.57 N/A N/A $64.64 N/A N/A N/A N/A N/A $87.91 N/A N/A $80.15 N/A N/A $53.00 N/A N/A $90.50 N/A N/A $103.42 N/A N/A $71.10 N/A N/A $90.50 N/A N/A $43.31 N/A N/A N/A N/A N/A $77.57 N/A N/A $45.25 N/A N/A $84.03 N/A N/A N/A N/A N/A $77.57 N/A N/A $90.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $129.28 $129.28 N/A 4409686 Pharmacy docusate-senna 50 mg-8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401973 Pharmacy diphenhydrAMINE 25 mg Tab [BCH] Q0163 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400032 Pharmacy simethicone 80 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400516 Pharmacy sodium bicarbonate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407521 Pharmacy ocular lubricant preserved Sol 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400122 Pharmacy ocular lubricant - Oin [BCH] 250 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A $5.58 N/A N/A $3.69 N/A N/A $6.30 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $6.30 N/A N/A $3.01 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A N/A N/A N/A $5.40 N/A N/A $6.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.00 $9.00 N/A 4407521 Pharmacy NATURES TEARS 0.1%-0.3% Drops [BCH] 250 $8.70 $- $2.26 $- $- $6.96 $- N/A $2.26 N/A N/A $3.29 N/A N/A $5.22 N/A N/A $4.35 N/A N/A N/A N/A N/A $5.92 N/A N/A $5.39 N/A N/A $3.57 N/A N/A $6.09 N/A N/A $6.96 N/A N/A $4.79 N/A N/A $6.09 N/A N/A $2.91 N/A N/A N/A N/A N/A $5.22 N/A N/A $3.05 N/A N/A $5.66 N/A N/A N/A N/A N/A $5.22 N/A N/A $6.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.70 $8.70 N/A 4404172 Pharmacy CARBAMIDE PEROXIDE OTIC 6.5% 6.5% Soln-Otic 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400891 Pharmacy aspirin 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401973 Pharmacy diphenhydrAMINE 25 mg Tab [BCH] Q0163 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409295 Pharmacy phenol topical 1.4% Spr [BCH] 250 $6.10 $- $1.59 $- $- $4.88 $- N/A $1.59 N/A N/A $2.31 N/A N/A $3.66 N/A N/A $3.05 N/A N/A N/A N/A N/A $4.15 N/A N/A $3.78 N/A N/A $2.50 N/A N/A $4.27 N/A N/A $4.88 N/A N/A $3.36 N/A N/A $4.27 N/A N/A $2.04 N/A N/A N/A N/A N/A $3.66 N/A N/A $2.14 N/A N/A $3.97 N/A N/A N/A N/A N/A $3.66 N/A N/A $4.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.10 $6.10 N/A 4405814 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400875 Pharmacy povidone iodine topical 10% Oin [BCH] 250 $3.59 $- $0.93 $- $- $2.87 $- N/A $0.93 N/A N/A $1.36 N/A N/A $2.16 N/A N/A $1.80 N/A N/A N/A N/A N/A $2.44 N/A N/A $2.23 N/A N/A $1.47 N/A N/A $2.52 N/A N/A $2.87 N/A N/A $1.98 N/A N/A $2.52 N/A N/A $1.20 N/A N/A N/A N/A N/A $2.16 N/A N/A $1.26 N/A N/A $2.34 N/A N/A N/A N/A N/A $2.16 N/A N/A $2.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.59 $3.59 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402054 Pharmacy bisacodyl 10 mg Sup 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400031 Pharmacy simethicone 40 mg/0.6 mL Liq [BCH] 250 $14.10 $- $3.67 $- $- $11.28 $- N/A $3.67 N/A N/A $5.33 N/A N/A $8.46 N/A N/A $7.05 N/A N/A N/A N/A N/A $9.59 N/A N/A $8.74 N/A N/A $5.78 N/A N/A $9.87 N/A N/A $11.28 N/A N/A $7.76 N/A N/A $9.87 N/A N/A $4.72 N/A N/A N/A N/A N/A $8.46 N/A N/A $4.94 N/A N/A $9.17 N/A N/A N/A N/A N/A $8.46 N/A N/A $9.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.10 $14.10 N/A 4409295 Pharmacy phenol Top 1.4% Spry [BCH] 250 $5.96 $- $1.55 $- $- $4.77 $- N/A $1.55 N/A N/A $2.25 N/A N/A $3.57 N/A N/A $2.98 N/A N/A N/A N/A N/A $4.05 N/A N/A $3.69 N/A N/A $2.44 N/A N/A $4.17 N/A N/A $4.77 N/A N/A $3.28 N/A N/A $4.17 N/A N/A $2.00 N/A N/A N/A N/A N/A $3.57 N/A N/A $2.09 N/A N/A $3.87 N/A N/A N/A N/A N/A $3.57 N/A N/A $4.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.96 $5.96 N/A 4400572 Pharmacy capsaicin Top 0.025% Crm [BCH] 250 $19.90 $- $5.17 $- $- $15.92 $- N/A $5.17 N/A N/A $7.52 N/A N/A $11.94 N/A N/A $9.95 N/A N/A N/A N/A N/A $13.53 N/A N/A $12.34 N/A N/A $8.16 N/A N/A $13.93 N/A N/A $15.92 N/A N/A $10.94 N/A N/A $13.93 N/A N/A $6.67 N/A N/A N/A N/A N/A $11.94 N/A N/A $6.96 N/A N/A $12.93 N/A N/A N/A N/A N/A $11.94 N/A N/A $13.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.90 $19.90 N/A 4400677 Pharmacy cholecalciferol 1000 intl units oral tablet [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402413 Pharmacy magnesium oxide 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400043 Pharmacy Multiple Vitamins Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401973 Pharmacy diphenhydrAMINE 25 mg Tab [BCH] Q0163 636 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400399 Pharmacy cholecalciferol 2000 intl units Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404076 Pharmacy niacin 500 mg ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400516 Pharmacy sodium bicarbonate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400059 Pharmacy Vitamin B Complex Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400682 Pharmacy zinc oxide topical 20% Oin [BCH] 250 $2.35 $- $0.61 $- $- $1.88 $- N/A $0.61 N/A N/A $0.89 N/A N/A $1.41 N/A N/A $1.18 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.46 N/A N/A $0.96 N/A N/A $1.65 N/A N/A $1.88 N/A N/A $1.29 N/A N/A $1.65 N/A N/A $0.79 N/A N/A N/A N/A N/A $1.41 N/A N/A $0.82 N/A N/A $1.53 N/A N/A N/A N/A N/A $1.41 N/A N/A $1.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.35 $2.35 N/A 4408289 Pharmacy nicotine 7 mg/24 hr Transderm ER Film [BCH] 250 $4.28 $- $1.11 $- $- $3.43 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.57 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.66 N/A N/A $1.76 N/A N/A $3.00 N/A N/A $3.43 N/A N/A $2.36 N/A N/A $3.00 N/A N/A $1.44 N/A N/A N/A N/A N/A $2.57 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.57 N/A N/A $3.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.28 $4.28 N/A 4408297 Pharmacy nicotine 14 mg/24 hr Transderm ER Film [BCH] 250 $4.28 $- $1.11 $- $- $3.43 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.57 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.66 N/A N/A $1.76 N/A N/A $3.00 N/A N/A $3.43 N/A N/A $2.36 N/A N/A $3.00 N/A N/A $1.44 N/A N/A N/A N/A N/A $2.57 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.57 N/A N/A $3.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.28 $4.28 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Transderm ER Film [BCH] 250 $4.28 $- $1.11 $- $- $3.43 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.57 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.66 N/A N/A $1.76 N/A N/A $3.00 N/A N/A $3.43 N/A N/A $2.36 N/A N/A $3.00 N/A N/A $1.44 N/A N/A N/A N/A N/A $2.57 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.57 N/A N/A $3.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.28 $4.28 N/A 4409509 Pharmacy Vitamin B Complex with C and Folic Acid Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409747 Pharmacy sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 135 mL [BCH] 250 $2.09 $- $0.54 $- $- $1.67 $- N/A $0.54 N/A N/A $0.79 N/A N/A $1.25 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.42 N/A N/A $1.30 N/A N/A $0.86 N/A N/A $1.46 N/A N/A $1.67 N/A N/A $1.15 N/A N/A $1.46 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.25 N/A N/A $0.73 N/A N/A $1.36 N/A N/A N/A N/A N/A $1.25 N/A N/A $1.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.09 $2.09 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol [BCH] J1650 636 $14.40 $- $0.69 $- $- $11.52 $- N/A $3.74 N/A N/A Not Reimbursed N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A $0.69 N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400111 Pharmacy enoxaparin 60 mg/0.6 mL Sol J1650 636 $21.60 $- $0.69 $- $- $17.28 $- N/A $5.62 N/A N/A Not Reimbursed N/A N/A $12.96 N/A N/A $10.80 N/A N/A N/A N/A N/A $14.69 N/A N/A $13.39 N/A N/A $8.86 N/A N/A $15.12 N/A N/A $17.28 N/A N/A $11.88 N/A N/A $15.12 N/A N/A $7.24 N/A N/A N/A N/A N/A $12.96 N/A N/A $7.56 N/A N/A $14.04 N/A N/A $0.69 N/A N/A $12.96 N/A N/A $15.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.60 $21.60 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $28.80 $- $0.69 $- $- $23.04 $- N/A $7.49 N/A N/A Not Reimbursed N/A N/A $17.28 N/A N/A $14.40 N/A N/A N/A N/A N/A $19.58 N/A N/A $17.86 N/A N/A $11.81 N/A N/A $20.16 N/A N/A $23.04 N/A N/A $15.84 N/A N/A $20.16 N/A N/A $9.65 N/A N/A N/A N/A N/A $17.28 N/A N/A $10.08 N/A N/A $18.72 N/A N/A $0.69 N/A N/A $17.28 N/A N/A $20.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.80 $28.80 N/A 4400204 Pharmacy cosyntropin 0.25 mg Inj [BCH] J0834 636 $255.79 $- $46.24 $- $- $204.63 $- N/A $66.51 N/A N/A Not Reimbursed N/A N/A $153.48 N/A N/A $127.90 N/A N/A N/A N/A N/A $173.94 N/A N/A $158.59 N/A N/A $104.87 N/A N/A $179.05 N/A N/A $204.63 N/A N/A $140.69 N/A N/A $179.05 N/A N/A $85.69 N/A N/A N/A N/A N/A $153.48 N/A N/A $89.53 N/A N/A $166.26 N/A N/A $46.24 N/A N/A $153.48 N/A N/A $179.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $255.79 $255.79 N/A 4407141 Pharmacy EPINEPHrine 1 mg/mL Inj Sol [BCH] J0171 636 $12.00 $- $0.91 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.91 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400655 Pharmacy isoniazid 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400655 Pharmacy isoniazid 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403201 Pharmacy chlordiazePOXIDE 5 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401071 Pharmacy chlordiazePOXIDE 25 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401071 Pharmacy chlordiazePOXIDE 25 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408960 Pharmacy meperidine 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409252 Pharmacy demeclocycline 150 mg Tab [BCH] 250 $21.15 $- $5.50 $- $- $16.92 $- N/A $5.50 N/A N/A $8.00 N/A N/A $12.69 N/A N/A $10.58 N/A N/A N/A N/A N/A $14.38 N/A N/A $13.11 N/A N/A $8.67 N/A N/A $14.81 N/A N/A $16.92 N/A N/A $11.63 N/A N/A $14.81 N/A N/A $7.09 N/A N/A N/A N/A N/A $12.69 N/A N/A $7.40 N/A N/A $13.75 N/A N/A N/A N/A N/A $12.69 N/A N/A $14.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.15 $21.15 N/A 4405602 Pharmacy warfarin 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405114 Pharmacy medroxyPROGESTERone 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400909 Pharmacy estradiol 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400858 Pharmacy amphetamine-dextroamphetamine 10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400726 Pharmacy amphetamine-dextroamphetamine 30 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404125 Pharmacy fludrocortisone 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406120 Pharmacy cloNIDine 0.1 mg/24 hr Transderm ER Film [BCH] 250 $66.32 $- $17.24 $- $- $53.05 $- N/A $17.24 N/A N/A $25.07 N/A N/A $39.79 N/A N/A $33.16 N/A N/A N/A N/A N/A $45.09 N/A N/A $41.12 N/A N/A $27.19 N/A N/A $46.42 N/A N/A $53.05 N/A N/A $36.47 N/A N/A $46.42 N/A N/A $22.22 N/A N/A N/A N/A N/A $39.79 N/A N/A $23.21 N/A N/A $43.10 N/A N/A N/A N/A N/A $39.79 N/A N/A $46.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $66.32 $66.32 N/A 4400665 Pharmacy RHo (D) immune globulin 50 mcg/mL IM Sol [BCH] J2788 636 $132.74 $- $25.93 $- $- $106.19 $- N/A $34.51 N/A N/A Not Reimbursed N/A N/A $79.64 N/A N/A $66.37 N/A N/A N/A N/A N/A $90.26 N/A N/A $82.30 N/A N/A $54.42 N/A N/A $92.92 N/A N/A $106.19 N/A N/A $73.01 N/A N/A $92.92 N/A N/A $44.47 N/A N/A N/A N/A N/A $79.64 N/A N/A $46.46 N/A N/A $86.28 N/A N/A $25.93 N/A N/A $79.64 N/A N/A $92.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $132.74 $132.74 N/A 4400816 Pharmacy benzocaine topical 20% Gel [BCH] 250 $16.67 $- $4.33 $- $- $13.33 $- N/A $4.33 N/A N/A $6.30 N/A N/A $10.00 N/A N/A $8.33 N/A N/A N/A N/A N/A $11.33 N/A N/A $10.33 N/A N/A $6.83 N/A N/A $11.67 N/A N/A $13.33 N/A N/A $9.17 N/A N/A $11.67 N/A N/A $5.58 N/A N/A N/A N/A N/A $10.00 N/A N/A $5.83 N/A N/A $10.83 N/A N/A N/A N/A N/A $10.00 N/A N/A $11.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.67 $16.67 N/A 4401003 Pharmacy mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin [BCH] 250 $23.16 $- $6.02 $- $- $18.53 $- N/A $6.02 N/A N/A $8.75 N/A N/A $13.90 N/A N/A $11.58 N/A N/A N/A N/A N/A $15.75 N/A N/A $14.36 N/A N/A $9.50 N/A N/A $16.21 N/A N/A $18.53 N/A N/A $12.74 N/A N/A $16.21 N/A N/A $7.76 N/A N/A N/A N/A N/A $13.90 N/A N/A $8.11 N/A N/A $15.05 N/A N/A N/A N/A N/A $13.90 N/A N/A $16.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.16 $23.16 N/A 4409675 Pharmacy glucose 40% Oral gel [BCH] 250 $7.90 $- $2.05 $- $- $6.32 $- N/A $2.05 N/A N/A $2.99 N/A N/A $4.74 N/A N/A $3.95 N/A N/A N/A N/A N/A $5.37 N/A N/A $4.90 N/A N/A $3.24 N/A N/A $5.53 N/A N/A $6.32 N/A N/A $4.34 N/A N/A $5.53 N/A N/A $2.65 N/A N/A N/A N/A N/A $4.74 N/A N/A $2.76 N/A N/A $5.13 N/A N/A N/A N/A N/A $4.74 N/A N/A $5.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.90 $7.90 N/A 4409360 Pharmacy clotrimazole 10 mg Loz [BCH] 250 $3.22 $- $0.84 $- $- $2.57 $- N/A $0.84 N/A N/A $1.22 N/A N/A $1.93 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.19 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.77 N/A N/A $2.25 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.93 N/A N/A $1.13 N/A N/A $2.09 N/A N/A N/A N/A N/A $1.93 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.22 $3.22 N/A 4409360 Pharmacy clotrimazole 10 mg Loz [BCH] 250 $2.86 $- $0.74 $- $- $2.29 $- N/A $0.74 N/A N/A $1.08 N/A N/A $1.71 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.94 N/A N/A $1.77 N/A N/A $1.17 N/A N/A $2.00 N/A N/A $2.29 N/A N/A $1.57 N/A N/A $2.00 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.71 N/A N/A $1.00 N/A N/A $1.86 N/A N/A N/A N/A N/A $1.71 N/A N/A $2.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.86 $2.86 N/A 4400729 Pharmacy liothyronine 5 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400456 Pharmacy liothyronine 25 mcg Tab [BCH] 250 $2.10 $- $0.55 $- $- $1.68 $- N/A $0.55 N/A N/A $0.79 N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.30 N/A N/A $0.86 N/A N/A $1.47 N/A N/A $1.68 N/A N/A $1.16 N/A N/A $1.47 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.74 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.26 N/A N/A $1.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.10 $2.10 N/A 4405593 Pharmacy charcoal-sorbitol 50 g Sus [BCH] 250 $47.30 $- $12.30 $- $- $37.84 $- N/A $12.30 N/A N/A $17.88 N/A N/A $28.38 N/A N/A $23.65 N/A N/A N/A N/A N/A $32.16 N/A N/A $29.33 N/A N/A $19.39 N/A N/A $33.11 N/A N/A $37.84 N/A N/A $26.01 N/A N/A $33.11 N/A N/A $15.85 N/A N/A N/A N/A N/A $28.38 N/A N/A $16.55 N/A N/A $30.74 N/A N/A N/A N/A N/A $28.38 N/A N/A $33.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.30 $47.30 N/A 4409796 Pharmacy acetylcysteine 20% IV Sol 30 mL [BCH] J0132 636 $451.20 $- $1.08 $- $- $360.96 $- N/A $117.31 N/A N/A Not Reimbursed N/A N/A $270.72 N/A N/A $225.60 N/A N/A N/A N/A N/A $306.82 N/A N/A $279.74 N/A N/A $184.99 N/A N/A $315.84 N/A N/A $360.96 N/A N/A $248.16 N/A N/A $315.84 N/A N/A $151.15 N/A N/A N/A N/A N/A $270.72 N/A N/A $157.92 N/A N/A $293.28 N/A N/A $1.08 N/A N/A $270.72 N/A N/A $315.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $451.20 $451.20 N/A 4404893 Pharmacy sodium polystyrene sulfonate 15 g/60 mL Sus [BCH] 250 $22.50 $- $5.85 $- $- $18.00 $- N/A $5.85 N/A N/A $8.51 N/A N/A $13.50 N/A N/A $11.25 N/A N/A N/A N/A N/A $15.30 N/A N/A $13.95 N/A N/A $9.23 N/A N/A $15.75 N/A N/A $18.00 N/A N/A $12.38 N/A N/A $15.75 N/A N/A $7.54 N/A N/A N/A N/A N/A $13.50 N/A N/A $7.88 N/A N/A $14.63 N/A N/A N/A N/A N/A $13.50 N/A N/A $15.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.50 $22.50 N/A 4402970 Pharmacy "nystatin Top 100,000 units/g Pwdr [BCH]" 250 $47.94 $- $12.46 $- $- $38.35 $- N/A $12.46 N/A N/A $18.12 N/A N/A $28.76 N/A N/A $23.97 N/A N/A N/A N/A N/A $32.60 N/A N/A $29.72 N/A N/A $19.66 N/A N/A $33.56 N/A N/A $38.35 N/A N/A $26.37 N/A N/A $33.56 N/A N/A $16.06 N/A N/A N/A N/A N/A $28.76 N/A N/A $16.78 N/A N/A $31.16 N/A N/A N/A N/A N/A $28.76 N/A N/A $33.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.94 $47.94 N/A 4402970 Pharmacy "nystatin Top 100,000 units/g Pwdr [BCH]" 250 $54.92 $- $14.28 $- $- $43.94 $- N/A $14.28 N/A N/A $20.76 N/A N/A $32.95 N/A N/A $27.46 N/A N/A N/A N/A N/A $37.35 N/A N/A $34.05 N/A N/A $22.52 N/A N/A $38.44 N/A N/A $43.94 N/A N/A $30.21 N/A N/A $38.44 N/A N/A $18.40 N/A N/A N/A N/A N/A $32.95 N/A N/A $19.22 N/A N/A $35.70 N/A N/A N/A N/A N/A $32.95 N/A N/A $38.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $54.92 $54.92 N/A 4400661 Pharmacy bacitracin Ophth 500 units/g Oint [BCH] 250 $225.60 $- $58.66 $- $- $180.48 $- N/A $58.66 N/A N/A $85.28 N/A N/A $135.36 N/A N/A $112.80 N/A N/A N/A N/A N/A $153.41 N/A N/A $139.87 N/A N/A $92.50 N/A N/A $157.92 N/A N/A $180.48 N/A N/A $124.08 N/A N/A $157.92 N/A N/A $75.58 N/A N/A N/A N/A N/A $135.36 N/A N/A $78.96 N/A N/A $146.64 N/A N/A N/A N/A N/A $135.36 N/A N/A $157.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $225.60 $225.60 N/A 4400554 Pharmacy bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 m 250 $119.96 $- $31.19 $- $- $95.97 $- N/A $31.19 N/A N/A $45.34 N/A N/A $71.98 N/A N/A $59.98 N/A N/A N/A N/A N/A $81.57 N/A N/A $74.38 N/A N/A $49.18 N/A N/A $83.97 N/A N/A $95.97 N/A N/A $65.98 N/A N/A $83.97 N/A N/A $40.19 N/A N/A N/A N/A N/A $71.98 N/A N/A $41.99 N/A N/A $77.97 N/A N/A N/A N/A N/A $71.98 N/A N/A $83.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $119.96 $119.96 N/A 4408963 Pharmacy aspirin 600 mg Supp [BCH] 250 $3.02 $- $0.78 $- $- $2.41 $- N/A $0.78 N/A N/A $1.14 N/A N/A $1.81 N/A N/A $1.51 N/A N/A N/A N/A N/A $2.05 N/A N/A $1.87 N/A N/A $1.24 N/A N/A $2.11 N/A N/A $2.41 N/A N/A $1.66 N/A N/A $2.11 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.06 N/A N/A $1.96 N/A N/A N/A N/A N/A $1.81 N/A N/A $2.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.02 $3.02 N/A 4400916 Pharmacy belladonna-opium 16.2 mg-60 mg Sup 250 $66.91 $- $17.40 $- $- $53.52 $- N/A $17.40 N/A N/A $25.29 N/A N/A $40.14 N/A N/A $33.45 N/A N/A N/A N/A N/A $45.50 N/A N/A $41.48 N/A N/A $27.43 N/A N/A $46.83 N/A N/A $53.52 N/A N/A $36.80 N/A N/A $46.83 N/A N/A $22.41 N/A N/A N/A N/A N/A $40.14 N/A N/A $23.42 N/A N/A $43.49 N/A N/A N/A N/A N/A $40.14 N/A N/A $46.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $66.91 $66.91 N/A 4401234 Pharmacy belladonna-opium 16.2 mg-30 mg Supp [BCH] 250 $55.04 $- $14.31 $- $- $44.03 $- N/A $14.31 N/A N/A $20.80 N/A N/A $33.02 N/A N/A $27.52 N/A N/A N/A N/A N/A $37.42 N/A N/A $34.12 N/A N/A $22.56 N/A N/A $38.52 N/A N/A $44.03 N/A N/A $30.27 N/A N/A $38.52 N/A N/A $18.44 N/A N/A N/A N/A N/A $33.02 N/A N/A $19.26 N/A N/A $35.77 N/A N/A N/A N/A N/A $33.02 N/A N/A $38.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $55.04 $55.04 N/A 4402054 Pharmacy bisacodyl 10 mg Sup [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401832 Pharmacy prochlorperazine 25 mg Sup 250 $25.17 $- $6.54 $- $- $20.13 $- N/A $6.54 N/A N/A $9.51 N/A N/A $15.10 N/A N/A $12.58 N/A N/A N/A N/A N/A $17.11 N/A N/A $15.60 N/A N/A $10.32 N/A N/A $17.62 N/A N/A $20.13 N/A N/A $13.84 N/A N/A $17.62 N/A N/A $8.43 N/A N/A N/A N/A N/A $15.10 N/A N/A $8.81 N/A N/A $16.36 N/A N/A N/A N/A N/A $15.10 N/A N/A $17.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.17 $25.17 N/A 4405013 Pharmacy LORazepam 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400311 Pharmacy LORazepam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400305 Pharmacy hydrochlorothiazide 12.5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400937 Pharmacy loxapine 5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400859 Pharmacy loxapine 25 mg Cap [BCH] 250 $3.85 $- $1.00 $- $- $3.08 $- N/A $1.00 N/A N/A $1.45 N/A N/A $2.31 N/A N/A $1.92 N/A N/A N/A N/A N/A $2.62 N/A N/A $2.39 N/A N/A $1.58 N/A N/A $2.69 N/A N/A $3.08 N/A N/A $2.12 N/A N/A $2.69 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.31 N/A N/A $1.35 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.85 $3.85 N/A 4400643 Pharmacy verapamil 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.12 $- $0.55 $- $- $1.69 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.27 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.31 N/A N/A $0.87 N/A N/A $1.48 N/A N/A $1.69 N/A N/A $1.16 N/A N/A $1.48 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.27 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.27 N/A N/A $1.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.12 $2.12 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403280 Pharmacy propafenone 150 mg Tab [BCH] 250 $3.27 $- $0.85 $- $- $2.62 $- N/A $0.85 N/A N/A $1.24 N/A N/A $1.96 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.22 N/A N/A $2.03 N/A N/A $1.34 N/A N/A $2.29 N/A N/A $2.62 N/A N/A $1.80 N/A N/A $2.29 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.96 N/A N/A $1.15 N/A N/A $2.13 N/A N/A N/A N/A N/A $1.96 N/A N/A $2.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.27 $3.27 N/A 4404159 Pharmacy labetalol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405940 Pharmacy silver sulfADIAZINE Top 1% Crm [BCH] 250 $17.98 $- $4.67 $- $- $14.38 $- N/A $4.67 N/A N/A $6.80 N/A N/A $10.79 N/A N/A $8.99 N/A N/A N/A N/A N/A $12.23 N/A N/A $11.15 N/A N/A $7.37 N/A N/A $12.59 N/A N/A $14.38 N/A N/A $9.89 N/A N/A $12.59 N/A N/A $6.02 N/A N/A N/A N/A N/A $10.79 N/A N/A $6.29 N/A N/A $11.69 N/A N/A N/A N/A N/A $10.79 N/A N/A $12.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.98 $17.98 N/A 4400679 Pharmacy glipiZIDE 2.5 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409915 Pharmacy propofol 10 mg/mL Emu [BCH] S0144 636 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4406469 Pharmacy promethazine 25 mg Supp [BCH] 250 $35.41 $- $9.21 $- $- $28.33 $- N/A $9.21 N/A N/A $13.38 N/A N/A $21.25 N/A N/A $17.71 N/A N/A N/A N/A N/A $24.08 N/A N/A $21.95 N/A N/A $14.52 N/A N/A $24.79 N/A N/A $28.33 N/A N/A $19.48 N/A N/A $24.79 N/A N/A $11.86 N/A N/A N/A N/A N/A $21.25 N/A N/A $12.39 N/A N/A $23.02 N/A N/A N/A N/A N/A $21.25 N/A N/A $24.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.41 $35.41 N/A 4409666 Pharmacy lidocaine topical 5% Fil [BCH] 250 $18.72 $- $4.87 $- $- $14.98 $- N/A $4.87 N/A N/A $7.08 N/A N/A $11.23 N/A N/A $9.36 N/A N/A N/A N/A N/A $12.73 N/A N/A $11.61 N/A N/A $7.68 N/A N/A $13.10 N/A N/A $14.98 N/A N/A $10.30 N/A N/A $13.10 N/A N/A $6.27 N/A N/A N/A N/A N/A $11.23 N/A N/A $6.55 N/A N/A $12.17 N/A N/A N/A N/A N/A $11.23 N/A N/A $13.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.72 $18.72 N/A 4400454 Pharmacy levalbuterol 45 mcg/inh Aer [BCH] 250 $147.40 $- $38.32 $- $- $117.92 $- N/A $38.32 N/A N/A $55.72 N/A N/A $88.44 N/A N/A $73.70 N/A N/A N/A N/A N/A $100.23 N/A N/A $91.39 N/A N/A $60.43 N/A N/A $103.18 N/A N/A $117.92 N/A N/A $81.07 N/A N/A $103.18 N/A N/A $49.38 N/A N/A N/A N/A N/A $88.44 N/A N/A $51.59 N/A N/A $95.81 N/A N/A N/A N/A N/A $88.44 N/A N/A $103.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $147.40 $147.40 N/A 4402951 Pharmacy promethazine 12.5 mg Sup [BCH] 250 $35.41 $- $9.21 $- $- $28.33 $- N/A $9.21 N/A N/A $13.38 N/A N/A $21.25 N/A N/A $17.71 N/A N/A N/A N/A N/A $24.08 N/A N/A $21.95 N/A N/A $14.52 N/A N/A $24.79 N/A N/A $28.33 N/A N/A $19.48 N/A N/A $24.79 N/A N/A $11.86 N/A N/A N/A N/A N/A $21.25 N/A N/A $12.39 N/A N/A $23.02 N/A N/A N/A N/A N/A $21.25 N/A N/A $24.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.41 $35.41 N/A 4400462 Pharmacy ursodiol 300 mg Cap [BCH] 250 $14.70 $- $3.82 $- $- $11.76 $- N/A $3.82 N/A N/A $5.56 N/A N/A $8.82 N/A N/A $7.35 N/A N/A N/A N/A N/A $10.00 N/A N/A $9.12 N/A N/A $6.03 N/A N/A $10.29 N/A N/A $11.76 N/A N/A $8.09 N/A N/A $10.29 N/A N/A $4.93 N/A N/A N/A N/A N/A $8.82 N/A N/A $5.15 N/A N/A $9.56 N/A N/A N/A N/A N/A $8.82 N/A N/A $10.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.70 $14.70 N/A 4401326 Pharmacy fentaNYL 25 mcg/hr Transderm ER Film [BCH] 250 $28.87 $- $7.51 $- $- $23.09 $- N/A $7.51 N/A N/A $10.91 N/A N/A $17.32 N/A N/A $14.43 N/A N/A N/A N/A N/A $19.63 N/A N/A $17.90 N/A N/A $11.84 N/A N/A $20.21 N/A N/A $23.09 N/A N/A $15.88 N/A N/A $20.21 N/A N/A $9.67 N/A N/A N/A N/A N/A $17.32 N/A N/A $10.10 N/A N/A $18.76 N/A N/A N/A N/A N/A $17.32 N/A N/A $20.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.87 $28.87 N/A 4401474 Pharmacy fentaNYL 50 mcg/hr Transderm ER Film [BCH] 250 $52.77 $- $13.72 $- $- $42.21 $- N/A $13.72 N/A N/A $19.95 N/A N/A $31.66 N/A N/A $26.38 N/A N/A N/A N/A N/A $35.88 N/A N/A $32.72 N/A N/A $21.63 N/A N/A $36.94 N/A N/A $42.21 N/A N/A $29.02 N/A N/A $36.94 N/A N/A $17.68 N/A N/A N/A N/A N/A $31.66 N/A N/A $18.47 N/A N/A $34.30 N/A N/A N/A N/A N/A $31.66 N/A N/A $36.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.77 $52.77 N/A 4409026 Pharmacy fentaNYL 100 mcg/hr Transderm ER Film [BCH] 250 $106.83 $- $27.78 $- $- $85.46 $- N/A $27.78 N/A N/A $40.38 N/A N/A $64.10 N/A N/A $53.41 N/A N/A N/A N/A N/A $72.64 N/A N/A $66.23 N/A N/A $43.80 N/A N/A $74.78 N/A N/A $85.46 N/A N/A $58.76 N/A N/A $74.78 N/A N/A $35.79 N/A N/A N/A N/A N/A $64.10 N/A N/A $37.39 N/A N/A $69.44 N/A N/A N/A N/A N/A $64.10 N/A N/A $74.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $106.83 $106.83 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours Tab [BCH] 250 $10.44 $- $2.71 $- $- $8.35 $- N/A $2.71 N/A N/A $3.95 N/A N/A $6.26 N/A N/A $5.22 N/A N/A N/A N/A N/A $7.10 N/A N/A $6.47 N/A N/A $4.28 N/A N/A $7.31 N/A N/A $8.35 N/A N/A $5.74 N/A N/A $7.31 N/A N/A $3.50 N/A N/A N/A N/A N/A $6.26 N/A N/A $3.65 N/A N/A $6.79 N/A N/A N/A N/A N/A $6.26 N/A N/A $7.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.44 $10.44 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours XLTab [BCH] 250 $10.44 $- $2.71 $- $- $8.35 $- N/A $2.71 N/A N/A $3.95 N/A N/A $6.26 N/A N/A $5.22 N/A N/A N/A N/A N/A $7.10 N/A N/A $6.47 N/A N/A $4.28 N/A N/A $7.31 N/A N/A $8.35 N/A N/A $5.74 N/A N/A $7.31 N/A N/A $3.50 N/A N/A N/A N/A N/A $6.26 N/A N/A $3.65 N/A N/A $6.79 N/A N/A N/A N/A N/A $6.26 N/A N/A $7.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.44 $10.44 N/A 4401030 Pharmacy APAP/butalbital/caffeine 325 mg-50 mg-40 mg Tab [BCH] 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4409666 Pharmacy lidocaine topical 5% Fil [BCH] 250 $18.72 $- $4.87 $- $- $14.98 $- N/A $4.87 N/A N/A $7.08 N/A N/A $11.23 N/A N/A $9.36 N/A N/A N/A N/A N/A $12.73 N/A N/A $11.61 N/A N/A $7.68 N/A N/A $13.10 N/A N/A $14.98 N/A N/A $10.30 N/A N/A $13.10 N/A N/A $6.27 N/A N/A N/A N/A N/A $11.23 N/A N/A $6.55 N/A N/A $12.17 N/A N/A N/A N/A N/A $11.23 N/A N/A $13.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.72 $18.72 N/A 4400129 Pharmacy buPROPion 100 mg/12 hours Tab [BCH] 250 $3.37 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.02 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.37 $3.37 N/A 4409329 Pharmacy buPROPion 150 mg/12 hours Tab 250 $3.87 $- $1.01 $- $- $3.10 $- N/A $1.01 N/A N/A $1.46 N/A N/A $2.32 N/A N/A $1.94 N/A N/A N/A N/A N/A $2.63 N/A N/A $2.40 N/A N/A $1.59 N/A N/A $2.71 N/A N/A $3.10 N/A N/A $2.13 N/A N/A $2.71 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.32 N/A N/A $1.35 N/A N/A $2.52 N/A N/A N/A N/A N/A $2.32 N/A N/A $2.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.87 $3.87 N/A 4409710 Pharmacy ezetimibe 10 mg Tab 250 $22.59 $- $5.87 $- $- $18.07 $- N/A $5.87 N/A N/A $8.54 N/A N/A $13.56 N/A N/A $11.30 N/A N/A N/A N/A N/A $15.36 N/A N/A $14.01 N/A N/A $9.26 N/A N/A $15.82 N/A N/A $18.07 N/A N/A $12.43 N/A N/A $15.82 N/A N/A $7.57 N/A N/A N/A N/A N/A $13.56 N/A N/A $7.91 N/A N/A $14.69 N/A N/A N/A N/A N/A $13.56 N/A N/A $15.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.59 $22.59 N/A 4400365 Pharmacy albuterol 0.08albuterol 0.083% Inh Sol 3 mL [BCH] J7611 636 $5.00 $- $0.24 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.24 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400365 Pharmacy albuterol 0.083% Inh Sol 3 mL [BCH] J7611 636 $5.00 $- $0.24 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.24 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400911 Pharmacy perphenazine 2 mg Tab [BCH] Q0175 250 $3.49 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A Not Reimbursed N/A N/A $2.09 N/A N/A $1.75 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.44 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.44 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.49 $3.49 N/A 4405098 Pharmacy promethazine 25 mg Tab [BCH] Q0169 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405750 Pharmacy primidone 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409748 Pharmacy trihexyphenidyl 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400953 Pharmacy trihexyphenidyl 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400953 Pharmacy trihexyphenidyl 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408564 Pharmacy allopurinol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400526 Pharmacy allopurinol 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403292 Pharmacy minoxidil 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab [BCh] 250 $2.30 $- $0.60 $- $- $1.84 $- N/A $0.60 N/A N/A $0.87 N/A N/A $1.38 N/A N/A $1.15 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.42 N/A N/A $0.94 N/A N/A $1.61 N/A N/A $1.84 N/A N/A $1.26 N/A N/A $1.61 N/A N/A $0.77 N/A N/A N/A N/A N/A $1.38 N/A N/A $0.80 N/A N/A $1.49 N/A N/A N/A N/A N/A $1.38 N/A N/A $1.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.30 $2.30 N/A 4400295 Pharmacy atenolol-chlorthalidone 50 mg-25 mg Tab [BCH] 250 $3.01 $- $0.78 $- $- $2.41 $- N/A $0.78 N/A N/A $1.14 N/A N/A $1.81 N/A N/A $1.51 N/A N/A N/A N/A N/A $2.05 N/A N/A $1.87 N/A N/A $1.24 N/A N/A $2.11 N/A N/A $2.41 N/A N/A $1.66 N/A N/A $2.11 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.05 N/A N/A $1.96 N/A N/A N/A N/A N/A $1.81 N/A N/A $2.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.01 $3.01 N/A 4400120 Pharmacy aspirin-dipyridamole 25 mg-200 mg ERCap [BCH] 250 $18.59 $- $4.83 $- $- $14.87 $- N/A $4.83 N/A N/A $7.03 N/A N/A $11.15 N/A N/A $9.29 N/A N/A N/A N/A N/A $12.64 N/A N/A $11.52 N/A N/A $7.62 N/A N/A $13.01 N/A N/A $14.87 N/A N/A $10.22 N/A N/A $13.01 N/A N/A $6.23 N/A N/A N/A N/A N/A $11.15 N/A N/A $6.51 N/A N/A $12.08 N/A N/A N/A N/A N/A $11.15 N/A N/A $13.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.59 $18.59 N/A 4409464 Pharmacy albuterol-ipratropium CFC free 100 mcg-20 mcg/inh Aer [BCH] 250 "$1,064.48 " $- $276.76 $- $- $851.58 $- N/A $276.76 N/A N/A $402.37 N/A N/A $638.69 N/A N/A $532.24 N/A N/A N/A N/A N/A $723.85 N/A N/A $659.98 N/A N/A $436.44 N/A N/A $745.14 N/A N/A $851.58 N/A N/A $585.46 N/A N/A $745.14 N/A N/A $356.60 N/A N/A N/A N/A N/A $638.69 N/A N/A $372.57 N/A N/A $691.91 N/A N/A N/A N/A N/A $638.69 N/A N/A $745.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,064.48 " "$1,064.48 " N/A 4409814 Pharmacy tiotropium 18 mcg Inh Cap [BCH] 250 $37.80 $- $9.83 $- $- $30.24 $- N/A $9.83 N/A N/A $14.29 N/A N/A $22.68 N/A N/A $18.90 N/A N/A N/A N/A N/A $25.71 N/A N/A $23.44 N/A N/A $15.50 N/A N/A $26.46 N/A N/A $30.24 N/A N/A $20.79 N/A N/A $26.46 N/A N/A $12.66 N/A N/A N/A N/A N/A $22.68 N/A N/A $13.23 N/A N/A $24.57 N/A N/A N/A N/A N/A $22.68 N/A N/A $26.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.80 $37.80 N/A 4400504 Pharmacy dabigatran 75 mg Cap UD [BCH] 250 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A $8.68 N/A N/A $5.74 N/A N/A $9.80 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.80 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A N/A N/A N/A $8.40 N/A N/A $9.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.00 $14.00 N/A 4400504 Pharmacy dabigatran 75 mg Cap UD [BCH] 250 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A $8.68 N/A N/A $5.74 N/A N/A $9.80 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.80 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A N/A N/A N/A $8.40 N/A N/A $9.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.00 $14.00 N/A 4404886 Pharmacy glucagon 1 mg Pow [BCH] J1610 636 $411.84 $- $107.08 $- $- $329.47 $- N/A $107.08 N/A N/A Not Reimbursed N/A N/A $247.10 N/A N/A $205.92 N/A N/A N/A N/A N/A $280.05 N/A N/A $255.34 N/A N/A $168.85 N/A N/A $288.29 N/A N/A $329.47 N/A N/A $226.51 N/A N/A $288.29 N/A N/A $137.97 N/A N/A N/A N/A N/A $247.10 N/A N/A $144.14 N/A N/A $267.70 N/A N/A $199.13 N/A N/A $247.10 N/A N/A $288.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $411.84 $411.84 N/A 4400504 Pharmacy dabigatran 75 mg Cap [BCH] 250 $17.30 $- $4.50 $- $- $13.84 $- N/A $4.50 N/A N/A $6.54 N/A N/A $10.38 N/A N/A $8.65 N/A N/A N/A N/A N/A $11.77 N/A N/A $10.73 N/A N/A $7.09 N/A N/A $12.11 N/A N/A $13.84 N/A N/A $9.52 N/A N/A $12.11 N/A N/A $5.80 N/A N/A N/A N/A N/A $10.38 N/A N/A $6.06 N/A N/A $11.25 N/A N/A N/A N/A N/A $10.38 N/A N/A $12.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.30 $17.30 N/A 4400504 Pharmacy dabigatran 75 mg Cap [BCH] 250 $19.08 $- $4.96 $- $- $15.26 $- N/A $4.96 N/A N/A $7.21 N/A N/A $11.45 N/A N/A $9.54 N/A N/A N/A N/A N/A $12.97 N/A N/A $11.83 N/A N/A $7.82 N/A N/A $13.35 N/A N/A $15.26 N/A N/A $10.49 N/A N/A $13.35 N/A N/A $6.39 N/A N/A N/A N/A N/A $11.45 N/A N/A $6.68 N/A N/A $12.40 N/A N/A N/A N/A N/A $11.45 N/A N/A $13.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.08 $19.08 N/A 4408945 Pharmacy aspirin 81 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409686 Pharmacy docusate-senna 50 mg-8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400891 Pharmacy aspirin 325 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402413 Pharmacy magnesium oxide 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406309 Pharmacy hydrocortisone topical 1% Cre 250 $5.32 $- $1.38 $- $- $4.26 $- N/A $1.38 N/A N/A $2.01 N/A N/A $3.19 N/A N/A $2.66 N/A N/A N/A N/A N/A $3.62 N/A N/A $3.30 N/A N/A $2.18 N/A N/A $3.72 N/A N/A $4.26 N/A N/A $2.93 N/A N/A $3.72 N/A N/A $1.78 N/A N/A N/A N/A N/A $3.19 N/A N/A $1.86 N/A N/A $3.46 N/A N/A N/A N/A N/A $3.19 N/A N/A $3.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.32 $5.32 N/A 4400572 Pharmacy capsaicin Top 0.025% Crm [BCH] 250 $33.00 $- $8.58 $- $- $26.40 $- N/A $8.58 N/A N/A $12.47 N/A N/A $19.80 N/A N/A $16.50 N/A N/A N/A N/A N/A $22.44 N/A N/A $20.46 N/A N/A $13.53 N/A N/A $23.10 N/A N/A $26.40 N/A N/A $18.15 N/A N/A $23.10 N/A N/A $11.06 N/A N/A N/A N/A N/A $19.80 N/A N/A $11.55 N/A N/A $21.45 N/A N/A N/A N/A N/A $19.80 N/A N/A $23.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.00 $33.00 N/A 4400378 Pharmacy dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq 120 lBCH] 250 $4.76 $- $1.24 $- $- $3.81 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.86 N/A N/A $2.38 N/A N/A N/A N/A N/A $3.24 N/A N/A $2.95 N/A N/A $1.95 N/A N/A $3.33 N/A N/A $3.81 N/A N/A $2.62 N/A N/A $3.33 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.86 N/A N/A $1.67 N/A N/A $3.09 N/A N/A N/A N/A N/A $2.86 N/A N/A $3.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.76 $4.76 N/A 4400031 Pharmacy simethicone 40 mg/0.6 mL Oral Liq [BCH] 250 $11.88 $- $3.09 $- $- $9.50 $- N/A $3.09 N/A N/A $4.49 N/A N/A $7.13 N/A N/A $5.94 N/A N/A N/A N/A N/A $8.08 N/A N/A $7.37 N/A N/A $4.87 N/A N/A $8.32 N/A N/A $9.50 N/A N/A $6.53 N/A N/A $8.32 N/A N/A $3.98 N/A N/A N/A N/A N/A $7.13 N/A N/A $4.16 N/A N/A $7.72 N/A N/A N/A N/A N/A $7.13 N/A N/A $8.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.88 $11.88 N/A 4400133 Pharmacy codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 120 mL [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400133 Pharmacy codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup 120 mL [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4402369 Pharmacy lactulose 10 g/15 mL Oral Syrup [BCH] 250 $36.74 $- $9.55 $- $- $29.39 $- N/A $9.55 N/A N/A $13.89 N/A N/A $22.04 N/A N/A $18.37 N/A N/A N/A N/A N/A $24.98 N/A N/A $22.78 N/A N/A $15.06 N/A N/A $25.71 N/A N/A $29.39 N/A N/A $20.20 N/A N/A $25.71 N/A N/A $12.31 N/A N/A N/A N/A N/A $22.04 N/A N/A $12.86 N/A N/A $23.88 N/A N/A N/A N/A N/A $22.04 N/A N/A $25.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.74 $36.74 N/A 4400578 Pharmacy lidocaine Top 2% viscous Sol 100 mL [BCH] 250 $28.40 $- $7.38 $- $- $22.72 $- N/A $7.38 N/A N/A $10.74 N/A N/A $17.04 N/A N/A $14.20 N/A N/A N/A N/A N/A $19.31 N/A N/A $17.61 N/A N/A $11.64 N/A N/A $19.88 N/A N/A $22.72 N/A N/A $15.62 N/A N/A $19.88 N/A N/A $9.51 N/A N/A N/A N/A N/A $17.04 N/A N/A $9.94 N/A N/A $18.46 N/A N/A N/A N/A N/A $17.04 N/A N/A $19.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.40 $28.40 N/A 4407103 Pharmacy PHENobarbital 20 mg/5 mL Oral Elix [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400925 Pharmacy potassium chloride 20 mEq Pow [BCH] 250 $21.48 $- $5.58 $- $- $17.18 $- N/A $5.58 N/A N/A $8.12 N/A N/A $12.89 N/A N/A $10.74 N/A N/A N/A N/A N/A $14.61 N/A N/A $13.32 N/A N/A $8.81 N/A N/A $15.04 N/A N/A $17.18 N/A N/A $11.81 N/A N/A $15.04 N/A N/A $7.20 N/A N/A N/A N/A N/A $12.89 N/A N/A $7.52 N/A N/A $13.96 N/A N/A N/A N/A N/A $12.89 N/A N/A $15.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.48 $21.48 N/A 4405632 Pharmacy prednisoLONE 15 mg/5 mL Syr [BCH] J7510 250 $231.14 $- $0.12 $- $- $184.91 $- N/A $60.10 N/A N/A Not Reimbursed N/A N/A $138.68 N/A N/A $115.57 N/A N/A N/A N/A N/A $157.17 N/A N/A $143.31 N/A N/A $94.77 N/A N/A $161.80 N/A N/A $184.91 N/A N/A $127.13 N/A N/A $161.80 N/A N/A $77.43 N/A N/A N/A N/A N/A $138.68 N/A N/A $80.90 N/A N/A $150.24 N/A N/A $0.12 N/A N/A $138.68 N/A N/A $161.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $231.14 $231.14 N/A 4403850 Pharmacy codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [B 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409666 Pharmacy lidocaine Top 5% film [BCH] 250 $20.55 $- $5.34 $- $- $16.44 $- N/A $5.34 N/A N/A $7.77 N/A N/A $12.33 N/A N/A $10.28 N/A N/A N/A N/A N/A $13.97 N/A N/A $12.74 N/A N/A $8.43 N/A N/A $14.39 N/A N/A $16.44 N/A N/A $11.30 N/A N/A $14.39 N/A N/A $6.88 N/A N/A N/A N/A N/A $12.33 N/A N/A $7.19 N/A N/A $13.36 N/A N/A N/A N/A N/A $12.33 N/A N/A $14.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.55 $20.55 N/A 4400364 Pharmacy amLODIPine 5 mg Tab [BCH] 250 $3.90 $- $1.01 $- $- $3.12 $- N/A $1.01 N/A N/A $1.47 N/A N/A $2.34 N/A N/A $1.95 N/A N/A N/A N/A N/A $2.65 N/A N/A $2.42 N/A N/A $1.60 N/A N/A $2.73 N/A N/A $3.12 N/A N/A $2.14 N/A N/A $2.73 N/A N/A $1.31 N/A N/A N/A N/A N/A $2.34 N/A N/A $1.36 N/A N/A $2.53 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.90 $3.90 N/A 4409603 Pharmacy amitriptyline 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408002 Pharmacy acetaminophen-codeine 300 mg-30 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407364 Pharmacy baclofen 10 mg Tab [BCH] 250 $4.94 $- $1.28 $- $- $3.95 $- N/A $1.28 N/A N/A $1.87 N/A N/A $2.97 N/A N/A $2.47 N/A N/A N/A N/A N/A $3.36 N/A N/A $3.06 N/A N/A $2.03 N/A N/A $3.46 N/A N/A $3.95 N/A N/A $2.72 N/A N/A $3.46 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.97 N/A N/A $1.73 N/A N/A $3.21 N/A N/A N/A N/A N/A $2.97 N/A N/A $3.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.94 $4.94 N/A 4402518 Pharmacy benztropine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402518 Pharmacy benztropine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407939 Pharmacy carisoprodol 350 mg Tab [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab [BCH] 250 $2.32 $- $0.60 $- $- $1.85 $- N/A $0.60 N/A N/A $0.88 N/A N/A $1.39 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.57 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.62 N/A N/A $1.85 N/A N/A $1.27 N/A N/A $1.62 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.39 N/A N/A $0.81 N/A N/A $1.50 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.32 $2.32 N/A 4404729 Pharmacy folic acid 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408101 Pharmacy diazepam 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403110 Pharmacy furosemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404778 Pharmacy hydrochlorothiazide 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400228 Pharmacy acetaminophen-HYDROcodone 325 mg-10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400228 Pharmacy acetaminophen-HYDROcodone 325 mg-10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400229 Pharmacy acetaminophen-HYDROcodone 325 mg-7.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400644 Pharmacy hydrocortisone 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409457 Pharmacy isosorbide mononitrate 30 mg Tab 250 $2.23 $- $0.58 $- $- $1.79 $- N/A $0.58 N/A N/A $0.84 N/A N/A $1.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.39 N/A N/A $0.92 N/A N/A $1.56 N/A N/A $1.79 N/A N/A $1.23 N/A N/A $1.56 N/A N/A $0.75 N/A N/A N/A N/A N/A $1.34 N/A N/A $0.78 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.34 N/A N/A $1.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.23 $2.23 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.70 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.28 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.87 N/A N/A $1.49 N/A N/A $1.70 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4400478 Pharmacy losartan 100 mg Tab [BCH] 250 $6.16 $- $1.60 $- $- $4.93 $- N/A $1.60 N/A N/A $2.33 N/A N/A $3.70 N/A N/A $3.08 N/A N/A N/A N/A N/A $4.19 N/A N/A $3.82 N/A N/A $2.53 N/A N/A $4.31 N/A N/A $4.93 N/A N/A $3.39 N/A N/A $4.31 N/A N/A $2.06 N/A N/A N/A N/A N/A $3.70 N/A N/A $2.16 N/A N/A $4.01 N/A N/A N/A N/A N/A $3.70 N/A N/A $4.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.16 $6.16 N/A 4400311 Pharmacy LORazepam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403607 Pharmacy methylPREDNISolone 4 mg Tab J7509 636 $5.00 $- $0.34 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.34 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407273 Pharmacy montelukast 10 mg Tab [BCH] 250 $11.31 $- $2.94 $- $- $9.05 $- N/A $2.94 N/A N/A $4.28 N/A N/A $6.79 N/A N/A $5.66 N/A N/A N/A N/A N/A $7.69 N/A N/A $7.01 N/A N/A $4.64 N/A N/A $7.92 N/A N/A $9.05 N/A N/A $6.22 N/A N/A $7.92 N/A N/A $3.79 N/A N/A N/A N/A N/A $6.79 N/A N/A $3.96 N/A N/A $7.35 N/A N/A N/A N/A N/A $6.79 N/A N/A $7.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.31 $11.31 N/A 4400062 Pharmacy acetaminophen-oxyCODONE 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4406360 Pharmacy acetaminophen-oxyCODONE 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400911 Pharmacy perphenazine 2 mg Tab [BCH] Q0175 250 $2.33 $- $0.61 $- $- $1.86 $- N/A $0.61 N/A N/A Not Reimbursed N/A N/A $1.40 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.58 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.63 N/A N/A $1.86 N/A N/A $1.28 N/A N/A $1.63 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.40 N/A N/A $0.81 N/A N/A $1.51 N/A N/A N/A N/A N/A $1.40 N/A N/A $1.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.33 $2.33 N/A 4400593 Pharmacy PHENobarbital 32.4 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404635 Pharmacy primidone 50 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405750 Pharmacy primidone 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405098 Pharmacy promethazine 25 mg Tab [BCH] Q0169 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404387 Pharmacy propranolol 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400309 Pharmacy risperiDONE 0.25 mg Tab[BCH] 250 $7.80 $- $2.03 $- $- $6.24 $- N/A $2.03 N/A N/A $2.95 N/A N/A $4.68 N/A N/A $3.90 N/A N/A N/A N/A N/A $5.31 N/A N/A $4.84 N/A N/A $3.20 N/A N/A $5.46 N/A N/A $6.24 N/A N/A $4.29 N/A N/A $5.46 N/A N/A $2.61 N/A N/A N/A N/A N/A $4.68 N/A N/A $2.73 N/A N/A $5.07 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.80 $7.80 N/A 4405798 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $9.10 $- $2.37 $- $- $7.28 $- N/A $2.37 N/A N/A $3.44 N/A N/A $5.46 N/A N/A $4.55 N/A N/A N/A N/A N/A $6.19 N/A N/A $5.64 N/A N/A $3.73 N/A N/A $6.37 N/A N/A $7.28 N/A N/A $5.01 N/A N/A $6.37 N/A N/A $3.05 N/A N/A N/A N/A N/A $5.46 N/A N/A $3.19 N/A N/A $5.92 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.10 $9.10 N/A 4400316 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $15.21 $- $3.96 $- $- $12.17 $- N/A $3.96 N/A N/A $5.75 N/A N/A $9.13 N/A N/A $7.61 N/A N/A N/A N/A N/A $10.35 N/A N/A $9.43 N/A N/A $6.24 N/A N/A $10.65 N/A N/A $12.17 N/A N/A $8.37 N/A N/A $10.65 N/A N/A $5.10 N/A N/A N/A N/A N/A $9.13 N/A N/A $5.32 N/A N/A $9.89 N/A N/A N/A N/A N/A $9.13 N/A N/A $10.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.21 $15.21 N/A 4400170 Pharmacy sotalol 80 mg Tab [BCH] 250 $5.13 $- $1.33 $- $- $4.10 $- N/A $1.33 N/A N/A $1.94 N/A N/A $3.08 N/A N/A $2.56 N/A N/A N/A N/A N/A $3.49 N/A N/A $3.18 N/A N/A $2.10 N/A N/A $3.59 N/A N/A $4.10 N/A N/A $2.82 N/A N/A $3.59 N/A N/A $1.72 N/A N/A N/A N/A N/A $3.08 N/A N/A $1.79 N/A N/A $3.33 N/A N/A N/A N/A N/A $3.08 N/A N/A $3.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.13 $5.13 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400240 Pharmacy sulfaSALAzine 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401909 Pharmacy traZODone 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409748 Pharmacy trihexyphenidyl 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404254 Pharmacy zolpidem 5 mg Tab [BCH] 250 $9.25 $- $2.41 $- $- $7.40 $- N/A $2.41 N/A N/A $3.50 N/A N/A $5.55 N/A N/A $4.63 N/A N/A N/A N/A N/A $6.29 N/A N/A $5.74 N/A N/A $3.79 N/A N/A $6.48 N/A N/A $7.40 N/A N/A $5.09 N/A N/A $6.48 N/A N/A $3.10 N/A N/A N/A N/A N/A $5.55 N/A N/A $3.24 N/A N/A $6.01 N/A N/A N/A N/A N/A $5.55 N/A N/A $6.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.25 $9.25 N/A 4409567 Pharmacy acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 120 mL [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400071 Pharmacy HYDROmorphone 2 mg/mL Inj Sol [BCH] J1170 636 $- $- $3.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4404940 Pharmacy dexamethasone 10 mg/mL Sol 1ML [BCH] J1100 636 $12.00 $- $0.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.12 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400165 Pharmacy diphenhydrAMINE 50 mg/mL Inj Sol [BCH] J1200 636 $12.00 $- $0.72 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.72 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400165 Pharmacy diphenhydrAMINE 50 mg/mL Inj Sol [BCH] J1200 636 $12.00 $- $0.72 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.72 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400743 Pharmacy PHENobarbital 65 mg/mL Inj Sol [BCH] J2560 636 $44.57 $- $11.59 $- $- $42.59 $- N/A $11.59 N/A N/A Not Reimbursed N/A N/A $26.74 N/A N/A $22.29 N/A N/A N/A N/A N/A $30.31 N/A N/A $27.64 N/A N/A $18.27 N/A N/A $31.20 N/A N/A $35.66 N/A N/A $24.52 N/A N/A $31.20 N/A N/A $14.93 N/A N/A N/A N/A N/A $26.74 N/A N/A $15.60 N/A N/A $28.97 N/A N/A $42.59 N/A N/A $26.74 N/A N/A $31.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.57 $44.57 N/A 4408834 Pharmacy phenytoin 50 mg/mL Inj Sol 2ml [BCH] J1165 636 $12.00 $- $0.41 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.41 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409406 Pharmacy promethazine 25 mg/mL Inj Sol [BCH] J2550 636 $12.00 $- $2.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $2.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409406 Pharmacy promethazine 25 mg/mL Sol J2550 636 $12.00 $- $2.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $2.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409406 Pharmacy promethazine 25 mg/mL Sol [BCH] J2550 250 $12.00 $- $2.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $2.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400932 Pharmacy promethazine 50 mg/mL Sol [BCH] J2550 636 $12.00 $- $2.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $2.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402228 Pharmacy chlorproMAZINE 25 mg/mL Inj Sol [BCH] J3230 636 $53.70 $- $13.96 $- $- $42.96 $- N/A $13.96 N/A N/A Not Reimbursed N/A N/A $32.22 N/A N/A $26.85 N/A N/A N/A N/A N/A $36.51 N/A N/A $33.29 N/A N/A $22.02 N/A N/A $37.59 N/A N/A $42.96 N/A N/A $29.53 N/A N/A $37.59 N/A N/A $17.99 N/A N/A N/A N/A N/A $32.22 N/A N/A $18.79 N/A N/A $34.90 N/A N/A $33.29 N/A N/A $32.22 N/A N/A $37.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $53.70 $53.70 N/A 4402228 Pharmacy chlorproMAZINE 25 mg/mL Sol [BCH] J3230 636 $30.76 $- $8.00 $- $- $33.29 $- N/A $8.00 N/A N/A Not Reimbursed N/A N/A $18.46 N/A N/A $15.38 N/A N/A N/A N/A N/A $20.92 N/A N/A $19.07 N/A N/A $12.61 N/A N/A $21.53 N/A N/A $24.61 N/A N/A $16.92 N/A N/A $21.53 N/A N/A $10.31 N/A N/A N/A N/A N/A $18.46 N/A N/A $10.77 N/A N/A $20.00 N/A N/A $33.29 N/A N/A $18.46 N/A N/A $21.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.76 $30.76 N/A 4403938 Pharmacy digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [BCH] J1160 636 $13.20 $- $3.43 $- $- $11.41 $- N/A $3.43 N/A N/A Not Reimbursed N/A N/A $7.92 N/A N/A $6.60 N/A N/A N/A N/A N/A $8.98 N/A N/A $8.18 N/A N/A $5.41 N/A N/A $9.24 N/A N/A $10.56 N/A N/A $7.26 N/A N/A $9.24 N/A N/A $4.42 N/A N/A N/A N/A N/A $7.92 N/A N/A $4.62 N/A N/A $8.58 N/A N/A $11.41 N/A N/A $7.92 N/A N/A $9.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.20 $13.20 N/A 4404661 Pharmacy phenytoin 50 mg/mL Inj Sol 5ml [BCH] J1165 636 $12.00 $- $0.41 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.41 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400740 Pharmacy LORazepam 2 mg/mL Sol [BCH] J2060 636 $22.00 $- $0.69 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.69 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400782 Pharmacy bumetanide 0.25 mg/mL Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409402 Pharmacy diltiazem 5 mg/mL 5ml IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400429 Pharmacy diltiazem 5 mg/mL IV Sol 25mL [BCH] 258 $13.92 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.35 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.74 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.74 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.35 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.35 N/A N/A $9.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.92 $13.92 N/A 4400021 Pharmacy doxapram 20 mg/mL IV Sol [BCH] 250 $100.80 $- $26.21 $- $- $80.64 $- N/A $26.21 N/A N/A $38.10 N/A N/A $60.48 N/A N/A $50.40 N/A N/A N/A N/A N/A $68.54 N/A N/A $62.50 N/A N/A $41.33 N/A N/A $70.56 N/A N/A $80.64 N/A N/A $55.44 N/A N/A $70.56 N/A N/A $33.77 N/A N/A N/A N/A N/A $60.48 N/A N/A $35.28 N/A N/A $65.52 N/A N/A N/A N/A N/A $60.48 N/A N/A $70.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $100.80 $100.80 N/A 4403861 Pharmacy famotidine 10 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405155 Pharmacy fentaNYL 50 mcg/mL Sol J3010 636 $22.00 $- $0.91 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.91 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400740 Pharmacy LORazepam 2 mg/mL Inj Sol [BCH] J2060 636 $22.00 $- $0.69 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.69 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400740 Pharmacy LORazepam 2 mg/mL Sol J2060 636 $22.00 $- $0.69 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.69 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4404927 Pharmacy meperidine 50 mg/mL Inj Sol [BCH] J2175 636 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $7.41 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4409376 Pharmacy midazolam 1 mg/mL Inj Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4409376 Pharmacy midazolam 1 mg/mL Inj Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400765 Pharmacy midazolam 5 mg/mL Inj Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4400057 Pharmacy morphine 10 mg/mL Inj Sol [BCH] J2270 636 $22.00 $- $3.72 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.72 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4407467 Pharmacy neostigmine 1 mg/mL Inj Sol [BCH] J2710 636 $34.11 $- $8.87 $- $- $27.28 $- N/A $8.87 N/A N/A Not Reimbursed N/A N/A $20.46 N/A N/A $17.05 N/A N/A N/A N/A N/A $23.19 N/A N/A $21.15 N/A N/A $13.98 N/A N/A $23.87 N/A N/A $27.28 N/A N/A $18.76 N/A N/A $23.87 N/A N/A $11.43 N/A N/A N/A N/A N/A $20.46 N/A N/A $11.94 N/A N/A $22.17 N/A N/A N/A N/A N/A $20.46 N/A N/A $23.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.11 $34.11 N/A 4401250 Pharmacy ondansetron 2 mg/mL Inj Sol [BCH] J2405 636 $12.00 $- $0.10 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.10 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401250 Pharmacy ondansetron 2 mg/mL Sol J2405 636 $12.00 $- $0.10 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.10 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407673 Pharmacy methocarbamol 100 mg/mL Inj Sol [BCH] J2800 636 $158.60 $- $6.28 $- $- $126.88 $- N/A $41.23 N/A N/A Not Reimbursed N/A N/A $95.16 N/A N/A $79.30 N/A N/A N/A N/A N/A $107.84 N/A N/A $98.33 N/A N/A $65.02 N/A N/A $111.02 N/A N/A $126.88 N/A N/A $87.23 N/A N/A $111.02 N/A N/A $53.13 N/A N/A N/A N/A N/A $95.16 N/A N/A $55.51 N/A N/A $103.09 N/A N/A $6.28 N/A N/A $95.16 N/A N/A $111.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $158.60 $158.60 N/A 4406964 Pharmacy ampicillin-sulbactam 1 g-0.5 g Pow [BCH] J0295 636 $28.00 $- $2.76 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.76 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400177 Pharmacy ampicillin-sulbactam 2 g-1 g Inj [BCH] J0295 636 $28.00 $- $2.76 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.76 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400989 Pharmacy morphine 4 mg/mL preservative-free Sol [BCH] J2270 636 $22.00 $- $3.72 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $3.72 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4404661 Pharmacy phenytoin 50 mg/mL Sol [BCH] J1165 636 $12.00 $- $0.41 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.41 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408404 Pharmacy phenylephrine 10 mg/mL Inj Sol [BCH] J2370 636 $28.80 $- $7.49 $- $- $23.04 $- N/A $7.49 N/A N/A Not Reimbursed N/A N/A $17.28 N/A N/A $14.40 N/A N/A N/A N/A N/A $19.58 N/A N/A $17.86 N/A N/A $11.81 N/A N/A $20.16 N/A N/A $23.04 N/A N/A $15.84 N/A N/A $20.16 N/A N/A $9.65 N/A N/A N/A N/A N/A $17.28 N/A N/A $10.08 N/A N/A $18.72 N/A N/A N/A N/A N/A $17.28 N/A N/A $20.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.80 $28.80 N/A 4400782 Pharmacy bumetanide 0.25 mg/mL Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401676 Pharmacy hydrALAZINE 20 mg/mL Sol [BCH] J0360 636 $36.00 $- $2.88 $- $- $28.80 $- N/A $9.36 N/A N/A Not Reimbursed N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A $22.32 N/A N/A $14.76 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A $2.88 N/A N/A $21.60 N/A N/A $25.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.00 $36.00 N/A 4409402 Pharmacy dilTIAZem 5 mg/mL Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400429 Pharmacy dilTIAZem 5 mg/mL Sol [BCH] 636 $13.92 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.35 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.74 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.74 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.35 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.35 N/A N/A $9.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.92 $13.92 N/A 4409680 Pharmacy vecuronium 10 mg Pow [BCH] 250 $15.12 $- $3.93 $- $- $12.10 $- N/A $3.93 N/A N/A $5.72 N/A N/A $9.07 N/A N/A $7.56 N/A N/A N/A N/A N/A $10.28 N/A N/A $9.37 N/A N/A $6.20 N/A N/A $10.58 N/A N/A $12.10 N/A N/A $8.32 N/A N/A $10.58 N/A N/A $5.07 N/A N/A N/A N/A N/A $9.07 N/A N/A $5.29 N/A N/A $9.83 N/A N/A N/A N/A N/A $9.07 N/A N/A $10.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.12 $15.12 N/A 4407608 Pharmacy metoclopramide 5 mg/mL Sol [BCH] J2765 636 $12.00 $- $1.23 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $1.23 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4406671 Pharmacy enoxaparin 30 mg/0.3 mL Sol [BCH] J1650 636 $14.33 $- $0.69 $- $- $11.46 $- N/A $3.73 N/A N/A Not Reimbursed N/A N/A $8.60 N/A N/A $7.16 N/A N/A N/A N/A N/A $9.74 N/A N/A $8.88 N/A N/A $5.87 N/A N/A $10.03 N/A N/A $11.46 N/A N/A $7.88 N/A N/A $10.03 N/A N/A $4.80 N/A N/A N/A N/A N/A $8.60 N/A N/A $5.01 N/A N/A $9.31 N/A N/A $0.69 N/A N/A $8.60 N/A N/A $10.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.33 $14.33 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol [BCH] J1650 636 $19.06 $- $0.69 $- $- $15.24 $- N/A $4.95 N/A N/A Not Reimbursed N/A N/A $11.43 N/A N/A $9.53 N/A N/A N/A N/A N/A $12.96 N/A N/A $11.81 N/A N/A $7.81 N/A N/A $13.34 N/A N/A $15.24 N/A N/A $10.48 N/A N/A $13.34 N/A N/A $6.38 N/A N/A N/A N/A N/A $11.43 N/A N/A $6.67 N/A N/A $12.39 N/A N/A $0.69 N/A N/A $11.43 N/A N/A $13.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.06 $19.06 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $38.16 $- $0.69 $- $- $30.53 $- N/A $9.92 N/A N/A Not Reimbursed N/A N/A $22.90 N/A N/A $19.08 N/A N/A N/A N/A N/A $25.95 N/A N/A $23.66 N/A N/A $15.65 N/A N/A $26.71 N/A N/A $30.53 N/A N/A $20.99 N/A N/A $26.71 N/A N/A $12.78 N/A N/A N/A N/A N/A $22.90 N/A N/A $13.36 N/A N/A $24.80 N/A N/A $0.69 N/A N/A $22.90 N/A N/A $26.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.16 $38.16 N/A 4400767 Pharmacy amikacin 250 mg/mL IV Sol [BCH] J0278 636 $58.82 $- $1.39 $- $- $47.06 $- N/A $15.29 N/A N/A Not Reimbursed N/A N/A $35.29 N/A N/A $29.41 N/A N/A N/A N/A N/A $40.00 N/A N/A $36.47 N/A N/A $24.12 N/A N/A $41.18 N/A N/A $47.06 N/A N/A $32.35 N/A N/A $41.18 N/A N/A $19.71 N/A N/A N/A N/A N/A $35.29 N/A N/A $20.59 N/A N/A $38.24 N/A N/A $1.39 N/A N/A $35.29 N/A N/A $41.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $58.82 $58.82 N/A 4409535 Pharmacy linezolid 2 mg/mL IV Sol [BCH] J2020 636 $149.99 $- $6.46 $- $- $120.00 $- N/A $39.00 N/A N/A Not Reimbursed N/A N/A $90.00 N/A N/A $75.00 N/A N/A N/A N/A N/A $102.00 N/A N/A $93.00 N/A N/A $61.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A N/A N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $6.46 N/A N/A $90.00 N/A N/A $105.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $149.99 $149.99 N/A 4409438 Pharmacy sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL [BCH] 250 $30.10 $- $7.82 $- $- $24.08 $- N/A $7.82 N/A N/A $11.38 N/A N/A $18.06 N/A N/A $15.05 N/A N/A N/A N/A N/A $20.47 N/A N/A $18.66 N/A N/A $12.34 N/A N/A $21.07 N/A N/A $24.08 N/A N/A $16.55 N/A N/A $21.07 N/A N/A $10.08 N/A N/A N/A N/A N/A $18.06 N/A N/A $10.53 N/A N/A $19.56 N/A N/A N/A N/A N/A $18.06 N/A N/A $21.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.10 $30.10 N/A 4405643 Pharmacy glycerin adult Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405643 Pharmacy glycerin adult Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405643 Pharmacy glycerin adult Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402054 Pharmacy bisacodyl 10 mg Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401832 Pharmacy prochlorperazine 25 mg Supp [BCH] 250 $26.80 $- $6.97 $- $- $21.44 $- N/A $6.97 N/A N/A $10.13 N/A N/A $16.08 N/A N/A $13.40 N/A N/A N/A N/A N/A $18.22 N/A N/A $16.61 N/A N/A $10.99 N/A N/A $18.76 N/A N/A $21.44 N/A N/A $14.74 N/A N/A $18.76 N/A N/A $8.98 N/A N/A N/A N/A N/A $16.08 N/A N/A $9.38 N/A N/A $17.42 N/A N/A N/A N/A N/A $16.08 N/A N/A $18.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.80 $26.80 N/A 4401367 Pharmacy acetaminophen 325 mg Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405321 Pharmacy acetaminophen 650 mg Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401692 Pharmacy hydrocortisone 25 mg Supp [BCH] 250 $45.29 $- $11.78 $- $- $36.23 $- N/A $11.78 N/A N/A $17.12 N/A N/A $27.18 N/A N/A $22.65 N/A N/A N/A N/A N/A $30.80 N/A N/A $28.08 N/A N/A $18.57 N/A N/A $31.71 N/A N/A $36.23 N/A N/A $24.91 N/A N/A $31.71 N/A N/A $15.17 N/A N/A N/A N/A N/A $27.18 N/A N/A $15.85 N/A N/A $29.44 N/A N/A N/A N/A N/A $27.18 N/A N/A $31.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.29 $45.29 N/A 4402951 Pharmacy promethazine 12.5 mg Supp [BCH] 250 $35.41 $- $9.21 $- $- $28.33 $- N/A $9.21 N/A N/A $13.38 N/A N/A $21.25 N/A N/A $17.71 N/A N/A N/A N/A N/A $24.08 N/A N/A $21.95 N/A N/A $14.52 N/A N/A $24.79 N/A N/A $28.33 N/A N/A $19.48 N/A N/A $24.79 N/A N/A $11.86 N/A N/A N/A N/A N/A $21.25 N/A N/A $12.39 N/A N/A $23.02 N/A N/A N/A N/A N/A $21.25 N/A N/A $24.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.41 $35.41 N/A 4400676 Pharmacy mometasone topical 0.1% Cre [BCH] 250 $105.84 $- $27.52 $- $- $84.67 $- N/A $27.52 N/A N/A $40.01 N/A N/A $63.50 N/A N/A $52.92 N/A N/A N/A N/A N/A $71.97 N/A N/A $65.62 N/A N/A $43.39 N/A N/A $74.09 N/A N/A $84.67 N/A N/A $58.21 N/A N/A $74.09 N/A N/A $35.46 N/A N/A N/A N/A N/A $63.50 N/A N/A $37.04 N/A N/A $68.80 N/A N/A N/A N/A N/A $63.50 N/A N/A $74.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.84 $105.84 N/A 4403827 Pharmacy triamcinolone topical 0.1% Pas 250 $166.06 $- $43.18 $- $- $132.85 $- N/A $43.18 N/A N/A $62.77 N/A N/A $99.64 N/A N/A $83.03 N/A N/A N/A N/A N/A $112.92 N/A N/A $102.96 N/A N/A $68.08 N/A N/A $116.24 N/A N/A $132.85 N/A N/A $91.33 N/A N/A $116.24 N/A N/A $55.63 N/A N/A N/A N/A N/A $99.64 N/A N/A $58.12 N/A N/A $107.94 N/A N/A N/A N/A N/A $99.64 N/A N/A $116.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $166.06 $166.06 N/A 4401626 Pharmacy gentamicin topical 0.1% Oin[BCH] 250 $98.76 $- $25.68 $- $- $79.01 $- N/A $25.68 N/A N/A $37.33 N/A N/A $59.26 N/A N/A $49.38 N/A N/A N/A N/A N/A $67.16 N/A N/A $61.23 N/A N/A $40.49 N/A N/A $69.13 N/A N/A $79.01 N/A N/A $54.32 N/A N/A $69.13 N/A N/A $33.08 N/A N/A N/A N/A N/A $59.26 N/A N/A $34.57 N/A N/A $64.19 N/A N/A N/A N/A N/A $59.26 N/A N/A $69.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $98.76 $98.76 N/A 4400830 Pharmacy trifluoperazine 2 mg Tab [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.80 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.80 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.68 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4400611 Pharmacy buPROPion 75 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400069 Pharmacy atenolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402939 Pharmacy haloperidol 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404936 Pharmacy haloperidol 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $2.19 $- $0.57 $- $- $1.75 $- N/A $0.57 N/A N/A $0.83 N/A N/A $1.31 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.36 N/A N/A $0.90 N/A N/A $1.53 N/A N/A $1.75 N/A N/A $1.21 N/A N/A $1.53 N/A N/A $0.73 N/A N/A N/A N/A N/A $1.31 N/A N/A $0.77 N/A N/A $1.42 N/A N/A N/A N/A N/A $1.31 N/A N/A $1.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.19 $2.19 N/A 4400846 Pharmacy fluPHENAZine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402566 Pharmacy glipiZIDE 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405370 Pharmacy amitriptyline 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406543 Pharmacy atenolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400708 Pharmacy isosorbide dinitrate 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400356 Pharmacy amoxicillin-clavulanate 400 mg-57 mg Chew Tab [BCH] 250 $8.09 $- $2.10 $- $- $6.47 $- N/A $2.10 N/A N/A $3.06 N/A N/A $4.85 N/A N/A $4.04 N/A N/A N/A N/A N/A $5.50 N/A N/A $5.01 N/A N/A $3.32 N/A N/A $5.66 N/A N/A $6.47 N/A N/A $4.45 N/A N/A $5.66 N/A N/A $2.71 N/A N/A N/A N/A N/A $4.85 N/A N/A $2.83 N/A N/A $5.26 N/A N/A N/A N/A N/A $4.85 N/A N/A $5.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.09 $8.09 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $47.26 $- $0.02 $- $- $37.81 $- N/A $12.29 N/A N/A Not Reimbursed N/A N/A $28.36 N/A N/A $23.63 N/A N/A N/A N/A N/A $32.14 N/A N/A $29.30 N/A N/A $19.38 N/A N/A $33.08 N/A N/A $37.81 N/A N/A $25.99 N/A N/A $33.08 N/A N/A $15.83 N/A N/A N/A N/A N/A $28.36 N/A N/A $16.54 N/A N/A $30.72 N/A N/A $0.02 N/A N/A $28.36 N/A N/A $33.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.26 $47.26 N/A 4402688 Pharmacy isosorbide dinitrate 20 mg Tab [BCH] 250 $2.38 $- $0.62 $- $- $1.91 $- N/A $0.62 N/A N/A $0.90 N/A N/A $1.43 N/A N/A $1.19 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.48 N/A N/A $0.98 N/A N/A $1.67 N/A N/A $1.91 N/A N/A $1.31 N/A N/A $1.67 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.43 N/A N/A $0.83 N/A N/A $1.55 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.38 $2.38 N/A 4401601 Pharmacy amantadine 100 mg Cap [BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.75 N/A N/A $2.50 N/A N/A $1.66 N/A N/A $2.83 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.83 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.62 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4402988 Pharmacy terazosin 1 mg Cap [BCH] 250 $3.21 $- $0.83 $- $- $2.57 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.76 N/A N/A $2.25 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.21 $3.21 N/A 4404791 Pharmacy terazosin 5 mg Cap [BCH] 250 $3.21 $- $0.83 $- $- $2.57 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.76 N/A N/A $2.25 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.21 $3.21 N/A 4409815 Pharmacy hydrochlorothiazide-triamterene 25 mg-37.5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409204 Pharmacy tamsulosin 0.4 mg Oral Cap [BCH] 250 $8.44 $- $2.19 $- $- $6.75 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.22 N/A N/A N/A N/A N/A $5.74 N/A N/A $5.23 N/A N/A $3.46 N/A N/A $5.91 N/A N/A $6.75 N/A N/A $4.64 N/A N/A $5.91 N/A N/A $2.83 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.44 $8.44 N/A 4404059 Pharmacy ampicillin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $17.73 $- $4.61 $- $- $14.18 $- N/A $4.61 N/A N/A $6.70 N/A N/A $10.64 N/A N/A $8.86 N/A N/A N/A N/A N/A $12.05 N/A N/A $10.99 N/A N/A $7.27 N/A N/A $12.41 N/A N/A $14.18 N/A N/A $9.75 N/A N/A $12.41 N/A N/A $5.94 N/A N/A N/A N/A N/A $10.64 N/A N/A $6.20 N/A N/A $11.52 N/A N/A N/A N/A N/A $10.64 N/A N/A $12.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.73 $17.73 N/A 4400163 Pharmacy ziprasidone 40 mg Cap [BCH] 250 $17.73 $- $4.61 $- $- $14.18 $- N/A $4.61 N/A N/A $6.70 N/A N/A $10.64 N/A N/A $8.86 N/A N/A N/A N/A N/A $12.05 N/A N/A $10.99 N/A N/A $7.27 N/A N/A $12.41 N/A N/A $14.18 N/A N/A $9.75 N/A N/A $12.41 N/A N/A $5.94 N/A N/A N/A N/A N/A $10.64 N/A N/A $6.20 N/A N/A $11.52 N/A N/A N/A N/A N/A $10.64 N/A N/A $12.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.73 $17.73 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400895 Pharmacy temazepam 30 mg Cap [BCH] 258 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406515 Pharmacy divalproex sodium 125 mg Oral EC Cap [BCH] 250 $2.24 $- $0.58 $- $- $1.79 $- N/A $0.58 N/A N/A $0.85 N/A N/A $1.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.39 N/A N/A $0.92 N/A N/A $1.57 N/A N/A $1.79 N/A N/A $1.23 N/A N/A $1.57 N/A N/A $0.75 N/A N/A N/A N/A N/A $1.34 N/A N/A $0.78 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.34 N/A N/A $1.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.24 $2.24 N/A 4400642 Pharmacy dicloxacillin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap [BCH] 250 $5.33 $- $1.39 $- $- $4.26 $- N/A $1.39 N/A N/A $2.01 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.62 N/A N/A $3.30 N/A N/A $2.19 N/A N/A $3.73 N/A N/A $4.26 N/A N/A $2.93 N/A N/A $3.73 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.46 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.33 $5.33 N/A 4405095 Pharmacy FLUoxetine 10 mg Cap [BCH] 250 $5.20 $- $1.35 $- $- $4.16 $- N/A $1.35 N/A N/A $1.96 N/A N/A $3.12 N/A N/A $2.60 N/A N/A N/A N/A N/A $3.53 N/A N/A $3.22 N/A N/A $2.13 N/A N/A $3.64 N/A N/A $4.16 N/A N/A $2.86 N/A N/A $3.64 N/A N/A $1.74 N/A N/A N/A N/A N/A $3.12 N/A N/A $1.82 N/A N/A $3.38 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.20 $5.20 N/A 4409392 Pharmacy succinylcholine 20 mg/mL Inj Sol [BCH] J0330 636 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4403938 Pharmacy digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol [BCH] J1160 636 $14.95 $- $3.89 $- $- $11.96 $- N/A $3.89 N/A N/A Not Reimbursed N/A N/A $8.97 N/A N/A $7.48 N/A N/A N/A N/A N/A $10.17 N/A N/A $9.27 N/A N/A $6.13 N/A N/A $10.47 N/A N/A $11.96 N/A N/A $8.22 N/A N/A $10.47 N/A N/A $5.01 N/A N/A N/A N/A N/A $8.97 N/A N/A $5.23 N/A N/A $9.72 N/A N/A $11.41 N/A N/A $8.97 N/A N/A $10.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.95 $14.95 N/A 4408347 Pharmacy oxacillin 1 g Inj [BCH] J2700 636 $29.20 $- $1.13 $- $- $23.36 $- N/A $7.59 N/A N/A Not Reimbursed N/A N/A $17.52 N/A N/A $14.60 N/A N/A N/A N/A N/A $19.86 N/A N/A $18.10 N/A N/A $11.97 N/A N/A $20.44 N/A N/A $23.36 N/A N/A $16.06 N/A N/A $20.44 N/A N/A $9.78 N/A N/A N/A N/A N/A $17.52 N/A N/A $10.22 N/A N/A $18.98 N/A N/A $1.13 N/A N/A $17.52 N/A N/A $20.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.20 $29.20 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g Pow [BCH] J2543 636 $36.93 $- $1.68 $- $- $29.54 $- N/A $9.60 N/A N/A Not Reimbursed N/A N/A $22.16 N/A N/A $18.46 N/A N/A N/A N/A N/A $25.11 N/A N/A $22.90 N/A N/A $15.14 N/A N/A $25.85 N/A N/A $29.54 N/A N/A $20.31 N/A N/A $25.85 N/A N/A $12.37 N/A N/A N/A N/A N/A $22.16 N/A N/A $12.92 N/A N/A $24.00 N/A N/A $1.68 N/A N/A $22.16 N/A N/A $25.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.93 $36.93 N/A 4409162 Pharmacy piperacillin-tazobactam 4 g-0.5 g Pow [BCH] J2543 636 $46.77 $- $1.68 $- $- $37.42 $- N/A $12.16 N/A N/A Not Reimbursed N/A N/A $28.06 N/A N/A $23.39 N/A N/A N/A N/A N/A $31.80 N/A N/A $29.00 N/A N/A $19.18 N/A N/A $32.74 N/A N/A $37.42 N/A N/A $25.72 N/A N/A $32.74 N/A N/A $15.67 N/A N/A N/A N/A N/A $28.06 N/A N/A $16.37 N/A N/A $30.40 N/A N/A $1.68 N/A N/A $28.06 N/A N/A $32.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $46.77 $46.77 N/A 4400694 Pharmacy OLANZapine 10 mg IM Inj [BCH] 250 $83.00 $- $21.58 $- $- $66.40 $- N/A $21.58 N/A N/A $31.37 N/A N/A $49.80 N/A N/A $41.50 N/A N/A N/A N/A N/A $56.44 N/A N/A $51.46 N/A N/A $34.03 N/A N/A $58.10 N/A N/A $66.40 N/A N/A $45.65 N/A N/A $58.10 N/A N/A $27.81 N/A N/A N/A N/A N/A $49.80 N/A N/A $29.05 N/A N/A $53.95 N/A N/A N/A N/A N/A $49.80 N/A N/A $58.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $83.00 $83.00 N/A 4402373 Pharmacy SUMAtriptan 6 mg/0.5 mL SubQ Sol [BCH] J3030 636 $181.68 $- $47.24 $- $- $145.34 $- N/A $47.24 N/A N/A Not Reimbursed N/A N/A $109.01 N/A N/A $90.84 N/A N/A N/A N/A N/A $123.54 N/A N/A $112.64 N/A N/A $74.49 N/A N/A $127.18 N/A N/A $145.34 N/A N/A $99.92 N/A N/A $127.18 N/A N/A $60.86 N/A N/A N/A N/A N/A $109.01 N/A N/A $63.59 N/A N/A $118.09 N/A N/A N/A N/A N/A $109.01 N/A N/A $127.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $181.68 $181.68 N/A 4405537 Pharmacy cefTAZidime 1 g Inj [BCH] J0713 636 $28.00 $- $1.99 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.99 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400357 Pharmacy cefTAZidime 2 g Inj [BCH] J0713 636 $40.05 $- $1.99 $- $- $32.04 $- N/A $10.41 N/A N/A Not Reimbursed N/A N/A $24.03 N/A N/A $20.02 N/A N/A N/A N/A N/A $27.23 N/A N/A $24.83 N/A N/A $16.42 N/A N/A $28.03 N/A N/A $32.04 N/A N/A $22.03 N/A N/A $28.03 N/A N/A $13.42 N/A N/A N/A N/A N/A $24.03 N/A N/A $14.02 N/A N/A $26.03 N/A N/A $1.99 N/A N/A $24.03 N/A N/A $28.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.05 $40.05 N/A 4400195 Pharmacy fomepizole 1 g/mL IV Sol [BCH] J1451 636 "$2,729.70 " $- $709.72 $- $- "$2,183.76 " $- N/A $709.72 N/A N/A Not Reimbursed N/A N/A "$1,637.82 " N/A N/A "$1,364.85 " N/A N/A N/A N/A N/A "$1,856.20 " N/A N/A "$1,692.41 " N/A N/A "$1,119.18 " N/A N/A "$1,910.79 " N/A N/A "$2,183.76 " N/A N/A "$1,501.34 " N/A N/A "$1,910.79 " N/A N/A $914.45 N/A N/A N/A N/A N/A "$1,637.82 " N/A N/A $955.40 N/A N/A "$1,774.31 " N/A N/A N/A N/A N/A "$1,637.82 " N/A N/A "$1,910.79 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,729.70 " "$2,729.70 " N/A 4407723 Pharmacy cefTRIAXone 250 mg Pow [BCH] J0696 636 $29.66 $- $0.53 $- $- $23.73 $- N/A $7.71 N/A N/A Not Reimbursed N/A N/A $17.80 N/A N/A $14.83 N/A N/A N/A N/A N/A $20.17 N/A N/A $18.39 N/A N/A $12.16 N/A N/A $20.76 N/A N/A $23.73 N/A N/A $16.32 N/A N/A $20.76 N/A N/A $9.94 N/A N/A N/A N/A N/A $17.80 N/A N/A $10.38 N/A N/A $19.28 N/A N/A $0.53 N/A N/A $17.80 N/A N/A $20.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.66 $29.66 N/A 4400880 Pharmacy cefTRIAXone 1 g Inj [BCH] J0696 636 $92.00 $- $0.53 $- $- $73.60 $- N/A $23.92 N/A N/A Not Reimbursed N/A N/A $55.20 N/A N/A $46.00 N/A N/A N/A N/A N/A $62.56 N/A N/A $57.04 N/A N/A $37.72 N/A N/A $64.40 N/A N/A $73.60 N/A N/A $50.60 N/A N/A $64.40 N/A N/A $30.82 N/A N/A N/A N/A N/A $55.20 N/A N/A $32.20 N/A N/A $59.80 N/A N/A $0.53 N/A N/A $55.20 N/A N/A $64.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $92.00 $92.00 N/A 4404650 Pharmacy rocuronium 10 mg/mL IV Sol [BCH] 250 $39.33 $- $10.23 $- $- $31.46 $- N/A $10.23 N/A N/A $14.87 N/A N/A $23.60 N/A N/A $19.66 N/A N/A N/A N/A N/A $26.74 N/A N/A $24.38 N/A N/A $16.12 N/A N/A $27.53 N/A N/A $31.46 N/A N/A $21.63 N/A N/A $27.53 N/A N/A $13.17 N/A N/A N/A N/A N/A $23.60 N/A N/A $13.76 N/A N/A $25.56 N/A N/A N/A N/A N/A $23.60 N/A N/A $27.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.33 $39.33 N/A 4409522 Pharmacy cefepime 1 g Inj [BCH] J0692 636 $40.67 $- $1.93 $- $- $32.53 $- N/A $10.57 N/A N/A Not Reimbursed N/A N/A $24.40 N/A N/A $20.33 N/A N/A N/A N/A N/A $27.65 N/A N/A $25.21 N/A N/A $16.67 N/A N/A $28.47 N/A N/A $32.53 N/A N/A $22.37 N/A N/A $28.47 N/A N/A $13.62 N/A N/A N/A N/A N/A $24.40 N/A N/A $14.23 N/A N/A $26.43 N/A N/A $1.93 N/A N/A $24.40 N/A N/A $28.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.67 $40.67 N/A 4400446 Pharmacy meropenem 500 mg IV Inj [BCH] J2185 636 $71.39 $- $0.79 $- $- $57.11 $- N/A $18.56 N/A N/A Not Reimbursed N/A N/A $42.83 N/A N/A $35.69 N/A N/A N/A N/A N/A $48.54 N/A N/A $44.26 N/A N/A $29.27 N/A N/A $49.97 N/A N/A $57.11 N/A N/A $39.26 N/A N/A $49.97 N/A N/A $23.91 N/A N/A N/A N/A N/A $42.83 N/A N/A $24.99 N/A N/A $46.40 N/A N/A $0.79 N/A N/A $42.83 N/A N/A $49.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $71.39 $71.39 N/A 4400865 Pharmacy argatroban 1 mg/mL Sol 125 mL [BCH] 250 "$1,418.58 " $- $368.83 $- $- "$1,134.86 " $- N/A $368.83 N/A N/A $536.22 N/A N/A $851.15 N/A N/A $709.29 N/A N/A N/A N/A N/A $964.63 N/A N/A $879.52 N/A N/A $581.62 N/A N/A $993.01 N/A N/A "$1,134.86 " N/A N/A $780.22 N/A N/A $993.01 N/A N/A $475.22 N/A N/A N/A N/A N/A $851.15 N/A N/A $496.50 N/A N/A $922.08 N/A N/A N/A N/A N/A $851.15 N/A N/A $993.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,418.58 " "$1,418.58 " N/A 4400769 Pharmacy argatroban 1 mg/mL Sol [BCH] 250 $557.87 $- $145.04 $- $- $446.29 $- N/A $145.04 N/A N/A $210.87 N/A N/A $334.72 N/A N/A $278.93 N/A N/A N/A N/A N/A $379.35 N/A N/A $345.88 N/A N/A $228.72 N/A N/A $390.51 N/A N/A $446.29 N/A N/A $306.83 N/A N/A $390.51 N/A N/A $186.88 N/A N/A N/A N/A N/A $334.72 N/A N/A $195.25 N/A N/A $362.61 N/A N/A N/A N/A N/A $334.72 N/A N/A $390.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $557.87 $557.87 N/A 4400095 Pharmacy levofloxacin 250 mg/50 mL IV Sol [BCH] J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409647 Pharmacy piperacillin-tazobactam 2 g-0.25 g Pow J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400111 Pharmacy enoxaparin 60 mg/0.6 mL Sol J1650 636 $97.54 $- $0.69 $- $- $78.03 $- N/A $25.36 N/A N/A Not Reimbursed N/A N/A $58.53 N/A N/A $48.77 N/A N/A N/A N/A N/A $66.33 N/A N/A $60.48 N/A N/A $39.99 N/A N/A $68.28 N/A N/A $78.03 N/A N/A $53.65 N/A N/A $68.28 N/A N/A $32.68 N/A N/A N/A N/A N/A $58.53 N/A N/A $34.14 N/A N/A $63.40 N/A N/A $0.69 N/A N/A $58.53 N/A N/A $68.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $97.54 $97.54 N/A 4400980 Pharmacy ampicillin 2 g Pow J0290 636 $33.60 $- $0.93 $- $- $26.88 $- N/A $8.74 N/A N/A Not Reimbursed N/A N/A $20.16 N/A N/A $16.80 N/A N/A N/A N/A N/A $22.85 N/A N/A $20.83 N/A N/A $13.78 N/A N/A $23.52 N/A N/A $26.88 N/A N/A $18.48 N/A N/A $23.52 N/A N/A $11.26 N/A N/A N/A N/A N/A $20.16 N/A N/A $11.76 N/A N/A $21.84 N/A N/A $0.93 N/A N/A $20.16 N/A N/A $23.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.60 $33.60 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL SC Sol [BCH] J1650 636 $130.05 $- $0.69 $- $- $104.04 $- N/A $33.81 N/A N/A Not Reimbursed N/A N/A $78.03 N/A N/A $65.03 N/A N/A N/A N/A N/A $88.43 N/A N/A $80.63 N/A N/A $53.32 N/A N/A $91.04 N/A N/A $104.04 N/A N/A $71.53 N/A N/A $91.04 N/A N/A $43.57 N/A N/A N/A N/A N/A $78.03 N/A N/A $45.52 N/A N/A $84.53 N/A N/A $0.69 N/A N/A $78.03 N/A N/A $91.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $130.05 $130.05 N/A 4408965 Pharmacy enoxaparin 100 mg/mL SubQ Sol [BCH] J1650 636 $162.56 $- $0.69 $- $- $130.05 $- N/A $42.27 N/A N/A Not Reimbursed N/A N/A $97.53 N/A N/A $81.28 N/A N/A N/A N/A N/A $110.54 N/A N/A $100.79 N/A N/A $66.65 N/A N/A $113.79 N/A N/A $130.05 N/A N/A $89.41 N/A N/A $113.79 N/A N/A $54.46 N/A N/A N/A N/A N/A $97.53 N/A N/A $56.90 N/A N/A $105.66 N/A N/A $0.69 N/A N/A $97.53 N/A N/A $113.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $162.56 $162.56 N/A 4403151 Pharmacy norepinephrine 1 mg/mL Sol [BCH] 636 $30.59 $- $7.95 $- $- $24.47 $- N/A $7.95 N/A N/A $11.56 N/A N/A $18.35 N/A N/A $15.29 N/A N/A N/A N/A N/A $20.80 N/A N/A $18.96 N/A N/A $12.54 N/A N/A $21.41 N/A N/A $24.47 N/A N/A $16.82 N/A N/A $21.41 N/A N/A $10.25 N/A N/A N/A N/A N/A $18.35 N/A N/A $10.71 N/A N/A $19.88 N/A N/A N/A N/A N/A $18.35 N/A N/A $21.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.59 $30.59 N/A 4402575 Pharmacy prochlorperazine 5 mg Tab [BCH] Q0164 250 $2.00 $- $0.23 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A $0.23 N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403615 Pharmacy methylPREDNISolone 4 mg Tab [BCH] J7509 636 $2.86 $- $0.34 $- $- $2.29 $- N/A $0.74 N/A N/A Not Reimbursed N/A N/A $1.72 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.94 N/A N/A $1.77 N/A N/A $1.17 N/A N/A $2.00 N/A N/A $2.29 N/A N/A $1.57 N/A N/A $2.00 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.72 N/A N/A $1.00 N/A N/A $1.86 N/A N/A $0.34 N/A N/A $1.72 N/A N/A $2.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.86 $2.86 N/A 4403607 Pharmacy methylPREDNISolone 4 mg Tab [BCH] J7509 636 $5.00 $- $0.34 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.34 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404163 Pharmacy loratadine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400942 Pharmacy levothyroxine 25 mcg (0.025 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409561 Pharmacy levothyroxine 137 mcg (0.137 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400719 Pharmacy ondansetron 4 mg Dis Tab [BCH] Q0162 250 $44.59 $- $0.02 $- $- $35.67 $- N/A $11.59 N/A N/A Not Reimbursed N/A N/A $26.75 N/A N/A $22.29 N/A N/A N/A N/A N/A $30.32 N/A N/A $27.64 N/A N/A $18.28 N/A N/A $31.21 N/A N/A $35.67 N/A N/A $24.52 N/A N/A $31.21 N/A N/A $14.94 N/A N/A N/A N/A N/A $26.75 N/A N/A $15.60 N/A N/A $28.98 N/A N/A $0.02 N/A N/A $26.75 N/A N/A $31.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.59 $44.59 N/A 4400749 Pharmacy risperiDONE 0.5 mg Dis Tab [BCH] 250 $9.82 $- $2.55 $- $- $7.86 $- N/A $2.55 N/A N/A $3.71 N/A N/A $5.89 N/A N/A $4.91 N/A N/A N/A N/A N/A $6.68 N/A N/A $6.09 N/A N/A $4.03 N/A N/A $6.88 N/A N/A $7.86 N/A N/A $5.40 N/A N/A $6.88 N/A N/A $3.29 N/A N/A N/A N/A N/A $5.89 N/A N/A $3.44 N/A N/A $6.38 N/A N/A N/A N/A N/A $5.89 N/A N/A $6.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.82 $9.82 N/A 4400748 Pharmacy risperiDONE 1 mg Dis Tab [BCH] 250 $11.01 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A $6.82 N/A N/A $4.51 N/A N/A $7.70 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.70 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A N/A N/A N/A $6.60 N/A N/A $7.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.01 $11.01 N/A 4400750 Pharmacy risperiDONE 2 mg Dis Tab [BCH] 250 $17.89 $- $4.65 $- $- $14.31 $- N/A $4.65 N/A N/A $6.76 N/A N/A $10.74 N/A N/A $8.95 N/A N/A N/A N/A N/A $12.17 N/A N/A $11.09 N/A N/A $7.34 N/A N/A $12.52 N/A N/A $14.31 N/A N/A $9.84 N/A N/A $12.52 N/A N/A $5.99 N/A N/A N/A N/A N/A $10.74 N/A N/A $6.26 N/A N/A $11.63 N/A N/A N/A N/A N/A $10.74 N/A N/A $12.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.89 $17.89 N/A 4400757 Pharmacy risperiDONE 3 mg oral Dis Tab [BCH] 250 $22.58 $- $5.87 $- $- $18.06 $- N/A $5.87 N/A N/A $8.54 N/A N/A $13.55 N/A N/A $11.29 N/A N/A N/A N/A N/A $15.35 N/A N/A $14.00 N/A N/A $9.26 N/A N/A $15.81 N/A N/A $18.06 N/A N/A $12.42 N/A N/A $15.81 N/A N/A $7.56 N/A N/A N/A N/A N/A $13.55 N/A N/A $7.90 N/A N/A $14.68 N/A N/A N/A N/A N/A $13.55 N/A N/A $15.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.58 $22.58 N/A 4405013 Pharmacy LORazepam 0.5 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $14.01 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A $5.30 N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.74 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.90 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.01 $14.01 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $14.01 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A $5.30 N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.74 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.90 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.01 $14.01 N/A 4401527 Pharmacy entacapone 200 mg Tab [BCH] 250 $7.91 $- $2.06 $- $- $6.33 $- N/A $2.06 N/A N/A $2.99 N/A N/A $4.75 N/A N/A $3.95 N/A N/A N/A N/A N/A $5.38 N/A N/A $4.90 N/A N/A $3.24 N/A N/A $5.54 N/A N/A $6.33 N/A N/A $4.35 N/A N/A $5.54 N/A N/A $2.65 N/A N/A N/A N/A N/A $4.75 N/A N/A $2.77 N/A N/A $5.14 N/A N/A N/A N/A N/A $4.75 N/A N/A $5.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.91 $7.91 N/A 4409710 Pharmacy ezetimibe 10 mg Tab [BCH] 250 $5.24 $- $1.36 $- $- $4.20 $- N/A $1.36 N/A N/A $1.98 N/A N/A $3.15 N/A N/A $2.62 N/A N/A N/A N/A N/A $3.57 N/A N/A $3.25 N/A N/A $2.15 N/A N/A $3.67 N/A N/A $4.20 N/A N/A $2.88 N/A N/A $3.67 N/A N/A $1.76 N/A N/A N/A N/A N/A $3.15 N/A N/A $1.84 N/A N/A $3.41 N/A N/A N/A N/A N/A $3.15 N/A N/A $3.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.24 $5.24 N/A 4400291 Pharmacy potassium chloride 20 mEq ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409741 Pharmacy levofloxacin 250 mg Tab [BCH] 250 $33.80 $- $8.79 $- $- $27.04 $- N/A $8.79 N/A N/A $12.78 N/A N/A $20.28 N/A N/A $16.90 N/A N/A N/A N/A N/A $22.98 N/A N/A $20.95 N/A N/A $13.86 N/A N/A $23.66 N/A N/A $27.04 N/A N/A $18.59 N/A N/A $23.66 N/A N/A $11.32 N/A N/A N/A N/A N/A $20.28 N/A N/A $11.83 N/A N/A $21.97 N/A N/A N/A N/A N/A $20.28 N/A N/A $23.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.80 $33.80 N/A 4408655 Pharmacy chlorproMAZINE 25 mg Tab [BCH] 250 $9.45 $- $2.46 $- $- $7.56 $- N/A $2.46 N/A N/A $3.57 N/A N/A $5.67 N/A N/A $4.73 N/A N/A N/A N/A N/A $6.43 N/A N/A $5.86 N/A N/A $3.87 N/A N/A $6.62 N/A N/A $7.56 N/A N/A $5.20 N/A N/A $6.62 N/A N/A $3.17 N/A N/A N/A N/A N/A $5.67 N/A N/A $3.31 N/A N/A $6.14 N/A N/A N/A N/A N/A $5.67 N/A N/A $6.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.45 $9.45 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $2.04 $- $0.53 $- $- $1.63 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.22 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.26 N/A N/A $0.84 N/A N/A $1.43 N/A N/A $1.63 N/A N/A $1.12 N/A N/A $1.43 N/A N/A $0.68 N/A N/A N/A N/A N/A $1.22 N/A N/A $0.71 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.22 N/A N/A $1.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.04 $2.04 N/A 4409240 Pharmacy amoxicillin 250 mg/5 mL Pow [BCH] 250 $7.53 $- $1.96 $- $- $6.02 $- N/A $1.96 N/A N/A $2.85 N/A N/A $4.52 N/A N/A $3.77 N/A N/A N/A N/A N/A $5.12 N/A N/A $4.67 N/A N/A $3.09 N/A N/A $5.27 N/A N/A $6.02 N/A N/A $4.14 N/A N/A $5.27 N/A N/A $2.52 N/A N/A N/A N/A N/A $4.52 N/A N/A $2.64 N/A N/A $4.90 N/A N/A N/A N/A N/A $4.52 N/A N/A $5.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.53 $7.53 N/A 4409240 Pharmacy amoxicillin 250 mg/5 mL Oral Liq [BCH] 250 $10.62 $- $2.76 $- $- $8.50 $- N/A $2.76 N/A N/A $4.01 N/A N/A $6.37 N/A N/A $5.31 N/A N/A N/A N/A N/A $7.22 N/A N/A $6.58 N/A N/A $4.35 N/A N/A $7.43 N/A N/A $8.50 N/A N/A $5.84 N/A N/A $7.43 N/A N/A $3.56 N/A N/A N/A N/A N/A $6.37 N/A N/A $3.72 N/A N/A $6.90 N/A N/A N/A N/A N/A $6.37 N/A N/A $7.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.62 $10.62 N/A 4409444 Pharmacy ketoconazole Top 2% Shampoo [BCH] 250 $55.58 $- $14.45 $- $- $44.47 $- N/A $14.45 N/A N/A $21.01 N/A N/A $33.35 N/A N/A $27.79 N/A N/A N/A N/A N/A $37.80 N/A N/A $34.46 N/A N/A $22.79 N/A N/A $38.91 N/A N/A $44.47 N/A N/A $30.57 N/A N/A $38.91 N/A N/A $18.62 N/A N/A N/A N/A N/A $33.35 N/A N/A $19.45 N/A N/A $36.13 N/A N/A N/A N/A N/A $33.35 N/A N/A $38.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $55.58 $55.58 N/A 4409725 Pharmacy albuterol 90 mcg/inh Aer [BCH] 250 $114.13 $- $29.67 $- $- $91.30 $- N/A $29.67 N/A N/A $43.14 N/A N/A $68.48 N/A N/A $57.06 N/A N/A N/A N/A N/A $77.61 N/A N/A $70.76 N/A N/A $46.79 N/A N/A $79.89 N/A N/A $91.30 N/A N/A $62.77 N/A N/A $79.89 N/A N/A $38.23 N/A N/A N/A N/A N/A $68.48 N/A N/A $39.94 N/A N/A $74.18 N/A N/A N/A N/A N/A $68.48 N/A N/A $79.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $114.13 $114.13 N/A 4400830 Pharmacy trifluoperazine 2 mg Tab [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.80 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.80 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.68 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4409647 Pharmacy piperacillin-tazobactam 2 g-0.25 g Pow J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409224 Pharmacy ampicillin 1 g Pow[BCH] J0290 636 $28.00 $- $0.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400742 Pharmacy menthol-zinc oxide topical 0.44%-20.625% Oin [BCH] 250 $10.00 $- $2.60 $- $- $8.00 $- N/A $2.60 N/A N/A $3.78 N/A N/A $6.00 N/A N/A $5.00 N/A N/A N/A N/A N/A $6.80 N/A N/A $6.20 N/A N/A $4.10 N/A N/A $7.00 N/A N/A $8.00 N/A N/A $5.50 N/A N/A $7.00 N/A N/A $3.35 N/A N/A N/A N/A N/A $6.00 N/A N/A $3.50 N/A N/A $6.50 N/A N/A N/A N/A N/A $6.00 N/A N/A $7.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.00 $10.00 N/A 4403595 Pharmacy oxybutynin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403595 Pharmacy oxybutynin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408655 Pharmacy chlorproMAZINE 25 mg Tab [BCH] 250 $15.28 $- $3.97 $- $- $12.23 $- N/A $3.97 N/A N/A $5.78 N/A N/A $9.17 N/A N/A $7.64 N/A N/A N/A N/A N/A $10.39 N/A N/A $9.47 N/A N/A $6.27 N/A N/A $10.70 N/A N/A $12.23 N/A N/A $8.40 N/A N/A $10.70 N/A N/A $5.12 N/A N/A N/A N/A N/A $9.17 N/A N/A $5.35 N/A N/A $9.93 N/A N/A N/A N/A N/A $9.17 N/A N/A $10.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.28 $15.28 N/A 4402970 Pharmacy "nystatin Top 100,000 units/g Pwdr [BCH]" 250 $74.92 $- $19.48 $- $- $59.94 $- N/A $19.48 N/A N/A $28.32 N/A N/A $44.95 N/A N/A $37.46 N/A N/A N/A N/A N/A $50.95 N/A N/A $46.45 N/A N/A $30.72 N/A N/A $52.44 N/A N/A $59.94 N/A N/A $41.21 N/A N/A $52.44 N/A N/A $25.10 N/A N/A N/A N/A N/A $44.95 N/A N/A $26.22 N/A N/A $48.70 N/A N/A N/A N/A N/A $44.95 N/A N/A $52.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $74.92 $74.92 N/A 4400830 Pharmacy trifluoperazine 2 mg Tab [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.80 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.80 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.68 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4403284 Pharmacy atropine-diphenoxylate 0.025 mg-2.5 mg Tab[BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405954 Pharmacy warfarin 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405954 Pharmacy warfarin 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405954 Pharmacy warfarin 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402641 Pharmacy warfarin 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402641 Pharmacy warfarin 2 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405602 Pharmacy warfarin 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405602 Pharmacy warfarin 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402414 Pharmacy warfarin 3 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400675 Pharmacy warfarin 4 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400675 Pharmacy warfarin 4 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405610 Pharmacy warfarin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404936 Pharmacy haloperidol 5 mg Tab[BCH] 250 $2.05 $- $0.53 $- $- $1.64 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.23 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.27 N/A N/A $0.84 N/A N/A $1.43 N/A N/A $1.64 N/A N/A $1.13 N/A N/A $1.43 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.23 N/A N/A $0.72 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.23 N/A N/A $1.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.05 $2.05 N/A 4403713 Pharmacy divalproex sodium 250 mg Tab 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4403713 Pharmacy divalproex sodium 250 mg DR Oral EC Tab [BCH] 250 $4.33 $- $1.13 $- $- $3.46 $- N/A $1.13 N/A N/A $1.64 N/A N/A $2.60 N/A N/A $2.16 N/A N/A N/A N/A N/A $2.94 N/A N/A $2.68 N/A N/A $1.77 N/A N/A $3.03 N/A N/A $3.46 N/A N/A $2.38 N/A N/A $3.03 N/A N/A $1.45 N/A N/A N/A N/A N/A $2.60 N/A N/A $1.52 N/A N/A $2.81 N/A N/A N/A N/A N/A $2.60 N/A N/A $3.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.33 $4.33 N/A 4400130 Pharmacy magnesium citrate 8.85% Oral Liq 300 mL [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.98 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.81 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.81 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.68 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4400378 Pharmacy dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liq 120 mL [BCH] 250 $7.06 $- $1.84 $- $- $5.65 $- N/A $1.84 N/A N/A $2.67 N/A N/A $4.24 N/A N/A $3.53 N/A N/A N/A N/A N/A $4.80 N/A N/A $4.38 N/A N/A $2.89 N/A N/A $4.94 N/A N/A $5.65 N/A N/A $3.88 N/A N/A $4.94 N/A N/A $2.37 N/A N/A N/A N/A N/A $4.24 N/A N/A $2.47 N/A N/A $4.59 N/A N/A N/A N/A N/A $4.24 N/A N/A $4.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.06 $7.06 N/A 4400457 Pharmacy guaiFENesin 100 mg/5 mL Oral Liq [BCH] 250 $5.28 $- $1.37 $- $- $4.22 $- N/A $1.37 N/A N/A $2.00 N/A N/A $3.17 N/A N/A $2.64 N/A N/A N/A N/A N/A $3.59 N/A N/A $3.27 N/A N/A $2.16 N/A N/A $3.70 N/A N/A $4.22 N/A N/A $2.90 N/A N/A $3.70 N/A N/A $1.77 N/A N/A N/A N/A N/A $3.17 N/A N/A $1.85 N/A N/A $3.43 N/A N/A N/A N/A N/A $3.17 N/A N/A $3.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.28 $5.28 N/A 4400406 Pharmacy pyridoxine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402365 Pharmacy ascorbic acid 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402365 Pharmacy ascorbic acid 500 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406725 Pharmacy thiamine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404076 Pharmacy niacin 500 mg ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400430 Pharmacy bacitracin/neomycin/polymyxin B Top Oint 28gm [BCH] 250 $6.96 $- $1.81 $- $- $5.57 $- N/A $1.81 N/A N/A $2.63 N/A N/A $4.18 N/A N/A $3.48 N/A N/A N/A N/A N/A $4.74 N/A N/A $4.32 N/A N/A $2.86 N/A N/A $4.87 N/A N/A $5.57 N/A N/A $3.83 N/A N/A $4.87 N/A N/A $2.33 N/A N/A N/A N/A N/A $4.18 N/A N/A $2.44 N/A N/A $4.53 N/A N/A N/A N/A N/A $4.18 N/A N/A $4.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.96 $6.96 N/A 4400875 Pharmacy povidone iodine topical 10% Oin 28.35GM [BCH] 250 $6.24 $- $1.62 $- $- $4.99 $- N/A $1.62 N/A N/A $2.36 N/A N/A $3.74 N/A N/A $3.12 N/A N/A N/A N/A N/A $4.24 N/A N/A $3.87 N/A N/A $2.56 N/A N/A $4.37 N/A N/A $4.99 N/A N/A $3.43 N/A N/A $4.37 N/A N/A $2.09 N/A N/A N/A N/A N/A $3.74 N/A N/A $2.18 N/A N/A $4.06 N/A N/A N/A N/A N/A $3.74 N/A N/A $4.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.24 $6.24 N/A 4405699 Pharmacy diphenhydrAMINE 12.5 mg/5 mL Oral Liq [BCH] Q0163 250 $5.52 $- $1.44 $- $- $4.42 $- N/A $1.44 N/A N/A Not Reimbursed N/A N/A $3.31 N/A N/A $2.76 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.42 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.42 N/A N/A $3.04 N/A N/A $3.86 N/A N/A $1.85 N/A N/A N/A N/A N/A $3.31 N/A N/A $1.93 N/A N/A $3.59 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.52 $5.52 N/A 4405544 Pharmacy calcium carbonate 500 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408964 Pharmacy bismuth subsalicylate 262 mg/15 mL Oral Susp [BCH] 250 $5.08 $- $1.32 $- $- $4.07 $- N/A $1.32 N/A N/A $1.92 N/A N/A $3.05 N/A N/A $2.54 N/A N/A N/A N/A N/A $3.46 N/A N/A $3.15 N/A N/A $2.08 N/A N/A $3.56 N/A N/A $4.07 N/A N/A $2.80 N/A N/A $3.56 N/A N/A $1.70 N/A N/A N/A N/A N/A $3.05 N/A N/A $1.78 N/A N/A $3.30 N/A N/A N/A N/A N/A $3.05 N/A N/A $3.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.08 $5.08 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403952 Pharmacy acetaminophen 500 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400891 Pharmacy aspirin 325 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404172 Pharmacy carbamide peroxide Otic 6.5% Sol [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400731 Pharmacy calcium-vitamin D 600 mg-400 intl units Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400731 Pharmacy calcium-vitamin D 600 mg-400 intl units oral tablet [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405277 Pharmacy carBAMazepine 100 mg Ta [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401949 Pharmacy sodium chloride Nasal 0.65% Spry [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408945 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407521 Pharmacy ocular lubricant preserved Sol [BCH] 250 $6.60 $- $1.72 $- $- $5.28 $- N/A $1.72 N/A N/A $2.49 N/A N/A $3.96 N/A N/A $3.30 N/A N/A N/A N/A N/A $4.49 N/A N/A $4.09 N/A N/A $2.71 N/A N/A $4.62 N/A N/A $5.28 N/A N/A $3.63 N/A N/A $4.62 N/A N/A $2.21 N/A N/A N/A N/A N/A $3.96 N/A N/A $2.31 N/A N/A $4.29 N/A N/A N/A N/A N/A $3.96 N/A N/A $4.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.60 $6.60 N/A 4400906 Pharmacy captopril 12.5 mg Tab [BCH] 250 $3.39 $- $0.88 $- $- $2.71 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.70 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.10 N/A N/A $1.39 N/A N/A $2.37 N/A N/A $2.71 N/A N/A $1.86 N/A N/A $2.37 N/A N/A $1.14 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.19 N/A N/A $2.20 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.39 $3.39 N/A 4406220 Pharmacy pseudoephedrine 30 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406220 Pharmacy pseudoephedrine 30 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400032 Pharmacy simethicone 80 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400768 Pharmacy APAP/ASA/caffeine 250 mg-250 mg-65 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400897 Pharmacy rifAMPin 300 mg Cap 250 $2.65 $- $0.69 $- $- $2.12 $- N/A $0.69 N/A N/A $1.00 N/A N/A $1.59 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.64 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.12 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.59 N/A N/A $0.93 N/A N/A $1.72 N/A N/A N/A N/A N/A $1.59 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.65 $2.65 N/A 4401451 Pharmacy zinc sulfate 220 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406865 Pharmacy pentoxifylline 400 mg Tab[BCH] 250 $3.00 $- $0.78 $- $- $2.40 $- N/A $0.78 N/A N/A $1.13 N/A N/A $1.80 N/A N/A $1.50 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.86 N/A N/A $1.23 N/A N/A $2.10 N/A N/A $2.40 N/A N/A $1.65 N/A N/A $2.10 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.05 N/A N/A $1.95 N/A N/A N/A N/A N/A $1.80 N/A N/A $2.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.00 $3.00 N/A 4400414 Pharmacy Therapeutic Multiple Vitamins with Minerals Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400414 Pharmacy Therapeutic Multiple Vitamins with Minerals Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401929 Pharmacy nitroglycerin 0.2 mg/hr Fil [BCH] 250 $3.23 $- $0.84 $- $- $2.59 $- N/A $0.84 N/A N/A $1.22 N/A N/A $1.94 N/A N/A $1.62 N/A N/A N/A N/A N/A $2.20 N/A N/A $2.00 N/A N/A $1.33 N/A N/A $2.26 N/A N/A $2.59 N/A N/A $1.78 N/A N/A $2.26 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.94 N/A N/A $1.13 N/A N/A $2.10 N/A N/A N/A N/A N/A $1.94 N/A N/A $2.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.23 $3.23 N/A 4406913 Pharmacy doxazosin 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401973 Pharmacy diphenhydrAMINE 25 mg Tab [BCH] Q0163 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $3.32 $- $0.86 $- $- $2.66 $- N/A $0.86 N/A N/A $1.25 N/A N/A $1.99 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.26 N/A N/A $2.06 N/A N/A $1.36 N/A N/A $2.32 N/A N/A $2.66 N/A N/A $1.83 N/A N/A $2.32 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.16 N/A N/A $2.16 N/A N/A N/A N/A N/A $1.99 N/A N/A $2.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.32 $3.32 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $3.99 $- $1.04 $- $- $3.19 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.39 N/A N/A $1.99 N/A N/A N/A N/A N/A $2.71 N/A N/A $2.47 N/A N/A $1.63 N/A N/A $2.79 N/A N/A $3.19 N/A N/A $2.19 N/A N/A $2.79 N/A N/A $1.33 N/A N/A N/A N/A N/A $2.39 N/A N/A $1.39 N/A N/A $2.59 N/A N/A N/A N/A N/A $2.39 N/A N/A $2.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.99 $3.99 N/A 4409686 Pharmacy docusate-senna 50 mg-8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401977 Pharmacy oxymetazoline Nasal 0.05% Spry [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4404163 Pharmacy loratadine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405095 Pharmacy FLUoxetine 10 mg Cap [BCH] 250 $4.84 $- $1.26 $- $- $3.87 $- N/A $1.26 N/A N/A $1.83 N/A N/A $2.90 N/A N/A $2.42 N/A N/A N/A N/A N/A $3.29 N/A N/A $3.00 N/A N/A $1.98 N/A N/A $3.39 N/A N/A $3.87 N/A N/A $2.66 N/A N/A $3.39 N/A N/A $1.62 N/A N/A N/A N/A N/A $2.90 N/A N/A $1.69 N/A N/A $3.14 N/A N/A N/A N/A N/A $2.90 N/A N/A $3.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.84 $4.84 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap 250 $4.97 $- $1.29 $- $- $3.97 $- N/A $1.29 N/A N/A $1.88 N/A N/A $2.98 N/A N/A $2.48 N/A N/A N/A N/A N/A $3.38 N/A N/A $3.08 N/A N/A $2.04 N/A N/A $3.48 N/A N/A $3.97 N/A N/A $2.73 N/A N/A $3.48 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.98 N/A N/A $1.74 N/A N/A $3.23 N/A N/A N/A N/A N/A $2.98 N/A N/A $3.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.97 $4.97 N/A 4403761 Pharmacy acyclovir 200 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403128 Pharmacy furosemide 40 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406317 Pharmacy lisinopril 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400208 Pharmacy cholecalciferol 400 intl units Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400677 Pharmacy cholecalciferol 1000 intl units oral tablet [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405685 Pharmacy ibuprofen 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405693 Pharmacy ibuprofen 600 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400913 Pharmacy docusate sodium 100 mg Tab (BCH) 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409664 Pharmacy digoxin 125 mcg (0.125 mg) Tab [BCH] 250 $3.37 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.85 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.37 $3.37 N/A 4404159 Pharmacy labetalol 100 mg Tab [BCH] 250 $4.56 $- $1.19 $- $- $3.65 $- N/A $1.19 N/A N/A $1.72 N/A N/A $2.74 N/A N/A $2.28 N/A N/A N/A N/A N/A $3.10 N/A N/A $2.83 N/A N/A $1.87 N/A N/A $3.19 N/A N/A $3.65 N/A N/A $2.51 N/A N/A $3.19 N/A N/A $1.53 N/A N/A N/A N/A N/A $2.74 N/A N/A $1.60 N/A N/A $2.97 N/A N/A N/A N/A N/A $2.74 N/A N/A $3.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.56 $4.56 N/A 4407463 Pharmacy clindamycin 150 mg Cap[BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400902 Pharmacy bicalutamide 50 mg Tab [BCH] 250 $32.93 $- $8.56 $- $- $26.34 $- N/A $8.56 N/A N/A $12.45 N/A N/A $19.76 N/A N/A $16.47 N/A N/A N/A N/A N/A $22.39 N/A N/A $20.42 N/A N/A $13.50 N/A N/A $23.05 N/A N/A $26.34 N/A N/A $18.11 N/A N/A $23.05 N/A N/A $11.03 N/A N/A N/A N/A N/A $19.76 N/A N/A $11.53 N/A N/A $21.40 N/A N/A N/A N/A N/A $19.76 N/A N/A $23.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.93 $32.93 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $6.33 $- $1.64 $- $- $5.06 $- N/A $1.64 N/A N/A $2.39 N/A N/A $3.80 N/A N/A $3.16 N/A N/A N/A N/A N/A $4.30 N/A N/A $3.92 N/A N/A $2.59 N/A N/A $4.43 N/A N/A $5.06 N/A N/A $3.48 N/A N/A $4.43 N/A N/A $2.12 N/A N/A N/A N/A N/A $3.80 N/A N/A $2.21 N/A N/A $4.11 N/A N/A N/A N/A N/A $3.80 N/A N/A $4.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.33 $6.33 N/A 4404254 Pharmacy zolpidem 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400419 Pharmacy citalopram 20 mg Tab 250 $5.39 $- $1.40 $- $- $4.31 $- N/A $1.40 N/A N/A $2.04 N/A N/A $3.23 N/A N/A $2.69 N/A N/A N/A N/A N/A $3.66 N/A N/A $3.34 N/A N/A $2.21 N/A N/A $3.77 N/A N/A $4.31 N/A N/A $2.96 N/A N/A $3.77 N/A N/A $1.80 N/A N/A N/A N/A N/A $3.23 N/A N/A $1.89 N/A N/A $3.50 N/A N/A N/A N/A N/A $3.23 N/A N/A $3.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.39 $5.39 N/A 4402988 Pharmacy terazosin 1 mg Cap 250 $2.89 $- $0.75 $- $- $2.31 $- N/A $0.75 N/A N/A $1.09 N/A N/A $1.73 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.97 N/A N/A $1.79 N/A N/A $1.18 N/A N/A $2.02 N/A N/A $2.31 N/A N/A $1.59 N/A N/A $2.02 N/A N/A $0.97 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.01 N/A N/A $1.88 N/A N/A N/A N/A N/A $1.73 N/A N/A $2.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.89 $2.89 N/A 4405965 Pharmacy phenytoin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408762 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab [BCH} 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400464 Pharmacy carbidopa-levodopa 25 mg-250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402377 Pharmacy benzocaine-menthol topical 15 mg-3.6 mg Loz [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $17.93 $- $4.66 $- $- $14.34 $- N/A $4.66 N/A N/A $6.78 N/A N/A $10.76 N/A N/A $8.96 N/A N/A N/A N/A N/A $12.19 N/A N/A $11.11 N/A N/A $7.35 N/A N/A $12.55 N/A N/A $14.34 N/A N/A $9.86 N/A N/A $12.55 N/A N/A $6.01 N/A N/A N/A N/A N/A $10.76 N/A N/A $6.27 N/A N/A $11.65 N/A N/A N/A N/A N/A $10.76 N/A N/A $12.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.93 $17.93 N/A 4400651 Pharmacy cholecalciferol 400 intl units/mL Liq [BCH] 250 $10.04 $- $2.61 $- $- $8.03 $- N/A $2.61 N/A N/A $3.80 N/A N/A $6.02 N/A N/A $5.02 N/A N/A N/A N/A N/A $6.83 N/A N/A $6.22 N/A N/A $4.12 N/A N/A $7.03 N/A N/A $8.03 N/A N/A $5.52 N/A N/A $7.03 N/A N/A $3.36 N/A N/A N/A N/A N/A $6.02 N/A N/A $3.51 N/A N/A $6.53 N/A N/A N/A N/A N/A $6.02 N/A N/A $7.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.04 $10.04 N/A 4408945 Pharmacy aspirin 81 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400520 Pharmacy atorvastatin 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400519 Pharmacy atorvastatin 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400678 Pharmacy atorvastatin 40 mg Tab {BCH} 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400143 Pharmacy atorvastatin 80 mg Tab [BCH] 250 $3.88 $- $1.01 $- $- $3.11 $- N/A $1.01 N/A N/A $1.47 N/A N/A $2.33 N/A N/A $1.94 N/A N/A N/A N/A N/A $2.64 N/A N/A $2.41 N/A N/A $1.59 N/A N/A $2.72 N/A N/A $3.11 N/A N/A $2.14 N/A N/A $2.72 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.33 N/A N/A $1.36 N/A N/A $2.52 N/A N/A N/A N/A N/A $2.33 N/A N/A $2.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.88 $3.88 N/A 4407265 Pharmacy clopidogrel 75 mg Tab 250 $8.72 $- $2.27 $- $- $6.98 $- N/A $2.27 N/A N/A $3.30 N/A N/A $5.23 N/A N/A $4.36 N/A N/A N/A N/A N/A $5.93 N/A N/A $5.41 N/A N/A $3.58 N/A N/A $6.11 N/A N/A $6.98 N/A N/A $4.80 N/A N/A $6.11 N/A N/A $2.92 N/A N/A N/A N/A N/A $5.23 N/A N/A $3.05 N/A N/A $5.67 N/A N/A N/A N/A N/A $5.23 N/A N/A $6.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.72 $8.72 N/A 4408792 Pharmacy carvedilol 3.125 mg Tab [BCH] 250 $4.20 $- $1.09 $- $- $3.36 $- N/A $1.09 N/A N/A $1.59 N/A N/A $2.52 N/A N/A $2.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $2.61 N/A N/A $1.72 N/A N/A $2.94 N/A N/A $3.36 N/A N/A $2.31 N/A N/A $2.94 N/A N/A $1.41 N/A N/A N/A N/A N/A $2.52 N/A N/A $1.47 N/A N/A $2.73 N/A N/A N/A N/A N/A $2.52 N/A N/A $2.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.20 $4.20 N/A 4400099 Pharmacy carvedilol 6.25 mg Tab 250 $4.20 $- $1.09 $- $- $3.36 $- N/A $1.09 N/A N/A $1.59 N/A N/A $2.52 N/A N/A $2.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $2.61 N/A N/A $1.72 N/A N/A $2.94 N/A N/A $3.36 N/A N/A $2.31 N/A N/A $2.94 N/A N/A $1.41 N/A N/A N/A N/A N/A $2.52 N/A N/A $1.47 N/A N/A $2.73 N/A N/A N/A N/A N/A $2.52 N/A N/A $2.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.20 $4.20 N/A 4408784 Pharmacy carvedilol 12.5 mg Tab [BCH] 250 $4.20 $- $1.09 $- $- $3.36 $- N/A $1.09 N/A N/A $1.59 N/A N/A $2.52 N/A N/A $2.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $2.61 N/A N/A $1.72 N/A N/A $2.94 N/A N/A $3.36 N/A N/A $2.31 N/A N/A $2.94 N/A N/A $1.41 N/A N/A N/A N/A N/A $2.52 N/A N/A $1.47 N/A N/A $2.73 N/A N/A N/A N/A N/A $2.52 N/A N/A $2.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.20 $4.20 N/A 4409295 Pharmacy phenol Top 1.4% Spry [BCH] 250 $5.08 $- $1.32 $- $- $4.07 $- N/A $1.32 N/A N/A $1.92 N/A N/A $3.05 N/A N/A $2.54 N/A N/A N/A N/A N/A $3.46 N/A N/A $3.15 N/A N/A $2.08 N/A N/A $3.56 N/A N/A $4.07 N/A N/A $2.80 N/A N/A $3.56 N/A N/A $1.70 N/A N/A N/A N/A N/A $3.05 N/A N/A $1.78 N/A N/A $3.30 N/A N/A N/A N/A N/A $3.05 N/A N/A $3.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.08 $5.08 N/A 4400707 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.48 $- $0.64 $- $- $1.98 $- N/A $0.64 N/A N/A $0.94 N/A N/A $1.49 N/A N/A $1.24 N/A N/A N/A N/A N/A $1.69 N/A N/A $1.54 N/A N/A $1.02 N/A N/A $1.74 N/A N/A $1.98 N/A N/A $1.36 N/A N/A $1.74 N/A N/A $0.83 N/A N/A N/A N/A N/A $1.49 N/A N/A $0.87 N/A N/A $1.61 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.48 $2.48 N/A 4402118 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.48 $- $0.64 $- $- $1.98 $- N/A $0.64 N/A N/A $0.94 N/A N/A $1.49 N/A N/A $1.24 N/A N/A N/A N/A N/A $1.69 N/A N/A $1.54 N/A N/A $1.02 N/A N/A $1.74 N/A N/A $1.98 N/A N/A $1.36 N/A N/A $1.74 N/A N/A $0.83 N/A N/A N/A N/A N/A $1.49 N/A N/A $0.87 N/A N/A $1.61 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.48 $2.48 N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403326 Pharmacy metoprolol 50 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400629 Pharmacy metoprolol 100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409741 Pharmacy levoFLOXacin 250 mg Tab [BCH] 250 $29.45 $- $7.66 $- $- $23.56 $- N/A $7.66 N/A N/A $11.13 N/A N/A $17.67 N/A N/A $14.73 N/A N/A N/A N/A N/A $20.03 N/A N/A $18.26 N/A N/A $12.08 N/A N/A $20.62 N/A N/A $23.56 N/A N/A $16.20 N/A N/A $20.62 N/A N/A $9.87 N/A N/A N/A N/A N/A $17.67 N/A N/A $10.31 N/A N/A $19.14 N/A N/A N/A N/A N/A $17.67 N/A N/A $20.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.45 $29.45 N/A 4400309 Pharmacy risperiDONE 0.25 mg Tab [BCH] 250 $7.16 $- $1.86 $- $- $5.73 $- N/A $1.86 N/A N/A $2.71 N/A N/A $4.30 N/A N/A $3.58 N/A N/A N/A N/A N/A $4.87 N/A N/A $4.44 N/A N/A $2.94 N/A N/A $5.01 N/A N/A $5.73 N/A N/A $3.94 N/A N/A $5.01 N/A N/A $2.40 N/A N/A N/A N/A N/A $4.30 N/A N/A $2.51 N/A N/A $4.66 N/A N/A N/A N/A N/A $4.30 N/A N/A $5.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.16 $7.16 N/A 4400293 Pharmacy risperiDONE 0.5 mg Tab [BCH] 250 $7.86 $- $2.04 $- $- $6.29 $- N/A $2.04 N/A N/A $2.97 N/A N/A $4.72 N/A N/A $3.93 N/A N/A N/A N/A N/A $5.35 N/A N/A $4.88 N/A N/A $3.22 N/A N/A $5.50 N/A N/A $6.29 N/A N/A $4.33 N/A N/A $5.50 N/A N/A $2.63 N/A N/A N/A N/A N/A $4.72 N/A N/A $2.75 N/A N/A $5.11 N/A N/A N/A N/A N/A $4.72 N/A N/A $5.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.86 $7.86 N/A 4405798 Pharmacy risperiDONE 1 mg Tab 250 $9.13 $- $2.37 $- $- $7.30 $- N/A $2.37 N/A N/A $3.45 N/A N/A $5.48 N/A N/A $4.56 N/A N/A N/A N/A N/A $6.21 N/A N/A $5.66 N/A N/A $3.74 N/A N/A $6.39 N/A N/A $7.30 N/A N/A $5.02 N/A N/A $6.39 N/A N/A $3.06 N/A N/A N/A N/A N/A $5.48 N/A N/A $3.19 N/A N/A $5.93 N/A N/A N/A N/A N/A $5.48 N/A N/A $6.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.13 $9.13 N/A 4400316 Pharmacy risperiDONE 2 mg Tab 250 $14.12 $- $3.67 $- $- $11.29 $- N/A $3.67 N/A N/A $5.34 N/A N/A $8.47 N/A N/A $7.06 N/A N/A N/A N/A N/A $9.60 N/A N/A $8.75 N/A N/A $5.79 N/A N/A $9.88 N/A N/A $11.29 N/A N/A $7.76 N/A N/A $9.88 N/A N/A $4.73 N/A N/A N/A N/A N/A $8.47 N/A N/A $4.94 N/A N/A $9.18 N/A N/A N/A N/A N/A $8.47 N/A N/A $9.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.12 $14.12 N/A 4400131 Pharmacy divalproex sodium 250 mg Tab [BCH] 250 $3.10 $- $0.81 $- $- $2.48 $- N/A $0.81 N/A N/A $1.17 N/A N/A $1.86 N/A N/A $1.55 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.92 N/A N/A $1.27 N/A N/A $2.17 N/A N/A $2.48 N/A N/A $1.71 N/A N/A $2.17 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.86 N/A N/A $1.09 N/A N/A $2.02 N/A N/A N/A N/A N/A $1.86 N/A N/A $2.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.10 $3.10 N/A 4400364 Pharmacy amLODIPine 5 mg Tab [BCH] 250 $3.29 $- $0.85 $- $- $2.63 $- N/A $0.85 N/A N/A $1.24 N/A N/A $1.97 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.23 N/A N/A $2.04 N/A N/A $1.35 N/A N/A $2.30 N/A N/A $2.63 N/A N/A $1.81 N/A N/A $2.30 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.97 N/A N/A $1.15 N/A N/A $2.14 N/A N/A N/A N/A N/A $1.97 N/A N/A $2.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.29 $3.29 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.51 $- $1.17 $- $- $3.61 $- N/A $1.17 N/A N/A $1.70 N/A N/A $2.71 N/A N/A $2.26 N/A N/A N/A N/A N/A $3.07 N/A N/A $2.80 N/A N/A $1.85 N/A N/A $3.16 N/A N/A $3.61 N/A N/A $2.48 N/A N/A $3.16 N/A N/A $1.51 N/A N/A N/A N/A N/A $2.71 N/A N/A $1.58 N/A N/A $2.93 N/A N/A N/A N/A N/A $2.71 N/A N/A $3.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.51 $4.51 N/A 4409668 Pharmacy rOPINIRole 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409204 Pharmacy tamsulosin 0.4 mg Cap [BCH] 250 $8.42 $- $2.19 $- $- $6.73 $- N/A $2.19 N/A N/A $3.18 N/A N/A $5.05 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.72 N/A N/A $5.22 N/A N/A $3.45 N/A N/A $5.89 N/A N/A $6.73 N/A N/A $4.63 N/A N/A $5.89 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.05 N/A N/A $2.95 N/A N/A $5.47 N/A N/A N/A N/A N/A $5.05 N/A N/A $5.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.42 $8.42 N/A 4402340 Pharmacy bisacodyl 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405544 Pharmacy calcium carbonate 500 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409738 Pharmacy escitalopram 10 mg Tab 250 $8.76 $- $2.28 $- $- $7.01 $- N/A $2.28 N/A N/A $3.31 N/A N/A $5.26 N/A N/A $4.38 N/A N/A N/A N/A N/A $5.96 N/A N/A $5.43 N/A N/A $3.59 N/A N/A $6.13 N/A N/A $7.01 N/A N/A $4.82 N/A N/A $6.13 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.26 N/A N/A $3.07 N/A N/A $5.69 N/A N/A N/A N/A N/A $5.26 N/A N/A $6.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.76 $8.76 N/A 4400307 Pharmacy escitalopram 20 mg Tab [BCH] 250 $9.14 $- $2.38 $- $- $7.31 $- N/A $2.38 N/A N/A $3.46 N/A N/A $5.48 N/A N/A $4.57 N/A N/A N/A N/A N/A $6.22 N/A N/A $5.67 N/A N/A $3.75 N/A N/A $6.40 N/A N/A $7.31 N/A N/A $5.03 N/A N/A $6.40 N/A N/A $3.06 N/A N/A N/A N/A N/A $5.48 N/A N/A $3.20 N/A N/A $5.94 N/A N/A N/A N/A N/A $5.48 N/A N/A $6.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.14 $9.14 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400062 Pharmacy acetaminophen-oxycodone 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4403736 Pharmacy hydrALAZINE 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400633 Pharmacy hydrALAZINE 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409457 Pharmacy isosorbide mononitrate 30 mg Tab [BCH] 250 $3.32 $- $0.86 $- $- $2.66 $- N/A $0.86 N/A N/A $1.25 N/A N/A $1.99 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.26 N/A N/A $2.06 N/A N/A $1.36 N/A N/A $2.32 N/A N/A $2.66 N/A N/A $1.83 N/A N/A $2.32 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.16 N/A N/A $2.16 N/A N/A N/A N/A N/A $1.99 N/A N/A $2.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.32 $3.32 N/A 4400688 Pharmacy DULoxetine 20 mg Cap[BCH] 250 $3.49 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.10 N/A N/A $1.75 N/A N/A N/A N/A N/A $2.38 N/A N/A $2.17 N/A N/A $1.43 N/A N/A $2.45 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.45 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.10 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.10 N/A N/A $2.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.49 $3.49 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $11.85 $- $3.08 $- $- $9.48 $- N/A $3.08 N/A N/A $4.48 N/A N/A $7.11 N/A N/A $5.93 N/A N/A N/A N/A N/A $8.06 N/A N/A $7.35 N/A N/A $4.86 N/A N/A $8.30 N/A N/A $9.48 N/A N/A $6.52 N/A N/A $8.30 N/A N/A $3.97 N/A N/A N/A N/A N/A $7.11 N/A N/A $4.15 N/A N/A $7.70 N/A N/A N/A N/A N/A $7.11 N/A N/A $8.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.85 $11.85 N/A 4400680 Pharmacy DULoxetine 60 mg Cap 250 $11.85 $- $3.08 $- $- $9.48 $- N/A $3.08 N/A N/A $4.48 N/A N/A $7.11 N/A N/A $5.93 N/A N/A N/A N/A N/A $8.06 N/A N/A $7.35 N/A N/A $4.86 N/A N/A $8.30 N/A N/A $9.48 N/A N/A $6.52 N/A N/A $8.30 N/A N/A $3.97 N/A N/A N/A N/A N/A $7.11 N/A N/A $4.15 N/A N/A $7.70 N/A N/A N/A N/A N/A $7.11 N/A N/A $8.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.85 $11.85 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405098 Pharmacy promethazine 25 mg Tab [BCH] Q0169 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400378 Pharmacy dextromethorphan-guaifenesin 10 mg-100 mg/5 mL Liq [BCH] 250 $4.58 $- $1.19 $- $- $3.66 $- N/A $1.19 N/A N/A $1.73 N/A N/A $2.75 N/A N/A $2.29 N/A N/A N/A N/A N/A $3.11 N/A N/A $2.84 N/A N/A $1.88 N/A N/A $3.20 N/A N/A $3.66 N/A N/A $2.52 N/A N/A $3.20 N/A N/A $1.53 N/A N/A N/A N/A N/A $2.75 N/A N/A $1.60 N/A N/A $2.97 N/A N/A N/A N/A N/A $2.75 N/A N/A $3.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.58 $4.58 N/A 4409523 Pharmacy venlafaxine 75 mg Cap[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407364 Pharmacy baclofen 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408966 Pharmacy celecoxib 200 mg Cap [BCH] 250 $15.16 $- $3.94 $- $- $12.13 $- N/A $3.94 N/A N/A $5.73 N/A N/A $9.09 N/A N/A $7.58 N/A N/A N/A N/A N/A $10.31 N/A N/A $9.40 N/A N/A $6.21 N/A N/A $10.61 N/A N/A $12.13 N/A N/A $8.34 N/A N/A $10.61 N/A N/A $5.08 N/A N/A N/A N/A N/A $9.09 N/A N/A $5.30 N/A N/A $9.85 N/A N/A N/A N/A N/A $9.09 N/A N/A $10.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.16 $15.16 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab 250 $5.68 $- $1.48 $- $- $4.54 $- N/A $1.48 N/A N/A $2.15 N/A N/A $3.41 N/A N/A $2.84 N/A N/A N/A N/A N/A $3.86 N/A N/A $3.52 N/A N/A $2.33 N/A N/A $3.97 N/A N/A $4.54 N/A N/A $3.12 N/A N/A $3.97 N/A N/A $1.90 N/A N/A N/A N/A N/A $3.41 N/A N/A $1.99 N/A N/A $3.69 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.68 $5.68 N/A 4407307 Pharmacy mirtazapine 15 mg Tab [BCH] 250 $5.72 $- $1.49 $- $- $4.57 $- N/A $1.49 N/A N/A $2.16 N/A N/A $3.43 N/A N/A $2.86 N/A N/A N/A N/A N/A $3.89 N/A N/A $3.55 N/A N/A $2.34 N/A N/A $4.00 N/A N/A $4.57 N/A N/A $3.14 N/A N/A $4.00 N/A N/A $1.92 N/A N/A N/A N/A N/A $3.43 N/A N/A $2.00 N/A N/A $3.72 N/A N/A N/A N/A N/A $3.43 N/A N/A $4.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.72 $5.72 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401030 Pharmacy acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab 250 $5.23 $- $1.36 $- $- $4.18 $- N/A $1.36 N/A N/A $1.98 N/A N/A $3.14 N/A N/A $2.61 N/A N/A N/A N/A N/A $3.56 N/A N/A $3.24 N/A N/A $2.14 N/A N/A $3.66 N/A N/A $4.18 N/A N/A $2.88 N/A N/A $3.66 N/A N/A $1.75 N/A N/A N/A N/A N/A $3.14 N/A N/A $1.83 N/A N/A $3.40 N/A N/A N/A N/A N/A $3.14 N/A N/A $3.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.23 $5.23 N/A 4400654 Pharmacy traZODone 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406576 Pharmacy benzonatate 100 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400593 Pharmacy PHENobarbital 32.4 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409475 Pharmacy tolterodine 2 mg Cap 250 $27.11 $- $7.05 $- $- $21.69 $- N/A $7.05 N/A N/A $10.25 N/A N/A $16.26 N/A N/A $13.55 N/A N/A N/A N/A N/A $18.43 N/A N/A $16.81 N/A N/A $11.11 N/A N/A $18.98 N/A N/A $21.69 N/A N/A $14.91 N/A N/A $18.98 N/A N/A $9.08 N/A N/A N/A N/A N/A $16.26 N/A N/A $9.49 N/A N/A $17.62 N/A N/A N/A N/A N/A $16.26 N/A N/A $18.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.11 $27.11 N/A 4404172 Pharmacy carbamide peroxide otic 6.5% Sol [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402566 Pharmacy glipiZIDE 5 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401962 Pharmacy QUEtiapine 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400433 Pharmacy QUEtiapine 50 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400452 Pharmacy QUEtiapine 400 mg Tab [BCH] 250 $3.36 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.08 N/A N/A $1.38 N/A N/A $2.35 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.35 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.36 $3.36 N/A 4400603 Pharmacy acetaZOLAMIDE 250 mg Tab [BCH] 250 $8.67 $- $2.25 $- $- $6.93 $- N/A $2.25 N/A N/A $3.28 N/A N/A $5.20 N/A N/A $4.33 N/A N/A N/A N/A N/A $5.89 N/A N/A $5.37 N/A N/A $3.55 N/A N/A $6.07 N/A N/A $6.93 N/A N/A $4.77 N/A N/A $6.07 N/A N/A $2.90 N/A N/A N/A N/A N/A $5.20 N/A N/A $3.03 N/A N/A $5.63 N/A N/A N/A N/A N/A $5.20 N/A N/A $6.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.67 $8.67 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400627 Pharmacy sildenafil 20 mg Tab 250 $2.79 $- $0.72 $- $- $2.23 $- N/A $0.72 N/A N/A $1.05 N/A N/A $1.67 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.90 N/A N/A $1.73 N/A N/A $1.14 N/A N/A $1.95 N/A N/A $2.23 N/A N/A $1.53 N/A N/A $1.95 N/A N/A $0.93 N/A N/A N/A N/A N/A $1.67 N/A N/A $0.98 N/A N/A $1.81 N/A N/A N/A N/A N/A $1.67 N/A N/A $1.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.79 $2.79 N/A 4400627 Pharmacy sildenafil 20 mg Tab [BCH] 250 $2.01 $- $0.52 $- $- $1.61 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.21 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.25 N/A N/A $0.83 N/A N/A $1.41 N/A N/A $1.61 N/A N/A $1.11 N/A N/A $1.41 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.21 N/A N/A $0.70 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.21 N/A N/A $1.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.01 $2.01 N/A 4401957 Pharmacy bacitracin topical zinc 500 units/g Oin [BCH] 250 $4.91 $- $1.28 $- $- $3.93 $- N/A $1.28 N/A N/A $1.86 N/A N/A $2.95 N/A N/A $2.46 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.05 N/A N/A $2.01 N/A N/A $3.44 N/A N/A $3.93 N/A N/A $2.70 N/A N/A $3.44 N/A N/A $1.65 N/A N/A N/A N/A N/A $2.95 N/A N/A $1.72 N/A N/A $3.19 N/A N/A N/A N/A N/A $2.95 N/A N/A $3.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.91 $4.91 N/A 4401938 Pharmacy bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404387 Pharmacy propranolol 20 mg Tab [BCH] 250 $2.68 $- $0.70 $- $- $2.14 $- N/A $0.70 N/A N/A $1.01 N/A N/A $1.61 N/A N/A $1.34 N/A N/A N/A N/A N/A $1.82 N/A N/A $1.66 N/A N/A $1.10 N/A N/A $1.88 N/A N/A $2.14 N/A N/A $1.47 N/A N/A $1.88 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.61 N/A N/A $0.94 N/A N/A $1.74 N/A N/A N/A N/A N/A $1.61 N/A N/A $1.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.68 $2.68 N/A 4402019 Pharmacy azithromycin 250 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409767 Pharmacy guaiFENesin 600 mg Tab [BCH] 250 $2.14 $- $0.56 $- $- $1.71 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.28 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.71 N/A N/A $1.17 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.14 $2.14 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400842 Pharmacy ibuprofen 200 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400842 Pharmacy ibuprofen 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400457 Pharmacy guaifenesin 200 mg / 10 mL Liquid [BCH] 250 $2.24 $- $0.58 $- $- $1.79 $- N/A $0.58 N/A N/A $0.85 N/A N/A $1.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.39 N/A N/A $0.92 N/A N/A $1.57 N/A N/A $1.79 N/A N/A $1.23 N/A N/A $1.57 N/A N/A $0.75 N/A N/A N/A N/A N/A $1.34 N/A N/A $0.78 N/A N/A $1.46 N/A N/A N/A N/A N/A $1.34 N/A N/A $1.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.24 $2.24 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408945 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407273 Pharmacy montelukast 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403512 Pharmacy finasteride 5 mg Tab[BCH] S0138 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404163 Pharmacy loratadine 10 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401909 Pharmacy traZODone 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409594 Pharmacy pantoprazole 40 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400345 Pharmacy sertraline 100 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400135 Pharmacy pregabalin 50 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401977 Pharmacy oxymetazoline nasal 0.05% Spr [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401902 Pharmacy lamoTRIgine 100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400688 Pharmacy DULoxetine 20 mg Cap 250 $3.49 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.10 N/A N/A $1.75 N/A N/A N/A N/A N/A $2.38 N/A N/A $2.17 N/A N/A $1.43 N/A N/A $2.45 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.45 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.10 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.10 N/A N/A $2.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.49 $3.49 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $3.45 $- $0.90 $- $- $2.76 $- N/A $0.90 N/A N/A $1.30 N/A N/A $2.07 N/A N/A $1.72 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.14 N/A N/A $1.41 N/A N/A $2.41 N/A N/A $2.76 N/A N/A $1.90 N/A N/A $2.41 N/A N/A $1.15 N/A N/A N/A N/A N/A $2.07 N/A N/A $1.21 N/A N/A $2.24 N/A N/A N/A N/A N/A $2.07 N/A N/A $2.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.45 $3.45 N/A 4400680 Pharmacy DULoxetine 60 mg Cap [BCH] 250 $3.45 $- $0.90 $- $- $2.76 $- N/A $0.90 N/A N/A $1.30 N/A N/A $2.07 N/A N/A $1.72 N/A N/A N/A N/A N/A $2.34 N/A N/A $2.14 N/A N/A $1.41 N/A N/A $2.41 N/A N/A $2.76 N/A N/A $1.90 N/A N/A $2.41 N/A N/A $1.15 N/A N/A N/A N/A N/A $2.07 N/A N/A $1.21 N/A N/A $2.24 N/A N/A N/A N/A N/A $2.07 N/A N/A $2.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.45 $3.45 N/A 4400066 Pharmacy losartan 50 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400291 Pharmacy potassium chloride 20 mEq Tab[BCH] 250 $2.01 $- $0.52 $- $- $1.61 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.21 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.25 N/A N/A $0.82 N/A N/A $1.41 N/A N/A $1.61 N/A N/A $1.11 N/A N/A $1.41 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.21 N/A N/A $0.70 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.21 N/A N/A $1.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.01 $2.01 N/A 4400291 Pharmacy potassium chloride 20 mEq Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404159 Pharmacy labetalol 100 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate 100 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409790 Pharmacy fenofibrate 160 mg Tab [BCH] 250 $6.46 $- $1.68 $- $- $5.16 $- N/A $1.68 N/A N/A $2.44 N/A N/A $3.87 N/A N/A $3.23 N/A N/A N/A N/A N/A $4.39 N/A N/A $4.00 N/A N/A $2.65 N/A N/A $4.52 N/A N/A $5.16 N/A N/A $3.55 N/A N/A $4.52 N/A N/A $2.16 N/A N/A N/A N/A N/A $3.87 N/A N/A $2.26 N/A N/A $4.20 N/A N/A N/A N/A N/A $3.87 N/A N/A $4.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.46 $6.46 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400069 Pharmacy atenolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400667 Pharmacy phenylephrine 0.25% Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400696 Pharmacy loperamide 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403473 Pharmacy calcium carbonate-magnesium chloride 112 mg-64 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400842 Pharmacy ibuprofen 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400842 Pharmacy ibuprofen 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400842 Pharmacy ibuprofen 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402340 Pharmacy bisacodyl 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402340 Pharmacy bisacodyl 5 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400881 Pharmacy SODIUM CITRATE SOLUTION 250 mL Soln-IV 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401002 Pharmacy immune globulin intravenous 10 g Pow [BCH] J1566 636 "$4,510.08 " $- $66.94 $- $- "$3,608.06 " $- N/A "$1,172.62 " N/A N/A Not Reimbursed N/A N/A "$2,706.05 " N/A N/A "$2,255.04 " N/A N/A N/A N/A N/A "$3,066.85 " N/A N/A "$2,796.25 " N/A N/A "$1,849.13 " N/A N/A "$3,157.06 " N/A N/A "$3,608.06 " N/A N/A "$2,480.54 " N/A N/A "$3,157.06 " N/A N/A "$1,510.88 " N/A N/A N/A N/A N/A "$2,706.05 " N/A N/A "$1,578.53 " N/A N/A "$2,931.55 " N/A N/A $66.94 N/A N/A "$2,706.05 " N/A N/A "$3,157.06 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$4,510.08 " "$4,510.08 " N/A 4400649 Pharmacy immune globulin intravenous and subcutaneous 10% Sol J1561 636 $372.58 $- $41.69 $- $- $298.06 $- N/A $96.87 N/A N/A Not Reimbursed N/A N/A $223.55 N/A N/A $186.29 N/A N/A N/A N/A N/A $253.35 N/A N/A $231.00 N/A N/A $152.76 N/A N/A $260.80 N/A N/A $298.06 N/A N/A $204.92 N/A N/A $260.80 N/A N/A $124.81 N/A N/A N/A N/A N/A $223.55 N/A N/A $130.40 N/A N/A $242.17 N/A N/A $41.69 N/A N/A $223.55 N/A N/A $260.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $372.58 $372.58 N/A 4400649 Pharmacy immune globulin intravenous and subcutaneous 10% Sol (GAMMAGARD) [BCH] J1561 636 $332.69 $- $41.69 $- $- $266.15 $- N/A $86.50 N/A N/A Not Reimbursed N/A N/A $199.61 N/A N/A $166.34 N/A N/A N/A N/A N/A $226.23 N/A N/A $206.27 N/A N/A $136.40 N/A N/A $232.88 N/A N/A $266.15 N/A N/A $182.98 N/A N/A $232.88 N/A N/A $111.45 N/A N/A N/A N/A N/A $199.61 N/A N/A $116.44 N/A N/A $216.25 N/A N/A $41.69 N/A N/A $199.61 N/A N/A $232.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $332.69 $332.69 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $41.02 $- $0.69 $- $- $32.82 $- N/A $10.67 N/A N/A Not Reimbursed N/A N/A $24.61 N/A N/A $20.51 N/A N/A N/A N/A N/A $27.90 N/A N/A $25.43 N/A N/A $16.82 N/A N/A $28.72 N/A N/A $32.82 N/A N/A $22.56 N/A N/A $28.72 N/A N/A $13.74 N/A N/A N/A N/A N/A $24.61 N/A N/A $14.36 N/A N/A $26.67 N/A N/A $0.69 N/A N/A $24.61 N/A N/A $28.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.02 $41.02 N/A 4409544 Pharmacy LVP solution with potassium Sodium Chloride 0.9% with KCl 20 mEq/L Sol [BCH] J3480 258 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400524 Pharmacy LVP solution with potassium Sodium Chloride 0.9% with KCl 40 mEq/L Sol [BCH] J3480 258 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4407548 Pharmacy LVP solution with potassium Dextrose 5% with 0.45% NaCl and KCl 20 mEq/L Sol [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400523 Pharmacy LVP solution with potassium Dextrose 5% with 0.45% NaCl and KCl 40 mEq/L Sol [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4404230 Pharmacy LVP solution Dextrose 5% in Water Sol [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404131 Pharmacy LVP solution Dextrose 5% in Water Sol [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404248 Pharmacy LVP solution Dextrose 5% in Water Sol [BCH] J7060 636 $75.00 $- $1.78 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.78 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404164 Pharmacy LVP solution Dextrose 5% with 0.45% NaCl Sol [BCH] J7042 258 $75.00 $- $1.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400055 Pharmacy LVP solution Dextrose 5% with 0.9% NaCl Sol [BCH] J7042 636 $75.00 $- $1.02 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.02 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404255 Pharmacy LVP solution Lactated Ringers Injection Sol J7120 636 $75.00 $- $2.34 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.34 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404297 Pharmacy LVP solution Sodium Chloride 0.9% Sol [BCH] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400428 Pharmacy LVP solution Sodium Chloride 0.9% Sol [BCH] J7040 258 $75.00 $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404271 Pharmacy Sodium Chloride 0.9% IV Sol 1000 mL [BCH] J7030 258 $75.00 $- $2.55 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $2.55 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404693 Pharmacy LVP solution Sodium Chloride 0.9% Sol [BCHG] J7050 258 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403496 Pharmacy Sodium Chloride 0.9% IV Sol 100 mL [BCH] J7040 258 $- $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4404370 Pharmacy LVP solution Sodium Chloride 0.45% Sol [BCH] 258 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400576 Pharmacy LVP solution with potassium Sodium Chloride 0.45% with KCl 20 mEq/L Sol [BCH] J3480 636 $90.00 $- $0.18 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $0.18 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4400982 Pharmacy VALPROIC ACID 500 mg Syrup [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400012 Pharmacy Triampterene and Hydrochlorothiazide 37.5 MG/25 MG Tab 250 $53.40 $- $13.88 $- $- $42.72 $- N/A $13.88 N/A N/A $20.19 N/A N/A $32.04 N/A N/A $26.70 N/A N/A N/A N/A N/A $36.31 N/A N/A $33.11 N/A N/A $21.89 N/A N/A $37.38 N/A N/A $42.72 N/A N/A $29.37 N/A N/A $37.38 N/A N/A $17.89 N/A N/A N/A N/A N/A $32.04 N/A N/A $18.69 N/A N/A $34.71 N/A N/A N/A N/A N/A $32.04 N/A N/A $37.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $53.40 $53.40 N/A 4404191 Pharmacy nalbuphine 10 mg Amp [BCH] J2300 636 $86.16 $- $2.37 $- $- $68.93 $- N/A $22.40 N/A N/A Not Reimbursed N/A N/A $51.70 N/A N/A $43.08 N/A N/A N/A N/A N/A $58.59 N/A N/A $53.42 N/A N/A $35.33 N/A N/A $60.31 N/A N/A $68.93 N/A N/A $47.39 N/A N/A $60.31 N/A N/A $28.86 N/A N/A N/A N/A N/A $51.70 N/A N/A $30.16 N/A N/A $56.00 N/A N/A $2.37 N/A N/A $51.70 N/A N/A $60.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $86.16 $86.16 N/A Pharmacy Clindamycin 600 mg Soln-IV $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4407285 Pharmacy potassium chloride 2mEq/ml Soln [BCH] J3480 250 $42.00 $- $0.18 $- $- $33.60 $- N/A $10.92 N/A N/A Not Reimbursed N/A N/A $25.20 N/A N/A $21.00 N/A N/A N/A N/A N/A $28.56 N/A N/A $26.04 N/A N/A $17.22 N/A N/A $29.40 N/A N/A $33.60 N/A N/A $23.10 N/A N/A $29.40 N/A N/A $14.07 N/A N/A N/A N/A N/A $25.20 N/A N/A $14.70 N/A N/A $27.30 N/A N/A $0.18 N/A N/A $25.20 N/A N/A $29.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.00 $42.00 N/A 7000007 Pharmacy RHo (D) immune globulin 1500 IU / syringe Injection [BCH] 636 $252.28 $- $65.59 $- $- $201.82 $- N/A $65.59 N/A N/A $95.36 N/A N/A $151.37 N/A N/A $126.14 N/A N/A N/A N/A N/A $171.55 N/A N/A $156.41 N/A N/A $103.43 N/A N/A $176.60 N/A N/A $201.82 N/A N/A $138.75 N/A N/A $176.60 N/A N/A $84.51 N/A N/A N/A N/A N/A $151.37 N/A N/A $88.30 N/A N/A $163.98 N/A N/A N/A N/A N/A $151.37 N/A N/A $176.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $252.28 $252.28 N/A 4400403 Pharmacy lactobacillus acidophilus and bulgaricus - Gra 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400559 Pharmacy sodium chloride 0.9% Inj Sol 10 mL [BCH] 258 $- $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400823 Pharmacy sodium chloride 0.9% Inj Sol 10 mL [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400134 Pharmacy heparin flush 100 units/mL Sol [BCH] J1642 636 $- $- $0.01 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.01 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400823 Pharmacy sodium chloride 0.9% Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400991 Pharmacy vitamin E 200 intl units Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400879 Pharmacy isoflurane 100% Liq [BCH 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404395 Pharmacy desflurane 100% Inh Liq 240 mL [BCH] 250 $384.53 $- $99.98 $- $- $307.62 $- N/A $99.98 N/A N/A $145.35 N/A N/A $230.72 N/A N/A $192.26 N/A N/A N/A N/A N/A $261.48 N/A N/A $238.41 N/A N/A $157.66 N/A N/A $269.17 N/A N/A $307.62 N/A N/A $211.49 N/A N/A $269.17 N/A N/A $128.82 N/A N/A N/A N/A N/A $230.72 N/A N/A $134.58 N/A N/A $249.94 N/A N/A N/A N/A N/A $230.72 N/A N/A $269.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $384.53 $384.53 N/A 4401912 Pharmacy sevoflurane Inh Liq 250 mL [BCH] 250 "$1,973.40 " $- $513.08 $- $- "$1,578.72 " $- N/A $513.08 N/A N/A $745.95 N/A N/A "$1,184.04 " N/A N/A $986.70 N/A N/A N/A N/A N/A "$1,341.91 " N/A N/A "$1,223.51 " N/A N/A $809.09 N/A N/A "$1,381.38 " N/A N/A "$1,578.72 " N/A N/A "$1,085.37 " N/A N/A "$1,381.38 " N/A N/A $661.09 N/A N/A N/A N/A N/A "$1,184.04 " N/A N/A $690.69 N/A N/A "$1,282.71 " N/A N/A N/A N/A N/A "$1,184.04 " N/A N/A "$1,381.38 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,973.40 " "$1,973.40 " N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $3.18 $- $0.83 $- $- $2.54 $- N/A $0.83 N/A N/A $1.20 N/A N/A $1.91 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.16 N/A N/A $1.97 N/A N/A $1.30 N/A N/A $2.23 N/A N/A $2.54 N/A N/A $1.75 N/A N/A $2.23 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.91 N/A N/A $1.11 N/A N/A $2.07 N/A N/A N/A N/A N/A $1.91 N/A N/A $2.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.18 $3.18 N/A 4408792 Pharmacy carvedilol 3.125 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400099 Pharmacy carvedilol 6.25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409444 Pharmacy ketoconazole topical 2% Sha [BCH] 250 $55.56 $- $14.45 $- $- $44.45 $- N/A $14.45 N/A N/A $21.00 N/A N/A $33.34 N/A N/A $27.78 N/A N/A N/A N/A N/A $37.78 N/A N/A $34.45 N/A N/A $22.78 N/A N/A $38.89 N/A N/A $44.45 N/A N/A $30.56 N/A N/A $38.89 N/A N/A $18.61 N/A N/A N/A N/A N/A $33.34 N/A N/A $19.45 N/A N/A $36.11 N/A N/A N/A N/A N/A $33.34 N/A N/A $38.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $55.56 $55.56 N/A 4409537 Pharmacy galantamine 4 mg Tab [BCH] 250 $6.10 $- $1.59 $- $- $4.88 $- N/A $1.59 N/A N/A $2.31 N/A N/A $3.66 N/A N/A $3.05 N/A N/A N/A N/A N/A $4.15 N/A N/A $3.78 N/A N/A $2.50 N/A N/A $4.27 N/A N/A $4.88 N/A N/A $3.36 N/A N/A $4.27 N/A N/A $2.04 N/A N/A N/A N/A N/A $3.66 N/A N/A $2.14 N/A N/A $3.97 N/A N/A N/A N/A N/A $3.66 N/A N/A $4.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.10 $6.10 N/A 4400123 Pharmacy haloperidol decanoate 100 mg/mL Inj Sol [BCH] J1631 636 $118.44 $- $15.65 $- $- $94.75 $- N/A $30.79 N/A N/A Not Reimbursed N/A N/A $71.06 N/A N/A $59.22 N/A N/A N/A N/A N/A $80.54 N/A N/A $73.43 N/A N/A $48.56 N/A N/A $82.91 N/A N/A $94.75 N/A N/A $65.14 N/A N/A $82.91 N/A N/A $39.68 N/A N/A N/A N/A N/A $71.06 N/A N/A $41.45 N/A N/A $76.99 N/A N/A $15.65 N/A N/A $71.06 N/A N/A $82.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $118.44 $118.44 N/A 4400860 Pharmacy paliperidone 3 mg Tab [BCH] 250 $61.06 $- $15.87 $- $- $48.84 $- N/A $15.87 N/A N/A $23.08 N/A N/A $36.63 N/A N/A $30.53 N/A N/A N/A N/A N/A $41.52 N/A N/A $37.85 N/A N/A $25.03 N/A N/A $42.74 N/A N/A $48.84 N/A N/A $33.58 N/A N/A $42.74 N/A N/A $20.45 N/A N/A N/A N/A N/A $36.63 N/A N/A $21.37 N/A N/A $39.69 N/A N/A N/A N/A N/A $36.63 N/A N/A $42.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $61.06 $61.06 N/A 4400860 Pharmacy paliperidone 3 mg Tab [BCH] 250 $61.06 $- $15.87 $- $- $48.84 $- N/A $15.87 N/A N/A $23.08 N/A N/A $36.63 N/A N/A $30.53 N/A N/A N/A N/A N/A $41.52 N/A N/A $37.85 N/A N/A $25.03 N/A N/A $42.74 N/A N/A $48.84 N/A N/A $33.58 N/A N/A $42.74 N/A N/A $20.45 N/A N/A N/A N/A N/A $36.63 N/A N/A $21.37 N/A N/A $39.69 N/A N/A N/A N/A N/A $36.63 N/A N/A $42.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $61.06 $61.06 N/A 4403439 Pharmacy benzocaine/butamben/tetracaine Top Aer [BCH] 250 $158.00 $- $41.08 $- $- $126.40 $- N/A $41.08 N/A N/A $59.72 N/A N/A $94.80 N/A N/A $79.00 N/A N/A N/A N/A N/A $107.44 N/A N/A $97.96 N/A N/A $64.78 N/A N/A $110.60 N/A N/A $126.40 N/A N/A $86.90 N/A N/A $110.60 N/A N/A $52.93 N/A N/A N/A N/A N/A $94.80 N/A N/A $55.30 N/A N/A $102.70 N/A N/A N/A N/A N/A $94.80 N/A N/A $110.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $158.00 $158.00 N/A 4403439 Pharmacy benzocaine/butamben/tetracaine top AER [BCH] 250 $442.40 $- $115.02 $- $- $353.92 $- N/A $115.02 N/A N/A $167.23 N/A N/A $265.44 N/A N/A $221.20 N/A N/A N/A N/A N/A $300.83 N/A N/A $274.29 N/A N/A $181.38 N/A N/A $309.68 N/A N/A $353.92 N/A N/A $243.32 N/A N/A $309.68 N/A N/A $148.20 N/A N/A N/A N/A N/A $265.44 N/A N/A $154.84 N/A N/A $287.56 N/A N/A N/A N/A N/A $265.44 N/A N/A $309.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $442.40 $442.40 N/A 4400051 Pharmacy "emollients, Top Crm [BCH]" 250 $12.24 $- $3.18 $- $- $9.79 $- N/A $3.18 N/A N/A $4.63 N/A N/A $7.34 N/A N/A $6.12 N/A N/A N/A N/A N/A $8.32 N/A N/A $7.59 N/A N/A $5.02 N/A N/A $8.57 N/A N/A $9.79 N/A N/A $6.73 N/A N/A $8.57 N/A N/A $4.10 N/A N/A N/A N/A N/A $7.34 N/A N/A $4.28 N/A N/A $7.96 N/A N/A N/A N/A N/A $7.34 N/A N/A $8.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.24 $12.24 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours XLTab [BCH] 250 $9.57 $- $2.49 $- $- $7.65 $- N/A $2.49 N/A N/A $3.62 N/A N/A $5.74 N/A N/A $4.78 N/A N/A N/A N/A N/A $6.51 N/A N/A $5.93 N/A N/A $3.92 N/A N/A $6.70 N/A N/A $7.65 N/A N/A $5.26 N/A N/A $6.70 N/A N/A $3.20 N/A N/A N/A N/A N/A $5.74 N/A N/A $3.35 N/A N/A $6.22 N/A N/A N/A N/A N/A $5.74 N/A N/A $6.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.57 $9.57 N/A 7000003 Pharmacy melatonin 5 mg Tab 250 $5.50 $- $1.43 $- $- $4.40 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.30 N/A N/A $2.75 N/A N/A N/A N/A N/A $3.74 N/A N/A $3.41 N/A N/A $2.26 N/A N/A $3.85 N/A N/A $4.40 N/A N/A $3.03 N/A N/A $3.85 N/A N/A $1.84 N/A N/A N/A N/A N/A $3.30 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.50 $5.50 N/A 4401004 Pharmacy hydrocortisone topical 2.5% Cre [BCH] 250 $- $- $45.41 $- $- $139.73 $- N/A $45.41 N/A N/A $66.02 N/A N/A $104.80 N/A N/A $87.33 N/A N/A N/A N/A N/A $118.77 N/A N/A $108.29 N/A N/A $71.61 N/A N/A $122.26 N/A N/A $139.73 N/A N/A $96.06 N/A N/A $122.26 N/A N/A $58.51 N/A N/A N/A N/A N/A $104.80 N/A N/A $61.13 N/A N/A $113.53 N/A N/A N/A N/A N/A $104.80 N/A N/A $122.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4405098 Pharmacy promethazine 25 mg Tab [BCH] Q0169 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab[BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403595 Pharmacy oxybutynin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401030 Pharmacy acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4401601 Pharmacy amantadine 100 mg Cap [BCH] 250 $3.88 $- $1.01 $- $- $3.10 $- N/A $1.01 N/A N/A $1.47 N/A N/A $2.33 N/A N/A $1.94 N/A N/A N/A N/A N/A $2.64 N/A N/A $2.40 N/A N/A $1.59 N/A N/A $2.71 N/A N/A $3.10 N/A N/A $2.13 N/A N/A $2.71 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.33 N/A N/A $1.36 N/A N/A $2.52 N/A N/A N/A N/A N/A $2.33 N/A N/A $2.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.88 $3.88 N/A 4400058 Pharmacy polyethylene glycol 3350 Oral Pwdr for Recon [BCH] 250 $3.28 $- $0.85 $- $- $2.62 $- N/A $0.85 N/A N/A $1.24 N/A N/A $1.97 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.23 N/A N/A $2.03 N/A N/A $1.34 N/A N/A $2.30 N/A N/A $2.62 N/A N/A $1.80 N/A N/A $2.30 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.97 N/A N/A $1.15 N/A N/A $2.13 N/A N/A N/A N/A N/A $1.97 N/A N/A $2.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.28 $3.28 N/A 4400058 Pharmacy polyethylene glycol 3350 Oral Pwdr for Recon [BCH] 250 $2.12 $- $0.55 $- $- $1.69 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.27 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.31 N/A N/A $0.87 N/A N/A $1.48 N/A N/A $1.69 N/A N/A $1.16 N/A N/A $1.48 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.27 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.27 N/A N/A $1.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.12 $2.12 N/A 4409410 Pharmacy urea Top 10% Crm [BCH] 250 $41.68 $- $10.84 $- $- $33.34 $- N/A $10.84 N/A N/A $15.75 N/A N/A $25.01 N/A N/A $20.84 N/A N/A N/A N/A N/A $28.34 N/A N/A $25.84 N/A N/A $17.09 N/A N/A $29.18 N/A N/A $33.34 N/A N/A $22.92 N/A N/A $29.18 N/A N/A $13.96 N/A N/A N/A N/A N/A $25.01 N/A N/A $14.59 N/A N/A $27.09 N/A N/A N/A N/A N/A $25.01 N/A N/A $29.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.68 $41.68 N/A 4400819 Pharmacy sulfacetamide sodium ophthalmic 10% Sol [BCH] 250 $277.60 $- $72.18 $- $- $222.08 $- N/A $72.18 N/A N/A $104.93 N/A N/A $166.56 N/A N/A $138.80 N/A N/A N/A N/A N/A $188.77 N/A N/A $172.11 N/A N/A $113.82 N/A N/A $194.32 N/A N/A $222.08 N/A N/A $152.68 N/A N/A $194.32 N/A N/A $93.00 N/A N/A N/A N/A N/A $166.56 N/A N/A $97.16 N/A N/A $180.44 N/A N/A N/A N/A N/A $166.56 N/A N/A $194.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $277.60 $277.60 N/A 4408545 Pharmacy prednisoLONE-sodium sulfacetamide Ophth 0.2%-10% Susp [BCH] 250 $277.60 $- $72.18 $- $- $222.08 $- N/A $72.18 N/A N/A $104.93 N/A N/A $166.56 N/A N/A $138.80 N/A N/A N/A N/A N/A $188.77 N/A N/A $172.11 N/A N/A $113.82 N/A N/A $194.32 N/A N/A $222.08 N/A N/A $152.68 N/A N/A $194.32 N/A N/A $93.00 N/A N/A N/A N/A N/A $166.56 N/A N/A $97.16 N/A N/A $180.44 N/A N/A N/A N/A N/A $166.56 N/A N/A $194.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $277.60 $277.60 N/A 4400760 Pharmacy prednisoLONE ophthalmic acetate 0.12% Sus [BCH] 250 $277.60 $- $72.18 $- $- $222.08 $- N/A $72.18 N/A N/A $104.93 N/A N/A $166.56 N/A N/A $138.80 N/A N/A N/A N/A N/A $188.77 N/A N/A $172.11 N/A N/A $113.82 N/A N/A $194.32 N/A N/A $222.08 N/A N/A $152.68 N/A N/A $194.32 N/A N/A $93.00 N/A N/A N/A N/A N/A $166.56 N/A N/A $97.16 N/A N/A $180.44 N/A N/A N/A N/A N/A $166.56 N/A N/A $194.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $277.60 $277.60 N/A 4407855 Pharmacy silver nitrate Top Stick [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409587 Pharmacy mirtazapine 30 mg Tab [BCH] 250 $5.53 $- $1.44 $- $- $4.43 $- N/A $1.44 N/A N/A $2.09 N/A N/A $3.32 N/A N/A $2.77 N/A N/A N/A N/A N/A $3.76 N/A N/A $3.43 N/A N/A $2.27 N/A N/A $3.87 N/A N/A $4.43 N/A N/A $3.04 N/A N/A $3.87 N/A N/A $1.85 N/A N/A N/A N/A N/A $3.32 N/A N/A $1.94 N/A N/A $3.60 N/A N/A N/A N/A N/A $3.32 N/A N/A $3.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.53 $5.53 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400610 Pharmacy oxyCODONE 15 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400858 Pharmacy amphetamine-dextroamphetamine 10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405013 Pharmacy LORazepam 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402316 Pharmacy PARoxetine 20 mg Tab [BCH] 250 $5.29 $- $1.37 $- $- $4.23 $- N/A $1.37 N/A N/A $2.00 N/A N/A $3.17 N/A N/A $2.64 N/A N/A N/A N/A N/A $3.59 N/A N/A $3.28 N/A N/A $2.17 N/A N/A $3.70 N/A N/A $4.23 N/A N/A $2.91 N/A N/A $3.70 N/A N/A $1.77 N/A N/A N/A N/A N/A $3.17 N/A N/A $1.85 N/A N/A $3.44 N/A N/A N/A N/A N/A $3.17 N/A N/A $3.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.29 $5.29 N/A 4409980 Pharmacy RHo (D) immune globulin 1500 intl units IM Sol [BCH] J2790 636 $220.54 $- $57.34 $- $- $176.43 $- N/A $57.34 N/A N/A Not Reimbursed N/A N/A $132.32 N/A N/A $110.27 N/A N/A N/A N/A N/A $149.97 N/A N/A $136.73 N/A N/A $90.42 N/A N/A $154.38 N/A N/A $176.43 N/A N/A $121.30 N/A N/A $154.38 N/A N/A $73.88 N/A N/A N/A N/A N/A $132.32 N/A N/A $77.19 N/A N/A $143.35 N/A N/A $84.90 N/A N/A $132.32 N/A N/A $154.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $220.54 $220.54 N/A 4405123 Pharmacy tetanus immune globulin 250 units Sol J1670 636 "$1,112.80 " $- $289.33 $- $- $890.24 $- N/A $289.33 N/A N/A Not Reimbursed N/A N/A $667.68 N/A N/A $556.40 N/A N/A N/A N/A N/A $756.70 N/A N/A $689.94 N/A N/A $456.25 N/A N/A $778.96 N/A N/A $890.24 N/A N/A $612.04 N/A N/A $778.96 N/A N/A $372.79 N/A N/A N/A N/A N/A $667.68 N/A N/A $389.48 N/A N/A $723.32 N/A N/A $535.78 N/A N/A $667.68 N/A N/A $778.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,112.80 " "$1,112.80 " N/A 4400649 Pharmacy immune globulin intravenous and subcutaneous 10% Sol [BCH] J1561 636 $313.00 $- $41.69 $- $- $250.40 $- N/A $81.38 N/A N/A Not Reimbursed N/A N/A $187.80 N/A N/A $156.50 N/A N/A N/A N/A N/A $212.84 N/A N/A $194.06 N/A N/A $128.33 N/A N/A $219.10 N/A N/A $250.40 N/A N/A $172.15 N/A N/A $219.10 N/A N/A $104.86 N/A N/A N/A N/A N/A $187.80 N/A N/A $109.55 N/A N/A $203.45 N/A N/A $41.69 N/A N/A $187.80 N/A N/A $219.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $313.00 $313.00 N/A 4400298 Pharmacy citalopram 40 mg Tab [BCH] 250 $5.56 $- $1.45 $- $- $4.45 $- N/A $1.45 N/A N/A $2.10 N/A N/A $3.34 N/A N/A $2.78 N/A N/A N/A N/A N/A $3.78 N/A N/A $3.45 N/A N/A $2.28 N/A N/A $3.89 N/A N/A $4.45 N/A N/A $3.06 N/A N/A $3.89 N/A N/A $1.86 N/A N/A N/A N/A N/A $3.34 N/A N/A $1.95 N/A N/A $3.61 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.56 $5.56 N/A 4400316 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $15.21 $- $3.96 $- $- $12.17 $- N/A $3.96 N/A N/A $5.75 N/A N/A $9.13 N/A N/A $7.61 N/A N/A N/A N/A N/A $10.35 N/A N/A $9.43 N/A N/A $6.24 N/A N/A $10.65 N/A N/A $12.17 N/A N/A $8.37 N/A N/A $10.65 N/A N/A $5.10 N/A N/A N/A N/A N/A $9.13 N/A N/A $5.32 N/A N/A $9.89 N/A N/A N/A N/A N/A $9.13 N/A N/A $10.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.21 $15.21 N/A 4400117 Pharmacy OLANZapine 5 mg Tab [BCH] 250 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400866 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $41.90 $- $10.89 $- $- $33.52 $- N/A $10.89 N/A N/A $15.84 N/A N/A $25.14 N/A N/A $20.95 N/A N/A N/A N/A N/A $28.49 N/A N/A $25.98 N/A N/A $17.18 N/A N/A $29.33 N/A N/A $33.52 N/A N/A $23.05 N/A N/A $29.33 N/A N/A $14.04 N/A N/A N/A N/A N/A $25.14 N/A N/A $14.67 N/A N/A $27.24 N/A N/A N/A N/A N/A $25.14 N/A N/A $29.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.90 $41.90 N/A 4400413 Pharmacy pramipexole 0.5 mg Tab [BCH] 250 $5.90 $- $1.53 $- $- $4.72 $- N/A $1.53 N/A N/A $2.23 N/A N/A $3.54 N/A N/A $2.95 N/A N/A N/A N/A N/A $4.01 N/A N/A $3.66 N/A N/A $2.42 N/A N/A $4.13 N/A N/A $4.72 N/A N/A $3.24 N/A N/A $4.13 N/A N/A $1.98 N/A N/A N/A N/A N/A $3.54 N/A N/A $2.06 N/A N/A $3.83 N/A N/A N/A N/A N/A $3.54 N/A N/A $4.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.90 $5.90 N/A 4400288 Pharmacy donepezil 5 mg Tab [BCH] 250 $15.58 $- $4.05 $- $- $12.46 $- N/A $4.05 N/A N/A $5.89 N/A N/A $9.35 N/A N/A $7.79 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.66 N/A N/A $6.39 N/A N/A $10.91 N/A N/A $12.46 N/A N/A $8.57 N/A N/A $10.91 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.35 N/A N/A $5.45 N/A N/A $10.13 N/A N/A N/A N/A N/A $9.35 N/A N/A $10.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.58 $15.58 N/A 4400288 Pharmacy donepezil 5 mg Tab [BCH] 250 $15.58 $- $4.05 $- $- $12.46 $- N/A $4.05 N/A N/A $5.89 N/A N/A $9.35 N/A N/A $7.79 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.66 N/A N/A $6.39 N/A N/A $10.91 N/A N/A $12.46 N/A N/A $8.57 N/A N/A $10.91 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.35 N/A N/A $5.45 N/A N/A $10.13 N/A N/A N/A N/A N/A $9.35 N/A N/A $10.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.58 $15.58 N/A 4407182 Pharmacy donepezil 10 mg Tab [BCH] 250 $15.58 $- $4.05 $- $- $12.46 $- N/A $4.05 N/A N/A $5.89 N/A N/A $9.35 N/A N/A $7.79 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.66 N/A N/A $6.39 N/A N/A $10.91 N/A N/A $12.46 N/A N/A $8.57 N/A N/A $10.91 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.35 N/A N/A $5.45 N/A N/A $10.13 N/A N/A N/A N/A N/A $9.35 N/A N/A $10.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.58 $15.58 N/A 4409457 Pharmacy isosorbide mononitrate 30 mg ER Tab [BCH] 250 $6.70 $- $1.74 $- $- $5.36 $- N/A $1.74 N/A N/A $2.53 N/A N/A $4.02 N/A N/A $3.35 N/A N/A N/A N/A N/A $4.56 N/A N/A $4.16 N/A N/A $2.75 N/A N/A $4.69 N/A N/A $5.36 N/A N/A $3.69 N/A N/A $4.69 N/A N/A $2.25 N/A N/A N/A N/A N/A $4.02 N/A N/A $2.35 N/A N/A $4.36 N/A N/A N/A N/A N/A $4.02 N/A N/A $4.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.70 $6.70 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $13.96 $- $3.63 $- $- $11.17 $- N/A $3.63 N/A N/A $5.28 N/A N/A $8.38 N/A N/A $6.98 N/A N/A N/A N/A N/A $9.49 N/A N/A $8.65 N/A N/A $5.72 N/A N/A $9.77 N/A N/A $11.17 N/A N/A $7.68 N/A N/A $9.77 N/A N/A $4.68 N/A N/A N/A N/A N/A $8.38 N/A N/A $4.89 N/A N/A $9.07 N/A N/A N/A N/A N/A $8.38 N/A N/A $9.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.96 $13.96 N/A 4400794 Pharmacy losartan 25 mg Tab [BCH] 250 $3.36 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.08 N/A N/A $1.38 N/A N/A $2.35 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.35 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.36 $3.36 N/A 4400627 Pharmacy sildenafil 20 mg oral tablet [BCH] 250 $42.14 $- $10.96 $- $- $33.71 $- N/A $10.96 N/A N/A $15.93 N/A N/A $25.28 N/A N/A $21.07 N/A N/A N/A N/A N/A $28.66 N/A N/A $26.13 N/A N/A $17.28 N/A N/A $29.50 N/A N/A $33.71 N/A N/A $23.18 N/A N/A $29.50 N/A N/A $14.12 N/A N/A N/A N/A N/A $25.28 N/A N/A $14.75 N/A N/A $27.39 N/A N/A N/A N/A N/A $25.28 N/A N/A $29.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.14 $42.14 N/A 4409475 Pharmacy tolterodine 2 mg ERCap [BCH] 250 $19.09 $- $4.96 $- $- $15.28 $- N/A $4.96 N/A N/A $7.22 N/A N/A $11.46 N/A N/A $9.55 N/A N/A N/A N/A N/A $12.98 N/A N/A $11.84 N/A N/A $7.83 N/A N/A $13.37 N/A N/A $15.28 N/A N/A $10.50 N/A N/A $13.37 N/A N/A $6.40 N/A N/A N/A N/A N/A $11.46 N/A N/A $6.68 N/A N/A $12.41 N/A N/A N/A N/A N/A $11.46 N/A N/A $13.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.09 $19.09 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.96 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.96 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4400883 Pharmacy ARIPiprazole 10 mg Tab 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.96 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.96 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4400883 Pharmacy ARIPiprazole 10 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.96 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.96 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4405277 Pharmacy carBAMazepine 100 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400066 Pharmacy losartan 50 mg Tab [BCH] 250 $4.52 $- $1.18 $- $- $3.62 $- N/A $1.18 N/A N/A $1.71 N/A N/A $2.71 N/A N/A $2.26 N/A N/A N/A N/A N/A $3.08 N/A N/A $2.81 N/A N/A $1.86 N/A N/A $3.17 N/A N/A $3.62 N/A N/A $2.49 N/A N/A $3.17 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.71 N/A N/A $1.58 N/A N/A $2.94 N/A N/A N/A N/A N/A $2.71 N/A N/A $3.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.52 $4.52 N/A 4400515 Pharmacy risperiDONE 1 mg/mL Sol [BCH] 250 $305.12 $- $79.33 $- $- $244.10 $- N/A $79.33 N/A N/A $115.34 N/A N/A $183.07 N/A N/A $152.56 N/A N/A N/A N/A N/A $207.48 N/A N/A $189.17 N/A N/A $125.10 N/A N/A $213.58 N/A N/A $244.10 N/A N/A $167.82 N/A N/A $213.58 N/A N/A $102.22 N/A N/A N/A N/A N/A $183.07 N/A N/A $106.79 N/A N/A $198.33 N/A N/A N/A N/A N/A $183.07 N/A N/A $213.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $305.12 $305.12 N/A 4407442 Pharmacy procainamide 500 mg/mL Sol J2690 636 $150.00 $- $39.00 $- $- $120.00 $- N/A $39.00 N/A N/A Not Reimbursed N/A N/A $90.00 N/A N/A $75.00 N/A N/A N/A N/A N/A $102.00 N/A N/A $93.00 N/A N/A $61.50 N/A N/A $105.00 N/A N/A $120.00 N/A N/A $82.50 N/A N/A $105.00 N/A N/A $50.25 N/A N/A N/A N/A N/A $90.00 N/A N/A $52.50 N/A N/A $97.50 N/A N/A $90.52 N/A N/A $90.00 N/A N/A $105.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $150.00 $150.00 N/A 4401692 Pharmacy hydrocortisone topical 25 mg Sup [BCH] 250 $43.03 $- $11.19 $- $- $34.42 $- N/A $11.19 N/A N/A $16.26 N/A N/A $25.82 N/A N/A $21.51 N/A N/A N/A N/A N/A $29.26 N/A N/A $26.68 N/A N/A $17.64 N/A N/A $30.12 N/A N/A $34.42 N/A N/A $23.67 N/A N/A $30.12 N/A N/A $14.41 N/A N/A N/A N/A N/A $25.82 N/A N/A $15.06 N/A N/A $27.97 N/A N/A N/A N/A N/A $25.82 N/A N/A $30.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $43.03 $43.03 N/A 4409748 Pharmacy trihexyphenidyl 2 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400953 Pharmacy trihexyphenidyl 5 mg Tab 250 $2.20 $- $0.57 $- $- $1.76 $- N/A $0.57 N/A N/A $0.83 N/A N/A $1.32 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.50 N/A N/A $1.36 N/A N/A $0.90 N/A N/A $1.54 N/A N/A $1.76 N/A N/A $1.21 N/A N/A $1.54 N/A N/A $0.74 N/A N/A N/A N/A N/A $1.32 N/A N/A $0.77 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.32 N/A N/A $1.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.20 $2.20 N/A 4400691 Pharmacy fluPHENAZine 5 mg Tab [BCH] 250 $18.40 $- $4.78 $- $- $14.72 $- N/A $4.78 N/A N/A $6.96 N/A N/A $11.04 N/A N/A $9.20 N/A N/A N/A N/A N/A $12.51 N/A N/A $11.41 N/A N/A $7.54 N/A N/A $12.88 N/A N/A $14.72 N/A N/A $10.12 N/A N/A $12.88 N/A N/A $6.16 N/A N/A N/A N/A N/A $11.04 N/A N/A $6.44 N/A N/A $11.96 N/A N/A N/A N/A N/A $11.04 N/A N/A $12.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.40 $18.40 N/A 4400708 Pharmacy isosorbide dinitrate 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol [BCH] J1650 636 $33.74 $- $0.69 $- $- $26.99 $- N/A $8.77 N/A N/A Not Reimbursed N/A N/A $20.24 N/A N/A $16.87 N/A N/A N/A N/A N/A $22.94 N/A N/A $20.92 N/A N/A $13.83 N/A N/A $23.62 N/A N/A $26.99 N/A N/A $18.56 N/A N/A $23.62 N/A N/A $11.30 N/A N/A N/A N/A N/A $20.24 N/A N/A $11.81 N/A N/A $21.93 N/A N/A $0.69 N/A N/A $20.24 N/A N/A $23.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.74 $33.74 N/A 4409459 Pharmacy budesonide 0.25 mg/2 mL Sus [BCH] J7626 636 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $1.78 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404387 Pharmacy propranolol 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $6.96 $- $1.81 $- $- $5.57 $- N/A $1.81 N/A N/A $2.63 N/A N/A $4.18 N/A N/A $3.48 N/A N/A N/A N/A N/A $4.74 N/A N/A $4.32 N/A N/A $2.86 N/A N/A $4.88 N/A N/A $5.57 N/A N/A $3.83 N/A N/A $4.88 N/A N/A $2.33 N/A N/A N/A N/A N/A $4.18 N/A N/A $2.44 N/A N/A $4.53 N/A N/A N/A N/A N/A $4.18 N/A N/A $4.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.96 $6.96 N/A 4408564 Pharmacy allopurinol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408564 Pharmacy allopurinol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400526 Pharmacy allopurinol 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408655 Pharmacy chlorproMAZINE 25 mg Tab [BCH] 250 $14.88 $- $3.87 $- $- $11.91 $- N/A $3.87 N/A N/A $5.63 N/A N/A $8.93 N/A N/A $7.44 N/A N/A N/A N/A N/A $10.12 N/A N/A $9.23 N/A N/A $6.10 N/A N/A $10.42 N/A N/A $11.91 N/A N/A $8.19 N/A N/A $10.42 N/A N/A $4.99 N/A N/A N/A N/A N/A $8.93 N/A N/A $5.21 N/A N/A $9.67 N/A N/A N/A N/A N/A $8.93 N/A N/A $10.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.88 $14.88 N/A 4409411 Pharmacy mupirocin topical 2% Cre [BCH] 250 $831.12 $- $216.09 $- $- $664.90 $- N/A $216.09 N/A N/A $314.16 N/A N/A $498.67 N/A N/A $415.56 N/A N/A N/A N/A N/A $565.16 N/A N/A $515.29 N/A N/A $340.76 N/A N/A $581.78 N/A N/A $664.90 N/A N/A $457.12 N/A N/A $581.78 N/A N/A $278.43 N/A N/A N/A N/A N/A $498.67 N/A N/A $290.89 N/A N/A $540.23 N/A N/A N/A N/A N/A $498.67 N/A N/A $581.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $831.12 $831.12 N/A 4409881 Pharmacy metoclopramide 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401941 Pharmacy metoclopramide 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407364 Pharmacy baclofen 10 mg Tab [BCH] 250 $4.94 $- $1.28 $- $- $3.95 $- N/A $1.28 N/A N/A $1.87 N/A N/A $2.97 N/A N/A $2.47 N/A N/A N/A N/A N/A $3.36 N/A N/A $3.06 N/A N/A $2.03 N/A N/A $3.46 N/A N/A $3.95 N/A N/A $2.72 N/A N/A $3.46 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.97 N/A N/A $1.73 N/A N/A $3.21 N/A N/A N/A N/A N/A $2.97 N/A N/A $3.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.94 $4.94 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400578 Pharmacy lidocaine topical 2% Sol [BCH] 250 $26.40 $- $6.86 $- $- $21.12 $- N/A $6.86 N/A N/A $9.98 N/A N/A $15.84 N/A N/A $13.20 N/A N/A N/A N/A N/A $17.95 N/A N/A $16.37 N/A N/A $10.82 N/A N/A $18.48 N/A N/A $21.12 N/A N/A $14.52 N/A N/A $18.48 N/A N/A $8.84 N/A N/A N/A N/A N/A $15.84 N/A N/A $9.24 N/A N/A $17.16 N/A N/A N/A N/A N/A $15.84 N/A N/A $18.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.40 $26.40 N/A 4402233 Pharmacy gemfibrozil 600 mg Tab [BCH] 250 $4.36 $- $1.13 $- $- $3.49 $- N/A $1.13 N/A N/A $1.65 N/A N/A $2.62 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.97 N/A N/A $2.70 N/A N/A $1.79 N/A N/A $3.05 N/A N/A $3.49 N/A N/A $2.40 N/A N/A $3.05 N/A N/A $1.46 N/A N/A N/A N/A N/A $2.62 N/A N/A $1.53 N/A N/A $2.83 N/A N/A N/A N/A N/A $2.62 N/A N/A $3.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.36 $4.36 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [bch] 250 $8.37 $- $2.18 $- $- $6.70 $- N/A $2.18 N/A N/A $3.16 N/A N/A $5.02 N/A N/A $4.19 N/A N/A N/A N/A N/A $5.69 N/A N/A $5.19 N/A N/A $3.43 N/A N/A $5.86 N/A N/A $6.70 N/A N/A $4.60 N/A N/A $5.86 N/A N/A $2.80 N/A N/A N/A N/A N/A $5.02 N/A N/A $2.93 N/A N/A $5.44 N/A N/A N/A N/A N/A $5.02 N/A N/A $5.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.37 $8.37 N/A 4408941 Pharmacy chlorthalidone 25 mg Tab [bch] 250 $2.41 $- $0.63 $- $- $1.93 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.93 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.84 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4400753 Pharmacy doxepin 100 mg Cap [BCH] 250 $3.95 $- $1.03 $- $- $3.16 $- N/A $1.03 N/A N/A $1.49 N/A N/A $2.37 N/A N/A $1.97 N/A N/A N/A N/A N/A $2.68 N/A N/A $2.45 N/A N/A $1.62 N/A N/A $2.76 N/A N/A $3.16 N/A N/A $2.17 N/A N/A $2.76 N/A N/A $1.32 N/A N/A N/A N/A N/A $2.37 N/A N/A $1.38 N/A N/A $2.57 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.95 $3.95 N/A 4400143 Pharmacy atorvastatin 80 mg Tab 250 $11.42 $- $2.97 $- $- $9.14 $- N/A $2.97 N/A N/A $4.32 N/A N/A $6.85 N/A N/A $5.71 N/A N/A N/A N/A N/A $7.77 N/A N/A $7.08 N/A N/A $4.68 N/A N/A $7.99 N/A N/A $9.14 N/A N/A $6.28 N/A N/A $7.99 N/A N/A $3.83 N/A N/A N/A N/A N/A $6.85 N/A N/A $4.00 N/A N/A $7.42 N/A N/A N/A N/A N/A $6.85 N/A N/A $7.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.42 $11.42 N/A 4400719 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $45.13 $- $0.02 $- $- $36.11 $- N/A $11.73 N/A N/A Not Reimbursed N/A N/A $27.08 N/A N/A $22.57 N/A N/A N/A N/A N/A $30.69 N/A N/A $27.98 N/A N/A $18.50 N/A N/A $31.59 N/A N/A $36.11 N/A N/A $24.82 N/A N/A $31.59 N/A N/A $15.12 N/A N/A N/A N/A N/A $27.08 N/A N/A $15.80 N/A N/A $29.34 N/A N/A $0.02 N/A N/A $27.08 N/A N/A $31.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.13 $45.13 N/A 4407053 Pharmacy Penicillin V Potassium 250 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400354 Pharmacy amoxicillin-clavulanate 200 mg-28.5 mg/5 mL Oral Liq 50 mL [BCH] 250 $36.90 $- $9.59 $- $- $29.52 $- N/A $9.59 N/A N/A $13.95 N/A N/A $22.14 N/A N/A $18.45 N/A N/A N/A N/A N/A $25.09 N/A N/A $22.88 N/A N/A $15.13 N/A N/A $25.83 N/A N/A $29.52 N/A N/A $20.30 N/A N/A $25.83 N/A N/A $12.36 N/A N/A N/A N/A N/A $22.14 N/A N/A $12.92 N/A N/A $23.99 N/A N/A N/A N/A N/A $22.14 N/A N/A $25.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.90 $36.90 N/A 4400353 Pharmacy amoxicillin-clavulanate 500 mg-125 mg Tab [BCH] 250 $7.57 $- $1.97 $- $- $6.06 $- N/A $1.97 N/A N/A $2.86 N/A N/A $4.54 N/A N/A $3.78 N/A N/A N/A N/A N/A $5.15 N/A N/A $4.69 N/A N/A $3.10 N/A N/A $5.30 N/A N/A $6.06 N/A N/A $4.16 N/A N/A $5.30 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.54 N/A N/A $2.65 N/A N/A $4.92 N/A N/A N/A N/A N/A $4.54 N/A N/A $5.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.57 $7.57 N/A 4407612 Pharmacy amoxicillin-clavulanate 875 mg-125 mg Tab [BCH] 250 $10.10 $- $2.63 $- $- $8.08 $- N/A $2.63 N/A N/A $3.82 N/A N/A $6.06 N/A N/A $5.05 N/A N/A N/A N/A N/A $6.87 N/A N/A $6.26 N/A N/A $4.14 N/A N/A $7.07 N/A N/A $8.08 N/A N/A $5.56 N/A N/A $7.07 N/A N/A $3.38 N/A N/A N/A N/A N/A $6.06 N/A N/A $3.54 N/A N/A $6.57 N/A N/A N/A N/A N/A $6.06 N/A N/A $7.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.10 $10.10 N/A 4409499 Pharmacy amoxicillin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4405285 Pharmacy famciclovir 500 mg Tab [BCH] 250 $44.70 $- $11.62 $- $- $35.76 $- N/A $11.62 N/A N/A $16.90 N/A N/A $26.82 N/A N/A $22.35 N/A N/A N/A N/A N/A $30.40 N/A N/A $27.71 N/A N/A $18.33 N/A N/A $31.29 N/A N/A $35.76 N/A N/A $24.59 N/A N/A $31.29 N/A N/A $14.97 N/A N/A N/A N/A N/A $26.82 N/A N/A $15.65 N/A N/A $29.06 N/A N/A N/A N/A N/A $26.82 N/A N/A $31.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.70 $44.70 N/A 4400372 Pharmacy venlafaxine 37.5 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405095 Pharmacy FLUoxetine 10 mg Cap [BCH] 250 $5.20 $- $1.35 $- $- $4.16 $- N/A $1.35 N/A N/A $1.96 N/A N/A $3.12 N/A N/A $2.60 N/A N/A N/A N/A N/A $3.53 N/A N/A $3.22 N/A N/A $2.13 N/A N/A $3.64 N/A N/A $4.16 N/A N/A $2.86 N/A N/A $3.64 N/A N/A $1.74 N/A N/A N/A N/A N/A $3.12 N/A N/A $1.82 N/A N/A $3.38 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.20 $5.20 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap [BCH] 250 $5.33 $- $1.39 $- $- $4.26 $- N/A $1.39 N/A N/A $2.02 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.63 N/A N/A $3.31 N/A N/A $2.19 N/A N/A $3.73 N/A N/A $4.26 N/A N/A $2.93 N/A N/A $3.73 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.47 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.33 $5.33 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $7.03 $- $1.83 $- $- $5.62 $- N/A $1.83 N/A N/A $2.66 N/A N/A $4.22 N/A N/A $3.51 N/A N/A N/A N/A N/A $4.78 N/A N/A $4.36 N/A N/A $2.88 N/A N/A $4.92 N/A N/A $5.62 N/A N/A $3.87 N/A N/A $4.92 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.22 N/A N/A $2.46 N/A N/A $4.57 N/A N/A N/A N/A N/A $4.22 N/A N/A $4.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.03 $7.03 N/A 4401009 Pharmacy levETIRAcetam 100 mg/mL Sol 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400864 Pharmacy levETIRAcetam 100 mg/mL Sol 250 $6.09 $- $1.58 $- $- $4.87 $- N/A $1.58 N/A N/A $2.30 N/A N/A $3.66 N/A N/A $3.05 N/A N/A N/A N/A N/A $4.14 N/A N/A $3.78 N/A N/A $2.50 N/A N/A $4.27 N/A N/A $4.87 N/A N/A $3.35 N/A N/A $4.27 N/A N/A $2.04 N/A N/A N/A N/A N/A $3.66 N/A N/A $2.13 N/A N/A $3.96 N/A N/A N/A N/A N/A $3.66 N/A N/A $4.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.09 $6.09 N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab [BCH] 250 $8.48 $- $2.20 $- $- $6.78 $- N/A $2.20 N/A N/A $3.20 N/A N/A $5.09 N/A N/A $4.24 N/A N/A N/A N/A N/A $5.76 N/A N/A $5.26 N/A N/A $3.48 N/A N/A $5.93 N/A N/A $6.78 N/A N/A $4.66 N/A N/A $5.93 N/A N/A $2.84 N/A N/A N/A N/A N/A $5.09 N/A N/A $2.97 N/A N/A $5.51 N/A N/A N/A N/A N/A $5.09 N/A N/A $5.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.48 $8.48 N/A 4401902 Pharmacy lamoTRIgine 100 mg Tab [BCH] 250 $9.71 $- $2.52 $- $- $7.77 $- N/A $2.52 N/A N/A $3.67 N/A N/A $5.82 N/A N/A $4.85 N/A N/A N/A N/A N/A $6.60 N/A N/A $6.02 N/A N/A $3.98 N/A N/A $6.80 N/A N/A $7.77 N/A N/A $5.34 N/A N/A $6.80 N/A N/A $3.25 N/A N/A N/A N/A N/A $5.82 N/A N/A $3.40 N/A N/A $6.31 N/A N/A N/A N/A N/A $5.82 N/A N/A $6.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.71 $9.71 N/A 4401962 Pharmacy QUEtiapine 25 mg Tab [BCH] 250 $7.99 $- $2.08 $- $- $6.39 $- N/A $2.08 N/A N/A $3.02 N/A N/A $4.80 N/A N/A $4.00 N/A N/A N/A N/A N/A $5.43 N/A N/A $4.96 N/A N/A $3.28 N/A N/A $5.59 N/A N/A $6.39 N/A N/A $4.40 N/A N/A $5.59 N/A N/A $2.68 N/A N/A N/A N/A N/A $4.80 N/A N/A $2.80 N/A N/A $5.19 N/A N/A N/A N/A N/A $4.80 N/A N/A $5.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.99 $7.99 N/A 4400433 Pharmacy QUEtiapine 50 mg oral tablet [BCH] 250 $13.13 $- $3.41 $- $- $10.51 $- N/A $3.41 N/A N/A $4.96 N/A N/A $7.88 N/A N/A $6.57 N/A N/A N/A N/A N/A $8.93 N/A N/A $8.14 N/A N/A $5.38 N/A N/A $9.19 N/A N/A $10.51 N/A N/A $7.22 N/A N/A $9.19 N/A N/A $4.40 N/A N/A N/A N/A N/A $7.88 N/A N/A $4.60 N/A N/A $8.54 N/A N/A N/A N/A N/A $7.88 N/A N/A $9.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.13 $13.13 N/A 4400118 Pharmacy QUEtiapine 100 mg Tab [BCH] 250 $13.72 $- $3.57 $- $- $10.97 $- N/A $3.57 N/A N/A $5.18 N/A N/A $8.23 N/A N/A $6.86 N/A N/A N/A N/A N/A $9.33 N/A N/A $8.50 N/A N/A $5.62 N/A N/A $9.60 N/A N/A $10.97 N/A N/A $7.54 N/A N/A $9.60 N/A N/A $4.59 N/A N/A N/A N/A N/A $8.23 N/A N/A $4.80 N/A N/A $8.91 N/A N/A N/A N/A N/A $8.23 N/A N/A $9.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.72 $13.72 N/A 4400587 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 $25.87 $- $6.73 $- $- $20.70 $- N/A $6.73 N/A N/A $9.78 N/A N/A $15.52 N/A N/A $12.94 N/A N/A N/A N/A N/A $17.59 N/A N/A $16.04 N/A N/A $10.61 N/A N/A $18.11 N/A N/A $20.70 N/A N/A $14.23 N/A N/A $18.11 N/A N/A $8.67 N/A N/A N/A N/A N/A $15.52 N/A N/A $9.06 N/A N/A $16.82 N/A N/A N/A N/A N/A $15.52 N/A N/A $18.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.87 $25.87 N/A 4400322 Pharmacy QUEtiapine 300 mg Tab [BCH] 250 $33.93 $- $8.82 $- $- $27.14 $- N/A $8.82 N/A N/A $12.82 N/A N/A $20.36 N/A N/A $16.96 N/A N/A N/A N/A N/A $23.07 N/A N/A $21.03 N/A N/A $13.91 N/A N/A $23.75 N/A N/A $27.14 N/A N/A $18.66 N/A N/A $23.75 N/A N/A $11.36 N/A N/A N/A N/A N/A $20.36 N/A N/A $11.87 N/A N/A $22.05 N/A N/A N/A N/A N/A $20.36 N/A N/A $23.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.93 $33.93 N/A 4400783 Pharmacy cefdinir 300 mg Cap [BCH] 250 $10.23 $- $2.66 $- $- $8.18 $- N/A $2.66 N/A N/A $3.87 N/A N/A $6.14 N/A N/A $5.11 N/A N/A N/A N/A N/A $6.96 N/A N/A $6.34 N/A N/A $4.19 N/A N/A $7.16 N/A N/A $8.18 N/A N/A $5.63 N/A N/A $7.16 N/A N/A $3.43 N/A N/A N/A N/A N/A $6.14 N/A N/A $3.58 N/A N/A $6.65 N/A N/A N/A N/A N/A $6.14 N/A N/A $7.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.23 $10.23 N/A 4400783 Pharmacy cefdinir 300 mg Cap 250 $10.23 $- $2.66 $- $- $8.18 $- N/A $2.66 N/A N/A $3.87 N/A N/A $6.14 N/A N/A $5.11 N/A N/A N/A N/A N/A $6.95 N/A N/A $6.34 N/A N/A $4.19 N/A N/A $7.16 N/A N/A $8.18 N/A N/A $5.63 N/A N/A $7.16 N/A N/A $3.43 N/A N/A N/A N/A N/A $6.14 N/A N/A $3.58 N/A N/A $6.65 N/A N/A N/A N/A N/A $6.14 N/A N/A $7.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.23 $10.23 N/A 4403002 Pharmacy cefuroxime 250 mg Tab [BCH] 250 $8.73 $- $2.27 $- $- $6.98 $- N/A $2.27 N/A N/A $3.30 N/A N/A $5.24 N/A N/A $4.36 N/A N/A N/A N/A N/A $5.93 N/A N/A $5.41 N/A N/A $3.58 N/A N/A $6.11 N/A N/A $6.98 N/A N/A $4.80 N/A N/A $6.11 N/A N/A $2.92 N/A N/A N/A N/A N/A $5.24 N/A N/A $3.05 N/A N/A $5.67 N/A N/A N/A N/A N/A $5.24 N/A N/A $6.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.73 $8.73 N/A 4401847 Pharmacy nitrofurantoin macrocrystals-monohydrate 100 mg Cap [BCH] 250 $6.10 $- $1.59 $- $- $4.88 $- N/A $1.59 N/A N/A $2.30 N/A N/A $3.66 N/A N/A $3.05 N/A N/A N/A N/A N/A $4.15 N/A N/A $3.78 N/A N/A $2.50 N/A N/A $4.27 N/A N/A $4.88 N/A N/A $3.35 N/A N/A $4.27 N/A N/A $2.04 N/A N/A N/A N/A N/A $3.66 N/A N/A $2.13 N/A N/A $3.96 N/A N/A N/A N/A N/A $3.66 N/A N/A $4.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.10 $6.10 N/A 4405370 Pharmacy amitriptyline 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401962 Pharmacy QUEtiapine 25 mg Tab [BCH] 250 $7.22 $- $1.88 $- $- $5.78 $- N/A $1.88 N/A N/A $2.73 N/A N/A $4.33 N/A N/A $3.61 N/A N/A N/A N/A N/A $4.91 N/A N/A $4.48 N/A N/A $2.96 N/A N/A $5.06 N/A N/A $5.78 N/A N/A $3.97 N/A N/A $5.06 N/A N/A $2.42 N/A N/A N/A N/A N/A $4.33 N/A N/A $2.53 N/A N/A $4.70 N/A N/A N/A N/A N/A $4.33 N/A N/A $5.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.22 $7.22 N/A 4400433 Pharmacy QUEtiapine 50 mg Tab [BCH] 250 $13.04 $- $3.39 $- $- $10.43 $- N/A $3.39 N/A N/A $4.93 N/A N/A $7.83 N/A N/A $6.52 N/A N/A N/A N/A N/A $8.87 N/A N/A $8.09 N/A N/A $5.35 N/A N/A $9.13 N/A N/A $10.43 N/A N/A $7.17 N/A N/A $9.13 N/A N/A $4.37 N/A N/A N/A N/A N/A $7.83 N/A N/A $4.57 N/A N/A $8.48 N/A N/A N/A N/A N/A $7.83 N/A N/A $9.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.04 $13.04 N/A 4400118 Pharmacy QUEtiapine 100 mg Tab [BCH] 250 $12.37 $- $3.22 $- $- $9.89 $- N/A $3.22 N/A N/A $4.68 N/A N/A $7.42 N/A N/A $6.18 N/A N/A N/A N/A N/A $8.41 N/A N/A $7.67 N/A N/A $5.07 N/A N/A $8.66 N/A N/A $9.89 N/A N/A $6.80 N/A N/A $8.66 N/A N/A $4.14 N/A N/A N/A N/A N/A $7.42 N/A N/A $4.33 N/A N/A $8.04 N/A N/A N/A N/A N/A $7.42 N/A N/A $8.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.37 $12.37 N/A 4400587 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 $23.28 $- $6.05 $- $- $18.63 $- N/A $6.05 N/A N/A $8.80 N/A N/A $13.97 N/A N/A $11.64 N/A N/A N/A N/A N/A $15.83 N/A N/A $14.44 N/A N/A $9.55 N/A N/A $16.30 N/A N/A $18.63 N/A N/A $12.81 N/A N/A $16.30 N/A N/A $7.80 N/A N/A N/A N/A N/A $13.97 N/A N/A $8.15 N/A N/A $15.13 N/A N/A N/A N/A N/A $13.97 N/A N/A $16.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.28 $23.28 N/A 4400322 Pharmacy QUEtiapine 300 mg Tab [BCS] 250 $33.76 $- $8.78 $- $- $27.01 $- N/A $8.78 N/A N/A $12.76 N/A N/A $20.26 N/A N/A $16.88 N/A N/A N/A N/A N/A $22.96 N/A N/A $20.93 N/A N/A $13.84 N/A N/A $23.63 N/A N/A $27.01 N/A N/A $18.57 N/A N/A $23.63 N/A N/A $11.31 N/A N/A N/A N/A N/A $20.26 N/A N/A $11.82 N/A N/A $21.94 N/A N/A N/A N/A N/A $20.26 N/A N/A $23.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.76 $33.76 N/A 4400452 Pharmacy QUEtiapine 400 mg oral tablet [BCH] 250 $35.87 $- $9.33 $- $- $28.69 $- N/A $9.33 N/A N/A $13.56 N/A N/A $21.52 N/A N/A $17.93 N/A N/A N/A N/A N/A $24.39 N/A N/A $22.24 N/A N/A $14.71 N/A N/A $25.11 N/A N/A $28.69 N/A N/A $19.73 N/A N/A $25.11 N/A N/A $12.02 N/A N/A N/A N/A N/A $21.52 N/A N/A $12.55 N/A N/A $23.31 N/A N/A N/A N/A N/A $21.52 N/A N/A $25.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.87 $35.87 N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400353 Pharmacy amoxicillin-clavulanate 500 mg-125 mg Tab [BCH] 250 $7.57 $- $1.97 $- $- $6.06 $- N/A $1.97 N/A N/A $2.86 N/A N/A $4.54 N/A N/A $3.78 N/A N/A N/A N/A N/A $5.15 N/A N/A $4.69 N/A N/A $3.10 N/A N/A $5.30 N/A N/A $6.06 N/A N/A $4.16 N/A N/A $5.30 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.54 N/A N/A $2.65 N/A N/A $4.92 N/A N/A N/A N/A N/A $4.54 N/A N/A $5.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.57 $7.57 N/A 4407612 Pharmacy amoxicillin-clavulanate 875 mg-125 mg Tab [BCH] 250 $10.10 $- $2.63 $- $- $8.08 $- N/A $2.63 N/A N/A $3.82 N/A N/A $6.06 N/A N/A $5.05 N/A N/A N/A N/A N/A $6.87 N/A N/A $6.26 N/A N/A $4.14 N/A N/A $7.07 N/A N/A $8.08 N/A N/A $5.56 N/A N/A $7.07 N/A N/A $3.38 N/A N/A N/A N/A N/A $6.06 N/A N/A $3.54 N/A N/A $6.57 N/A N/A N/A N/A N/A $6.06 N/A N/A $7.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.10 $10.10 N/A 4407612 Pharmacy amoxicillin-clavulanate 875 mg-125 mg Tab [BCH] 250 $9.85 $- $2.56 $- $- $7.88 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.91 N/A N/A $4.93 N/A N/A N/A N/A N/A $6.70 N/A N/A $6.11 N/A N/A $4.04 N/A N/A $6.90 N/A N/A $7.88 N/A N/A $5.42 N/A N/A $6.90 N/A N/A $3.30 N/A N/A N/A N/A N/A $5.91 N/A N/A $3.45 N/A N/A $6.40 N/A N/A N/A N/A N/A $5.91 N/A N/A $6.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.85 $9.85 N/A 4404163 Pharmacy loratadine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404163 Pharmacy loratadine 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400854 Pharmacy DIVALPROEX SODIUM ER 500 mg Tab-ER [BCH] 250 $8.15 $- $2.12 $- $- $6.52 $- N/A $2.12 N/A N/A $3.08 N/A N/A $4.89 N/A N/A $4.07 N/A N/A N/A N/A N/A $5.54 N/A N/A $5.05 N/A N/A $3.34 N/A N/A $5.70 N/A N/A $6.52 N/A N/A $4.48 N/A N/A $5.70 N/A N/A $2.73 N/A N/A N/A N/A N/A $4.89 N/A N/A $2.85 N/A N/A $5.30 N/A N/A N/A N/A N/A $4.89 N/A N/A $5.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.15 $8.15 N/A 4400353 Pharmacy amoxicillin-clavulanate 500 mg-125 mg Tab [BCH] 250 $7.57 $- $1.97 $- $- $6.06 $- N/A $1.97 N/A N/A $2.86 N/A N/A $4.54 N/A N/A $3.78 N/A N/A N/A N/A N/A $5.15 N/A N/A $4.69 N/A N/A $3.10 N/A N/A $5.30 N/A N/A $6.06 N/A N/A $4.16 N/A N/A $5.30 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.54 N/A N/A $2.65 N/A N/A $4.92 N/A N/A N/A N/A N/A $4.54 N/A N/A $5.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.57 $7.57 N/A 4400368 Pharmacy betamethasone-clotrimazole top 0.05%-1% Cm [BCH] 250 $74.62 $- $19.40 $- $- $59.70 $- N/A $19.40 N/A N/A $28.21 N/A N/A $44.77 N/A N/A $37.31 N/A N/A N/A N/A N/A $50.74 N/A N/A $46.26 N/A N/A $30.59 N/A N/A $52.23 N/A N/A $59.70 N/A N/A $41.04 N/A N/A $52.23 N/A N/A $25.00 N/A N/A N/A N/A N/A $44.77 N/A N/A $26.12 N/A N/A $48.50 N/A N/A N/A N/A N/A $44.77 N/A N/A $52.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $74.62 $74.62 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $3.19 $- $0.83 $- $- $2.55 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.98 N/A N/A $1.31 N/A N/A $2.24 N/A N/A $2.55 N/A N/A $1.76 N/A N/A $2.24 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.19 $3.19 N/A 4407939 Pharmacy carisoprodol 350 mg Tab [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4409447 Pharmacy SUMAtriptan 50 mg Tab [BCH] 250 $50.28 $- $13.07 $- $- $40.22 $- N/A $13.07 N/A N/A $19.01 N/A N/A $30.17 N/A N/A $25.14 N/A N/A N/A N/A N/A $34.19 N/A N/A $31.17 N/A N/A $20.61 N/A N/A $35.20 N/A N/A $40.22 N/A N/A $27.65 N/A N/A $35.20 N/A N/A $16.84 N/A N/A N/A N/A N/A $30.17 N/A N/A $17.60 N/A N/A $32.68 N/A N/A N/A N/A N/A $30.17 N/A N/A $35.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.28 $50.28 N/A 4400066 Pharmacy losartan 50 mg Tab [BCH] 250 $4.53 $- $1.18 $- $- $3.62 $- N/A $1.18 N/A N/A $1.71 N/A N/A $2.72 N/A N/A $2.26 N/A N/A N/A N/A N/A $3.08 N/A N/A $2.81 N/A N/A $1.86 N/A N/A $3.17 N/A N/A $3.62 N/A N/A $2.49 N/A N/A $3.17 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.72 N/A N/A $1.58 N/A N/A $2.94 N/A N/A N/A N/A N/A $2.72 N/A N/A $3.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.53 $4.53 N/A 4409664 Pharmacy digoxin 125 mcg (0.125 mg) Tab [BCH] 250 $3.72 $- $0.97 $- $- $2.98 $- N/A $0.97 N/A N/A $1.41 N/A N/A $2.23 N/A N/A $1.86 N/A N/A N/A N/A N/A $2.53 N/A N/A $2.31 N/A N/A $1.53 N/A N/A $2.61 N/A N/A $2.98 N/A N/A $2.05 N/A N/A $2.61 N/A N/A $1.25 N/A N/A N/A N/A N/A $2.23 N/A N/A $1.30 N/A N/A $2.42 N/A N/A N/A N/A N/A $2.23 N/A N/A $2.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.72 $3.72 N/A 4400557 Pharmacy sertraline 25 mg Tab [BCH] 250 $5.56 $- $1.44 $- $- $4.45 $- N/A $1.44 N/A N/A $2.10 N/A N/A $3.33 N/A N/A $2.78 N/A N/A N/A N/A N/A $3.78 N/A N/A $3.44 N/A N/A $2.28 N/A N/A $3.89 N/A N/A $4.45 N/A N/A $3.06 N/A N/A $3.89 N/A N/A $1.86 N/A N/A N/A N/A N/A $3.33 N/A N/A $1.94 N/A N/A $3.61 N/A N/A N/A N/A N/A $3.33 N/A N/A $3.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.56 $5.56 N/A 4401987 Pharmacy sertraline 50 mg Tab [BCH] 250 $5.51 $- $1.43 $- $- $4.41 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.30 N/A N/A $2.75 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.41 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.41 N/A N/A $3.03 N/A N/A $3.86 N/A N/A $1.84 N/A N/A N/A N/A N/A $3.30 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.51 $5.51 N/A 4400345 Pharmacy sertraline 100 mg Tab [BCH] 250 $5.51 $- $1.43 $- $- $4.41 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.30 N/A N/A $2.75 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.41 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.41 N/A N/A $3.03 N/A N/A $3.86 N/A N/A $1.84 N/A N/A N/A N/A N/A $3.30 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.51 $5.51 N/A 4405285 Pharmacy famciclovir 500 mg Tab [BCH] 250 $25.71 $- $6.68 $- $- $20.57 $- N/A $6.68 N/A N/A $9.72 N/A N/A $15.43 N/A N/A $12.86 N/A N/A N/A N/A N/A $17.48 N/A N/A $15.94 N/A N/A $10.54 N/A N/A $18.00 N/A N/A $20.57 N/A N/A $14.14 N/A N/A $18.00 N/A N/A $8.61 N/A N/A N/A N/A N/A $15.43 N/A N/A $9.00 N/A N/A $16.71 N/A N/A N/A N/A N/A $15.43 N/A N/A $18.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.71 $25.71 N/A 4404254 Pharmacy zolpidem 5 mg Tab [BCH] 250 $9.24 $- $2.40 $- $- $7.39 $- N/A $2.40 N/A N/A $3.49 N/A N/A $5.54 N/A N/A $4.62 N/A N/A N/A N/A N/A $6.28 N/A N/A $5.73 N/A N/A $3.79 N/A N/A $6.47 N/A N/A $7.39 N/A N/A $5.08 N/A N/A $6.47 N/A N/A $3.10 N/A N/A N/A N/A N/A $5.54 N/A N/A $3.23 N/A N/A $6.01 N/A N/A N/A N/A N/A $5.54 N/A N/A $6.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.24 $9.24 N/A 4409758 Pharmacy alendronate 70 mg Tab [BCH] 250 $40.95 $- $10.65 $- $- $32.76 $- N/A $10.65 N/A N/A $15.48 N/A N/A $24.57 N/A N/A $20.48 N/A N/A N/A N/A N/A $27.85 N/A N/A $25.39 N/A N/A $16.79 N/A N/A $28.67 N/A N/A $32.76 N/A N/A $22.52 N/A N/A $28.67 N/A N/A $13.72 N/A N/A N/A N/A N/A $24.57 N/A N/A $14.33 N/A N/A $26.62 N/A N/A N/A N/A N/A $24.57 N/A N/A $28.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.95 $40.95 N/A 4403028 Pharmacy ciprofloxacin 250 mg Tab [BCH] 250 $9.19 $- $2.39 $- $- $7.35 $- N/A $2.39 N/A N/A $3.47 N/A N/A $5.51 N/A N/A $4.59 N/A N/A N/A N/A N/A $6.25 N/A N/A $5.70 N/A N/A $3.77 N/A N/A $6.43 N/A N/A $7.35 N/A N/A $5.05 N/A N/A $6.43 N/A N/A $3.08 N/A N/A N/A N/A N/A $5.51 N/A N/A $3.22 N/A N/A $5.97 N/A N/A N/A N/A N/A $5.51 N/A N/A $6.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.19 $9.19 N/A 4400372 Pharmacy venlafaxine 37.5 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400995 Pharmacy venlafaxine 50 mg Tab [BCH] 250 $4.12 $- $1.07 $- $- $3.30 $- N/A $1.07 N/A N/A $1.56 N/A N/A $2.47 N/A N/A $2.06 N/A N/A N/A N/A N/A $2.80 N/A N/A $2.56 N/A N/A $1.69 N/A N/A $2.89 N/A N/A $3.30 N/A N/A $2.27 N/A N/A $2.89 N/A N/A $1.38 N/A N/A N/A N/A N/A $2.47 N/A N/A $1.44 N/A N/A $2.68 N/A N/A N/A N/A N/A $2.47 N/A N/A $2.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.12 $4.12 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4409642 Pharmacy gabapentin 400 mg Cap 250 $3.19 $- $0.83 $- $- $2.56 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.98 N/A N/A $1.31 N/A N/A $2.24 N/A N/A $2.56 N/A N/A $1.76 N/A N/A $2.24 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.19 $3.19 N/A 4406457 Pharmacy simvastatin 5 mg Tab [BCH] 250 $2.75 $- $0.72 $- $- $2.20 $- N/A $0.72 N/A N/A $1.04 N/A N/A $1.65 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.71 N/A N/A $1.13 N/A N/A $1.93 N/A N/A $2.20 N/A N/A $1.51 N/A N/A $1.93 N/A N/A $0.92 N/A N/A N/A N/A N/A $1.65 N/A N/A $0.96 N/A N/A $1.79 N/A N/A N/A N/A N/A $1.65 N/A N/A $1.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.75 $2.75 N/A 4400176 Pharmacy simvastatin 10 mg Tab [BCH] 250 $3.80 $- $0.99 $- $- $3.04 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.28 N/A N/A $1.90 N/A N/A N/A N/A N/A $2.58 N/A N/A $2.35 N/A N/A $1.56 N/A N/A $2.66 N/A N/A $3.04 N/A N/A $2.09 N/A N/A $2.66 N/A N/A $1.27 N/A N/A N/A N/A N/A $2.28 N/A N/A $1.33 N/A N/A $2.47 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.80 $3.80 N/A 4400583 Pharmacy fluconazole 100 mg Tab [BCH] 250 $17.54 $- $4.56 $- $- $14.03 $- N/A $4.56 N/A N/A $6.63 N/A N/A $10.52 N/A N/A $8.77 N/A N/A N/A N/A N/A $11.93 N/A N/A $10.87 N/A N/A $7.19 N/A N/A $12.28 N/A N/A $14.03 N/A N/A $9.65 N/A N/A $12.28 N/A N/A $5.88 N/A N/A N/A N/A N/A $10.52 N/A N/A $6.14 N/A N/A $11.40 N/A N/A N/A N/A N/A $10.52 N/A N/A $12.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.54 $17.54 N/A 4400730 Pharmacy fluconazole 150 mg Tab 250 $27.19 $- $7.07 $- $- $21.75 $- N/A $7.07 N/A N/A $10.28 N/A N/A $16.31 N/A N/A $13.59 N/A N/A N/A N/A N/A $18.49 N/A N/A $16.85 N/A N/A $11.15 N/A N/A $19.03 N/A N/A $21.75 N/A N/A $14.95 N/A N/A $19.03 N/A N/A $9.11 N/A N/A N/A N/A N/A $16.31 N/A N/A $9.51 N/A N/A $17.67 N/A N/A N/A N/A N/A $16.31 N/A N/A $19.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.19 $27.19 N/A 4400015 Pharmacy valACYclovir 500 mg Tab [BCH] 250 $14.46 $- $3.76 $- $- $11.56 $- N/A $3.76 N/A N/A $5.46 N/A N/A $8.67 N/A N/A $7.23 N/A N/A N/A N/A N/A $9.83 N/A N/A $8.96 N/A N/A $5.93 N/A N/A $10.12 N/A N/A $11.56 N/A N/A $7.95 N/A N/A $10.12 N/A N/A $4.84 N/A N/A N/A N/A N/A $8.67 N/A N/A $5.06 N/A N/A $9.40 N/A N/A N/A N/A N/A $8.67 N/A N/A $10.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.46 $14.46 N/A 4401902 Pharmacy lamoTRIgine 100 mg Tab 250 $9.81 $- $2.55 $- $- $7.85 $- N/A $2.55 N/A N/A $3.71 N/A N/A $5.89 N/A N/A $4.91 N/A N/A N/A N/A N/A $6.67 N/A N/A $6.08 N/A N/A $4.02 N/A N/A $6.87 N/A N/A $7.85 N/A N/A $5.40 N/A N/A $6.87 N/A N/A $3.29 N/A N/A N/A N/A N/A $5.89 N/A N/A $3.43 N/A N/A $6.38 N/A N/A N/A N/A N/A $5.89 N/A N/A $6.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.81 $9.81 N/A 4407307 Pharmacy mirtazapine 15 mg Tab 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4409587 Pharmacy mirtazapine 30 mg Tab 250 $5.59 $- $1.45 $- $- $4.47 $- N/A $1.45 N/A N/A $2.11 N/A N/A $3.36 N/A N/A $2.80 N/A N/A N/A N/A N/A $3.80 N/A N/A $3.47 N/A N/A $2.29 N/A N/A $3.91 N/A N/A $4.47 N/A N/A $3.08 N/A N/A $3.91 N/A N/A $1.87 N/A N/A N/A N/A N/A $3.36 N/A N/A $1.96 N/A N/A $3.64 N/A N/A N/A N/A N/A $3.36 N/A N/A $3.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.59 $5.59 N/A 4409022 Pharmacy celecoxib 100 mg Cap [BCH] 250 $9.21 $- $2.39 $- $- $7.37 $- N/A $2.39 N/A N/A $3.48 N/A N/A $5.52 N/A N/A $4.60 N/A N/A N/A N/A N/A $6.26 N/A N/A $5.71 N/A N/A $3.78 N/A N/A $6.45 N/A N/A $7.37 N/A N/A $5.06 N/A N/A $6.45 N/A N/A $3.08 N/A N/A N/A N/A N/A $5.52 N/A N/A $3.22 N/A N/A $5.99 N/A N/A N/A N/A N/A $5.52 N/A N/A $6.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.21 $9.21 N/A 4408966 Pharmacy celecoxib 200 mg Cap [BCH] 250 $15.08 $- $3.92 $- $- $12.06 $- N/A $3.92 N/A N/A $5.70 N/A N/A $9.05 N/A N/A $7.54 N/A N/A N/A N/A N/A $10.25 N/A N/A $9.35 N/A N/A $6.18 N/A N/A $10.55 N/A N/A $12.06 N/A N/A $8.29 N/A N/A $10.55 N/A N/A $5.05 N/A N/A N/A N/A N/A $9.05 N/A N/A $5.28 N/A N/A $9.80 N/A N/A N/A N/A N/A $9.05 N/A N/A $10.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.08 $15.08 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $8.37 $- $2.18 $- $- $6.70 $- N/A $2.18 N/A N/A $3.16 N/A N/A $5.02 N/A N/A $4.19 N/A N/A N/A N/A N/A $5.69 N/A N/A $5.19 N/A N/A $3.43 N/A N/A $5.86 N/A N/A $6.70 N/A N/A $4.60 N/A N/A $5.86 N/A N/A $2.80 N/A N/A N/A N/A N/A $5.02 N/A N/A $2.93 N/A N/A $5.44 N/A N/A N/A N/A N/A $5.02 N/A N/A $5.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.37 $8.37 N/A 4402970 Pharmacy nystatin topical 100000 units/g Pow [BCH] 250 $49.02 $- $12.75 $- $- $39.22 $- N/A $12.75 N/A N/A $18.53 N/A N/A $29.41 N/A N/A $24.51 N/A N/A N/A N/A N/A $33.33 N/A N/A $30.39 N/A N/A $20.10 N/A N/A $34.31 N/A N/A $39.22 N/A N/A $26.96 N/A N/A $34.31 N/A N/A $16.42 N/A N/A N/A N/A N/A $29.41 N/A N/A $17.16 N/A N/A $31.86 N/A N/A N/A N/A N/A $29.41 N/A N/A $34.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.02 $49.02 N/A 4402970 Pharmacy nystatin topical 100000 units/g Pow [BCH] 250 $49.13 $- $12.77 $- $- $39.30 $- N/A $12.77 N/A N/A $18.57 N/A N/A $29.48 N/A N/A $24.57 N/A N/A N/A N/A N/A $33.41 N/A N/A $30.46 N/A N/A $20.14 N/A N/A $34.39 N/A N/A $39.30 N/A N/A $27.02 N/A N/A $34.39 N/A N/A $16.46 N/A N/A N/A N/A N/A $29.48 N/A N/A $17.20 N/A N/A $31.93 N/A N/A N/A N/A N/A $29.48 N/A N/A $34.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.13 $49.13 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab 250 $63.65 $- $16.55 $- $- $50.92 $- N/A $16.55 N/A N/A $24.06 N/A N/A $38.19 N/A N/A $31.83 N/A N/A N/A N/A N/A $43.28 N/A N/A $39.46 N/A N/A $26.10 N/A N/A $44.56 N/A N/A $50.92 N/A N/A $35.01 N/A N/A $44.56 N/A N/A $21.32 N/A N/A N/A N/A N/A $38.19 N/A N/A $22.28 N/A N/A $41.37 N/A N/A N/A N/A N/A $38.19 N/A N/A $44.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $63.65 $63.65 N/A 4400883 Pharmacy ARIPiprazole 10 mg Tab [BCH] 250 $63.74 $- $16.57 $- $- $51.00 $- N/A $16.57 N/A N/A $24.10 N/A N/A $38.25 N/A N/A $31.87 N/A N/A N/A N/A N/A $43.35 N/A N/A $39.52 N/A N/A $26.14 N/A N/A $44.62 N/A N/A $51.00 N/A N/A $35.06 N/A N/A $44.62 N/A N/A $21.35 N/A N/A N/A N/A N/A $38.25 N/A N/A $22.31 N/A N/A $41.43 N/A N/A N/A N/A N/A $38.25 N/A N/A $44.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $63.74 $63.74 N/A 4400704 Pharmacy terbinafine 250 mg Tab [BCH] 250 $25.34 $- $6.59 $- $- $20.27 $- N/A $6.59 N/A N/A $9.58 N/A N/A $15.20 N/A N/A $12.67 N/A N/A N/A N/A N/A $17.23 N/A N/A $15.71 N/A N/A $10.39 N/A N/A $17.74 N/A N/A $20.27 N/A N/A $13.94 N/A N/A $17.74 N/A N/A $8.49 N/A N/A N/A N/A N/A $15.20 N/A N/A $8.87 N/A N/A $16.47 N/A N/A N/A N/A N/A $15.20 N/A N/A $17.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.34 $25.34 N/A 4409447 Pharmacy SUMAtriptan 50 mg Tab [BCH] 250 $50.28 $- $13.07 $- $- $40.22 $- N/A $13.07 N/A N/A $19.01 N/A N/A $30.17 N/A N/A $25.14 N/A N/A N/A N/A N/A $34.19 N/A N/A $31.17 N/A N/A $20.61 N/A N/A $35.20 N/A N/A $40.22 N/A N/A $27.65 N/A N/A $35.20 N/A N/A $16.84 N/A N/A N/A N/A N/A $30.17 N/A N/A $17.60 N/A N/A $32.68 N/A N/A N/A N/A N/A $30.17 N/A N/A $35.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.28 $50.28 N/A 4408941 Pharmacy chlorthalidone 25 mg Tab [BCH] 250 $2.41 $- $0.63 $- $- $1.93 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.93 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.84 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4409710 Pharmacy ezetimibe 10 mg Tab[BCH] 250 $20.27 $- $5.27 $- $- $16.22 $- N/A $5.27 N/A N/A $7.66 N/A N/A $12.16 N/A N/A $10.14 N/A N/A N/A N/A N/A $13.78 N/A N/A $12.57 N/A N/A $8.31 N/A N/A $14.19 N/A N/A $16.22 N/A N/A $11.15 N/A N/A $14.19 N/A N/A $6.79 N/A N/A N/A N/A N/A $12.16 N/A N/A $7.09 N/A N/A $13.18 N/A N/A N/A N/A N/A $12.16 N/A N/A $14.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.27 $20.27 N/A 4400666 Pharmacy sevelamer carbonate 800 mg Tab [BCH] 250 $9.17 $- $2.38 $- $- $7.33 $- N/A $2.38 N/A N/A $3.47 N/A N/A $5.50 N/A N/A $4.58 N/A N/A N/A N/A N/A $6.23 N/A N/A $5.68 N/A N/A $3.76 N/A N/A $6.42 N/A N/A $7.33 N/A N/A $5.04 N/A N/A $6.42 N/A N/A $3.07 N/A N/A N/A N/A N/A $5.50 N/A N/A $3.21 N/A N/A $5.96 N/A N/A N/A N/A N/A $5.50 N/A N/A $6.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.17 $9.17 N/A 4400902 Pharmacy bicalutamide 50 mg Tab [BCH] 250 $36.50 $- $9.49 $- $- $29.20 $- N/A $9.49 N/A N/A $13.80 N/A N/A $21.90 N/A N/A $18.25 N/A N/A N/A N/A N/A $24.82 N/A N/A $22.63 N/A N/A $14.97 N/A N/A $25.55 N/A N/A $29.20 N/A N/A $20.08 N/A N/A $25.55 N/A N/A $12.23 N/A N/A N/A N/A N/A $21.90 N/A N/A $12.78 N/A N/A $23.73 N/A N/A N/A N/A N/A $21.90 N/A N/A $25.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.50 $36.50 N/A 4409479 Pharmacy oseltamivir 75 mg Cap [BCH] 250 $30.88 $- $8.03 $- $- $24.71 $- N/A $8.03 N/A N/A $11.67 N/A N/A $18.53 N/A N/A $15.44 N/A N/A N/A N/A N/A $21.00 N/A N/A $19.15 N/A N/A $12.66 N/A N/A $21.62 N/A N/A $24.71 N/A N/A $16.99 N/A N/A $21.62 N/A N/A $10.35 N/A N/A N/A N/A N/A $18.53 N/A N/A $10.81 N/A N/A $20.07 N/A N/A N/A N/A N/A $18.53 N/A N/A $21.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.88 $30.88 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab [BCH] 250 $3.99 $- $1.04 $- $- $3.19 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.39 N/A N/A $1.99 N/A N/A N/A N/A N/A $2.71 N/A N/A $2.47 N/A N/A $1.63 N/A N/A $2.79 N/A N/A $3.19 N/A N/A $2.19 N/A N/A $2.79 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.39 N/A N/A $1.39 N/A N/A $2.59 N/A N/A N/A N/A N/A $2.39 N/A N/A $2.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.99 $3.99 N/A 4400163 Pharmacy ziprasidone 40 mg Cap [BCH] 250 $17.71 $- $4.60 $- $- $14.16 $- N/A $4.60 N/A N/A $6.69 N/A N/A $10.62 N/A N/A $8.85 N/A N/A N/A N/A N/A $12.04 N/A N/A $10.98 N/A N/A $7.26 N/A N/A $12.39 N/A N/A $14.16 N/A N/A $9.74 N/A N/A $12.39 N/A N/A $5.93 N/A N/A N/A N/A N/A $10.62 N/A N/A $6.20 N/A N/A $11.51 N/A N/A N/A N/A N/A $10.62 N/A N/A $12.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.71 $17.71 N/A 4400725 Pharmacy ziprasidone 60 mg Cap [BCH] 250 $21.52 $- $5.60 $- $- $17.22 $- N/A $5.60 N/A N/A $8.14 N/A N/A $12.91 N/A N/A $10.76 N/A N/A N/A N/A N/A $14.64 N/A N/A $13.34 N/A N/A $8.82 N/A N/A $15.07 N/A N/A $17.22 N/A N/A $11.84 N/A N/A $15.07 N/A N/A $7.21 N/A N/A N/A N/A N/A $12.91 N/A N/A $7.53 N/A N/A $13.99 N/A N/A N/A N/A N/A $12.91 N/A N/A $15.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.52 $21.52 N/A 4400707 Pharmacy metoprolol ER 25 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4402118 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400860 Pharmacy paliperidone 3 mg Tab [BCH] 250 $61.08 $- $15.88 $- $- $48.86 $- N/A $15.88 N/A N/A $23.09 N/A N/A $36.65 N/A N/A $30.54 N/A N/A N/A N/A N/A $41.53 N/A N/A $37.87 N/A N/A $25.04 N/A N/A $42.75 N/A N/A $48.86 N/A N/A $33.59 N/A N/A $42.75 N/A N/A $20.46 N/A N/A N/A N/A N/A $36.65 N/A N/A $21.38 N/A N/A $39.70 N/A N/A N/A N/A N/A $36.65 N/A N/A $42.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $61.08 $61.08 N/A 4400645 Pharmacy lidocaine topical 5% Oin [BCH] 250 $543.86 $- $141.40 $- $- $435.09 $- N/A $141.40 N/A N/A $205.58 N/A N/A $326.32 N/A N/A $271.93 N/A N/A N/A N/A N/A $369.82 N/A N/A $337.19 N/A N/A $222.98 N/A N/A $380.70 N/A N/A $435.09 N/A N/A $299.12 N/A N/A $380.70 N/A N/A $182.19 N/A N/A N/A N/A N/A $326.32 N/A N/A $190.35 N/A N/A $353.51 N/A N/A N/A N/A N/A $326.32 N/A N/A $380.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $543.86 $543.86 N/A 4401905 Pharmacy acyclovir topical 5% Oin [BCH] 250 $723.82 $- $188.19 $- $- $579.06 $- N/A $188.19 N/A N/A $273.60 N/A N/A $434.29 N/A N/A $361.91 N/A N/A N/A N/A N/A $492.20 N/A N/A $448.77 N/A N/A $296.77 N/A N/A $506.67 N/A N/A $579.06 N/A N/A $398.10 N/A N/A $506.67 N/A N/A $242.48 N/A N/A N/A N/A N/A $434.29 N/A N/A $253.34 N/A N/A $470.48 N/A N/A N/A N/A N/A $434.29 N/A N/A $506.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $723.82 $723.82 N/A 4409821 Pharmacy DAPTOmycin 500 mg Pow [BCH] J0878 636 $991.22 $- $0.14 $- $- $792.98 $- N/A $257.72 N/A N/A Not Reimbursed N/A N/A $594.73 N/A N/A $495.61 N/A N/A N/A N/A N/A $674.03 N/A N/A $614.56 N/A N/A $406.40 N/A N/A $693.85 N/A N/A $792.98 N/A N/A $545.17 N/A N/A $693.85 N/A N/A $332.06 N/A N/A N/A N/A N/A $594.73 N/A N/A $346.93 N/A N/A $644.29 N/A N/A $0.14 N/A N/A $594.73 N/A N/A $693.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $991.22 $991.22 N/A 4400679 Pharmacy glipiZIDE 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404163 Pharmacy loratadine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400120 Pharmacy aspirin-dipyridamole 25 mg-200 mg Cap[BCH] 250 $16.75 $- $4.35 $- $- $13.40 $- N/A $4.35 N/A N/A $6.33 N/A N/A $10.05 N/A N/A $8.37 N/A N/A N/A N/A N/A $11.39 N/A N/A $10.38 N/A N/A $6.87 N/A N/A $11.72 N/A N/A $13.40 N/A N/A $9.21 N/A N/A $11.72 N/A N/A $5.61 N/A N/A N/A N/A N/A $10.05 N/A N/A $5.86 N/A N/A $10.89 N/A N/A N/A N/A N/A $10.05 N/A N/A $11.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.75 $16.75 N/A 4400676 Pharmacy mometasone topical 0.1% Cre [BCH] 250 $105.92 $- $27.54 $- $- $84.74 $- N/A $27.54 N/A N/A $40.04 N/A N/A $63.55 N/A N/A $52.96 N/A N/A N/A N/A N/A $72.03 N/A N/A $65.67 N/A N/A $43.43 N/A N/A $74.14 N/A N/A $84.74 N/A N/A $58.26 N/A N/A $74.14 N/A N/A $35.48 N/A N/A N/A N/A N/A $63.55 N/A N/A $37.07 N/A N/A $68.85 N/A N/A N/A N/A N/A $63.55 N/A N/A $74.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.92 $105.92 N/A 4400261 Pharmacy diclofenac topical 1% Gel 250 $115.40 $- $30.00 $- $- $92.32 $- N/A $30.00 N/A N/A $43.62 N/A N/A $69.24 N/A N/A $57.70 N/A N/A N/A N/A N/A $78.47 N/A N/A $71.55 N/A N/A $47.31 N/A N/A $80.78 N/A N/A $92.32 N/A N/A $63.47 N/A N/A $80.78 N/A N/A $38.66 N/A N/A N/A N/A N/A $69.24 N/A N/A $40.39 N/A N/A $75.01 N/A N/A N/A N/A N/A $69.24 N/A N/A $80.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $115.40 $115.40 N/A 4404163 Pharmacy loratadine 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408719 Pharmacy glimepiride 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400892 Pharmacy anastrozole 1 mg Tab [BCH] 250 $26.61 $- $6.92 $- $- $21.29 $- N/A $6.92 N/A N/A $10.06 N/A N/A $15.96 N/A N/A $13.30 N/A N/A N/A N/A N/A $18.09 N/A N/A $16.50 N/A N/A $10.91 N/A N/A $18.63 N/A N/A $21.29 N/A N/A $14.63 N/A N/A $18.63 N/A N/A $8.91 N/A N/A N/A N/A N/A $15.96 N/A N/A $9.31 N/A N/A $17.29 N/A N/A N/A N/A N/A $15.96 N/A N/A $18.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.61 $26.61 N/A 4403512 Pharmacy finasteride 5 mg Tab S0138 250 $6.26 $- $1.63 $- $- $5.01 $- N/A $1.63 N/A N/A Not Reimbursed N/A N/A $3.75 N/A N/A $3.13 N/A N/A N/A N/A N/A $4.25 N/A N/A $3.88 N/A N/A $2.57 N/A N/A $4.38 N/A N/A $5.01 N/A N/A $3.44 N/A N/A $4.38 N/A N/A $2.10 N/A N/A N/A N/A N/A $3.75 N/A N/A $2.19 N/A N/A $4.07 N/A N/A N/A N/A N/A $3.75 N/A N/A $4.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.26 $6.26 N/A 4400882 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 $35.05 $- $9.11 $- $- $28.04 $- N/A $9.11 N/A N/A $13.25 N/A N/A $21.03 N/A N/A $17.53 N/A N/A N/A N/A N/A $23.84 N/A N/A $21.73 N/A N/A $14.37 N/A N/A $24.54 N/A N/A $28.04 N/A N/A $19.28 N/A N/A $24.54 N/A N/A $11.74 N/A N/A N/A N/A N/A $21.03 N/A N/A $12.27 N/A N/A $22.79 N/A N/A N/A N/A N/A $21.03 N/A N/A $24.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.05 $35.05 N/A 4400869 Pharmacy QUEtiapine 300 mg Tab [BCH] 250 $45.96 $- $11.95 $- $- $36.77 $- N/A $11.95 N/A N/A $17.37 N/A N/A $27.58 N/A N/A $22.98 N/A N/A N/A N/A N/A $31.25 N/A N/A $28.50 N/A N/A $18.84 N/A N/A $32.17 N/A N/A $36.77 N/A N/A $25.28 N/A N/A $32.17 N/A N/A $15.40 N/A N/A N/A N/A N/A $27.58 N/A N/A $16.09 N/A N/A $29.87 N/A N/A N/A N/A N/A $27.58 N/A N/A $32.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.96 $45.96 N/A 4400754 Pharmacy QUEtiapine 50 mg Tab [BCH] 250 $17.74 $- $4.61 $- $- $14.19 $- N/A $4.61 N/A N/A $6.70 N/A N/A $10.64 N/A N/A $8.87 N/A N/A N/A N/A N/A $12.06 N/A N/A $11.00 N/A N/A $7.27 N/A N/A $12.42 N/A N/A $14.19 N/A N/A $9.76 N/A N/A $12.42 N/A N/A $5.94 N/A N/A N/A N/A N/A $10.64 N/A N/A $6.21 N/A N/A $11.53 N/A N/A N/A N/A N/A $10.64 N/A N/A $12.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.74 $17.74 N/A 4408564 Pharmacy allopurinol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405327 Pharmacy clonazePAM 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400299 Pharmacy clonazePAM 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400433 Pharmacy QUEtiapine 50 mg oral tablet [BCH] 250 $13.13 $- $3.41 $- $- $10.51 $- N/A $3.41 N/A N/A $4.96 N/A N/A $7.88 N/A N/A $6.57 N/A N/A N/A N/A N/A $8.93 N/A N/A $8.14 N/A N/A $5.38 N/A N/A $9.19 N/A N/A $10.51 N/A N/A $7.22 N/A N/A $9.19 N/A N/A $4.40 N/A N/A N/A N/A N/A $7.88 N/A N/A $4.60 N/A N/A $8.54 N/A N/A N/A N/A N/A $7.88 N/A N/A $9.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.13 $13.13 N/A 4400118 Pharmacy QUEtiapine 100 mg Tab [BCH] 250 $13.72 $- $3.57 $- $- $10.97 $- N/A $3.57 N/A N/A $5.18 N/A N/A $8.23 N/A N/A $6.86 N/A N/A N/A N/A N/A $9.33 N/A N/A $8.50 N/A N/A $5.62 N/A N/A $9.60 N/A N/A $10.97 N/A N/A $7.54 N/A N/A $9.60 N/A N/A $4.59 N/A N/A N/A N/A N/A $8.23 N/A N/A $4.80 N/A N/A $8.91 N/A N/A N/A N/A N/A $8.23 N/A N/A $9.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.72 $13.72 N/A 4400587 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 $25.87 $- $6.73 $- $- $20.70 $- N/A $6.73 N/A N/A $9.78 N/A N/A $15.52 N/A N/A $12.94 N/A N/A N/A N/A N/A $17.59 N/A N/A $16.04 N/A N/A $10.61 N/A N/A $18.11 N/A N/A $20.70 N/A N/A $14.23 N/A N/A $18.11 N/A N/A $8.67 N/A N/A N/A N/A N/A $15.52 N/A N/A $9.06 N/A N/A $16.82 N/A N/A N/A N/A N/A $15.52 N/A N/A $18.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.87 $25.87 N/A 4400452 Pharmacy QUEtiapine 400 mg oral tablet [BCH] 250 $39.87 $- $10.37 $- $- $31.90 $- N/A $10.37 N/A N/A $15.07 N/A N/A $23.92 N/A N/A $19.93 N/A N/A N/A N/A N/A $27.11 N/A N/A $24.72 N/A N/A $16.35 N/A N/A $27.91 N/A N/A $31.90 N/A N/A $21.93 N/A N/A $27.91 N/A N/A $13.36 N/A N/A N/A N/A N/A $23.92 N/A N/A $13.95 N/A N/A $25.92 N/A N/A N/A N/A N/A $23.92 N/A N/A $27.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.87 $39.87 N/A 4407265 Pharmacy clopidogrel 75 mg Tab [BCH] 250 $13.92 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.35 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.74 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.74 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.35 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.35 N/A N/A $9.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.92 $13.92 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab 250 $64.15 $- $16.68 $- $- $51.32 $- N/A $16.68 N/A N/A $24.25 N/A N/A $38.49 N/A N/A $32.07 N/A N/A N/A N/A N/A $43.62 N/A N/A $39.77 N/A N/A $26.30 N/A N/A $44.90 N/A N/A $51.32 N/A N/A $35.28 N/A N/A $44.90 N/A N/A $21.49 N/A N/A N/A N/A N/A $38.49 N/A N/A $22.45 N/A N/A $41.70 N/A N/A N/A N/A N/A $38.49 N/A N/A $44.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.15 $64.15 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours Tab [BCH] 250 $10.44 $- $2.71 $- $- $8.35 $- N/A $2.71 N/A N/A $3.95 N/A N/A $6.26 N/A N/A $5.22 N/A N/A N/A N/A N/A $7.10 N/A N/A $6.47 N/A N/A $4.28 N/A N/A $7.31 N/A N/A $8.35 N/A N/A $5.74 N/A N/A $7.31 N/A N/A $3.50 N/A N/A N/A N/A N/A $6.26 N/A N/A $3.65 N/A N/A $6.79 N/A N/A N/A N/A N/A $6.26 N/A N/A $7.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.44 $10.44 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours Tab 250 $10.44 $- $2.71 $- $- $8.35 $- N/A $2.71 N/A N/A $3.95 N/A N/A $6.26 N/A N/A $5.22 N/A N/A N/A N/A N/A $7.10 N/A N/A $6.47 N/A N/A $4.28 N/A N/A $7.31 N/A N/A $8.35 N/A N/A $5.74 N/A N/A $7.31 N/A N/A $3.50 N/A N/A N/A N/A N/A $6.26 N/A N/A $3.65 N/A N/A $6.79 N/A N/A N/A N/A N/A $6.26 N/A N/A $7.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.44 $10.44 N/A 4401910 Pharmacy methotrexate 2.5 mg Tab [BCH] J8610 636 $8.02 $- $0.22 $- $- $6.42 $- N/A $2.08 N/A N/A Not Reimbursed N/A N/A $4.81 N/A N/A $4.01 N/A N/A N/A N/A N/A $5.45 N/A N/A $4.97 N/A N/A $3.29 N/A N/A $5.61 N/A N/A $6.42 N/A N/A $4.41 N/A N/A $5.61 N/A N/A $2.69 N/A N/A N/A N/A N/A $4.81 N/A N/A $2.81 N/A N/A $5.21 N/A N/A $0.22 N/A N/A $4.81 N/A N/A $5.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.02 $8.02 N/A 4400336 Pharmacy fluorescein ophthalmic 1 mg Tes [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401136 Pharmacy benztropine 1 mg/mL Inj Sol [BCH] J0515 636 $119.18 $- $15.52 $- $- $95.34 $- N/A $30.99 N/A N/A Not Reimbursed N/A N/A $71.51 N/A N/A $59.59 N/A N/A N/A N/A N/A $81.04 N/A N/A $73.89 N/A N/A $48.86 N/A N/A $83.43 N/A N/A $95.34 N/A N/A $65.55 N/A N/A $83.43 N/A N/A $39.93 N/A N/A N/A N/A N/A $71.51 N/A N/A $41.71 N/A N/A $77.47 N/A N/A $15.52 N/A N/A $71.51 N/A N/A $83.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $119.18 $119.18 N/A 4400112 Pharmacy alfentanil 0.5 mg/mL Inj Sol [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4401709 Pharmacy erythromycin ophthalmic 0.5% Oin [BCH] 250 $37.30 $- $9.70 $- $- $29.84 $- N/A $9.70 N/A N/A $14.10 N/A N/A $22.38 N/A N/A $18.65 N/A N/A N/A N/A N/A $25.36 N/A N/A $23.13 N/A N/A $15.29 N/A N/A $26.11 N/A N/A $29.84 N/A N/A $20.51 N/A N/A $26.11 N/A N/A $12.50 N/A N/A N/A N/A N/A $22.38 N/A N/A $13.05 N/A N/A $24.24 N/A N/A N/A N/A N/A $22.38 N/A N/A $26.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.30 $37.30 N/A 4400552 Pharmacy ropivacaine 0.5% Sol [BCH] J2795 636 $15.00 $- $0.08 $- $- $12.00 $- N/A $3.90 N/A N/A Not Reimbursed N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $0.08 N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4401691 Pharmacy cyclopentolate ophthalmic 1% Sol 250 $59.08 $- $15.36 $- $- $47.26 $- N/A $15.36 N/A N/A $22.33 N/A N/A $35.45 N/A N/A $29.54 N/A N/A N/A N/A N/A $40.17 N/A N/A $36.63 N/A N/A $24.22 N/A N/A $41.36 N/A N/A $47.26 N/A N/A $32.49 N/A N/A $41.36 N/A N/A $19.79 N/A N/A N/A N/A N/A $35.45 N/A N/A $20.68 N/A N/A $38.40 N/A N/A N/A N/A N/A $35.45 N/A N/A $41.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $59.08 $59.08 N/A 4400814 Pharmacy tropicamide ophthalmic 1% Sol [BCH] 250 $21.30 $- $5.54 $- $- $17.04 $- N/A $5.54 N/A N/A $8.05 N/A N/A $12.78 N/A N/A $10.65 N/A N/A N/A N/A N/A $14.48 N/A N/A $13.21 N/A N/A $8.73 N/A N/A $14.91 N/A N/A $17.04 N/A N/A $11.72 N/A N/A $14.91 N/A N/A $7.14 N/A N/A N/A N/A N/A $12.78 N/A N/A $7.46 N/A N/A $13.85 N/A N/A N/A N/A N/A $12.78 N/A N/A $14.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.30 $21.30 N/A 4409481 Pharmacy rifampin 600 mg IV Inj [BCH] 250 $272.50 $- $70.85 $- $- $218.00 $- N/A $70.85 N/A N/A $103.01 N/A N/A $163.50 N/A N/A $136.25 N/A N/A N/A N/A N/A $185.30 N/A N/A $168.95 N/A N/A $111.73 N/A N/A $190.75 N/A N/A $218.00 N/A N/A $149.88 N/A N/A $190.75 N/A N/A $91.29 N/A N/A N/A N/A N/A $163.50 N/A N/A $95.38 N/A N/A $177.13 N/A N/A N/A N/A N/A $163.50 N/A N/A $190.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $272.50 $272.50 N/A 4409569 Pharmacy phenylephrine ophthalmic 2.5% Sol [BCH] 250 $609.45 $- $158.46 $- $- $487.56 $- N/A $158.46 N/A N/A $230.37 N/A N/A $365.67 N/A N/A $304.73 N/A N/A N/A N/A N/A $414.43 N/A N/A $377.86 N/A N/A $249.87 N/A N/A $426.62 N/A N/A $487.56 N/A N/A $335.20 N/A N/A $426.62 N/A N/A $204.17 N/A N/A N/A N/A N/A $365.67 N/A N/A $213.31 N/A N/A $396.14 N/A N/A N/A N/A N/A $365.67 N/A N/A $426.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $609.45 $609.45 N/A 4408412 Pharmacy phenylephrine Ophth 10% Sol [BCH] 250 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A $62.00 N/A N/A $41.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A N/A N/A N/A $60.00 N/A N/A $70.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $100.00 $100.00 N/A 4408412 Pharmacy phenylephrinephenylephrine Ophth 10% Sol [BCH] ophthalmic 10% Sol 250 $100.00 $- $26.00 $- $- $80.00 $- N/A $26.00 N/A N/A $37.80 N/A N/A $60.00 N/A N/A $50.00 N/A N/A N/A N/A N/A $68.00 N/A N/A $62.00 N/A N/A $41.00 N/A N/A $70.00 N/A N/A $80.00 N/A N/A $55.00 N/A N/A $70.00 N/A N/A $33.50 N/A N/A N/A N/A N/A $60.00 N/A N/A $35.00 N/A N/A $65.00 N/A N/A N/A N/A N/A $60.00 N/A N/A $70.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $100.00 $100.00 N/A 4400927 Pharmacy atropine ophthalmic 1% Sol [BCH] 250 $153.75 $- $39.98 $- $- $123.00 $- N/A $39.98 N/A N/A $58.12 N/A N/A $92.25 N/A N/A $76.88 N/A N/A N/A N/A N/A $104.55 N/A N/A $95.33 N/A N/A $63.04 N/A N/A $107.63 N/A N/A $123.00 N/A N/A $84.56 N/A N/A $107.63 N/A N/A $51.51 N/A N/A N/A N/A N/A $92.25 N/A N/A $53.81 N/A N/A $99.94 N/A N/A N/A N/A N/A $92.25 N/A N/A $107.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $153.75 $153.75 N/A 4404043 Pharmacy bacitracin/neomycin/polymyxin B Ophth Oint [BCH] 250 $110.50 $- $28.73 $- $- $88.40 $- N/A $28.73 N/A N/A $41.77 N/A N/A $66.30 N/A N/A $55.25 N/A N/A N/A N/A N/A $75.14 N/A N/A $68.51 N/A N/A $45.31 N/A N/A $77.35 N/A N/A $88.40 N/A N/A $60.78 N/A N/A $77.35 N/A N/A $37.02 N/A N/A N/A N/A N/A $66.30 N/A N/A $38.68 N/A N/A $71.83 N/A N/A N/A N/A N/A $66.30 N/A N/A $77.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $110.50 $110.50 N/A 4402480 Pharmacy gentamicin Ophth 0.3% Oint [BCH] 250 $39.34 $- $10.23 $- $- $31.47 $- N/A $10.23 N/A N/A $14.87 N/A N/A $23.60 N/A N/A $19.67 N/A N/A N/A N/A N/A $26.75 N/A N/A $24.39 N/A N/A $16.13 N/A N/A $27.54 N/A N/A $31.47 N/A N/A $21.64 N/A N/A $27.54 N/A N/A $13.18 N/A N/A N/A N/A N/A $23.60 N/A N/A $13.77 N/A N/A $25.57 N/A N/A N/A N/A N/A $23.60 N/A N/A $27.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.34 $39.34 N/A 4400336 Pharmacy fluorescein ophthalmic 1 mg Test [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405855 Pharmacy labetalol 5 mg/mL Sol [BCH] 258 $62.50 $- $16.25 $- $- $50.00 $- N/A $16.25 N/A N/A $23.63 N/A N/A $37.50 N/A N/A $31.25 N/A N/A N/A N/A N/A $42.50 N/A N/A $38.75 N/A N/A $25.63 N/A N/A $43.75 N/A N/A $50.00 N/A N/A $34.38 N/A N/A $43.75 N/A N/A $20.94 N/A N/A N/A N/A N/A $37.50 N/A N/A $21.88 N/A N/A $40.63 N/A N/A N/A N/A N/A $37.50 N/A N/A $43.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $62.50 $62.50 N/A 4403722 Pharmacy methylergonovine 0.2 mg/mL Inj Sol [BCH] J2210 636 $17.15 $- $4.46 $- $- $19.41 $- N/A $4.46 N/A N/A Not Reimbursed N/A N/A $10.29 N/A N/A $8.58 N/A N/A N/A N/A N/A $11.66 N/A N/A $10.64 N/A N/A $7.03 N/A N/A $12.01 N/A N/A $13.72 N/A N/A $9.43 N/A N/A $12.01 N/A N/A $5.75 N/A N/A N/A N/A N/A $10.29 N/A N/A $6.00 N/A N/A $11.15 N/A N/A $19.41 N/A N/A $10.29 N/A N/A $12.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.15 $17.15 N/A 4400033 Pharmacy indigo carmine 8 mg/mL Inj Sol [BCH] 250 $19.13 $- $4.97 $- $- $15.31 $- N/A $4.97 N/A N/A $7.23 N/A N/A $11.48 N/A N/A $9.57 N/A N/A N/A N/A N/A $13.01 N/A N/A $11.86 N/A N/A $7.84 N/A N/A $13.39 N/A N/A $15.31 N/A N/A $10.52 N/A N/A $13.39 N/A N/A $6.41 N/A N/A N/A N/A N/A $11.48 N/A N/A $6.70 N/A N/A $12.44 N/A N/A N/A N/A N/A $11.48 N/A N/A $13.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.13 $19.13 N/A 4400041 Pharmacy physostigmine 1 mg/mL Inj Sol [BCH] 250 $81.02 $- $21.07 $- $- $64.82 $- N/A $21.07 N/A N/A $30.63 N/A N/A $48.61 N/A N/A $40.51 N/A N/A N/A N/A N/A $55.10 N/A N/A $50.23 N/A N/A $33.22 N/A N/A $56.72 N/A N/A $64.82 N/A N/A $44.56 N/A N/A $56.72 N/A N/A $27.14 N/A N/A N/A N/A N/A $48.61 N/A N/A $28.36 N/A N/A $52.67 N/A N/A N/A N/A N/A $48.61 N/A N/A $56.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $81.02 $81.02 N/A 4404530 Pharmacy ePHEDrine 50 mg/mL Inj Sol [BCH] 250 $113.50 $- $29.51 $- $- $90.80 $- N/A $29.51 N/A N/A $42.90 N/A N/A $68.10 N/A N/A $56.75 N/A N/A N/A N/A N/A $77.18 N/A N/A $70.37 N/A N/A $46.53 N/A N/A $79.45 N/A N/A $90.80 N/A N/A $62.42 N/A N/A $79.45 N/A N/A $38.02 N/A N/A N/A N/A N/A $68.10 N/A N/A $39.72 N/A N/A $73.77 N/A N/A N/A N/A N/A $68.10 N/A N/A $79.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $113.50 $113.50 N/A 4404530 Pharmacy ePHEDrine 50 mg/mL Sol [BCH] 636 $113.50 $- $29.51 $- $- $90.80 $- N/A $29.51 N/A N/A $42.90 N/A N/A $68.10 N/A N/A $56.75 N/A N/A N/A N/A N/A $77.18 N/A N/A $70.37 N/A N/A $46.53 N/A N/A $79.45 N/A N/A $90.80 N/A N/A $62.42 N/A N/A $79.45 N/A N/A $38.02 N/A N/A N/A N/A N/A $68.10 N/A N/A $39.72 N/A N/A $73.77 N/A N/A N/A N/A N/A $68.10 N/A N/A $79.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $113.50 $113.50 N/A 4402394 Pharmacy adenosine 3 mg/mL Sol J0150 636 $14.88 $- $3.87 $- $- $11.90 $- N/A $3.87 N/A N/A Not Reimbursed N/A N/A $8.93 N/A N/A $7.44 N/A N/A N/A N/A N/A $10.12 N/A N/A $9.23 N/A N/A $6.10 N/A N/A $10.42 N/A N/A $11.90 N/A N/A $8.18 N/A N/A $10.42 N/A N/A $4.98 N/A N/A N/A N/A N/A $8.93 N/A N/A $5.21 N/A N/A $9.67 N/A N/A N/A N/A N/A $8.93 N/A N/A $10.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.88 $14.88 N/A 4409394 Pharmacy latanoprost Ophth 0.005% Sol [BCH] 250 $38.88 $- $10.11 $- $- $31.10 $- N/A $10.11 N/A N/A $14.70 N/A N/A $23.33 N/A N/A $19.44 N/A N/A N/A N/A N/A $26.44 N/A N/A $24.11 N/A N/A $15.94 N/A N/A $27.22 N/A N/A $31.10 N/A N/A $21.38 N/A N/A $27.22 N/A N/A $13.02 N/A N/A N/A N/A N/A $23.33 N/A N/A $13.61 N/A N/A $25.27 N/A N/A N/A N/A N/A $23.33 N/A N/A $27.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.88 $38.88 N/A 4408408 Pharmacy lidocaine topical 2% Gel [BCH] 250 $183.36 $- $47.67 $- $- $146.69 $- N/A $47.67 N/A N/A $69.31 N/A N/A $110.02 N/A N/A $91.68 N/A N/A N/A N/A N/A $124.68 N/A N/A $113.68 N/A N/A $75.18 N/A N/A $128.35 N/A N/A $146.69 N/A N/A $100.85 N/A N/A $128.35 N/A N/A $61.43 N/A N/A N/A N/A N/A $110.02 N/A N/A $64.18 N/A N/A $119.18 N/A N/A N/A N/A N/A $110.02 N/A N/A $128.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $183.36 $183.36 N/A 4400369 Pharmacy lidocaine topical 2% Gel 250 $16.80 $- $4.37 $- $- $13.44 $- N/A $4.37 N/A N/A $6.35 N/A N/A $10.08 N/A N/A $8.40 N/A N/A N/A N/A N/A $11.42 N/A N/A $10.42 N/A N/A $6.89 N/A N/A $11.76 N/A N/A $13.44 N/A N/A $9.24 N/A N/A $11.76 N/A N/A $5.63 N/A N/A N/A N/A N/A $10.08 N/A N/A $5.88 N/A N/A $10.92 N/A N/A N/A N/A N/A $10.08 N/A N/A $11.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.80 $16.80 N/A 4400125 Pharmacy ofloxacin Ophth 0.3% Sol [BCH] 250 $41.88 $- $10.89 $- $- $33.50 $- N/A $10.89 N/A N/A $15.83 N/A N/A $25.13 N/A N/A $20.94 N/A N/A N/A N/A N/A $28.48 N/A N/A $25.97 N/A N/A $17.17 N/A N/A $29.32 N/A N/A $33.50 N/A N/A $23.03 N/A N/A $29.32 N/A N/A $14.03 N/A N/A N/A N/A N/A $25.13 N/A N/A $14.66 N/A N/A $27.22 N/A N/A N/A N/A N/A $25.13 N/A N/A $29.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.88 $41.88 N/A 4409690 Pharmacy ketotifen 0.025% Ophth Sol [BCH] 250 $24.38 $- $6.34 $- $- $19.50 $- N/A $6.34 N/A N/A $9.22 N/A N/A $14.63 N/A N/A $12.19 N/A N/A N/A N/A N/A $16.58 N/A N/A $15.12 N/A N/A $10.00 N/A N/A $17.07 N/A N/A $19.50 N/A N/A $13.41 N/A N/A $17.07 N/A N/A $8.17 N/A N/A N/A N/A N/A $14.63 N/A N/A $8.53 N/A N/A $15.85 N/A N/A N/A N/A N/A $14.63 N/A N/A $17.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.38 $24.38 N/A 4400554 Pharmacy bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 m [BCH] 250 $125.14 $- $32.54 $- $- $100.11 $- N/A $32.54 N/A N/A $47.30 N/A N/A $75.09 N/A N/A $62.57 N/A N/A N/A N/A N/A $85.10 N/A N/A $77.59 N/A N/A $51.31 N/A N/A $87.60 N/A N/A $100.11 N/A N/A $68.83 N/A N/A $87.60 N/A N/A $41.92 N/A N/A N/A N/A N/A $75.09 N/A N/A $43.80 N/A N/A $81.34 N/A N/A N/A N/A N/A $75.09 N/A N/A $87.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $125.14 $125.14 N/A 4400950 Pharmacy dronabinol 2.5 mg Cap [BCH] Q0167 636 $15.00 $- $0.88 $- $- $12.00 $- N/A $3.90 N/A N/A Not Reimbursed N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $0.88 N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4400877 Pharmacy dronabinol 5 mg Cap [BCH] Q0167 636 $24.52 $- $0.88 $- $- $19.62 $- N/A $6.38 N/A N/A Not Reimbursed N/A N/A $14.71 N/A N/A $12.26 N/A N/A N/A N/A N/A $16.67 N/A N/A $15.20 N/A N/A $10.05 N/A N/A $17.16 N/A N/A $19.62 N/A N/A $13.49 N/A N/A $17.16 N/A N/A $8.21 N/A N/A N/A N/A N/A $14.71 N/A N/A $8.58 N/A N/A $15.94 N/A N/A $0.88 N/A N/A $14.71 N/A N/A $17.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.52 $24.52 N/A 4401676 Pharmacy hydrALAZINE 20 mg/mL Inj Sol [BCH] J0360 636 $106.14 $- $2.88 $- $- $84.91 $- N/A $27.60 N/A N/A Not Reimbursed N/A N/A $63.69 N/A N/A $53.07 N/A N/A N/A N/A N/A $72.18 N/A N/A $65.81 N/A N/A $43.52 N/A N/A $74.30 N/A N/A $84.91 N/A N/A $58.38 N/A N/A $74.30 N/A N/A $35.56 N/A N/A N/A N/A N/A $63.69 N/A N/A $37.15 N/A N/A $68.99 N/A N/A $2.88 N/A N/A $63.69 N/A N/A $74.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $106.14 $106.14 N/A 4409402 Pharmacy dilTIAZem 5 mg/mL Sol 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400429 Pharmacy diltiazem 5 mg/mL IV Sol [BCH] 258 $22.26 $- $5.79 $- $- $17.81 $- N/A $5.79 N/A N/A $8.41 N/A N/A $13.36 N/A N/A $11.13 N/A N/A N/A N/A N/A $15.14 N/A N/A $13.80 N/A N/A $9.13 N/A N/A $15.58 N/A N/A $17.81 N/A N/A $12.24 N/A N/A $15.58 N/A N/A $7.46 N/A N/A N/A N/A N/A $13.36 N/A N/A $7.79 N/A N/A $14.47 N/A N/A N/A N/A N/A $13.36 N/A N/A $15.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.26 $22.26 N/A 4401451 Pharmacy zinc sulfate 220 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400261 Pharmacy diclofenac topical 1% Gel 250 $116.70 $- $30.34 $- $- $93.36 $- N/A $30.34 N/A N/A $44.11 N/A N/A $70.02 N/A N/A $58.35 N/A N/A N/A N/A N/A $79.36 N/A N/A $72.35 N/A N/A $47.85 N/A N/A $81.69 N/A N/A $93.36 N/A N/A $64.19 N/A N/A $81.69 N/A N/A $39.09 N/A N/A N/A N/A N/A $70.02 N/A N/A $40.85 N/A N/A $75.86 N/A N/A N/A N/A N/A $70.02 N/A N/A $81.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $116.70 $116.70 N/A 4405248 Pharmacy indomethacin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406618 Pharmacy tetracycline 250 mg Cap [BCH] 250 $15.75 $- $4.10 $- $- $12.60 $- N/A $4.10 N/A N/A $5.95 N/A N/A $9.45 N/A N/A $7.88 N/A N/A N/A N/A N/A $10.71 N/A N/A $9.77 N/A N/A $6.46 N/A N/A $11.03 N/A N/A $12.60 N/A N/A $8.66 N/A N/A $11.03 N/A N/A $5.28 N/A N/A N/A N/A N/A $9.45 N/A N/A $5.51 N/A N/A $10.24 N/A N/A N/A N/A N/A $9.45 N/A N/A $11.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.75 $15.75 N/A 4400868 Pharmacy verapamil 80 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400643 Pharmacy verapamil 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400759 Pharmacy methimazole 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400370 Pharmacy niMODipine 30 mg Cap [BCH] 250 $38.47 $- $10.00 $- $- $30.77 $- N/A $10.00 N/A N/A $14.54 N/A N/A $23.08 N/A N/A $19.23 N/A N/A N/A N/A N/A $26.16 N/A N/A $23.85 N/A N/A $15.77 N/A N/A $26.93 N/A N/A $30.77 N/A N/A $21.16 N/A N/A $26.93 N/A N/A $12.89 N/A N/A N/A N/A N/A $23.08 N/A N/A $13.46 N/A N/A $25.00 N/A N/A N/A N/A N/A $23.08 N/A N/A $26.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.47 $38.47 N/A 4400623 Pharmacy calcitriol 0.25 mcg Oral Cap [BCH] 250 $2.42 $- $0.63 $- $- $1.94 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.94 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.85 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.42 $2.42 N/A 4408234 Pharmacy doxycycline monohydrate 100 mg Tab [BCH] 250 $9.84 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.89 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.89 N/A N/A $3.30 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.40 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.84 $9.84 N/A 4400223 Pharmacy zoledronic acid 5 mg/100 mL IV Sol [BCH] J3489 636 "$1,988.16 " $- $11.39 $- $- "$1,590.53 " $- N/A $516.92 N/A N/A Not Reimbursed N/A N/A "$1,192.90 " N/A N/A $994.08 N/A N/A N/A N/A N/A "$1,351.95 " N/A N/A "$1,232.66 " N/A N/A $815.15 N/A N/A "$1,391.71 " N/A N/A "$1,590.53 " N/A N/A "$1,093.49 " N/A N/A "$1,391.71 " N/A N/A $666.03 N/A N/A N/A N/A N/A "$1,192.90 " N/A N/A $695.86 N/A N/A "$1,292.30 " N/A N/A $11.39 N/A N/A "$1,192.90 " N/A N/A "$1,391.71 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,988.16 " "$1,988.16 " N/A 4400611 Pharmacy buPROPion 75 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400401 Pharmacy amikacin 250 mg/mL IV Sol [BCH] J0278 636 $29.41 $- $1.39 $- $- $23.53 $- N/A $7.65 N/A N/A Not Reimbursed N/A N/A $17.65 N/A N/A $14.71 N/A N/A N/A N/A N/A $20.00 N/A N/A $18.24 N/A N/A $12.06 N/A N/A $20.59 N/A N/A $23.53 N/A N/A $16.18 N/A N/A $20.59 N/A N/A $9.85 N/A N/A N/A N/A N/A $17.65 N/A N/A $10.29 N/A N/A $19.12 N/A N/A $1.39 N/A N/A $17.65 N/A N/A $20.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.41 $29.41 N/A 4409345 Pharmacy prochlorperazine 5 mg/mL Inj Sol [BCH] J0780 636 $44.40 $- $6.43 $- $- $35.52 $- N/A $11.54 N/A N/A Not Reimbursed N/A N/A $26.64 N/A N/A $22.20 N/A N/A N/A N/A N/A $30.19 N/A N/A $27.53 N/A N/A $18.20 N/A N/A $31.08 N/A N/A $35.52 N/A N/A $24.42 N/A N/A $31.08 N/A N/A $14.87 N/A N/A N/A N/A N/A $26.64 N/A N/A $15.54 N/A N/A $28.86 N/A N/A $6.43 N/A N/A $26.64 N/A N/A $31.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.40 $44.40 N/A 4400685 Pharmacy furosemide 10 mg/mL Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409345 Pharmacy prochlorperazine 5 mg/mL Sol [BCH] J0780 250 $44.40 $- $6.43 $- $- $35.52 $- N/A $11.54 N/A N/A Not Reimbursed N/A N/A $26.64 N/A N/A $22.20 N/A N/A N/A N/A N/A $30.19 N/A N/A $27.53 N/A N/A $18.20 N/A N/A $31.08 N/A N/A $35.52 N/A N/A $24.42 N/A N/A $31.08 N/A N/A $14.87 N/A N/A N/A N/A N/A $26.64 N/A N/A $15.54 N/A N/A $28.86 N/A N/A $6.43 N/A N/A $26.64 N/A N/A $31.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.40 $44.40 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409457 Pharmacy isosorbide mononitrate 30 mg Tab 250 $2.23 $- $0.58 $- $- $1.79 $- N/A $0.58 N/A N/A $0.84 N/A N/A $1.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.39 N/A N/A $0.92 N/A N/A $1.56 N/A N/A $1.79 N/A N/A $1.23 N/A N/A $1.56 N/A N/A $0.75 N/A N/A N/A N/A N/A $1.34 N/A N/A $0.78 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.34 N/A N/A $1.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.23 $2.23 N/A 4401250 Pharmacy ondansetron 2 mg/mL Sol J2405 636 $12.00 $- $0.10 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.10 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404159 Pharmacy labetalol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400894 Pharmacy BAG BALM 0 Oint-App [BCH] 258 $14.08 $- $3.66 $- $- $11.26 $- N/A $3.66 N/A N/A $5.32 N/A N/A $8.45 N/A N/A $7.04 N/A N/A N/A N/A N/A $9.57 N/A N/A $8.73 N/A N/A $5.77 N/A N/A $9.86 N/A N/A $11.26 N/A N/A $7.74 N/A N/A $9.86 N/A N/A $4.72 N/A N/A N/A N/A N/A $8.45 N/A N/A $4.93 N/A N/A $9.15 N/A N/A N/A N/A N/A $8.45 N/A N/A $9.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.08 $14.08 N/A 4403804 Pharmacy tobramycin Ophth 0.3% Sol [BCH] 250 $29.38 $- $7.64 $- $- $23.50 $- N/A $7.64 N/A N/A $11.11 N/A N/A $17.63 N/A N/A $14.69 N/A N/A N/A N/A N/A $19.98 N/A N/A $18.22 N/A N/A $12.05 N/A N/A $20.57 N/A N/A $23.50 N/A N/A $16.16 N/A N/A $20.57 N/A N/A $9.84 N/A N/A N/A N/A N/A $17.63 N/A N/A $10.28 N/A N/A $19.10 N/A N/A N/A N/A N/A $17.63 N/A N/A $20.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.38 $29.38 N/A 4402426 Pharmacy flurbiprofen Ophth 0.03% Sol [BCH] 250 $17.46 $- $4.54 $- $- $13.97 $- N/A $4.54 N/A N/A $6.60 N/A N/A $10.48 N/A N/A $8.73 N/A N/A N/A N/A N/A $11.87 N/A N/A $10.83 N/A N/A $7.16 N/A N/A $12.22 N/A N/A $13.97 N/A N/A $9.60 N/A N/A $12.22 N/A N/A $5.85 N/A N/A N/A N/A N/A $10.48 N/A N/A $6.11 N/A N/A $11.35 N/A N/A N/A N/A N/A $10.48 N/A N/A $12.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.46 $17.46 N/A 4400798 Pharmacy polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Sol [BCH] 250 $26.88 $- $6.99 $- $- $21.50 $- N/A $6.99 N/A N/A $10.16 N/A N/A $16.13 N/A N/A $13.44 N/A N/A N/A N/A N/A $18.28 N/A N/A $16.67 N/A N/A $11.02 N/A N/A $18.82 N/A N/A $21.50 N/A N/A $14.78 N/A N/A $18.82 N/A N/A $9.00 N/A N/A N/A N/A N/A $16.13 N/A N/A $9.41 N/A N/A $17.47 N/A N/A N/A N/A N/A $16.13 N/A N/A $18.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.88 $26.88 N/A 4400214 Pharmacy desmopressin 10 mcg/inh Nasal Spry [BCH] 250 $492.52 $- $128.06 $- $- $394.02 $- N/A $128.06 N/A N/A $186.17 N/A N/A $295.51 N/A N/A $246.26 N/A N/A N/A N/A N/A $334.91 N/A N/A $305.36 N/A N/A $201.93 N/A N/A $344.76 N/A N/A $394.02 N/A N/A $270.89 N/A N/A $344.76 N/A N/A $164.99 N/A N/A N/A N/A N/A $295.51 N/A N/A $172.38 N/A N/A $320.14 N/A N/A N/A N/A N/A $295.51 N/A N/A $344.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $492.52 $492.52 N/A 4400336 Pharmacy fluorescein ophthalmic 1 mg Test [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400795 Pharmacy ipratropium nasal 21 mcg/inh Spr 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402398 Pharmacy ofloxacin Otic 0.3% Sol [BCH] 250 $270.18 $- $70.25 $- $- $216.14 $- N/A $70.25 N/A N/A $102.13 N/A N/A $162.11 N/A N/A $135.09 N/A N/A N/A N/A N/A $183.72 N/A N/A $167.51 N/A N/A $110.77 N/A N/A $189.13 N/A N/A $216.14 N/A N/A $148.60 N/A N/A $189.13 N/A N/A $90.51 N/A N/A N/A N/A N/A $162.11 N/A N/A $94.56 N/A N/A $175.62 N/A N/A N/A N/A N/A $162.11 N/A N/A $189.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $270.18 $270.18 N/A 4409501 Pharmacy brimonidine Ophth 0.2% Sol [BCH] 250 $36.36 $- $9.45 $- $- $29.09 $- N/A $9.45 N/A N/A $13.74 N/A N/A $21.82 N/A N/A $18.18 N/A N/A N/A N/A N/A $24.73 N/A N/A $22.54 N/A N/A $14.91 N/A N/A $25.45 N/A N/A $29.09 N/A N/A $20.00 N/A N/A $25.45 N/A N/A $12.18 N/A N/A N/A N/A N/A $21.82 N/A N/A $12.73 N/A N/A $23.64 N/A N/A N/A N/A N/A $21.82 N/A N/A $25.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.36 $36.36 N/A 4409394 Pharmacy latanoprost Ophth 0.005% Sol [BCH] 250 $48.76 $- $12.68 $- $- $39.01 $- N/A $12.68 N/A N/A $18.43 N/A N/A $29.26 N/A N/A $24.38 N/A N/A N/A N/A N/A $33.16 N/A N/A $30.23 N/A N/A $19.99 N/A N/A $34.13 N/A N/A $39.01 N/A N/A $26.82 N/A N/A $34.13 N/A N/A $16.33 N/A N/A N/A N/A N/A $29.26 N/A N/A $17.07 N/A N/A $31.69 N/A N/A N/A N/A N/A $29.26 N/A N/A $34.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.76 $48.76 N/A 4406168 Pharmacy dorzolamide Ophth 2% Sol [BCH] 250 $91.78 $- $23.86 $- $- $73.42 $- N/A $23.86 N/A N/A $34.69 N/A N/A $55.07 N/A N/A $45.89 N/A N/A N/A N/A N/A $62.41 N/A N/A $56.90 N/A N/A $37.63 N/A N/A $64.25 N/A N/A $73.42 N/A N/A $50.48 N/A N/A $64.25 N/A N/A $30.75 N/A N/A N/A N/A N/A $55.07 N/A N/A $32.12 N/A N/A $59.66 N/A N/A N/A N/A N/A $55.07 N/A N/A $64.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $91.78 $91.78 N/A 4400037 Pharmacy dorzolamide-timolol Ophth 2%-0.5% Sol [BCH] 250 $134.98 $- $35.09 $- $- $107.98 $- N/A $35.09 N/A N/A $51.02 N/A N/A $80.99 N/A N/A $67.49 N/A N/A N/A N/A N/A $91.79 N/A N/A $83.69 N/A N/A $55.34 N/A N/A $94.49 N/A N/A $107.98 N/A N/A $74.24 N/A N/A $94.49 N/A N/A $45.22 N/A N/A N/A N/A N/A $80.99 N/A N/A $47.24 N/A N/A $87.74 N/A N/A N/A N/A N/A $80.99 N/A N/A $94.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $134.98 $134.98 N/A 4403652 Pharmacy levobunolol Ophth 0.5% Sol [BCH] 250 $48.36 $- $12.57 $- $- $38.69 $- N/A $12.57 N/A N/A $18.28 N/A N/A $29.02 N/A N/A $24.18 N/A N/A N/A N/A N/A $32.88 N/A N/A $29.98 N/A N/A $19.83 N/A N/A $33.85 N/A N/A $38.69 N/A N/A $26.60 N/A N/A $33.85 N/A N/A $16.20 N/A N/A N/A N/A N/A $29.02 N/A N/A $16.93 N/A N/A $31.43 N/A N/A N/A N/A N/A $29.02 N/A N/A $33.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.36 $48.36 N/A 4403813 Pharmacy acetylcholine ophthalmic 1% Pwdr for Recon [BCH] 250 $197.50 $- $51.35 $- $- $158.00 $- N/A $51.35 N/A N/A $74.66 N/A N/A $118.50 N/A N/A $98.75 N/A N/A N/A N/A N/A $134.30 N/A N/A $122.45 N/A N/A $80.98 N/A N/A $138.25 N/A N/A $158.00 N/A N/A $108.63 N/A N/A $138.25 N/A N/A $66.16 N/A N/A N/A N/A N/A $118.50 N/A N/A $69.13 N/A N/A $128.38 N/A N/A N/A N/A N/A $118.50 N/A N/A $138.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $197.50 $197.50 N/A 4400814 Pharmacy tropicamide ophthalmic 1% Sol[BCH] 250 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409605 Pharmacy hydrocortisone/neomycin/polymyxin B Otic Sol [BCH] 250 $201.36 $- $52.35 $- $- $161.09 $- N/A $52.35 N/A N/A $76.11 N/A N/A $120.82 N/A N/A $100.68 N/A N/A N/A N/A N/A $136.92 N/A N/A $124.84 N/A N/A $82.56 N/A N/A $140.95 N/A N/A $161.09 N/A N/A $110.75 N/A N/A $140.95 N/A N/A $67.46 N/A N/A N/A N/A N/A $120.82 N/A N/A $70.48 N/A N/A $130.88 N/A N/A N/A N/A N/A $120.82 N/A N/A $140.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $201.36 $201.36 N/A 4400162 Pharmacy sodium sulfacetamide Ophth 10% Sol [BCH] 250 $122.00 $- $31.72 $- $- $97.60 $- N/A $31.72 N/A N/A $46.12 N/A N/A $73.20 N/A N/A $61.00 N/A N/A N/A N/A N/A $82.96 N/A N/A $75.64 N/A N/A $50.02 N/A N/A $85.40 N/A N/A $97.60 N/A N/A $67.10 N/A N/A $85.40 N/A N/A $40.87 N/A N/A N/A N/A N/A $73.20 N/A N/A $42.70 N/A N/A $79.30 N/A N/A N/A N/A N/A $73.20 N/A N/A $85.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $122.00 $122.00 N/A 4400819 Pharmacy sulfacetamide sodium ophthalmic 10% Sol [BCH] 250 $40.67 $- $10.57 $- $- $32.53 $- N/A $10.57 N/A N/A $15.37 N/A N/A $24.40 N/A N/A $20.33 N/A N/A N/A N/A N/A $27.65 N/A N/A $25.21 N/A N/A $16.67 N/A N/A $28.47 N/A N/A $32.53 N/A N/A $22.37 N/A N/A $28.47 N/A N/A $13.62 N/A N/A N/A N/A N/A $24.40 N/A N/A $14.23 N/A N/A $26.43 N/A N/A N/A N/A N/A $24.40 N/A N/A $28.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.67 $40.67 N/A 4401691 Pharmacy cyclopentolate Ophth 1% Sol [BCH] 250 $32.66 $- $8.49 $- $- $26.13 $- N/A $8.49 N/A N/A $12.35 N/A N/A $19.60 N/A N/A $16.33 N/A N/A N/A N/A N/A $22.21 N/A N/A $20.25 N/A N/A $13.39 N/A N/A $22.86 N/A N/A $26.13 N/A N/A $17.96 N/A N/A $22.86 N/A N/A $10.94 N/A N/A N/A N/A N/A $19.60 N/A N/A $11.43 N/A N/A $21.23 N/A N/A N/A N/A N/A $19.60 N/A N/A $22.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.66 $32.66 N/A 4401691 Pharmacy cyclopentolate ophthalmic 1% Sol [BCH] 250 $9.07 $- $2.36 $- $- $7.26 $- N/A $2.36 N/A N/A $3.43 N/A N/A $5.44 N/A N/A $4.54 N/A N/A N/A N/A N/A $6.17 N/A N/A $5.62 N/A N/A $3.72 N/A N/A $6.35 N/A N/A $7.26 N/A N/A $4.99 N/A N/A $6.35 N/A N/A $3.04 N/A N/A N/A N/A N/A $5.44 N/A N/A $3.18 N/A N/A $5.90 N/A N/A N/A N/A N/A $5.44 N/A N/A $6.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.07 $9.07 N/A 4409655 Pharmacy atropine Ophth 1% Sol [BCH] 250 $33.64 $- $8.75 $- $- $26.91 $- N/A $8.75 N/A N/A $12.72 N/A N/A $20.18 N/A N/A $16.82 N/A N/A N/A N/A N/A $22.88 N/A N/A $20.86 N/A N/A $13.79 N/A N/A $23.55 N/A N/A $26.91 N/A N/A $18.50 N/A N/A $23.55 N/A N/A $11.27 N/A N/A N/A N/A N/A $20.18 N/A N/A $11.77 N/A N/A $21.87 N/A N/A N/A N/A N/A $20.18 N/A N/A $23.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.64 $33.64 N/A 4404043 Pharmacy bacitracin/neomycin/polymyxin B ophthalmic 400 units-3.5 mg-10000 units/g Oin [BCH] 250 $113.90 $- $29.61 $- $- $91.12 $- N/A $29.61 N/A N/A $43.05 N/A N/A $68.34 N/A N/A $56.95 N/A N/A N/A N/A N/A $77.45 N/A N/A $70.62 N/A N/A $46.70 N/A N/A $79.73 N/A N/A $91.12 N/A N/A $62.65 N/A N/A $79.73 N/A N/A $38.16 N/A N/A N/A N/A N/A $68.34 N/A N/A $39.87 N/A N/A $74.04 N/A N/A N/A N/A N/A $68.34 N/A N/A $79.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $113.90 $113.90 N/A 4400554 Pharmacy bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 units/g Oin [BCH] 250 $130.10 $- $33.83 $- $- $104.08 $- N/A $33.83 N/A N/A $49.18 N/A N/A $78.06 N/A N/A $65.05 N/A N/A N/A N/A N/A $88.47 N/A N/A $80.66 N/A N/A $53.34 N/A N/A $91.07 N/A N/A $104.08 N/A N/A $71.55 N/A N/A $91.07 N/A N/A $43.58 N/A N/A N/A N/A N/A $78.06 N/A N/A $45.53 N/A N/A $84.56 N/A N/A N/A N/A N/A $78.06 N/A N/A $91.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $130.10 $130.10 N/A 4400556 Pharmacy gramicidin/neomycin/polymyxin B Ophth Sol [BCH] 250 $123.88 $- $32.21 $- $- $99.10 $- N/A $32.21 N/A N/A $46.83 N/A N/A $74.33 N/A N/A $61.94 N/A N/A N/A N/A N/A $84.24 N/A N/A $76.81 N/A N/A $50.79 N/A N/A $86.72 N/A N/A $99.10 N/A N/A $68.13 N/A N/A $86.72 N/A N/A $41.50 N/A N/A N/A N/A N/A $74.33 N/A N/A $43.36 N/A N/A $80.52 N/A N/A N/A N/A N/A $74.33 N/A N/A $86.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $123.88 $123.88 N/A 4402383 Pharmacy dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/mL Sus[BCH] 250 $39.72 $- $10.33 $- $- $31.78 $- N/A $10.33 N/A N/A $15.01 N/A N/A $23.83 N/A N/A $19.86 N/A N/A N/A N/A N/A $27.01 N/A N/A $24.63 N/A N/A $16.29 N/A N/A $27.80 N/A N/A $31.78 N/A N/A $21.85 N/A N/A $27.80 N/A N/A $13.31 N/A N/A N/A N/A N/A $23.83 N/A N/A $13.90 N/A N/A $25.82 N/A N/A N/A N/A N/A $23.83 N/A N/A $27.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.72 $39.72 N/A 4401709 Pharmacy erythromycin ophthalmic 0.5% Oin [BCH] 250 $86.87 $- $22.59 $- $- $69.50 $- N/A $22.59 N/A N/A $32.84 N/A N/A $52.12 N/A N/A $43.44 N/A N/A N/A N/A N/A $59.07 N/A N/A $53.86 N/A N/A $35.62 N/A N/A $60.81 N/A N/A $69.50 N/A N/A $47.78 N/A N/A $60.81 N/A N/A $29.10 N/A N/A N/A N/A N/A $52.12 N/A N/A $30.40 N/A N/A $56.47 N/A N/A N/A N/A N/A $52.12 N/A N/A $60.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $86.87 $86.87 N/A 4401709 Pharmacy erythromycin Ophth 0.5% Oint [BCH] 250 $38.00 $- $9.88 $- $- $30.40 $- N/A $9.88 N/A N/A $14.36 N/A N/A $22.80 N/A N/A $19.00 N/A N/A N/A N/A N/A $25.84 N/A N/A $23.56 N/A N/A $15.58 N/A N/A $26.60 N/A N/A $30.40 N/A N/A $20.90 N/A N/A $26.60 N/A N/A $12.73 N/A N/A N/A N/A N/A $22.80 N/A N/A $13.30 N/A N/A $24.70 N/A N/A N/A N/A N/A $22.80 N/A N/A $26.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.00 $38.00 N/A 4402456 Pharmacy erythromycin 250 mg Tab [BCH] 250 $23.25 $- $6.04 $- $- $18.60 $- N/A $6.04 N/A N/A $8.79 N/A N/A $13.95 N/A N/A $11.62 N/A N/A N/A N/A N/A $15.81 N/A N/A $14.41 N/A N/A $9.53 N/A N/A $16.27 N/A N/A $18.60 N/A N/A $12.79 N/A N/A $16.27 N/A N/A $7.79 N/A N/A N/A N/A N/A $13.95 N/A N/A $8.14 N/A N/A $15.11 N/A N/A N/A N/A N/A $13.95 N/A N/A $16.27 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.25 $23.25 N/A 4402233 Pharmacy gemfibrozil 600 mg Tab [BCH] 250 $4.86 $- $1.26 $- $- $3.89 $- N/A $1.26 N/A N/A $1.84 N/A N/A $2.92 N/A N/A $2.43 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.01 N/A N/A $1.99 N/A N/A $3.40 N/A N/A $3.89 N/A N/A $2.67 N/A N/A $3.40 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.92 N/A N/A $1.70 N/A N/A $3.16 N/A N/A N/A N/A N/A $2.92 N/A N/A $3.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.86 $4.86 N/A 4400979 Pharmacy busPIRone 7.5 mg Tab [BCH] 250 $3.16 $- $0.82 $- $- $2.53 $- N/A $0.82 N/A N/A $1.19 N/A N/A $1.90 N/A N/A $1.58 N/A N/A N/A N/A N/A $2.15 N/A N/A $1.96 N/A N/A $1.30 N/A N/A $2.21 N/A N/A $2.53 N/A N/A $1.74 N/A N/A $2.21 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.90 N/A N/A $1.11 N/A N/A $2.05 N/A N/A N/A N/A N/A $1.90 N/A N/A $2.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.16 $3.16 N/A 4403348 Pharmacy cefOXitin 1 g Inj [BCH] J0694 636 $28.00 $- $6.55 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $6.55 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4406062 Pharmacy fluconazole 200 mg/100 mL-NS IV Sol [BCH] J1450 636 $75.00 $- $16.11 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $16.11 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4404612 Pharmacy clindamycin 150 mg/mL Sol [BCH] 636 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400095 Pharmacy levoFLOXacin 250 mg/50 mL Sol [BCH] J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4406802 Pharmacy levofloxacin 500 mg/100 mL IV Sol [BCH] J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409224 Pharmacy ampicillin 1 g Inj [BCH] J0290 636 $28.00 $- $0.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4408347 Pharmacy oxacillin 1 g Inj [BCH] J2700 636 $28.00 $- $1.13 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.13 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400896 Pharmacy colistimethate 150 mg (colistin base) Pow [BCH] J0770 636 $57.60 $- $14.98 $- $- $46.08 $- N/A $14.98 N/A N/A Not Reimbursed N/A N/A $34.56 N/A N/A $28.80 N/A N/A N/A N/A N/A $39.17 N/A N/A $35.71 N/A N/A $23.62 N/A N/A $40.32 N/A N/A $46.08 N/A N/A $31.68 N/A N/A $40.32 N/A N/A $19.30 N/A N/A N/A N/A N/A $34.56 N/A N/A $20.16 N/A N/A $37.44 N/A N/A $17.16 N/A N/A $34.56 N/A N/A $40.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $57.60 $57.60 N/A 4400941 Pharmacy oxacillin 2 g Pow J2700 636 $54.00 $- $1.13 $- $- $43.20 $- N/A $14.04 N/A N/A Not Reimbursed N/A N/A $32.40 N/A N/A $27.00 N/A N/A N/A N/A N/A $36.72 N/A N/A $33.48 N/A N/A $22.14 N/A N/A $37.80 N/A N/A $43.20 N/A N/A $29.70 N/A N/A $37.80 N/A N/A $18.09 N/A N/A N/A N/A N/A $32.40 N/A N/A $18.90 N/A N/A $35.10 N/A N/A $1.13 N/A N/A $32.40 N/A N/A $37.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $54.00 $54.00 N/A 4402394 Pharmacy adenosine 3 mg/mL IV Sol vl[BCH] J0150 250 $38.40 $- $9.98 $- $- $30.72 $- N/A $9.98 N/A N/A Not Reimbursed N/A N/A $23.04 N/A N/A $19.20 N/A N/A N/A N/A N/A $26.11 N/A N/A $23.81 N/A N/A $15.74 N/A N/A $26.88 N/A N/A $30.72 N/A N/A $21.12 N/A N/A $26.88 N/A N/A $12.86 N/A N/A N/A N/A N/A $23.04 N/A N/A $13.44 N/A N/A $24.96 N/A N/A N/A N/A N/A $23.04 N/A N/A $26.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.40 $38.40 N/A 4400172 Pharmacy heparin 1000 units/mL Inj Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405016 Pharmacy heparin 5000 units/mL Inj Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405803 Pharmacy octreotide 100 mcg/mL Inj Sol [BCH] J2354 636 $15.60 $- $0.83 $- $- $12.48 $- N/A $4.06 N/A N/A Not Reimbursed N/A N/A $9.36 N/A N/A $7.80 N/A N/A N/A N/A N/A $10.61 N/A N/A $9.67 N/A N/A $6.40 N/A N/A $10.92 N/A N/A $12.48 N/A N/A $8.58 N/A N/A $10.92 N/A N/A $5.23 N/A N/A N/A N/A N/A $9.36 N/A N/A $5.46 N/A N/A $10.14 N/A N/A $0.83 N/A N/A $9.36 N/A N/A $10.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.60 $15.60 N/A 4405395 Pharmacy propofol 10 mg/mL Emu [BCH] S0144 636 $14.02 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A Not Reimbursed N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.75 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.70 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.91 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.02 $14.02 N/A 4409915 Pharmacy propofol 10 mg/mL EMU [BCH] S0144 636 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400780 Pharmacy atracurium 10 mg/mL Sol [BCH] 636 $19.20 $- $4.99 $- $- $15.36 $- N/A $4.99 N/A N/A $7.26 N/A N/A $11.52 N/A N/A $9.60 N/A N/A N/A N/A N/A $13.06 N/A N/A $11.90 N/A N/A $7.87 N/A N/A $13.44 N/A N/A $15.36 N/A N/A $10.56 N/A N/A $13.44 N/A N/A $6.43 N/A N/A N/A N/A N/A $11.52 N/A N/A $6.72 N/A N/A $12.48 N/A N/A N/A N/A N/A $11.52 N/A N/A $13.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.20 $19.20 N/A 4400697 Pharmacy granisetron 1 mg/mL IV Sol [BCH] J1626 636 $24.00 $- $0.26 $- $- $19.20 $- N/A $6.24 N/A N/A Not Reimbursed N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A $14.88 N/A N/A $9.84 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $0.26 N/A N/A $14.40 N/A N/A $16.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.00 $24.00 N/A 4404944 Pharmacy haloperidol 5 mg/mL Sol [BCH] J1630 636 $12.00 $- $0.99 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.99 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409796 Pharmacy acetylcysteine 20% Sol [BCH] J0132 636 $360.00 $- $1.08 $- $- $288.00 $- N/A $93.60 N/A N/A Not Reimbursed N/A N/A $216.00 N/A N/A $180.00 N/A N/A N/A N/A N/A $244.80 N/A N/A $223.20 N/A N/A $147.60 N/A N/A $252.00 N/A N/A $288.00 N/A N/A $198.00 N/A N/A $252.00 N/A N/A $120.60 N/A N/A N/A N/A N/A $216.00 N/A N/A $126.00 N/A N/A $234.00 N/A N/A $1.08 N/A N/A $216.00 N/A N/A $252.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $360.00 $360.00 N/A 4400293 Pharmacy risperiDONE 0.5 mg Tab [BCH] 250 $8.56 $- $2.23 $- $- $6.85 $- N/A $2.23 N/A N/A $3.24 N/A N/A $5.14 N/A N/A $4.28 N/A N/A N/A N/A N/A $5.82 N/A N/A $5.31 N/A N/A $3.51 N/A N/A $5.99 N/A N/A $6.85 N/A N/A $4.71 N/A N/A $5.99 N/A N/A $2.87 N/A N/A N/A N/A N/A $5.14 N/A N/A $3.00 N/A N/A $5.57 N/A N/A N/A N/A N/A $5.14 N/A N/A $5.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.56 $8.56 N/A 4400316 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $15.21 $- $3.96 $- $- $12.17 $- N/A $3.96 N/A N/A $5.75 N/A N/A $9.13 N/A N/A $7.61 N/A N/A N/A N/A N/A $10.35 N/A N/A $9.43 N/A N/A $6.24 N/A N/A $10.65 N/A N/A $12.17 N/A N/A $8.37 N/A N/A $10.65 N/A N/A $5.10 N/A N/A N/A N/A N/A $9.13 N/A N/A $5.32 N/A N/A $9.89 N/A N/A N/A N/A N/A $9.13 N/A N/A $10.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.21 $15.21 N/A 4401527 Pharmacy entacapone 200 mg Tab 250 $9.08 $- $2.36 $- $- $7.26 $- N/A $2.36 N/A N/A $3.43 N/A N/A $5.45 N/A N/A $4.54 N/A N/A N/A N/A N/A $6.17 N/A N/A $5.63 N/A N/A $3.72 N/A N/A $6.35 N/A N/A $7.26 N/A N/A $4.99 N/A N/A $6.35 N/A N/A $3.04 N/A N/A N/A N/A N/A $5.45 N/A N/A $3.18 N/A N/A $5.90 N/A N/A N/A N/A N/A $5.45 N/A N/A $6.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.08 $9.08 N/A 4400680 Pharmacy DULoxetine 60 mg Cap 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4400515 Pharmacy risperiDONE 1 mg/mL Sol [BCH] 250 $335.34 $- $87.19 $- $- $268.27 $- N/A $87.19 N/A N/A $126.76 N/A N/A $201.20 N/A N/A $167.67 N/A N/A N/A N/A N/A $228.03 N/A N/A $207.91 N/A N/A $137.49 N/A N/A $234.74 N/A N/A $268.27 N/A N/A $184.44 N/A N/A $234.74 N/A N/A $112.34 N/A N/A N/A N/A N/A $201.20 N/A N/A $117.37 N/A N/A $217.97 N/A N/A N/A N/A N/A $201.20 N/A N/A $234.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $335.34 $335.34 N/A 4403850 Pharmacy codeine-promethazine 10 mg-6.25 mg/5 mL Syr 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403812 Pharmacy morphine 20 mg/mL Con [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403812 Pharmacy morphine 20 mg/mL Con [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402252 Pharmacy sucralfate 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400305 Pharmacy hydroCHLOROthiazide 12.5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403713 Pharmacy divalproex sodium 250 mg Tab [BCH] 250 $3.52 $- $0.92 $- $- $2.82 $- N/A $0.92 N/A N/A $1.33 N/A N/A $2.11 N/A N/A $1.76 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.19 N/A N/A $1.45 N/A N/A $2.47 N/A N/A $2.82 N/A N/A $1.94 N/A N/A $2.47 N/A N/A $1.18 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.23 N/A N/A $2.29 N/A N/A N/A N/A N/A $2.11 N/A N/A $2.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.52 $3.52 N/A 4402829 Pharmacy metroNIDAZOLE 500 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4402829 Pharmacy metroNIDAZOLE 500 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400690 Pharmacy witch hazel topical 50% Pad[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400983 Pharmacy saline rectal enema 100% Enema [BCH] 250 $3.00 $- $0.78 $- $- $2.40 $- N/A $0.78 N/A N/A $1.13 N/A N/A $1.80 N/A N/A $1.50 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.86 N/A N/A $1.23 N/A N/A $2.10 N/A N/A $2.40 N/A N/A $1.65 N/A N/A $2.10 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.05 N/A N/A $1.95 N/A N/A N/A N/A N/A $1.80 N/A N/A $2.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.00 $3.00 N/A 4400984 Pharmacy sodium chloride inhalation solution USP 0.9% 0.9% Soln-Inh 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401001 Pharmacy Oseltamivir Phosphate 30 mg Cap 250 $282.22 $- $73.38 $- $- $225.78 $- N/A $73.38 N/A N/A $106.68 N/A N/A $169.33 N/A N/A $141.11 N/A N/A N/A N/A N/A $191.91 N/A N/A $174.98 N/A N/A $115.71 N/A N/A $197.55 N/A N/A $225.78 N/A N/A $155.22 N/A N/A $197.55 N/A N/A $94.54 N/A N/A N/A N/A N/A $169.33 N/A N/A $98.78 N/A N/A $183.44 N/A N/A N/A N/A N/A $169.33 N/A N/A $197.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $282.22 $282.22 N/A Pharmacy elimite 5% Cream [BCH] 250 $242.40 $- $63.02 $- $- $193.92 $- N/A $63.02 N/A N/A $91.63 N/A N/A $145.44 N/A N/A $121.20 N/A N/A N/A N/A N/A $164.83 N/A N/A $150.29 N/A N/A $99.38 N/A N/A $169.68 N/A N/A $193.92 N/A N/A $133.32 N/A N/A $169.68 N/A N/A $81.20 N/A N/A N/A N/A N/A $145.44 N/A N/A $84.84 N/A N/A $157.56 N/A N/A N/A N/A N/A $145.44 N/A N/A $169.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $242.40 $242.40 N/A 4400298 Pharmacy citalopram 40 mg Tab [BCH] 250 $5.29 $- $1.38 $- $- $4.23 $- N/A $1.38 N/A N/A $2.00 N/A N/A $3.17 N/A N/A $2.64 N/A N/A N/A N/A N/A $3.60 N/A N/A $3.28 N/A N/A $2.17 N/A N/A $3.70 N/A N/A $4.23 N/A N/A $2.91 N/A N/A $3.70 N/A N/A $1.77 N/A N/A N/A N/A N/A $3.17 N/A N/A $1.85 N/A N/A $3.44 N/A N/A N/A N/A N/A $3.17 N/A N/A $3.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.29 $5.29 N/A 4402518 Pharmacy benztropine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $3.19 $- $0.83 $- $- $2.56 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.98 N/A N/A $1.31 N/A N/A $2.24 N/A N/A $2.56 N/A N/A $1.76 N/A N/A $2.24 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.19 $3.19 N/A 4400364 Pharmacy amLODIPine 5 mg Tab [BCH] 250 $3.48 $- $0.90 $- $- $2.78 $- N/A $0.90 N/A N/A $1.31 N/A N/A $2.09 N/A N/A $1.74 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.43 N/A N/A $2.78 N/A N/A $1.91 N/A N/A $2.43 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.26 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.48 $3.48 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.77 $- $1.24 $- $- $3.82 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.86 N/A N/A $2.39 N/A N/A N/A N/A N/A $3.25 N/A N/A $2.96 N/A N/A $1.96 N/A N/A $3.34 N/A N/A $3.82 N/A N/A $2.62 N/A N/A $3.34 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.86 N/A N/A $1.67 N/A N/A $3.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $3.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.77 $4.77 N/A 4409738 Pharmacy escitalopram 10 mg Tab [BCH] 250 $10.48 $- $2.72 $- $- $8.38 $- N/A $2.72 N/A N/A $3.96 N/A N/A $6.29 N/A N/A $5.24 N/A N/A N/A N/A N/A $7.13 N/A N/A $6.50 N/A N/A $4.30 N/A N/A $7.34 N/A N/A $8.38 N/A N/A $5.76 N/A N/A $7.34 N/A N/A $3.51 N/A N/A N/A N/A N/A $6.29 N/A N/A $3.67 N/A N/A $6.81 N/A N/A N/A N/A N/A $6.29 N/A N/A $7.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.48 $10.48 N/A 4400307 Pharmacy escitalopram 20 mg Tab [BCH] 250 $10.93 $- $2.84 $- $- $8.75 $- N/A $2.84 N/A N/A $4.13 N/A N/A $6.56 N/A N/A $5.47 N/A N/A N/A N/A N/A $7.44 N/A N/A $6.78 N/A N/A $4.48 N/A N/A $7.65 N/A N/A $8.75 N/A N/A $6.01 N/A N/A $7.65 N/A N/A $3.66 N/A N/A N/A N/A N/A $6.56 N/A N/A $3.83 N/A N/A $7.11 N/A N/A N/A N/A N/A $6.56 N/A N/A $7.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.93 $10.93 N/A 4409551 Pharmacy topiramate 25 mg Tab [BCH] 250 $5.05 $- $1.31 $- $- $4.04 $- N/A $1.31 N/A N/A $1.91 N/A N/A $3.03 N/A N/A $2.53 N/A N/A N/A N/A N/A $3.44 N/A N/A $3.13 N/A N/A $2.07 N/A N/A $3.54 N/A N/A $4.04 N/A N/A $2.78 N/A N/A $3.54 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.03 N/A N/A $1.77 N/A N/A $3.28 N/A N/A N/A N/A N/A $3.03 N/A N/A $3.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.05 $5.05 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab [BCH] 250 $2.32 $- $0.60 $- $- $1.85 $- N/A $0.60 N/A N/A $0.88 N/A N/A $1.39 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.57 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.62 N/A N/A $1.85 N/A N/A $1.27 N/A N/A $1.62 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.39 N/A N/A $0.81 N/A N/A $1.50 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.32 $2.32 N/A 4409393 Pharmacy naproxen 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400633 Pharmacy hydrALAZINE 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403512 Pharmacy finasteride 5 mg Tab [BCH] S0138 250 $6.23 $- $1.62 $- $- $4.98 $- N/A $1.62 N/A N/A Not Reimbursed N/A N/A $3.74 N/A N/A $3.11 N/A N/A N/A N/A N/A $4.23 N/A N/A $3.86 N/A N/A $2.55 N/A N/A $4.36 N/A N/A $4.98 N/A N/A $3.42 N/A N/A $4.36 N/A N/A $2.09 N/A N/A N/A N/A N/A $3.74 N/A N/A $2.18 N/A N/A $4.05 N/A N/A N/A N/A N/A $3.74 N/A N/A $4.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.23 $6.23 N/A 4406804 Pharmacy torsemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $7.03 $- $1.83 $- $- $5.62 $- N/A $1.83 N/A N/A $2.66 N/A N/A $4.22 N/A N/A $3.51 N/A N/A N/A N/A N/A $4.78 N/A N/A $4.36 N/A N/A $2.88 N/A N/A $4.92 N/A N/A $5.62 N/A N/A $3.87 N/A N/A $4.92 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.22 N/A N/A $2.46 N/A N/A $4.57 N/A N/A N/A N/A N/A $4.22 N/A N/A $4.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.03 $7.03 N/A 4405248 Pharmacy indomethacin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409479 Pharmacy oseltamivir 75 mg Cap 250 $30.91 $- $8.04 $- $- $24.73 $- N/A $8.04 N/A N/A $11.69 N/A N/A $18.55 N/A N/A $15.46 N/A N/A N/A N/A N/A $21.02 N/A N/A $19.17 N/A N/A $12.67 N/A N/A $21.64 N/A N/A $24.73 N/A N/A $17.00 N/A N/A $21.64 N/A N/A $10.36 N/A N/A N/A N/A N/A $18.55 N/A N/A $10.82 N/A N/A $20.09 N/A N/A N/A N/A N/A $18.55 N/A N/A $21.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.91 $30.91 N/A 4400794 Pharmacy losartan 25 mg Tab [BCH] 250 $3.34 $- $0.87 $- $- $2.68 $- N/A $0.87 N/A N/A $1.26 N/A N/A $2.01 N/A N/A $1.67 N/A N/A N/A N/A N/A $2.27 N/A N/A $2.07 N/A N/A $1.37 N/A N/A $2.34 N/A N/A $2.68 N/A N/A $1.84 N/A N/A $2.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $2.01 N/A N/A $1.17 N/A N/A $2.17 N/A N/A N/A N/A N/A $2.01 N/A N/A $2.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.34 $3.34 N/A 4400066 Pharmacy losartan 50 mg Tab 250 $4.50 $- $1.17 $- $- $3.60 $- N/A $1.17 N/A N/A $1.70 N/A N/A $2.70 N/A N/A $2.25 N/A N/A N/A N/A N/A $3.06 N/A N/A $2.79 N/A N/A $1.84 N/A N/A $3.15 N/A N/A $3.60 N/A N/A $2.47 N/A N/A $3.15 N/A N/A $1.51 N/A N/A N/A N/A N/A $2.70 N/A N/A $1.57 N/A N/A $2.92 N/A N/A N/A N/A N/A $2.70 N/A N/A $3.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.50 $4.50 N/A 4400478 Pharmacy losartan 100 mg Tab [BCH] 250 $6.12 $- $1.59 $- $- $4.90 $- N/A $1.59 N/A N/A $2.32 N/A N/A $3.67 N/A N/A $3.06 N/A N/A N/A N/A N/A $4.16 N/A N/A $3.80 N/A N/A $2.51 N/A N/A $4.29 N/A N/A $4.90 N/A N/A $3.37 N/A N/A $4.29 N/A N/A $2.05 N/A N/A N/A N/A N/A $3.67 N/A N/A $2.14 N/A N/A $3.98 N/A N/A N/A N/A N/A $3.67 N/A N/A $4.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.12 $6.12 N/A 4409741 Pharmacy levoFLOXacin 250 mg Tab 250 $33.62 $- $8.74 $- $- $26.90 $- N/A $8.74 N/A N/A $12.71 N/A N/A $20.17 N/A N/A $16.81 N/A N/A N/A N/A N/A $22.86 N/A N/A $20.85 N/A N/A $13.78 N/A N/A $23.54 N/A N/A $26.90 N/A N/A $18.49 N/A N/A $23.54 N/A N/A $11.26 N/A N/A N/A N/A N/A $20.17 N/A N/A $11.77 N/A N/A $21.85 N/A N/A N/A N/A N/A $20.17 N/A N/A $23.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.62 $33.62 N/A 4407273 Pharmacy montelukast 10 mg Tab [BCH] 250 $11.31 $- $2.94 $- $- $9.05 $- N/A $2.94 N/A N/A $4.28 N/A N/A $6.79 N/A N/A $5.66 N/A N/A N/A N/A N/A $7.69 N/A N/A $7.02 N/A N/A $4.64 N/A N/A $7.92 N/A N/A $9.05 N/A N/A $6.22 N/A N/A $7.92 N/A N/A $3.79 N/A N/A N/A N/A N/A $6.79 N/A N/A $3.96 N/A N/A $7.35 N/A N/A N/A N/A N/A $6.79 N/A N/A $7.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.31 $11.31 N/A 4409755 Pharmacy linezolid 600 mg Tab [BCH] 250 $367.34 $- $95.51 $- $- $293.87 $- N/A $95.51 N/A N/A $138.85 N/A N/A $220.40 N/A N/A $183.67 N/A N/A N/A N/A N/A $249.79 N/A N/A $227.75 N/A N/A $150.61 N/A N/A $257.14 N/A N/A $293.87 N/A N/A $202.04 N/A N/A $257.14 N/A N/A $123.06 N/A N/A N/A N/A N/A $220.40 N/A N/A $128.57 N/A N/A $238.77 N/A N/A N/A N/A N/A $220.40 N/A N/A $257.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $367.34 $367.34 N/A 4400979 Pharmacy busPIRone 7.5 mg Tab [BCH] 250 $3.16 $- $0.82 $- $- $2.53 $- N/A $0.82 N/A N/A $1.19 N/A N/A $1.90 N/A N/A $1.58 N/A N/A N/A N/A N/A $2.15 N/A N/A $1.96 N/A N/A $1.30 N/A N/A $2.21 N/A N/A $2.53 N/A N/A $1.74 N/A N/A $2.21 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.90 N/A N/A $1.11 N/A N/A $2.05 N/A N/A N/A N/A N/A $1.90 N/A N/A $2.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.16 $3.16 N/A 4400413 Pharmacy pramipexole 0.5 mg Tab [BCH] 250 $6.17 $- $1.60 $- $- $4.93 $- N/A $1.60 N/A N/A $2.33 N/A N/A $3.70 N/A N/A $3.08 N/A N/A N/A N/A N/A $4.19 N/A N/A $3.82 N/A N/A $2.53 N/A N/A $4.32 N/A N/A $4.93 N/A N/A $3.39 N/A N/A $4.32 N/A N/A $2.07 N/A N/A N/A N/A N/A $3.70 N/A N/A $2.16 N/A N/A $4.01 N/A N/A N/A N/A N/A $3.70 N/A N/A $4.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.17 $6.17 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $14.01 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A $5.30 N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.74 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.90 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.01 $14.01 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $14.01 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A $5.30 N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.74 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.90 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.01 $14.01 N/A 4400117 Pharmacy OLANZapine 5 mg Dis Tab [BCH] 250 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409418 Pharmacy rivastigmine 1.5 mg Cap[BCH] 250 $8.06 $- $2.10 $- $- $6.45 $- N/A $2.10 N/A N/A $3.05 N/A N/A $4.84 N/A N/A $4.03 N/A N/A N/A N/A N/A $5.48 N/A N/A $5.00 N/A N/A $3.31 N/A N/A $5.64 N/A N/A $6.45 N/A N/A $4.43 N/A N/A $5.64 N/A N/A $2.70 N/A N/A N/A N/A N/A $4.84 N/A N/A $2.82 N/A N/A $5.24 N/A N/A N/A N/A N/A $4.84 N/A N/A $5.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.06 $8.06 N/A 4408966 Pharmacy celecoxib 200 mg Cap 250 $15.14 $- $3.94 $- $- $12.11 $- N/A $3.94 N/A N/A $5.72 N/A N/A $9.08 N/A N/A $7.57 N/A N/A N/A N/A N/A $10.30 N/A N/A $9.39 N/A N/A $6.21 N/A N/A $10.60 N/A N/A $12.11 N/A N/A $8.33 N/A N/A $10.60 N/A N/A $5.07 N/A N/A N/A N/A N/A $9.08 N/A N/A $5.30 N/A N/A $9.84 N/A N/A N/A N/A N/A $9.08 N/A N/A $10.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.14 $15.14 N/A 4401527 Pharmacy entacapone 200 mg Tab 250 $7.90 $- $2.05 $- $- $6.32 $- N/A $2.05 N/A N/A $2.99 N/A N/A $4.74 N/A N/A $3.95 N/A N/A N/A N/A N/A $5.37 N/A N/A $4.90 N/A N/A $3.24 N/A N/A $5.53 N/A N/A $6.32 N/A N/A $4.35 N/A N/A $5.53 N/A N/A $2.65 N/A N/A N/A N/A N/A $4.74 N/A N/A $2.77 N/A N/A $5.14 N/A N/A N/A N/A N/A $4.74 N/A N/A $5.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.90 $7.90 N/A Pharmacy Methimazole 5 mg Tab 250 $88.88 $- $23.11 $- $- $71.10 $- N/A $23.11 N/A N/A $33.60 N/A N/A $53.33 N/A N/A $44.44 N/A N/A N/A N/A N/A $60.44 N/A N/A $55.11 N/A N/A $36.44 N/A N/A $62.22 N/A N/A $71.10 N/A N/A $48.88 N/A N/A $62.22 N/A N/A $29.77 N/A N/A N/A N/A N/A $53.33 N/A N/A $31.11 N/A N/A $57.77 N/A N/A N/A N/A N/A $53.33 N/A N/A $62.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $88.88 $88.88 N/A 7000002 Pharmacy triamcinolone acetonide 0.1% Ointment [BCH] 250 $432.00 $- $112.32 $- $- $345.60 $- N/A $112.32 N/A N/A $163.30 N/A N/A $259.20 N/A N/A $216.00 N/A N/A N/A N/A N/A $293.76 N/A N/A $267.84 N/A N/A $177.12 N/A N/A $302.40 N/A N/A $345.60 N/A N/A $237.60 N/A N/A $302.40 N/A N/A $144.72 N/A N/A N/A N/A N/A $259.20 N/A N/A $151.20 N/A N/A $280.80 N/A N/A N/A N/A N/A $259.20 N/A N/A $302.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $432.00 $432.00 N/A 4400992 Pharmacy Nortriptyline 10 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400978 4400978 Pharmacy LIDOCAINE 2% INJ 10ML VIAL 2% Injection [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400853 Pharmacy lidocaine topical 3% Gel [BCH] 250 $127.40 $- $33.12 $- $- $101.92 $- N/A $33.12 N/A N/A $48.16 N/A N/A $76.44 N/A N/A $63.70 N/A N/A N/A N/A N/A $86.63 N/A N/A $78.99 N/A N/A $52.23 N/A N/A $89.18 N/A N/A $101.92 N/A N/A $70.07 N/A N/A $89.18 N/A N/A $42.68 N/A N/A N/A N/A N/A $76.44 N/A N/A $44.59 N/A N/A $82.81 N/A N/A N/A N/A N/A $76.44 N/A N/A $89.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $127.40 $127.40 N/A 4400996 Pharmacy Venelex 60 gm Ointment [BCH] 250 "$4,500.00 " $- "$1,170.00 " $- $- "$3,600.00 " $- N/A "$1,170.00 " N/A N/A "$1,701.00 " N/A N/A "$2,700.00 " N/A N/A "$2,250.00 " N/A N/A N/A N/A N/A "$3,060.00 " N/A N/A "$2,790.00 " N/A N/A "$1,845.00 " N/A N/A "$3,150.00 " N/A N/A "$3,600.00 " N/A N/A "$2,475.00 " N/A N/A "$3,150.00 " N/A N/A "$1,507.50 " N/A N/A N/A N/A N/A "$2,700.00 " N/A N/A "$1,575.00 " N/A N/A "$2,925.00 " N/A N/A N/A N/A N/A "$2,700.00 " N/A N/A "$3,150.00 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$4,500.00 " "$4,500.00 " N/A 4400957 Pharmacy atazanavir sulfate 200 mg Cap [BCH] 250 $52.68 $- $13.70 $- $- $42.14 $- N/A $13.70 N/A N/A $19.91 N/A N/A $31.61 N/A N/A $26.34 N/A N/A N/A N/A N/A $35.82 N/A N/A $32.66 N/A N/A $21.60 N/A N/A $36.87 N/A N/A $42.14 N/A N/A $28.97 N/A N/A $36.87 N/A N/A $17.65 N/A N/A N/A N/A N/A $31.61 N/A N/A $18.44 N/A N/A $34.24 N/A N/A N/A N/A N/A $31.61 N/A N/A $36.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.68 $52.68 N/A 4401250 Pharmacy ondansetron 2 mg/mL Sol [BCH] J2405 636 $12.00 $- $0.10 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.10 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400693 Pharmacy metoprolol 1 mg/mL Inj Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4406802 Pharmacy levoFLOXacin 500 mg/100 mL Sol J1956 636 $75.00 $- $0.40 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.40 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403151 Pharmacy norepinephrine 1 mg/mL Sol [BCH] 636 $19.97 $- $5.19 $- $- $15.97 $- N/A $5.19 N/A N/A $7.55 N/A N/A $11.98 N/A N/A $9.98 N/A N/A N/A N/A N/A $13.58 N/A N/A $12.38 N/A N/A $8.19 N/A N/A $13.98 N/A N/A $15.97 N/A N/A $10.98 N/A N/A $13.98 N/A N/A $6.69 N/A N/A N/A N/A N/A $11.98 N/A N/A $6.99 N/A N/A $12.98 N/A N/A N/A N/A N/A $11.98 N/A N/A $13.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.97 $19.97 N/A 4403102 Pharmacy furosemide 10 mg/mL Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400685 Pharmacy furosemide 10 mg/mL Inj Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405855 Pharmacy labetalol 5 mg/mL Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401019 Pharmacy casirivimab and imdevimab 600 MG/600 MG per 10 ML Injection 636 $- $- $- $- $- $- $- N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4401018 Pharmacy vancomycin 50 MG/ ML Powder [BCH] 250 "$102,420.00 " $- "$26,629.20 " $- $- "$81,936.00 " $- N/A "$26,629.20 " N/A N/A "$38,714.76 " N/A N/A "$61,452.00 " N/A N/A "$51,210.00 " N/A N/A N/A N/A N/A "$69,645.60 " N/A N/A "$63,500.40 " N/A N/A "$41,992.20 " N/A N/A "$71,694.00 " N/A N/A "$81,936.00 " N/A N/A "$56,331.00 " N/A N/A "$71,694.00 " N/A N/A "$34,310.70 " N/A N/A N/A N/A N/A "$61,452.00 " N/A N/A "$35,847.00 " N/A N/A "$66,573.00 " N/A N/A N/A N/A N/A "$61,452.00 " N/A N/A "$71,694.00 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$102,420.00 " "$102,420.00 " N/A 4401017 Pharmacy ketamine 50 MG/ML Injection [BCH] 250 $175.50 $- $45.63 $- $- $140.40 $- N/A $45.63 N/A N/A $66.34 N/A N/A $105.30 N/A N/A $87.75 N/A N/A N/A N/A N/A $119.34 N/A N/A $108.81 N/A N/A $71.96 N/A N/A $122.85 N/A N/A $140.40 N/A N/A $96.53 N/A N/A $122.85 N/A N/A $58.79 N/A N/A N/A N/A N/A $105.30 N/A N/A $61.43 N/A N/A $114.08 N/A N/A N/A N/A N/A $105.30 N/A N/A $122.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $175.50 $175.50 N/A 4401013 Pharmacy vancomycin 1.25 gm Injection [BCH] J3370 636 $482.40 $- $2.77 $- $- $385.92 $- N/A $125.42 N/A N/A Not Reimbursed N/A N/A $289.44 N/A N/A $241.20 N/A N/A N/A N/A N/A $328.03 N/A N/A $299.09 N/A N/A $197.78 N/A N/A $337.68 N/A N/A $385.92 N/A N/A $265.32 N/A N/A $337.68 N/A N/A $161.60 N/A N/A N/A N/A N/A $289.44 N/A N/A $168.84 N/A N/A $313.56 N/A N/A $2.77 N/A N/A $289.44 N/A N/A $337.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $482.40 $482.40 N/A 4401015 Pharmacy vancomycin 1.5 gm Injection [BCH] J3370 636 $578.88 $- $2.77 $- $- $463.10 $- N/A $150.51 N/A N/A Not Reimbursed N/A N/A $347.33 N/A N/A $289.44 N/A N/A N/A N/A N/A $393.64 N/A N/A $358.91 N/A N/A $237.34 N/A N/A $405.22 N/A N/A $463.10 N/A N/A $318.38 N/A N/A $405.22 N/A N/A $193.92 N/A N/A N/A N/A N/A $347.33 N/A N/A $202.61 N/A N/A $376.27 N/A N/A $2.77 N/A N/A $347.33 N/A N/A $405.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $578.88 $578.88 N/A 4400990 Pharmacy Lithium Carbonate 450 mg Tab-ER [BCH] 250 $- $- $26.03 $- $- $80.08 $- N/A $26.03 N/A N/A $37.84 N/A N/A $60.06 N/A N/A $50.05 N/A N/A N/A N/A N/A $68.07 N/A N/A $62.06 N/A N/A $41.04 N/A N/A $70.07 N/A N/A $80.08 N/A N/A $55.06 N/A N/A $70.07 N/A N/A $33.53 N/A N/A N/A N/A N/A $60.06 N/A N/A $35.04 N/A N/A $65.07 N/A N/A N/A N/A N/A $60.06 N/A N/A $70.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400988 Pharmacy Diazepam 10 mg / 2 mL Injection [BCH] J3360 636 $29.54 $- $6.34 $- $- $23.63 $- N/A $7.68 N/A N/A Not Reimbursed N/A N/A $17.72 N/A N/A $14.77 N/A N/A N/A N/A N/A $20.09 N/A N/A $18.31 N/A N/A $12.11 N/A N/A $20.68 N/A N/A $23.63 N/A N/A $16.25 N/A N/A $20.68 N/A N/A $9.89 N/A N/A N/A N/A N/A $17.72 N/A N/A $10.34 N/A N/A $19.20 N/A N/A $6.34 N/A N/A $17.72 N/A N/A $20.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.54 $29.54 N/A 4400067 Pharmacy psyllium 5.8 g Oral Pwdr [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408964 Pharmacy bismuth subsalicylate 262 mg/15 mL Sus [BCH] 250 $9.16 $- $2.38 $- $- $7.33 $- N/A $2.38 N/A N/A $3.46 N/A N/A $5.50 N/A N/A $4.58 N/A N/A N/A N/A N/A $6.23 N/A N/A $5.68 N/A N/A $3.75 N/A N/A $6.41 N/A N/A $7.33 N/A N/A $5.04 N/A N/A $6.41 N/A N/A $3.07 N/A N/A N/A N/A N/A $5.50 N/A N/A $3.21 N/A N/A $5.95 N/A N/A N/A N/A N/A $5.50 N/A N/A $6.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.16 $9.16 N/A 4400809 Pharmacy senna 8.8 mg/5 mL Syr [BCH] 250 $35.75 $- $9.29 $- $- $28.60 $- N/A $9.29 N/A N/A $13.51 N/A N/A $21.45 N/A N/A $17.87 N/A N/A N/A N/A N/A $24.31 N/A N/A $22.16 N/A N/A $14.66 N/A N/A $25.02 N/A N/A $28.60 N/A N/A $19.66 N/A N/A $25.02 N/A N/A $11.98 N/A N/A N/A N/A N/A $21.45 N/A N/A $12.51 N/A N/A $23.24 N/A N/A N/A N/A N/A $21.45 N/A N/A $25.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.75 $35.75 N/A 4400508 Pharmacy "pancrelipase 5000 units-27,000 units-17,000 units Cap [BCH]" 250 $3.11 $- $0.81 $- $- $2.49 $- N/A $0.81 N/A N/A $1.18 N/A N/A $1.87 N/A N/A $1.56 N/A N/A N/A N/A N/A $2.12 N/A N/A $1.93 N/A N/A $1.28 N/A N/A $2.18 N/A N/A $2.49 N/A N/A $1.71 N/A N/A $2.18 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.09 N/A N/A $2.02 N/A N/A N/A N/A N/A $1.87 N/A N/A $2.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.11 $3.11 N/A 4404711 Pharmacy folic acid 5 mg/mL Sol 258 $87.50 $- $22.75 $- $- $70.00 $- N/A $22.75 N/A N/A $33.08 N/A N/A $52.50 N/A N/A $43.75 N/A N/A N/A N/A N/A $59.50 N/A N/A $54.25 N/A N/A $35.88 N/A N/A $61.25 N/A N/A $70.00 N/A N/A $48.13 N/A N/A $61.25 N/A N/A $29.31 N/A N/A N/A N/A N/A $52.50 N/A N/A $30.63 N/A N/A $56.88 N/A N/A N/A N/A N/A $52.50 N/A N/A $61.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $87.50 $87.50 N/A 4404001 Pharmacy neomycin-polymyxin B sulfate topical 40 mg-200000 units/mL Sol [BCH] 250 $25.69 $- $6.68 $- $- $20.55 $- N/A $6.68 N/A N/A $9.71 N/A N/A $15.42 N/A N/A $12.85 N/A N/A N/A N/A N/A $17.47 N/A N/A $15.93 N/A N/A $10.53 N/A N/A $17.98 N/A N/A $20.55 N/A N/A $14.13 N/A N/A $17.98 N/A N/A $8.61 N/A N/A N/A N/A N/A $15.42 N/A N/A $8.99 N/A N/A $16.70 N/A N/A N/A N/A N/A $15.42 N/A N/A $17.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.69 $25.69 N/A 4402970 Pharmacy nystatin topical 100000 units/g Pow [BCH] 250 $36.00 $- $9.36 $- $- $28.80 $- N/A $9.36 N/A N/A $13.61 N/A N/A $21.60 N/A N/A $18.00 N/A N/A N/A N/A N/A $24.48 N/A N/A $22.32 N/A N/A $14.76 N/A N/A $25.20 N/A N/A $28.80 N/A N/A $19.80 N/A N/A $25.20 N/A N/A $12.06 N/A N/A N/A N/A N/A $21.60 N/A N/A $12.60 N/A N/A $23.40 N/A N/A N/A N/A N/A $21.60 N/A N/A $25.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.00 $36.00 N/A 4400947 Pharmacy levETIRAcetam 100 mg/mL Sol [BCH] J1953 636 $14.88 $- $0.14 $- $- $11.90 $- N/A $3.87 N/A N/A Not Reimbursed N/A N/A $8.93 N/A N/A $7.44 N/A N/A N/A N/A N/A $10.12 N/A N/A $9.23 N/A N/A $6.10 N/A N/A $10.42 N/A N/A $11.90 N/A N/A $8.18 N/A N/A $10.42 N/A N/A $4.98 N/A N/A N/A N/A N/A $8.93 N/A N/A $5.21 N/A N/A $9.67 N/A N/A $0.14 N/A N/A $8.93 N/A N/A $10.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.88 $14.88 N/A 4400364 Pharmacy "Ammonia Inhalant (35% Aolcohol, 15% Ammonia) Amp [BCH]" 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4401502 Pharmacy triamcinolone Nasal 55 mcg/inh Spry [BCH] 250 $36.55 $- $9.50 $- $- $29.24 $- N/A $9.50 N/A N/A $13.82 N/A N/A $21.93 N/A N/A $18.28 N/A N/A N/A N/A N/A $24.86 N/A N/A $22.66 N/A N/A $14.99 N/A N/A $25.59 N/A N/A $29.24 N/A N/A $20.10 N/A N/A $25.59 N/A N/A $12.25 N/A N/A N/A N/A N/A $21.93 N/A N/A $12.79 N/A N/A $23.76 N/A N/A N/A N/A N/A $21.93 N/A N/A $25.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.55 $36.55 N/A 4409518 Pharmacy niCARdipine 2.5 mg/mL Sol 10mL [BCH] 250 $500.26 $- $130.07 $- $- $400.21 $- N/A $130.07 N/A N/A $189.10 N/A N/A $300.16 N/A N/A $250.13 N/A N/A N/A N/A N/A $340.18 N/A N/A $310.16 N/A N/A $205.11 N/A N/A $350.18 N/A N/A $400.21 N/A N/A $275.14 N/A N/A $350.18 N/A N/A $167.59 N/A N/A N/A N/A N/A $300.16 N/A N/A $175.09 N/A N/A $325.17 N/A N/A N/A N/A N/A $300.16 N/A N/A $350.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $500.26 $500.26 N/A 4409680 Pharmacy vecuronium 10 mg IV Inj [BCH] 250 $21.26 $- $5.53 $- $- $17.01 $- N/A $5.53 N/A N/A $8.04 N/A N/A $12.76 N/A N/A $10.63 N/A N/A N/A N/A N/A $14.46 N/A N/A $13.18 N/A N/A $8.72 N/A N/A $14.88 N/A N/A $17.01 N/A N/A $11.69 N/A N/A $14.88 N/A N/A $7.12 N/A N/A N/A N/A N/A $12.76 N/A N/A $7.44 N/A N/A $13.82 N/A N/A N/A N/A N/A $12.76 N/A N/A $14.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.26 $21.26 N/A 4404601 Pharmacy EPINEPHrine Top 1:1000 Sol [BCH] 250 $8.94 $- $2.32 $- $- $7.15 $- N/A $2.32 N/A N/A $3.38 N/A N/A $5.36 N/A N/A $4.47 N/A N/A N/A N/A N/A $6.08 N/A N/A $5.54 N/A N/A $3.66 N/A N/A $6.26 N/A N/A $7.15 N/A N/A $4.92 N/A N/A $6.26 N/A N/A $2.99 N/A N/A N/A N/A N/A $5.36 N/A N/A $3.13 N/A N/A $5.81 N/A N/A N/A N/A N/A $5.36 N/A N/A $6.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.94 $8.94 N/A 4401684 Pharmacy tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [BCH] 250 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A $12.40 N/A N/A $8.20 N/A N/A $14.00 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $14.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A N/A N/A N/A $12.00 N/A N/A $14.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.00 $20.00 N/A 4401684 Pharmacy tuberculin purified protein derivative 5 TU/0.1 mL ID Sol [B 250 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A $12.40 N/A N/A $8.20 N/A N/A $14.00 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $14.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A N/A N/A N/A $12.00 N/A N/A $14.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.00 $20.00 N/A 4400785 Pharmacy colistin/HC/neomycin/thonzonium Otic Susp [BCH] 250 $18.15 $- $4.72 $- $- $14.52 $- N/A $4.72 N/A N/A $6.86 N/A N/A $10.89 N/A N/A $9.08 N/A N/A N/A N/A N/A $12.34 N/A N/A $11.25 N/A N/A $7.44 N/A N/A $12.71 N/A N/A $14.52 N/A N/A $9.98 N/A N/A $12.71 N/A N/A $6.08 N/A N/A N/A N/A N/A $10.89 N/A N/A $6.35 N/A N/A $11.80 N/A N/A N/A N/A N/A $10.89 N/A N/A $12.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.15 $18.15 N/A 4400589 Pharmacy colistin/HC/neomycin/thonzonium Otic Susp [BCH] 250 $418.82 $- $108.89 $- $- $335.06 $- N/A $108.89 N/A N/A $158.31 N/A N/A $251.29 N/A N/A $209.41 N/A N/A N/A N/A N/A $284.80 N/A N/A $259.67 N/A N/A $171.72 N/A N/A $293.17 N/A N/A $335.06 N/A N/A $230.35 N/A N/A $293.17 N/A N/A $140.30 N/A N/A N/A N/A N/A $251.29 N/A N/A $146.59 N/A N/A $272.23 N/A N/A N/A N/A N/A $251.29 N/A N/A $293.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $418.82 $418.82 N/A 4407194 Pharmacy oxytocin 10 intl units/mL Inj Sol [BCH] J2590 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401300 Pharmacy vasopressin 20 units/mL Inj Sol [BCH] 250 $88.80 $- $23.09 $- $- $71.04 $- N/A $23.09 N/A N/A $33.57 N/A N/A $53.28 N/A N/A $44.40 N/A N/A N/A N/A N/A $60.38 N/A N/A $55.06 N/A N/A $36.41 N/A N/A $62.16 N/A N/A $71.04 N/A N/A $48.84 N/A N/A $62.16 N/A N/A $29.75 N/A N/A N/A N/A N/A $53.28 N/A N/A $31.08 N/A N/A $57.72 N/A N/A N/A N/A N/A $53.28 N/A N/A $62.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $88.80 $88.80 N/A 4404548 Pharmacy EPINEPHrine 1 mg/mL Inj Sol [BCH] J0171 636 $12.00 $- $0.91 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.91 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400209 Pharmacy dantrolene 20 mg IV Inj [BCH] 250 $212.74 $- $55.31 $- $- $170.19 $- N/A $55.31 N/A N/A $80.42 N/A N/A $127.64 N/A N/A $106.37 N/A N/A N/A N/A N/A $144.66 N/A N/A $131.90 N/A N/A $87.22 N/A N/A $148.92 N/A N/A $170.19 N/A N/A $117.01 N/A N/A $148.92 N/A N/A $71.27 N/A N/A N/A N/A N/A $127.64 N/A N/A $74.46 N/A N/A $138.28 N/A N/A N/A N/A N/A $127.64 N/A N/A $148.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $212.74 $212.74 N/A 4400896 Pharmacy colistimethate 150 mg (colistin base) Pow [BCH] J0770 636 $67.18 $- $17.16 $- $- $53.74 $- N/A $17.47 N/A N/A Not Reimbursed N/A N/A $40.31 N/A N/A $33.59 N/A N/A N/A N/A N/A $45.68 N/A N/A $41.65 N/A N/A $27.54 N/A N/A $47.03 N/A N/A $53.74 N/A N/A $36.95 N/A N/A $47.03 N/A N/A $22.51 N/A N/A N/A N/A N/A $40.31 N/A N/A $23.51 N/A N/A $43.67 N/A N/A $17.16 N/A N/A $40.31 N/A N/A $47.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $67.18 $67.18 N/A 4407194 Pharmacy oxytocin 10 intl units/mL Inj Sol [BCH] J2590 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404548 Pharmacy EPINEPHrine 1 mg/mL Sol J0171 636 $35.90 $- $0.91 $- $- $28.72 $- N/A $9.34 N/A N/A Not Reimbursed N/A N/A $21.54 N/A N/A $17.95 N/A N/A N/A N/A N/A $24.41 N/A N/A $22.26 N/A N/A $14.72 N/A N/A $25.13 N/A N/A $28.72 N/A N/A $19.75 N/A N/A $25.13 N/A N/A $12.03 N/A N/A N/A N/A N/A $21.54 N/A N/A $12.57 N/A N/A $23.34 N/A N/A $0.91 N/A N/A $21.54 N/A N/A $25.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.90 $35.90 N/A 4401300 Pharmacy vasopressin 20 units/mL Sol [BCH] 636 $509.70 $- $132.52 $- $- $407.76 $- N/A $132.52 N/A N/A $192.67 N/A N/A $305.82 N/A N/A $254.85 N/A N/A N/A N/A N/A $346.60 N/A N/A $316.02 N/A N/A $208.98 N/A N/A $356.79 N/A N/A $407.76 N/A N/A $280.34 N/A N/A $356.79 N/A N/A $170.75 N/A N/A N/A N/A N/A $305.82 N/A N/A $178.40 N/A N/A $331.31 N/A N/A N/A N/A N/A $305.82 N/A N/A $356.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $509.70 $509.70 N/A 4401300 Pharmacy vasopressin 20 units/mL Inj Sol [BCH] 636 $302.14 $- $78.56 $- $- $241.71 $- N/A $78.56 N/A N/A $114.21 N/A N/A $181.28 N/A N/A $151.07 N/A N/A N/A N/A N/A $205.45 N/A N/A $187.33 N/A N/A $123.88 N/A N/A $211.50 N/A N/A $241.71 N/A N/A $166.18 N/A N/A $211.50 N/A N/A $101.22 N/A N/A N/A N/A N/A $181.28 N/A N/A $105.75 N/A N/A $196.39 N/A N/A N/A N/A N/A $181.28 N/A N/A $211.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $302.14 $302.14 N/A 4407141 Pharmacy EPINEPHrine 1 mg/mL Sol [BCH] J0171 636 $16.70 $- $0.91 $- $- $13.36 $- N/A $4.34 N/A N/A Not Reimbursed N/A N/A $10.02 N/A N/A $8.35 N/A N/A N/A N/A N/A $11.36 N/A N/A $10.36 N/A N/A $6.85 N/A N/A $11.69 N/A N/A $13.36 N/A N/A $9.19 N/A N/A $11.69 N/A N/A $5.60 N/A N/A N/A N/A N/A $10.02 N/A N/A $5.85 N/A N/A $10.86 N/A N/A $0.91 N/A N/A $10.02 N/A N/A $11.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.70 $16.70 N/A 4407141 Pharmacy EPINEPHrine 1 mg/mL Sol [BCH] J0171 636 $20.05 $- $0.91 $- $- $16.04 $- N/A $5.21 N/A N/A Not Reimbursed N/A N/A $12.03 N/A N/A $10.02 N/A N/A N/A N/A N/A $13.63 N/A N/A $12.43 N/A N/A $8.22 N/A N/A $14.03 N/A N/A $16.04 N/A N/A $11.03 N/A N/A $14.03 N/A N/A $6.72 N/A N/A N/A N/A N/A $12.03 N/A N/A $7.02 N/A N/A $13.03 N/A N/A $0.91 N/A N/A $12.03 N/A N/A $14.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.05 $20.05 N/A 4406758 Pharmacy thyroid desiccated 60 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406614 Pharmacy hyoscyamine 0.125 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400120 Pharmacy aspirin-dipyridamole 25 mg-200 mg Cap 250 $13.85 $- $3.60 $- $- $11.08 $- N/A $3.60 N/A N/A $5.24 N/A N/A $8.31 N/A N/A $6.93 N/A N/A N/A N/A N/A $9.42 N/A N/A $8.59 N/A N/A $5.68 N/A N/A $9.70 N/A N/A $11.08 N/A N/A $7.62 N/A N/A $9.70 N/A N/A $4.64 N/A N/A N/A N/A N/A $8.31 N/A N/A $4.85 N/A N/A $9.00 N/A N/A N/A N/A N/A $8.31 N/A N/A $9.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.85 $13.85 N/A 4400920 Pharmacy entecavir 0.5 mg Tab [BCH] 250 $88.87 $- $23.11 $- $- $71.10 $- N/A $23.11 N/A N/A $33.59 N/A N/A $53.32 N/A N/A $44.44 N/A N/A N/A N/A N/A $60.43 N/A N/A $55.10 N/A N/A $36.44 N/A N/A $62.21 N/A N/A $71.10 N/A N/A $48.88 N/A N/A $62.21 N/A N/A $29.77 N/A N/A N/A N/A N/A $53.32 N/A N/A $31.10 N/A N/A $57.77 N/A N/A N/A N/A N/A $53.32 N/A N/A $62.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $88.87 $88.87 N/A 4406143 Pharmacy flecainide 50 mg Tab 250 $6.27 $- $1.63 $- $- $5.01 $- N/A $1.63 N/A N/A $2.37 N/A N/A $3.76 N/A N/A $3.13 N/A N/A N/A N/A N/A $4.26 N/A N/A $3.89 N/A N/A $2.57 N/A N/A $4.39 N/A N/A $5.01 N/A N/A $3.45 N/A N/A $4.39 N/A N/A $2.10 N/A N/A N/A N/A N/A $3.76 N/A N/A $2.19 N/A N/A $4.07 N/A N/A N/A N/A N/A $3.76 N/A N/A $4.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.27 $6.27 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $3.59 $- $0.93 $- $- $2.87 $- N/A $0.93 N/A N/A $1.36 N/A N/A $2.15 N/A N/A $1.80 N/A N/A N/A N/A N/A $2.44 N/A N/A $2.23 N/A N/A $1.47 N/A N/A $2.51 N/A N/A $2.87 N/A N/A $1.98 N/A N/A $2.51 N/A N/A $1.20 N/A N/A N/A N/A N/A $2.15 N/A N/A $1.26 N/A N/A $2.33 N/A N/A N/A N/A N/A $2.15 N/A N/A $2.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.59 $3.59 N/A 4400579 Pharmacy lactobacillus acidophilus and bulgaricus - Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400729 Pharmacy liothyronine 5 mcg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400492 Pharmacy midodrine 5 mg Tab 250 $4.86 $- $1.26 $- $- $3.89 $- N/A $1.26 N/A N/A $1.84 N/A N/A $2.92 N/A N/A $2.43 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.01 N/A N/A $1.99 N/A N/A $3.40 N/A N/A $3.89 N/A N/A $2.67 N/A N/A $3.40 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.92 N/A N/A $1.70 N/A N/A $3.16 N/A N/A N/A N/A N/A $2.92 N/A N/A $3.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.86 $4.86 N/A 4400954 Pharmacy midodrine 10 mg Tab 250 $9.67 $- $2.51 $- $- $7.74 $- N/A $2.51 N/A N/A $3.66 N/A N/A $5.80 N/A N/A $4.84 N/A N/A N/A N/A N/A $6.58 N/A N/A $6.00 N/A N/A $3.97 N/A N/A $6.77 N/A N/A $7.74 N/A N/A $5.32 N/A N/A $6.77 N/A N/A $3.24 N/A N/A N/A N/A N/A $5.80 N/A N/A $3.39 N/A N/A $6.29 N/A N/A N/A N/A N/A $5.80 N/A N/A $6.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.67 $9.67 N/A 4407273 Pharmacy montelukast 10 mg Tab 250 $11.30 $- $2.94 $- $- $9.04 $- N/A $2.94 N/A N/A $4.27 N/A N/A $6.78 N/A N/A $5.65 N/A N/A N/A N/A N/A $7.69 N/A N/A $7.01 N/A N/A $4.63 N/A N/A $7.91 N/A N/A $9.04 N/A N/A $6.22 N/A N/A $7.91 N/A N/A $3.79 N/A N/A N/A N/A N/A $6.78 N/A N/A $3.96 N/A N/A $7.35 N/A N/A N/A N/A N/A $6.78 N/A N/A $7.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.30 $11.30 N/A 4409594 Pharmacy pantoprazole 40 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400060 Pharmacy temazepam 7.5 mg Cap [BCH] 250 $19.88 $- $5.17 $- $- $15.90 $- N/A $5.17 N/A N/A $7.51 N/A N/A $11.93 N/A N/A $9.94 N/A N/A N/A N/A N/A $13.52 N/A N/A $12.33 N/A N/A $8.15 N/A N/A $13.92 N/A N/A $15.90 N/A N/A $10.93 N/A N/A $13.92 N/A N/A $6.66 N/A N/A N/A N/A N/A $11.93 N/A N/A $6.96 N/A N/A $12.92 N/A N/A N/A N/A N/A $11.93 N/A N/A $13.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.88 $19.88 N/A 4400654 Pharmacy traZODone 50 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401909 Pharmacy traZODone 100 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $8.78 $- $2.28 $- $- $7.02 $- N/A $2.28 N/A N/A $3.32 N/A N/A $5.27 N/A N/A $4.39 N/A N/A N/A N/A N/A $5.97 N/A N/A $5.44 N/A N/A $3.60 N/A N/A $6.15 N/A N/A $7.02 N/A N/A $4.83 N/A N/A $6.15 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.27 N/A N/A $3.07 N/A N/A $5.71 N/A N/A N/A N/A N/A $5.27 N/A N/A $6.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.78 $8.78 N/A 4400392 Pharmacy levothyroxine 88 mcg (0.088 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400350 Pharmacy levothyroxine 112 mcg (0.112 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400644 Pharmacy hydrocortisone 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407939 Pharmacy carisoprodol 350 mg Tab [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4406168 Pharmacy dorzolamide ophthalmic 2% Sol [BCH] 250 $133.60 $- $34.74 $- $- $106.88 $- N/A $34.74 N/A N/A $50.50 N/A N/A $80.16 N/A N/A $66.80 N/A N/A N/A N/A N/A $90.85 N/A N/A $82.83 N/A N/A $54.78 N/A N/A $93.52 N/A N/A $106.88 N/A N/A $73.48 N/A N/A $93.52 N/A N/A $44.76 N/A N/A N/A N/A N/A $80.16 N/A N/A $46.76 N/A N/A $86.84 N/A N/A N/A N/A N/A $80.16 N/A N/A $93.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $133.60 $133.60 N/A 4400037 Pharmacy dorzolamide-timolol ophthalmic 2.23%-0.68% Sol [BCH] 250 $244.00 $- $63.44 $- $- $195.20 $- N/A $63.44 N/A N/A $92.23 N/A N/A $146.40 N/A N/A $122.00 N/A N/A N/A N/A N/A $165.92 N/A N/A $151.28 N/A N/A $100.04 N/A N/A $170.80 N/A N/A $195.20 N/A N/A $134.20 N/A N/A $170.80 N/A N/A $81.74 N/A N/A N/A N/A N/A $146.40 N/A N/A $85.40 N/A N/A $158.60 N/A N/A N/A N/A N/A $146.40 N/A N/A $170.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $244.00 $244.00 N/A 4409569 Pharmacy phenylephrine Ophth 2.5% Sol [BCH] 250 $216.00 $- $56.16 $- $- $172.80 $- N/A $56.16 N/A N/A $81.65 N/A N/A $129.60 N/A N/A $108.00 N/A N/A N/A N/A N/A $146.88 N/A N/A $133.92 N/A N/A $88.56 N/A N/A $151.20 N/A N/A $172.80 N/A N/A $118.80 N/A N/A $151.20 N/A N/A $72.36 N/A N/A N/A N/A N/A $129.60 N/A N/A $75.60 N/A N/A $140.40 N/A N/A N/A N/A N/A $129.60 N/A N/A $151.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $216.00 $216.00 N/A 4400729 Pharmacy liothyronine 5 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400729 Pharmacy liothyronine 5 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab [BCH] 250 $4.81 $- $1.25 $- $- $3.84 $- N/A $1.25 N/A N/A $1.82 N/A N/A $2.88 N/A N/A $2.40 N/A N/A N/A N/A N/A $3.27 N/A N/A $2.98 N/A N/A $1.97 N/A N/A $3.36 N/A N/A $3.84 N/A N/A $2.64 N/A N/A $3.36 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.88 N/A N/A $1.68 N/A N/A $3.12 N/A N/A N/A N/A N/A $2.88 N/A N/A $3.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.81 $4.81 N/A 4409252 Pharmacy demeclocycline 150 mg Tab 250 $18.80 $- $4.89 $- $- $15.04 $- N/A $4.89 N/A N/A $7.11 N/A N/A $11.28 N/A N/A $9.40 N/A N/A N/A N/A N/A $12.79 N/A N/A $11.66 N/A N/A $7.71 N/A N/A $13.16 N/A N/A $15.04 N/A N/A $10.34 N/A N/A $13.16 N/A N/A $6.30 N/A N/A N/A N/A N/A $11.28 N/A N/A $6.58 N/A N/A $12.22 N/A N/A N/A N/A N/A $11.28 N/A N/A $13.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.80 $18.80 N/A 4403607 Pharmacy methylPREDNISolone 4 mg Tab [BCH] J7509 636 $5.00 $- $0.34 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.34 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $5.01 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab[BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409776 Pharmacy acetaminophen-oxycodone 325 mg-7.5 mg Tab 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4400062 Pharmacy acetaminophen-oxycodone 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4409666 Pharmacy lidocaine topical 5% Fil [BCH] 250 $5.20 $- $1.35 $- $- $4.16 $- N/A $1.35 N/A N/A $1.97 N/A N/A $3.12 N/A N/A $2.60 N/A N/A N/A N/A N/A $3.54 N/A N/A $3.22 N/A N/A $2.13 N/A N/A $3.64 N/A N/A $4.16 N/A N/A $2.86 N/A N/A $3.64 N/A N/A $1.74 N/A N/A N/A N/A N/A $3.12 N/A N/A $1.82 N/A N/A $3.38 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.20 $5.20 N/A 4409540 Pharmacy HYDROmorphone 2 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405817 Pharmacy morphine 30 mg/8 to 12 hr Tab 250 $19.20 $- $4.99 $- $- $15.36 $- N/A $4.99 N/A N/A $7.26 N/A N/A $11.52 N/A N/A $9.60 N/A N/A N/A N/A N/A $13.06 N/A N/A $11.90 N/A N/A $7.87 N/A N/A $13.44 N/A N/A $15.36 N/A N/A $10.56 N/A N/A $13.44 N/A N/A $6.43 N/A N/A N/A N/A N/A $11.52 N/A N/A $6.72 N/A N/A $12.48 N/A N/A N/A N/A N/A $11.52 N/A N/A $13.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.20 $19.20 N/A 4409790 Pharmacy fenofibrate 160 mg Tab 250 $5.76 $- $1.50 $- $- $4.61 $- N/A $1.50 N/A N/A $2.18 N/A N/A $3.46 N/A N/A $2.88 N/A N/A N/A N/A N/A $3.92 N/A N/A $3.57 N/A N/A $2.36 N/A N/A $4.03 N/A N/A $4.61 N/A N/A $3.17 N/A N/A $4.03 N/A N/A $1.93 N/A N/A N/A N/A N/A $3.46 N/A N/A $2.02 N/A N/A $3.74 N/A N/A N/A N/A N/A $3.46 N/A N/A $4.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.76 $5.76 N/A 4401920 Pharmacy morphine 15 mg ER Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405817 Pharmacy morphine 30 mg ER Tab [BCH] 250 $6.34 $- $1.65 $- $- $5.08 $- N/A $1.65 N/A N/A $2.40 N/A N/A $3.81 N/A N/A $3.17 N/A N/A N/A N/A N/A $4.31 N/A N/A $3.93 N/A N/A $2.60 N/A N/A $4.44 N/A N/A $5.08 N/A N/A $3.49 N/A N/A $4.44 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.81 N/A N/A $2.22 N/A N/A $4.12 N/A N/A N/A N/A N/A $3.81 N/A N/A $4.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.34 $6.34 N/A 4400763 Pharmacy morphine 60 mg/12 hours Tab [BCH] 250 $12.43 $- $3.23 $- $- $9.94 $- N/A $3.23 N/A N/A $4.70 N/A N/A $7.46 N/A N/A $6.21 N/A N/A N/A N/A N/A $8.45 N/A N/A $7.70 N/A N/A $5.09 N/A N/A $8.70 N/A N/A $9.94 N/A N/A $6.83 N/A N/A $8.70 N/A N/A $4.16 N/A N/A N/A N/A N/A $7.46 N/A N/A $4.35 N/A N/A $8.08 N/A N/A N/A N/A N/A $7.46 N/A N/A $8.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.43 $12.43 N/A 4400508 Pharmacy "pancrelipase 5000 units-27,000 units-17,000 units Cap [BCH]" 250 $3.11 $- $0.81 $- $- $2.49 $- N/A $0.81 N/A N/A $1.18 N/A N/A $1.87 N/A N/A $1.56 N/A N/A N/A N/A N/A $2.12 N/A N/A $1.93 N/A N/A $1.28 N/A N/A $2.18 N/A N/A $2.49 N/A N/A $1.71 N/A N/A $2.18 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.09 N/A N/A $2.02 N/A N/A N/A N/A N/A $1.87 N/A N/A $2.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.11 $3.11 N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $5.97 $- $1.55 $- $- $4.78 $- N/A $1.55 N/A N/A $2.26 N/A N/A $3.58 N/A N/A $2.99 N/A N/A N/A N/A N/A $4.06 N/A N/A $3.70 N/A N/A $2.45 N/A N/A $4.18 N/A N/A $4.78 N/A N/A $3.29 N/A N/A $4.18 N/A N/A $2.00 N/A N/A N/A N/A N/A $3.58 N/A N/A $2.09 N/A N/A $3.88 N/A N/A N/A N/A N/A $3.58 N/A N/A $4.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.97 $5.97 N/A 4402202 Pharmacy nitroprusside 25 mg/mL IV Sol [BCH] 250 "$1,921.97 " $- $499.71 $- $- "$1,537.58 " $- N/A $499.71 N/A N/A $726.51 N/A N/A "$1,153.18 " N/A N/A $960.99 N/A N/A N/A N/A N/A "$1,306.94 " N/A N/A "$1,191.62 " N/A N/A $788.01 N/A N/A "$1,345.38 " N/A N/A "$1,537.58 " N/A N/A "$1,057.08 " N/A N/A "$1,345.38 " N/A N/A $643.86 N/A N/A N/A N/A N/A "$1,153.18 " N/A N/A $672.69 N/A N/A "$1,249.28 " N/A N/A N/A N/A N/A "$1,153.18 " N/A N/A "$1,345.38 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,921.97 " "$1,921.97 " N/A 4400495 Pharmacy amiodarone 150 mg/100 mL-D5% Sol [BCH] J0282 636 $83.26 $- $21.65 $- $- $66.61 $- N/A $21.65 N/A N/A Not Reimbursed N/A N/A $49.96 N/A N/A $41.63 N/A N/A N/A N/A N/A $56.62 N/A N/A $51.62 N/A N/A $34.14 N/A N/A $58.28 N/A N/A $66.61 N/A N/A $45.79 N/A N/A $58.28 N/A N/A $27.89 N/A N/A N/A N/A N/A $49.96 N/A N/A $29.14 N/A N/A $54.12 N/A N/A N/A N/A N/A $49.96 N/A N/A $58.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $83.26 $83.26 N/A 4407224 Pharmacy amiodarone 360 mg/200 mL-D5% Sol [BCH] J0282 636 $110.74 $- $28.79 $- $- $88.59 $- N/A $28.79 N/A N/A Not Reimbursed N/A N/A $66.44 N/A N/A $55.37 N/A N/A N/A N/A N/A $75.30 N/A N/A $68.66 N/A N/A $45.40 N/A N/A $77.52 N/A N/A $88.59 N/A N/A $60.90 N/A N/A $77.52 N/A N/A $37.10 N/A N/A N/A N/A N/A $66.44 N/A N/A $38.76 N/A N/A $71.98 N/A N/A N/A N/A N/A $66.44 N/A N/A $77.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $110.74 $110.74 N/A 4400925 Pharmacy potassium chloride 20 mEq Pow[BCH] 250 $21.48 $- $5.58 $- $- $17.18 $- N/A $5.58 N/A N/A $8.12 N/A N/A $12.89 N/A N/A $10.74 N/A N/A N/A N/A N/A $14.61 N/A N/A $13.32 N/A N/A $8.81 N/A N/A $15.04 N/A N/A $17.18 N/A N/A $11.81 N/A N/A $15.04 N/A N/A $7.20 N/A N/A N/A N/A N/A $12.89 N/A N/A $7.52 N/A N/A $13.96 N/A N/A N/A N/A N/A $12.89 N/A N/A $15.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.48 $21.48 N/A 4401071 Pharmacy chlordiazePOXIDE 25 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409147 Pharmacy ropinirole 0.25 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400288 Pharmacy donepezil 5 mg Tab [BCH] 250 $17.31 $- $4.50 $- $- $13.85 $- N/A $4.50 N/A N/A $6.54 N/A N/A $10.39 N/A N/A $8.66 N/A N/A N/A N/A N/A $11.77 N/A N/A $10.73 N/A N/A $7.10 N/A N/A $12.12 N/A N/A $13.85 N/A N/A $9.52 N/A N/A $12.12 N/A N/A $5.80 N/A N/A N/A N/A N/A $10.39 N/A N/A $6.06 N/A N/A $11.25 N/A N/A N/A N/A N/A $10.39 N/A N/A $12.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.31 $17.31 N/A 4407182 Pharmacy donepezil 10 mg Tab 250 $17.31 $- $4.50 $- $- $13.85 $- N/A $4.50 N/A N/A $6.54 N/A N/A $10.39 N/A N/A $8.66 N/A N/A N/A N/A N/A $11.77 N/A N/A $10.73 N/A N/A $7.10 N/A N/A $12.12 N/A N/A $13.85 N/A N/A $9.52 N/A N/A $12.12 N/A N/A $5.80 N/A N/A N/A N/A N/A $10.39 N/A N/A $6.06 N/A N/A $11.25 N/A N/A N/A N/A N/A $10.39 N/A N/A $12.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.31 $17.31 N/A 4407182 Pharmacy donepezil 10 mg Tab [BCH] 250 $17.31 $- $4.50 $- $- $13.85 $- N/A $4.50 N/A N/A $6.54 N/A N/A $10.39 N/A N/A $8.66 N/A N/A N/A N/A N/A $11.77 N/A N/A $10.73 N/A N/A $7.10 N/A N/A $12.12 N/A N/A $13.85 N/A N/A $9.52 N/A N/A $12.12 N/A N/A $5.80 N/A N/A N/A N/A N/A $10.39 N/A N/A $6.06 N/A N/A $11.25 N/A N/A N/A N/A N/A $10.39 N/A N/A $12.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.31 $17.31 N/A 4402316 Pharmacy PARoxetine 20 mg Tab [BCH] 250 $5.33 $- $1.39 $- $- $4.27 $- N/A $1.39 N/A N/A $2.02 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.63 N/A N/A $3.31 N/A N/A $2.19 N/A N/A $3.73 N/A N/A $4.27 N/A N/A $2.93 N/A N/A $3.73 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.47 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.33 $5.33 N/A 4406317 Pharmacy lisinopril 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.12 $- $0.55 $- $- $1.70 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.27 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.31 N/A N/A $0.87 N/A N/A $1.48 N/A N/A $1.70 N/A N/A $1.17 N/A N/A $1.48 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.27 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.27 N/A N/A $1.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.12 $2.12 N/A 4400115 Pharmacy valsartan 80 mg Tab [BCH] 250 $9.33 $- $2.43 $- $- $7.47 $- N/A $2.43 N/A N/A $3.53 N/A N/A $5.60 N/A N/A $4.67 N/A N/A N/A N/A N/A $6.35 N/A N/A $5.79 N/A N/A $3.83 N/A N/A $6.53 N/A N/A $7.47 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.13 N/A N/A N/A N/A N/A $5.60 N/A N/A $3.27 N/A N/A $6.07 N/A N/A N/A N/A N/A $5.60 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.33 $9.33 N/A 4404778 Pharmacy hydroCHLOROthiazide 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400233 Pharmacy glycopyrrolate 0.2 mg/mL Sol [BCH] J7642 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405940 Pharmacy silver sulfADIAZINE Top 1% Crm [BCH] 250 $17.98 $- $4.67 $- $- $14.38 $- N/A $4.67 N/A N/A $6.80 N/A N/A $10.79 N/A N/A $8.99 N/A N/A N/A N/A N/A $12.23 N/A N/A $11.15 N/A N/A $7.37 N/A N/A $12.59 N/A N/A $14.38 N/A N/A $9.89 N/A N/A $12.59 N/A N/A $6.02 N/A N/A N/A N/A N/A $10.79 N/A N/A $6.29 N/A N/A $11.69 N/A N/A N/A N/A N/A $10.79 N/A N/A $12.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.98 $17.98 N/A 4400964 Pharmacy silver sulfADIAZINE topical 1% Cre [BCH] 250 $127.18 $- $33.07 $- $- $101.75 $- N/A $33.07 N/A N/A $48.08 N/A N/A $76.31 N/A N/A $63.59 N/A N/A N/A N/A N/A $86.49 N/A N/A $78.85 N/A N/A $52.15 N/A N/A $89.03 N/A N/A $101.75 N/A N/A $69.95 N/A N/A $89.03 N/A N/A $42.61 N/A N/A N/A N/A N/A $76.31 N/A N/A $44.51 N/A N/A $82.67 N/A N/A N/A N/A N/A $76.31 N/A N/A $89.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $127.18 $127.18 N/A 4405940 Pharmacy silver sulfADIAZINE Top 1% Crm [BCH] 250 $15.57 $- $4.05 $- $- $12.46 $- N/A $4.05 N/A N/A $5.89 N/A N/A $9.34 N/A N/A $7.79 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.65 N/A N/A $6.38 N/A N/A $10.90 N/A N/A $12.46 N/A N/A $8.56 N/A N/A $10.90 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.34 N/A N/A $5.45 N/A N/A $10.12 N/A N/A N/A N/A N/A $9.34 N/A N/A $10.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.57 $15.57 N/A 4400922 Pharmacy silver sulfADIAZINE topical 1% Cre [BCH] 250 $52.94 $- $13.76 $- $- $42.35 $- N/A $13.76 N/A N/A $20.01 N/A N/A $31.76 N/A N/A $26.47 N/A N/A N/A N/A N/A $36.00 N/A N/A $32.82 N/A N/A $21.71 N/A N/A $37.06 N/A N/A $42.35 N/A N/A $29.12 N/A N/A $37.06 N/A N/A $17.73 N/A N/A N/A N/A N/A $31.76 N/A N/A $18.53 N/A N/A $34.41 N/A N/A N/A N/A N/A $31.76 N/A N/A $37.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.94 $52.94 N/A 4406598 Pharmacy amoxicillin-clavulanate 200 mg-28.5 mg/5 mL Oral Liq 100 mL [BCH] 250 $72.34 $- $18.81 $- $- $57.87 $- N/A $18.81 N/A N/A $27.34 N/A N/A $43.40 N/A N/A $36.17 N/A N/A N/A N/A N/A $49.19 N/A N/A $44.85 N/A N/A $29.66 N/A N/A $50.64 N/A N/A $57.87 N/A N/A $39.79 N/A N/A $50.64 N/A N/A $24.23 N/A N/A N/A N/A N/A $43.40 N/A N/A $25.32 N/A N/A $47.02 N/A N/A N/A N/A N/A $43.40 N/A N/A $50.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $72.34 $72.34 N/A 4403728 Pharmacy nitroglycerin 0.4 mg Tab [BCH] 250 $2.03 $- $0.53 $- $- $1.62 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.22 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.38 N/A N/A $1.26 N/A N/A $0.83 N/A N/A $1.42 N/A N/A $1.62 N/A N/A $1.12 N/A N/A $1.42 N/A N/A $0.68 N/A N/A N/A N/A N/A $1.22 N/A N/A $0.71 N/A N/A $1.32 N/A N/A N/A N/A N/A $1.22 N/A N/A $1.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.03 $2.03 N/A 4408289 Pharmacy nicotine 7 mg/24 hr Fil 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4408297 Pharmacy nicotine 14 mg/24 hr Fil [BCH] 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Transderm ER Film [BCH] 250 $3.85 $- $1.00 $- $- $3.08 $- N/A $1.00 N/A N/A $1.45 N/A N/A $2.31 N/A N/A $1.92 N/A N/A N/A N/A N/A $2.62 N/A N/A $2.39 N/A N/A $1.58 N/A N/A $2.69 N/A N/A $3.08 N/A N/A $2.12 N/A N/A $2.69 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.31 N/A N/A $1.35 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.85 $3.85 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Transderm ER Film [BCH] 250 $4.27 $- $1.11 $- $- $3.41 $- N/A $1.11 N/A N/A $1.61 N/A N/A $2.56 N/A N/A $2.13 N/A N/A N/A N/A N/A $2.90 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.41 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.49 N/A N/A $2.77 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4400129 Pharmacy buPROPion 100 mg/12 hours Tab 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.20 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.37 $- N/A $16.70 N/A N/A $24.27 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.81 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.37 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4400883 Pharmacy Aripiprazole 10 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.37 $- N/A $16.70 N/A N/A $24.27 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.81 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.37 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4402202 Pharmacy sodium nitroprusside 25 mg/mL Sol [BCH] 636 $48.00 $- $12.48 $- $- $38.40 $- N/A $12.48 N/A N/A $18.14 N/A N/A $28.80 N/A N/A $24.00 N/A N/A N/A N/A N/A $32.64 N/A N/A $29.76 N/A N/A $19.68 N/A N/A $33.60 N/A N/A $38.40 N/A N/A $26.40 N/A N/A $33.60 N/A N/A $16.08 N/A N/A N/A N/A N/A $28.80 N/A N/A $16.80 N/A N/A $31.20 N/A N/A N/A N/A N/A $28.80 N/A N/A $33.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.00 $48.00 N/A 4400672 Pharmacy ziprasidone 20 mg Pow J3486 636 $112.80 $- $17.22 $- $- $90.24 $- N/A $29.33 N/A N/A Not Reimbursed N/A N/A $67.68 N/A N/A $56.40 N/A N/A N/A N/A N/A $76.70 N/A N/A $69.94 N/A N/A $46.25 N/A N/A $78.96 N/A N/A $90.24 N/A N/A $62.04 N/A N/A $78.96 N/A N/A $37.79 N/A N/A N/A N/A N/A $67.68 N/A N/A $39.48 N/A N/A $73.32 N/A N/A $17.22 N/A N/A $67.68 N/A N/A $78.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $112.80 $112.80 N/A 4400845 Pharmacy desmopressin 4 mcg/mL Sol J2597 636 $91.20 $- $11.06 $- $- $72.96 $- N/A $23.71 N/A N/A Not Reimbursed N/A N/A $54.72 N/A N/A $45.60 N/A N/A N/A N/A N/A $62.02 N/A N/A $56.54 N/A N/A $37.39 N/A N/A $63.84 N/A N/A $72.96 N/A N/A $50.16 N/A N/A $63.84 N/A N/A $30.55 N/A N/A N/A N/A N/A $54.72 N/A N/A $31.92 N/A N/A $59.28 N/A N/A $11.06 N/A N/A $54.72 N/A N/A $63.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $91.20 $91.20 N/A 4409475 Pharmacy tolterodine 2 mg Cap[BCH] 250 $16.07 $- $4.18 $- $- $12.86 $- N/A $4.18 N/A N/A $6.07 N/A N/A $9.64 N/A N/A $8.04 N/A N/A N/A N/A N/A $10.93 N/A N/A $9.96 N/A N/A $6.59 N/A N/A $11.25 N/A N/A $12.86 N/A N/A $8.84 N/A N/A $11.25 N/A N/A $5.38 N/A N/A N/A N/A N/A $9.64 N/A N/A $5.62 N/A N/A $10.45 N/A N/A N/A N/A N/A $9.64 N/A N/A $11.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.07 $16.07 N/A 4400375 Pharmacy albumin human 25% Sol P9047 636 $116.00 $- $30.16 $- $- $92.80 $- N/A $30.16 N/A N/A Not Reimbursed N/A N/A $69.60 N/A N/A $58.00 N/A N/A N/A N/A N/A $78.88 N/A N/A $71.92 N/A N/A $47.56 N/A N/A $81.20 N/A N/A $92.80 N/A N/A $63.80 N/A N/A $81.20 N/A N/A $38.86 N/A N/A N/A N/A N/A $69.60 N/A N/A $40.60 N/A N/A $75.40 N/A N/A $52.45 N/A N/A $69.60 N/A N/A $81.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $116.00 $116.00 N/A 4400822 Pharmacy immune globulin intravenous 10% Sol 100 mL [BCH] J1459 636 "$3,120.00 " $- $41.28 $- $- "$2,496.00 " $- N/A $811.20 N/A N/A Not Reimbursed N/A N/A "$1,872.00 " N/A N/A "$1,560.00 " N/A N/A N/A N/A N/A "$2,121.60 " N/A N/A "$1,934.40 " N/A N/A "$1,279.20 " N/A N/A "$2,184.00 " N/A N/A "$2,496.00 " N/A N/A "$1,716.00 " N/A N/A "$2,184.00 " N/A N/A "$1,045.20 " N/A N/A N/A N/A N/A "$1,872.00 " N/A N/A "$1,092.00 " N/A N/A "$2,028.00 " N/A N/A $41.28 N/A N/A "$1,872.00 " N/A N/A "$2,184.00 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,120.00 " "$3,120.00 " N/A 4400487 Pharmacy immune globulin 10% IV Sol 200 mL [BCH] J1459 636 "$6,240.00 " $- $41.28 $- $- "$4,992.00 " $- N/A "$1,622.40 " N/A N/A Not Reimbursed N/A N/A "$3,744.00 " N/A N/A "$3,120.00 " N/A N/A N/A N/A N/A "$4,243.20 " N/A N/A "$3,868.80 " N/A N/A "$2,558.40 " N/A N/A "$4,368.00 " N/A N/A "$4,992.00 " N/A N/A "$3,432.00 " N/A N/A "$4,368.00 " N/A N/A "$2,090.40 " N/A N/A N/A N/A N/A "$3,744.00 " N/A N/A "$2,184.00 " N/A N/A "$4,056.00 " N/A N/A $41.28 N/A N/A "$3,744.00 " N/A N/A "$4,368.00 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$6,240.00 " "$6,240.00 " N/A 4400949 Pharmacy immune globulin intravenous 10% Sol[BCH] J1459 636 $36.24 $- $9.42 $- $- $41.28 $- N/A $9.42 N/A N/A Not Reimbursed N/A N/A $21.74 N/A N/A $18.12 N/A N/A N/A N/A N/A $24.64 N/A N/A $22.47 N/A N/A $14.86 N/A N/A $25.37 N/A N/A $28.99 N/A N/A $19.93 N/A N/A $25.37 N/A N/A $12.14 N/A N/A N/A N/A N/A $21.74 N/A N/A $12.68 N/A N/A $23.56 N/A N/A $41.28 N/A N/A $21.74 N/A N/A $25.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.24 $36.24 N/A 4400177 Pharmacy ampicillin-sulbactam 2 g-1 g Inj [BCH] J0295 636 $38.28 $- $2.76 $- $- $30.62 $- N/A $9.95 N/A N/A Not Reimbursed N/A N/A $22.97 N/A N/A $19.14 N/A N/A N/A N/A N/A $26.03 N/A N/A $23.73 N/A N/A $15.69 N/A N/A $26.80 N/A N/A $30.62 N/A N/A $21.05 N/A N/A $26.80 N/A N/A $12.82 N/A N/A N/A N/A N/A $22.97 N/A N/A $13.40 N/A N/A $24.88 N/A N/A $2.76 N/A N/A $22.97 N/A N/A $26.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.28 $38.28 N/A 4405537 Pharmacy cefTAZidime 1 g Pow [BCH] J0713 636 $28.00 $- $1.99 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.99 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409522 Pharmacy cefepime 1 g Inj [BCH] J0692 636 $28.00 $- $1.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $28.00 $- $1.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400564 Pharmacy magnesium sulfate 2 g/50 mL-sterile water Sol [BCH] J3475 636 $75.00 $- $0.64 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $0.64 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400880 Pharmacy cefTRIAXone 1 g Inj [BCH] J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400488 Pharmacy hydrocortisone topical 2.5% Cre [BCH] 250 $23.14 $- $6.02 $- $- $18.51 $- N/A $6.02 N/A N/A $8.75 N/A N/A $13.89 N/A N/A $11.57 N/A N/A N/A N/A N/A $15.74 N/A N/A $14.35 N/A N/A $9.49 N/A N/A $16.20 N/A N/A $18.51 N/A N/A $12.73 N/A N/A $16.20 N/A N/A $7.75 N/A N/A N/A N/A N/A $13.89 N/A N/A $8.10 N/A N/A $15.04 N/A N/A N/A N/A N/A $13.89 N/A N/A $16.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.14 $23.14 N/A 4401626 Pharmacy gentamicin Top 0.1% Oint [BCH] 250 $98.76 $- $25.68 $- $- $79.01 $- N/A $25.68 N/A N/A $37.33 N/A N/A $59.26 N/A N/A $49.38 N/A N/A N/A N/A N/A $67.16 N/A N/A $61.23 N/A N/A $40.49 N/A N/A $69.13 N/A N/A $79.01 N/A N/A $54.32 N/A N/A $69.13 N/A N/A $33.08 N/A N/A N/A N/A N/A $59.26 N/A N/A $34.57 N/A N/A $64.19 N/A N/A N/A N/A N/A $59.26 N/A N/A $69.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $98.76 $98.76 N/A 4401659 Pharmacy "nystatin Top 100,000 units/g Oint [BCH]" 250 $52.50 $- $13.65 $- $- $42.00 $- N/A $13.65 N/A N/A $19.85 N/A N/A $31.50 N/A N/A $26.25 N/A N/A N/A N/A N/A $35.70 N/A N/A $32.55 N/A N/A $21.53 N/A N/A $36.75 N/A N/A $42.00 N/A N/A $28.88 N/A N/A $36.75 N/A N/A $17.59 N/A N/A N/A N/A N/A $31.50 N/A N/A $18.38 N/A N/A $34.13 N/A N/A N/A N/A N/A $31.50 N/A N/A $36.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.50 $52.50 N/A 4400829 Pharmacy nystatin topical 100000 units/g Oin [BCH] 250 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A $21.70 N/A N/A $14.35 N/A N/A $24.50 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $24.50 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A N/A N/A N/A $21.00 N/A N/A $24.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.00 $35.00 N/A 4404209 Pharmacy dibucaine Top 1% Oint [BCH] 250 $12.86 $- $3.34 $- $- $10.29 $- N/A $3.34 N/A N/A $4.86 N/A N/A $7.71 N/A N/A $6.43 N/A N/A N/A N/A N/A $8.74 N/A N/A $7.97 N/A N/A $5.27 N/A N/A $9.00 N/A N/A $10.29 N/A N/A $7.07 N/A N/A $9.00 N/A N/A $4.31 N/A N/A N/A N/A N/A $7.71 N/A N/A $4.50 N/A N/A $8.36 N/A N/A N/A N/A N/A $7.71 N/A N/A $9.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.86 $12.86 N/A 4409425 Pharmacy triamcinolone Top 0.1% Oint [BCH] 250 $82.72 $- $21.51 $- $- $66.18 $- N/A $21.51 N/A N/A $31.27 N/A N/A $49.63 N/A N/A $41.36 N/A N/A N/A N/A N/A $56.25 N/A N/A $51.29 N/A N/A $33.91 N/A N/A $57.90 N/A N/A $66.18 N/A N/A $45.50 N/A N/A $57.90 N/A N/A $27.71 N/A N/A N/A N/A N/A $49.63 N/A N/A $28.95 N/A N/A $53.77 N/A N/A N/A N/A N/A $49.63 N/A N/A $57.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $82.72 $82.72 N/A 4400188 Pharmacy triamcinolone topical 0.1% Oin 250 $11.28 $- $2.93 $- $- $9.02 $- N/A $2.93 N/A N/A $4.26 N/A N/A $6.77 N/A N/A $5.64 N/A N/A N/A N/A N/A $7.67 N/A N/A $6.99 N/A N/A $4.62 N/A N/A $7.90 N/A N/A $9.02 N/A N/A $6.20 N/A N/A $7.90 N/A N/A $3.78 N/A N/A N/A N/A N/A $6.77 N/A N/A $3.95 N/A N/A $7.33 N/A N/A N/A N/A N/A $6.77 N/A N/A $7.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.28 $11.28 N/A 4409550 Pharmacy gentamicin Top 0.1% Crm [BCH] 250 $98.76 $- $25.68 $- $- $79.01 $- N/A $25.68 N/A N/A $37.33 N/A N/A $59.26 N/A N/A $49.38 N/A N/A N/A N/A N/A $67.16 N/A N/A $61.23 N/A N/A $40.49 N/A N/A $69.13 N/A N/A $79.01 N/A N/A $54.32 N/A N/A $69.13 N/A N/A $33.08 N/A N/A N/A N/A N/A $59.26 N/A N/A $34.57 N/A N/A $64.19 N/A N/A N/A N/A N/A $59.26 N/A N/A $69.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $98.76 $98.76 N/A 4400803 Pharmacy "nystatin Top 100,000 units/g Crm [BCH]" 250 $52.50 $- $13.65 $- $- $42.00 $- N/A $13.65 N/A N/A $19.85 N/A N/A $31.50 N/A N/A $26.25 N/A N/A N/A N/A N/A $35.70 N/A N/A $32.55 N/A N/A $21.53 N/A N/A $36.75 N/A N/A $42.00 N/A N/A $28.88 N/A N/A $36.75 N/A N/A $17.59 N/A N/A N/A N/A N/A $31.50 N/A N/A $18.38 N/A N/A $34.13 N/A N/A N/A N/A N/A $31.50 N/A N/A $36.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.50 $52.50 N/A 4407760 Pharmacy "nystatin topical 100,000 units/g Cre [BCH]" 250 $35.00 $- $9.10 $- $- $28.00 $- N/A $9.10 N/A N/A $13.23 N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A $21.70 N/A N/A $14.35 N/A N/A $24.50 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $24.50 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A N/A N/A N/A $21.00 N/A N/A $24.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.00 $35.00 N/A 4400874 Pharmacy bacitracin topical 500 units/g Oin [BCH] 250 $7.28 $- $1.89 $- $- $5.82 $- N/A $1.89 N/A N/A $2.75 N/A N/A $4.37 N/A N/A $3.64 N/A N/A N/A N/A N/A $4.95 N/A N/A $4.51 N/A N/A $2.98 N/A N/A $5.10 N/A N/A $5.82 N/A N/A $4.00 N/A N/A $5.10 N/A N/A $2.44 N/A N/A N/A N/A N/A $4.37 N/A N/A $2.55 N/A N/A $4.73 N/A N/A N/A N/A N/A $4.37 N/A N/A $5.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.28 $7.28 N/A 4401938 Pharmacy bacitracin/neomycin/polymyxin B Top Oint ud [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400994 Pharmacy triamcinolone topical 0.025% Cre [BCH] 250 $8.90 $- $2.31 $- $- $7.12 $- N/A $2.31 N/A N/A $3.36 N/A N/A $5.34 N/A N/A $4.45 N/A N/A N/A N/A N/A $6.05 N/A N/A $5.52 N/A N/A $3.65 N/A N/A $6.23 N/A N/A $7.12 N/A N/A $4.90 N/A N/A $6.23 N/A N/A $2.98 N/A N/A N/A N/A N/A $5.34 N/A N/A $3.12 N/A N/A $5.79 N/A N/A N/A N/A N/A $5.34 N/A N/A $6.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.90 $8.90 N/A 4409472 Pharmacy triamcinolone topical 0.1% Cre 250 $7.78 $- $2.02 $- $- $6.22 $- N/A $2.02 N/A N/A $2.94 N/A N/A $4.67 N/A N/A $3.89 N/A N/A N/A N/A N/A $5.29 N/A N/A $4.82 N/A N/A $3.19 N/A N/A $5.45 N/A N/A $6.22 N/A N/A $4.28 N/A N/A $5.45 N/A N/A $2.61 N/A N/A N/A N/A N/A $4.67 N/A N/A $2.72 N/A N/A $5.06 N/A N/A N/A N/A N/A $4.67 N/A N/A $5.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.78 $7.78 N/A 4400247 Pharmacy triamcinolone topical 0.1% Cre [BCH] 250 $19.76 $- $5.14 $- $- $15.81 $- N/A $5.14 N/A N/A $7.47 N/A N/A $11.86 N/A N/A $9.88 N/A N/A N/A N/A N/A $13.44 N/A N/A $12.25 N/A N/A $8.10 N/A N/A $13.83 N/A N/A $15.81 N/A N/A $10.87 N/A N/A $13.83 N/A N/A $6.62 N/A N/A N/A N/A N/A $11.86 N/A N/A $6.92 N/A N/A $12.84 N/A N/A N/A N/A N/A $11.86 N/A N/A $13.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.76 $19.76 N/A 4402404 Pharmacy mupirocin Top 2% Oint [BCH] 250 $22.50 $- $5.85 $- $- $18.00 $- N/A $5.85 N/A N/A $8.50 N/A N/A $13.50 N/A N/A $11.25 N/A N/A N/A N/A N/A $15.30 N/A N/A $13.95 N/A N/A $9.22 N/A N/A $15.75 N/A N/A $18.00 N/A N/A $12.37 N/A N/A $15.75 N/A N/A $7.54 N/A N/A N/A N/A N/A $13.50 N/A N/A $7.87 N/A N/A $14.62 N/A N/A N/A N/A N/A $13.50 N/A N/A $15.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.50 $22.50 N/A 4400493 Pharmacy ciclopirox Top 8% Sol [BCH] 250 $337.12 $- $87.65 $- $- $269.70 $- N/A $87.65 N/A N/A $127.43 N/A N/A $202.27 N/A N/A $168.56 N/A N/A N/A N/A N/A $229.24 N/A N/A $209.01 N/A N/A $138.22 N/A N/A $235.98 N/A N/A $269.70 N/A N/A $185.42 N/A N/A $235.98 N/A N/A $112.94 N/A N/A N/A N/A N/A $202.27 N/A N/A $117.99 N/A N/A $219.13 N/A N/A N/A N/A N/A $202.27 N/A N/A $235.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $337.12 $337.12 N/A 4401938 Pharmacy bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401003 Pharmacy mineral oil/petrolatum/phenylephrine topical 14%-74.9%-0.25% Oin [BCH] 250 $9.98 $- $2.59 $- $- $7.98 $- N/A $2.59 N/A N/A $3.77 N/A N/A $5.99 N/A N/A $4.99 N/A N/A N/A N/A N/A $6.79 N/A N/A $6.19 N/A N/A $4.09 N/A N/A $6.99 N/A N/A $7.98 N/A N/A $5.49 N/A N/A $6.99 N/A N/A $3.34 N/A N/A N/A N/A N/A $5.99 N/A N/A $3.49 N/A N/A $6.49 N/A N/A N/A N/A N/A $5.99 N/A N/A $6.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.98 $9.98 N/A 4400676 Pharmacy mometasone topical 0.1% Cre[BCH] 250 $24.20 $- $6.29 $- $- $19.36 $- N/A $6.29 N/A N/A $9.15 N/A N/A $14.52 N/A N/A $12.10 N/A N/A N/A N/A N/A $16.46 N/A N/A $15.00 N/A N/A $9.92 N/A N/A $16.94 N/A N/A $19.36 N/A N/A $13.31 N/A N/A $16.94 N/A N/A $8.11 N/A N/A N/A N/A N/A $14.52 N/A N/A $8.47 N/A N/A $15.73 N/A N/A N/A N/A N/A $14.52 N/A N/A $16.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.20 $24.20 N/A 4409436 Pharmacy diphenhydrAMINE-zinc acetate Top 2%-0.1% Crm [BCH] 250 $8.55 $- $2.22 $- $- $6.84 $- N/A $2.22 N/A N/A $3.23 N/A N/A $5.13 N/A N/A $4.28 N/A N/A N/A N/A N/A $5.81 N/A N/A $5.30 N/A N/A $3.51 N/A N/A $5.99 N/A N/A $6.84 N/A N/A $4.70 N/A N/A $5.99 N/A N/A $2.86 N/A N/A N/A N/A N/A $5.13 N/A N/A $2.99 N/A N/A $5.56 N/A N/A N/A N/A N/A $5.13 N/A N/A $5.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.55 $8.55 N/A 4400050 Pharmacy vitamin A & D topical - Oin [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406220 Pharmacy pseudoephedrine 30 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401283 Pharmacy clotrimazole Top 1% Crm [BCH] 250 $17.18 $- $4.47 $- $- $13.74 $- N/A $4.47 N/A N/A $6.49 N/A N/A $10.31 N/A N/A $8.59 N/A N/A N/A N/A N/A $11.68 N/A N/A $10.65 N/A N/A $7.04 N/A N/A $12.03 N/A N/A $13.74 N/A N/A $9.45 N/A N/A $12.03 N/A N/A $5.76 N/A N/A N/A N/A N/A $10.31 N/A N/A $6.01 N/A N/A $11.17 N/A N/A N/A N/A N/A $10.31 N/A N/A $12.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.18 $17.18 N/A 4406309 Pharmacy hydrocortisone topical 1% Cre [BCH] 250 $8.09 $- $2.10 $- $- $6.48 $- N/A $2.10 N/A N/A $3.06 N/A N/A $4.86 N/A N/A $4.05 N/A N/A N/A N/A N/A $5.50 N/A N/A $5.02 N/A N/A $3.32 N/A N/A $5.67 N/A N/A $6.48 N/A N/A $4.45 N/A N/A $5.67 N/A N/A $2.71 N/A N/A N/A N/A N/A $4.86 N/A N/A $2.83 N/A N/A $5.26 N/A N/A N/A N/A N/A $4.86 N/A N/A $5.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.09 $8.09 N/A 4409444 Pharmacy ketoconazole Top 2% Shampoo [BCH] 250 $55.50 $- $14.43 $- $- $44.40 $- N/A $14.43 N/A N/A $20.98 N/A N/A $33.30 N/A N/A $27.75 N/A N/A N/A N/A N/A $37.74 N/A N/A $34.41 N/A N/A $22.76 N/A N/A $38.85 N/A N/A $44.40 N/A N/A $30.53 N/A N/A $38.85 N/A N/A $18.59 N/A N/A N/A N/A N/A $33.30 N/A N/A $19.43 N/A N/A $36.08 N/A N/A N/A N/A N/A $33.30 N/A N/A $38.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $55.50 $55.50 N/A 4409767 Pharmacy guaiFENesin 600 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405321 Pharmacy acetaminophen 650 mg Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401270 Pharmacy acetaminophen 120 mg Supp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406469 Pharmacy promethazine 25 mg Sup 250 $35.41 $- $9.21 $- $- $28.33 $- N/A $9.21 N/A N/A $13.38 N/A N/A $21.25 N/A N/A $17.71 N/A N/A N/A N/A N/A $24.08 N/A N/A $21.95 N/A N/A $14.52 N/A N/A $24.79 N/A N/A $28.33 N/A N/A $19.48 N/A N/A $24.79 N/A N/A $11.86 N/A N/A N/A N/A N/A $21.25 N/A N/A $12.39 N/A N/A $23.02 N/A N/A N/A N/A N/A $21.25 N/A N/A $24.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.41 $35.41 N/A 4400827 Pharmacy nystatin-triamcinolone topical 100000 units/g-0.1% Cre 250 $754.20 $- $196.09 $- $- $603.36 $- N/A $196.09 N/A N/A $285.09 N/A N/A $452.52 N/A N/A $377.10 N/A N/A N/A N/A N/A $512.86 N/A N/A $467.60 N/A N/A $309.22 N/A N/A $527.94 N/A N/A $603.36 N/A N/A $414.81 N/A N/A $527.94 N/A N/A $252.66 N/A N/A N/A N/A N/A $452.52 N/A N/A $263.97 N/A N/A $490.23 N/A N/A N/A N/A N/A $452.52 N/A N/A $527.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $754.20 $754.20 N/A 4402369 Pharmacy lactulose 10 g/15 mL Syr 250 $40.90 $- $10.63 $- $- $32.72 $- N/A $10.63 N/A N/A $15.46 N/A N/A $24.54 N/A N/A $20.45 N/A N/A N/A N/A N/A $27.81 N/A N/A $25.36 N/A N/A $16.77 N/A N/A $28.63 N/A N/A $32.72 N/A N/A $22.50 N/A N/A $28.63 N/A N/A $13.70 N/A N/A N/A N/A N/A $24.54 N/A N/A $14.32 N/A N/A $26.59 N/A N/A N/A N/A N/A $24.54 N/A N/A $28.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.90 $40.90 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $49.78 $- $0.02 $- $- $39.82 $- N/A $12.94 N/A N/A Not Reimbursed N/A N/A $29.87 N/A N/A $24.89 N/A N/A N/A N/A N/A $33.85 N/A N/A $30.86 N/A N/A $20.41 N/A N/A $34.84 N/A N/A $39.82 N/A N/A $27.38 N/A N/A $34.84 N/A N/A $16.68 N/A N/A N/A N/A N/A $29.87 N/A N/A $17.42 N/A N/A $32.36 N/A N/A $0.02 N/A N/A $29.87 N/A N/A $34.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.78 $49.78 N/A 4404893 Pharmacy sodium polystyrene sulfonate 15 g/60 mL Oral Susp [BCH] 250 $22.50 $- $5.85 $- $- $18.00 $- N/A $5.85 N/A N/A $8.51 N/A N/A $13.50 N/A N/A $11.25 N/A N/A N/A N/A N/A $15.30 N/A N/A $13.95 N/A N/A $9.23 N/A N/A $15.75 N/A N/A $18.00 N/A N/A $12.38 N/A N/A $15.75 N/A N/A $7.54 N/A N/A N/A N/A N/A $13.50 N/A N/A $7.88 N/A N/A $14.63 N/A N/A N/A N/A N/A $13.50 N/A N/A $15.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.50 $22.50 N/A 4400688 Pharmacy DULoxetine 20 mg Cap [BCH] 250 $3.60 $- $0.94 $- $- $2.88 $- N/A $0.94 N/A N/A $1.36 N/A N/A $2.16 N/A N/A $1.80 N/A N/A N/A N/A N/A $2.45 N/A N/A $2.23 N/A N/A $1.48 N/A N/A $2.52 N/A N/A $2.88 N/A N/A $1.98 N/A N/A $2.52 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.16 N/A N/A $1.26 N/A N/A $2.34 N/A N/A N/A N/A N/A $2.16 N/A N/A $2.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.60 $3.60 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $3.84 $- $1.00 $- $- $3.07 $- N/A $1.00 N/A N/A $1.45 N/A N/A $2.30 N/A N/A $1.92 N/A N/A N/A N/A N/A $2.61 N/A N/A $2.38 N/A N/A $1.57 N/A N/A $2.69 N/A N/A $3.07 N/A N/A $2.11 N/A N/A $2.69 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.30 N/A N/A $1.34 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.84 $3.84 N/A 4400680 Pharmacy DULoxetine 60 mg Cap [BCH] 250 $3.84 $- $1.00 $- $- $3.07 $- N/A $1.00 N/A N/A $1.45 N/A N/A $2.30 N/A N/A $1.92 N/A N/A N/A N/A N/A $2.61 N/A N/A $2.38 N/A N/A $1.57 N/A N/A $2.69 N/A N/A $3.07 N/A N/A $2.11 N/A N/A $2.69 N/A N/A $1.29 N/A N/A N/A N/A N/A $2.30 N/A N/A $1.34 N/A N/A $2.50 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.84 $3.84 N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404577 Pharmacy ALPRAZolam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403520 Pharmacy diltiazem 120 mg/24 hours ERCap [BCH] 250 $2.07 $- $0.54 $- $- $1.66 $- N/A $0.54 N/A N/A $0.78 N/A N/A $1.24 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.41 N/A N/A $1.29 N/A N/A $0.85 N/A N/A $1.45 N/A N/A $1.66 N/A N/A $1.14 N/A N/A $1.45 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.24 N/A N/A $0.73 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.24 N/A N/A $1.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.07 $2.07 N/A 4401714 Pharmacy dilTIAZem 180 mg/24 hours Cap 250 $2.50 $- $0.65 $- $- $2.00 $- N/A $0.65 N/A N/A $0.95 N/A N/A $1.50 N/A N/A $1.25 N/A N/A N/A N/A N/A $1.70 N/A N/A $1.55 N/A N/A $1.03 N/A N/A $1.75 N/A N/A $2.00 N/A N/A $1.38 N/A N/A $1.75 N/A N/A $0.84 N/A N/A N/A N/A N/A $1.50 N/A N/A $0.88 N/A N/A $1.63 N/A N/A N/A N/A N/A $1.50 N/A N/A $1.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.50 $2.50 N/A 4400653 Pharmacy diltiazem 360 mg/24 hours ERCap [BCH] 250 $4.69 $- $1.22 $- $- $3.75 $- N/A $1.22 N/A N/A $1.77 N/A N/A $2.81 N/A N/A $2.34 N/A N/A N/A N/A N/A $3.19 N/A N/A $2.91 N/A N/A $1.92 N/A N/A $3.28 N/A N/A $3.75 N/A N/A $2.58 N/A N/A $3.28 N/A N/A $1.57 N/A N/A N/A N/A N/A $2.81 N/A N/A $1.64 N/A N/A $3.05 N/A N/A N/A N/A N/A $2.81 N/A N/A $3.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.69 $4.69 N/A 4400231 Pharmacy diltiazem 240 mg/24 hours ERCap [BCH] 250 $4.10 $- $1.07 $- $- $3.28 $- N/A $1.07 N/A N/A $1.55 N/A N/A $2.46 N/A N/A $2.05 N/A N/A N/A N/A N/A $2.79 N/A N/A $2.54 N/A N/A $1.68 N/A N/A $2.87 N/A N/A $3.28 N/A N/A $2.26 N/A N/A $2.87 N/A N/A $1.37 N/A N/A N/A N/A N/A $2.46 N/A N/A $1.44 N/A N/A $2.67 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.10 $4.10 N/A 4400365 Pharmacy albuterol 2.5 mg/3 mL (0.083%) Sol[BCH] J7611 636 $5.00 $- $0.24 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.24 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400717 Pharmacy topiramate 100 mg Tab [BCH] 250 $13.90 $- $3.61 $- $- $11.12 $- N/A $3.61 N/A N/A $5.25 N/A N/A $8.34 N/A N/A $6.95 N/A N/A N/A N/A N/A $9.45 N/A N/A $8.62 N/A N/A $5.70 N/A N/A $9.73 N/A N/A $11.12 N/A N/A $7.65 N/A N/A $9.73 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.34 N/A N/A $4.87 N/A N/A $9.04 N/A N/A N/A N/A N/A $8.34 N/A N/A $9.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.90 $13.90 N/A 4403512 Pharmacy finasteride 5 mg Tab [BCH] S0138 250 $6.25 $- $1.63 $- $- $5.00 $- N/A $1.63 N/A N/A Not Reimbursed N/A N/A $3.75 N/A N/A $3.13 N/A N/A N/A N/A N/A $4.25 N/A N/A $3.88 N/A N/A $2.56 N/A N/A $4.38 N/A N/A $5.00 N/A N/A $3.44 N/A N/A $4.38 N/A N/A $2.09 N/A N/A N/A N/A N/A $3.75 N/A N/A $2.19 N/A N/A $4.06 N/A N/A N/A N/A N/A $3.75 N/A N/A $4.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.25 $6.25 N/A 4400129 Pharmacy buPROPion 100 mg ER Tab [BCH] 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.20 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4409329 Pharmacy buPROPion 150 mg ER Tab [BCH] 250 $3.87 $- $1.01 $- $- $3.09 $- N/A $1.01 N/A N/A $1.46 N/A N/A $2.32 N/A N/A $1.93 N/A N/A N/A N/A N/A $2.63 N/A N/A $2.40 N/A N/A $1.59 N/A N/A $2.71 N/A N/A $3.09 N/A N/A $2.13 N/A N/A $2.71 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.32 N/A N/A $1.35 N/A N/A $2.51 N/A N/A N/A N/A N/A $2.32 N/A N/A $2.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.87 $3.87 N/A 4409408 Pharmacy azelastine nasal 137 mcg/inh Spr [BCH] 250 $210.40 $- $54.70 $- $- $168.32 $- N/A $54.70 N/A N/A $79.53 N/A N/A $126.24 N/A N/A $105.20 N/A N/A N/A N/A N/A $143.07 N/A N/A $130.45 N/A N/A $86.26 N/A N/A $147.28 N/A N/A $168.32 N/A N/A $115.72 N/A N/A $147.28 N/A N/A $70.48 N/A N/A N/A N/A N/A $126.24 N/A N/A $73.64 N/A N/A $136.76 N/A N/A N/A N/A N/A $126.24 N/A N/A $147.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $210.40 $210.40 N/A 4401962 Pharmacy QUEtiapine 25 mg Tab [BCH] 250 $7.90 $- $2.05 $- $- $6.32 $- N/A $2.05 N/A N/A $2.99 N/A N/A $4.74 N/A N/A $3.95 N/A N/A N/A N/A N/A $5.37 N/A N/A $4.90 N/A N/A $3.24 N/A N/A $5.53 N/A N/A $6.32 N/A N/A $4.35 N/A N/A $5.53 N/A N/A $2.65 N/A N/A N/A N/A N/A $4.74 N/A N/A $2.77 N/A N/A $5.14 N/A N/A N/A N/A N/A $4.74 N/A N/A $5.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.90 $7.90 N/A 4400433 Pharmacy QUEtiapine 50 mg oral tablet [BCH] 250 $12.99 $- $3.38 $- $- $10.39 $- N/A $3.38 N/A N/A $4.91 N/A N/A $7.79 N/A N/A $6.49 N/A N/A N/A N/A N/A $8.83 N/A N/A $8.05 N/A N/A $5.32 N/A N/A $9.09 N/A N/A $10.39 N/A N/A $7.14 N/A N/A $9.09 N/A N/A $4.35 N/A N/A N/A N/A N/A $7.79 N/A N/A $4.55 N/A N/A $8.44 N/A N/A N/A N/A N/A $7.79 N/A N/A $9.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.99 $12.99 N/A 4400118 Pharmacy QUEtiapine 100 mg Tab [BCH] 250 $13.56 $- $3.53 $- $- $10.85 $- N/A $3.53 N/A N/A $5.13 N/A N/A $8.14 N/A N/A $6.78 N/A N/A N/A N/A N/A $9.22 N/A N/A $8.41 N/A N/A $5.56 N/A N/A $9.49 N/A N/A $10.85 N/A N/A $7.46 N/A N/A $9.49 N/A N/A $4.54 N/A N/A N/A N/A N/A $8.14 N/A N/A $4.75 N/A N/A $8.82 N/A N/A N/A N/A N/A $8.14 N/A N/A $9.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.56 $13.56 N/A 4400322 Pharmacy QUEtiapine 300 mg Tab [BCH] 250 $33.55 $- $8.72 $- $- $26.84 $- N/A $8.72 N/A N/A $12.68 N/A N/A $20.13 N/A N/A $16.77 N/A N/A N/A N/A N/A $22.81 N/A N/A $20.80 N/A N/A $13.75 N/A N/A $23.48 N/A N/A $26.84 N/A N/A $18.45 N/A N/A $23.48 N/A N/A $11.24 N/A N/A N/A N/A N/A $20.13 N/A N/A $11.74 N/A N/A $21.81 N/A N/A N/A N/A N/A $20.13 N/A N/A $23.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.55 $33.55 N/A 4400452 Pharmacy QUEtiapine 400 mg oral tablet [BCH] 250 $39.43 $- $10.25 $- $- $31.54 $- N/A $10.25 N/A N/A $14.90 N/A N/A $23.66 N/A N/A $19.71 N/A N/A N/A N/A N/A $26.81 N/A N/A $24.44 N/A N/A $16.16 N/A N/A $27.60 N/A N/A $31.54 N/A N/A $21.68 N/A N/A $27.60 N/A N/A $13.21 N/A N/A N/A N/A N/A $23.66 N/A N/A $13.80 N/A N/A $25.63 N/A N/A N/A N/A N/A $23.66 N/A N/A $27.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.43 $39.43 N/A 4409680 Pharmacy vecuronium 10 mg IV Inj [BCH] 250 $20.40 $- $5.30 $- $- $16.32 $- N/A $5.30 N/A N/A $7.71 N/A N/A $12.24 N/A N/A $10.20 N/A N/A N/A N/A N/A $13.87 N/A N/A $12.65 N/A N/A $8.36 N/A N/A $14.28 N/A N/A $16.32 N/A N/A $11.22 N/A N/A $14.28 N/A N/A $6.83 N/A N/A N/A N/A N/A $12.24 N/A N/A $7.14 N/A N/A $13.26 N/A N/A N/A N/A N/A $12.24 N/A N/A $14.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.40 $20.40 N/A 4408556 Pharmacy alfuzosin 10 mg ER Tab [BCH] 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.22 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.63 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4400062 Pharmacy acetaminophen-oxyCODONE 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4401847 Pharmacy nitrofurantoin macrocrystals-monohydrate 100 mg Cap [BCH] 250 $7.63 $- $1.98 $- $- $6.10 $- N/A $1.98 N/A N/A $2.88 N/A N/A $4.58 N/A N/A $3.81 N/A N/A N/A N/A N/A $5.19 N/A N/A $4.73 N/A N/A $3.13 N/A N/A $5.34 N/A N/A $6.10 N/A N/A $4.20 N/A N/A $5.34 N/A N/A $2.56 N/A N/A N/A N/A N/A $4.58 N/A N/A $2.67 N/A N/A $4.96 N/A N/A N/A N/A N/A $4.58 N/A N/A $5.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.63 $7.63 N/A 4401326 Pharmacy fentaNYL 25 mcg/hr Fil 250 $42.53 $- $11.06 $- $- $34.03 $- N/A $11.06 N/A N/A $16.08 N/A N/A $25.52 N/A N/A $21.27 N/A N/A N/A N/A N/A $28.92 N/A N/A $26.37 N/A N/A $17.44 N/A N/A $29.77 N/A N/A $34.03 N/A N/A $23.39 N/A N/A $29.77 N/A N/A $14.25 N/A N/A N/A N/A N/A $25.52 N/A N/A $14.89 N/A N/A $27.65 N/A N/A N/A N/A N/A $25.52 N/A N/A $29.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.53 $42.53 N/A 4401474 Pharmacy fentaNYL 50 mcg/hr Fil [BCH] 250 $77.76 $- $20.22 $- $- $62.21 $- N/A $20.22 N/A N/A $29.39 N/A N/A $46.66 N/A N/A $38.88 N/A N/A N/A N/A N/A $52.88 N/A N/A $48.21 N/A N/A $31.88 N/A N/A $54.43 N/A N/A $62.21 N/A N/A $42.77 N/A N/A $54.43 N/A N/A $26.05 N/A N/A N/A N/A N/A $46.66 N/A N/A $27.22 N/A N/A $50.55 N/A N/A N/A N/A N/A $46.66 N/A N/A $54.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $77.76 $77.76 N/A 4409479 Pharmacy oseltamivir 75 mg Cap 250 $30.91 $- $8.04 $- $- $24.73 $- N/A $8.04 N/A N/A $11.69 N/A N/A $18.55 N/A N/A $15.46 N/A N/A N/A N/A N/A $21.02 N/A N/A $19.17 N/A N/A $12.67 N/A N/A $21.64 N/A N/A $24.73 N/A N/A $17.00 N/A N/A $21.64 N/A N/A $10.36 N/A N/A N/A N/A N/A $18.55 N/A N/A $10.82 N/A N/A $20.09 N/A N/A N/A N/A N/A $18.55 N/A N/A $21.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.91 $30.91 N/A 4405855 Pharmacy labetalol 5 mg/mL Sol [BCH] 258 $27.50 $- $7.15 $- $- $22.00 $- N/A $7.15 N/A N/A $10.40 N/A N/A $16.50 N/A N/A $13.75 N/A N/A N/A N/A N/A $18.70 N/A N/A $17.05 N/A N/A $11.28 N/A N/A $19.25 N/A N/A $22.00 N/A N/A $15.13 N/A N/A $19.25 N/A N/A $9.21 N/A N/A N/A N/A N/A $16.50 N/A N/A $9.63 N/A N/A $17.88 N/A N/A N/A N/A N/A $16.50 N/A N/A $19.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.50 $27.50 N/A 4408610 Pharmacy vancomycin 500 mg Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400661 Pharmacy bacitracin Ophth 500 units/g Oint [BCH] 250 $225.60 $- $58.66 $- $- $180.48 $- N/A $58.66 N/A N/A $85.28 N/A N/A $135.36 N/A N/A $112.80 N/A N/A N/A N/A N/A $153.41 N/A N/A $139.87 N/A N/A $92.50 N/A N/A $157.92 N/A N/A $180.48 N/A N/A $124.08 N/A N/A $157.92 N/A N/A $75.58 N/A N/A N/A N/A N/A $135.36 N/A N/A $78.96 N/A N/A $146.64 N/A N/A N/A N/A N/A $135.36 N/A N/A $157.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $225.60 $225.60 N/A 4409706 Pharmacy sodium sulfacetamide Ophth 10% Oint [BCH] 250 $131.72 $- $34.25 $- $- $105.38 $- N/A $34.25 N/A N/A $49.79 N/A N/A $79.03 N/A N/A $65.86 N/A N/A N/A N/A N/A $89.57 N/A N/A $81.67 N/A N/A $54.00 N/A N/A $92.20 N/A N/A $105.38 N/A N/A $72.45 N/A N/A $92.20 N/A N/A $44.13 N/A N/A N/A N/A N/A $79.03 N/A N/A $46.10 N/A N/A $85.62 N/A N/A N/A N/A N/A $79.03 N/A N/A $92.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $131.72 $131.72 N/A 4400677 Pharmacy cholecalciferol 1000 intl units Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400016 Pharmacy "rabies immune globulin, human 150 intl units/mL IM Sol [BCH]" 90376 636 "$1,590.92 " $- $413.64 $- $- "$1,272.74 " $- N/A $413.64 N/A N/A $601.37 N/A N/A $954.55 N/A N/A $795.46 N/A N/A N/A N/A N/A "$1,081.83 " N/A N/A $986.37 N/A N/A $652.28 N/A N/A "$1,113.64 " N/A N/A "$1,272.74 " N/A N/A $875.01 N/A N/A "$1,113.64 " N/A N/A $532.96 N/A N/A N/A N/A N/A $954.55 N/A N/A $556.82 N/A N/A "$1,034.10 " N/A N/A N/A N/A N/A $954.55 N/A N/A "$1,113.64 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,590.92 " "$1,590.92 " N/A 4404258 Pharmacy tetanus-diphtheria toxoids adult IM Susp 0 mL [BCH] 90714 636 $141.52 $- $36.80 $- $- $113.22 $- N/A $36.80 N/A N/A $53.49 N/A N/A $84.91 N/A N/A $70.76 N/A N/A N/A N/A N/A $96.23 N/A N/A $87.74 N/A N/A $58.02 N/A N/A $99.06 N/A N/A $113.22 N/A N/A $77.84 N/A N/A $99.06 N/A N/A $47.41 N/A N/A N/A N/A N/A $84.91 N/A N/A $49.53 N/A N/A $91.99 N/A N/A N/A N/A N/A $84.91 N/A N/A $99.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $141.52 $141.52 N/A 4400022 Pharmacy "rabies vaccine, human diploid cell 2.5 intl units IM Inj [BCH]" 90675 636 $773.52 $- $201.12 $- $- $618.82 $- N/A $201.12 N/A N/A $292.39 N/A N/A $464.11 N/A N/A $386.76 N/A N/A N/A N/A N/A $525.99 N/A N/A $479.58 N/A N/A $317.14 N/A N/A $541.46 N/A N/A $618.82 N/A N/A $425.44 N/A N/A $541.46 N/A N/A $259.13 N/A N/A N/A N/A N/A $464.11 N/A N/A $270.73 N/A N/A $502.79 N/A N/A N/A N/A N/A $464.11 N/A N/A $541.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $773.52 $773.52 N/A 4400221 Pharmacy "diphtheria/tetanus/pertussis, acel (DTaP) 15 units-5 units-23 mcg/0.5 mL IM Susp 0 mL [BCH]" 90700 636 $67.29 $- $17.49 $- $- $53.83 $- N/A $17.49 N/A N/A $25.43 N/A N/A $40.37 N/A N/A $33.64 N/A N/A N/A N/A N/A $45.75 N/A N/A $41.72 N/A N/A $27.59 N/A N/A $47.10 N/A N/A $53.83 N/A N/A $37.01 N/A N/A $47.10 N/A N/A $22.54 N/A N/A N/A N/A N/A $40.37 N/A N/A $23.55 N/A N/A $43.74 N/A N/A N/A N/A N/A $40.37 N/A N/A $47.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $67.29 $67.29 N/A 4400943 Pharmacy tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Sus [BCH] 90715 636 $105.28 $- $27.37 $- $- $84.22 $- N/A $27.37 N/A N/A $39.80 N/A N/A $63.17 N/A N/A $52.64 N/A N/A N/A N/A N/A $71.59 N/A N/A $65.27 N/A N/A $43.16 N/A N/A $73.69 N/A N/A $84.22 N/A N/A $57.90 N/A N/A $73.69 N/A N/A $35.27 N/A N/A N/A N/A N/A $63.17 N/A N/A $36.85 N/A N/A $68.43 N/A N/A N/A N/A N/A $63.17 N/A N/A $73.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.28 $105.28 N/A 4400943 Pharmacy tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Sus 90715 636 $105.28 $- $27.37 $- $- $84.22 $- N/A $27.37 N/A N/A $39.80 N/A N/A $63.17 N/A N/A $52.64 N/A N/A N/A N/A N/A $71.59 N/A N/A $65.27 N/A N/A $43.16 N/A N/A $73.70 N/A N/A $84.22 N/A N/A $57.90 N/A N/A $73.70 N/A N/A $35.27 N/A N/A N/A N/A N/A $63.17 N/A N/A $36.85 N/A N/A $68.43 N/A N/A N/A N/A N/A $63.17 N/A N/A $73.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.28 $105.28 N/A 4401684 Pharmacy tuberculin purified protein derivative 5 tuberculin units/0.1 mL Sol [BCH] 636 $20.00 $- $5.20 $- $- $16.00 $- N/A $5.20 N/A N/A $7.56 N/A N/A $12.00 N/A N/A $10.00 N/A N/A N/A N/A N/A $13.60 N/A N/A $12.40 N/A N/A $8.20 N/A N/A $14.00 N/A N/A $16.00 N/A N/A $11.00 N/A N/A $14.00 N/A N/A $6.70 N/A N/A N/A N/A N/A $12.00 N/A N/A $7.00 N/A N/A $13.00 N/A N/A N/A N/A N/A $12.00 N/A N/A $14.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.00 $20.00 N/A 4400010 Pharmacy calamine-zinc oxide topical 8%-8% Lot [BCH] 250 $4.98 $- $1.29 $- $- $3.98 $- N/A $1.29 N/A N/A $1.88 N/A N/A $2.99 N/A N/A $2.49 N/A N/A N/A N/A N/A $3.39 N/A N/A $3.09 N/A N/A $2.04 N/A N/A $3.49 N/A N/A $3.98 N/A N/A $2.74 N/A N/A $3.49 N/A N/A $1.67 N/A N/A N/A N/A N/A $2.99 N/A N/A $1.74 N/A N/A $3.24 N/A N/A N/A N/A N/A $2.99 N/A N/A $3.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.98 $4.98 N/A 4400378 Pharmacy dextromethorphan-guaifenesin 20 mg-200 mg/10 mL Liq [BCH] 250 $4.44 $- $1.15 $- $- $3.55 $- N/A $1.15 N/A N/A $1.68 N/A N/A $2.66 N/A N/A $2.22 N/A N/A N/A N/A N/A $3.02 N/A N/A $2.75 N/A N/A $1.82 N/A N/A $3.11 N/A N/A $3.55 N/A N/A $2.44 N/A N/A $3.11 N/A N/A $1.49 N/A N/A N/A N/A N/A $2.66 N/A N/A $1.55 N/A N/A $2.89 N/A N/A N/A N/A N/A $2.66 N/A N/A $3.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.44 $4.44 N/A 4400513 Pharmacy magnesium sulfate compounding Pwdr [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400430 Pharmacy bacitracin/neomycin/polymyxin B Top Oint 30gm [BCH] 250 $11.98 $- $3.11 $- $- $9.58 $- N/A $3.11 N/A N/A $4.53 N/A N/A $7.19 N/A N/A $5.99 N/A N/A N/A N/A N/A $8.15 N/A N/A $7.43 N/A N/A $4.91 N/A N/A $8.39 N/A N/A $9.58 N/A N/A $6.59 N/A N/A $8.39 N/A N/A $4.01 N/A N/A N/A N/A N/A $7.19 N/A N/A $4.19 N/A N/A $7.79 N/A N/A N/A N/A N/A $7.19 N/A N/A $8.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.98 $11.98 N/A 4400235 Pharmacy hydrogen peroxide Top 3% Sol [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400235 Pharmacy hydrogen peroxide Top 3% Sol [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400876 Pharmacy hydrogen peroxide topical 3% Sol [BCH] 250 $2.62 $- $0.68 $- $- $2.10 $- N/A $0.68 N/A N/A $0.99 N/A N/A $1.57 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.78 N/A N/A $1.62 N/A N/A $1.07 N/A N/A $1.83 N/A N/A $2.10 N/A N/A $1.44 N/A N/A $1.83 N/A N/A $0.88 N/A N/A N/A N/A N/A $1.57 N/A N/A $0.92 N/A N/A $1.70 N/A N/A N/A N/A N/A $1.57 N/A N/A $1.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.62 $2.62 N/A 4400457 Pharmacy guaiFENesin 100 mg/5 mL Liq [BCH] 250 $10.15 $- $2.64 $- $- $8.12 $- N/A $2.64 N/A N/A $3.84 N/A N/A $6.09 N/A N/A $5.07 N/A N/A N/A N/A N/A $6.90 N/A N/A $6.29 N/A N/A $4.16 N/A N/A $7.10 N/A N/A $8.12 N/A N/A $5.58 N/A N/A $7.10 N/A N/A $3.40 N/A N/A N/A N/A N/A $6.09 N/A N/A $3.55 N/A N/A $6.60 N/A N/A N/A N/A N/A $6.09 N/A N/A $7.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.15 $10.15 N/A 4408297 Pharmacy nicotine 14 mg/24 hr Transderm ER Film [BCH] 250 $5.70 $- $1.48 $- $- $4.56 $- N/A $1.48 N/A N/A $2.15 N/A N/A $3.42 N/A N/A $2.85 N/A N/A N/A N/A N/A $3.88 N/A N/A $3.53 N/A N/A $2.34 N/A N/A $3.99 N/A N/A $4.56 N/A N/A $3.13 N/A N/A $3.99 N/A N/A $1.91 N/A N/A N/A N/A N/A $3.42 N/A N/A $1.99 N/A N/A $3.70 N/A N/A N/A N/A N/A $3.42 N/A N/A $3.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.70 $5.70 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400235 Pharmacy hydrogen peroxide topical 3% Sol [BCH] 250 $364.80 $- $94.85 $- $- $291.84 $- N/A $94.85 N/A N/A $137.89 N/A N/A $218.88 N/A N/A $182.40 N/A N/A N/A N/A N/A $248.06 N/A N/A $226.18 N/A N/A $149.57 N/A N/A $255.36 N/A N/A $291.84 N/A N/A $200.64 N/A N/A $255.36 N/A N/A $122.21 N/A N/A N/A N/A N/A $218.88 N/A N/A $127.68 N/A N/A $237.12 N/A N/A N/A N/A N/A $218.88 N/A N/A $255.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $364.80 $364.80 N/A 4400876 Pharmacy hydrogen peroxide topical 3% Sol [BCH] 250 $2.93 $- $0.76 $- $- $2.34 $- N/A $0.76 N/A N/A $1.11 N/A N/A $1.76 N/A N/A $1.46 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.82 N/A N/A $1.20 N/A N/A $2.05 N/A N/A $2.34 N/A N/A $1.61 N/A N/A $2.05 N/A N/A $0.98 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.02 N/A N/A $1.90 N/A N/A N/A N/A N/A $1.76 N/A N/A $2.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.93 $2.93 N/A 4400189 Pharmacy mineral oil 100% Ene [BCH] 250 $3.32 $- $0.86 $- $- $2.66 $- N/A $0.86 N/A N/A $1.25 N/A N/A $1.99 N/A N/A $1.66 N/A N/A N/A N/A N/A $2.26 N/A N/A $2.06 N/A N/A $1.36 N/A N/A $2.32 N/A N/A $2.66 N/A N/A $1.83 N/A N/A $2.32 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.16 N/A N/A $2.16 N/A N/A N/A N/A N/A $1.99 N/A N/A $2.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.32 $3.32 N/A 4409747 Pharmacy sodium biphosphate-sodium phosphate 7 g-19 g Ene 250 $2.05 $- $0.53 $- $- $1.64 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.23 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.27 N/A N/A $0.84 N/A N/A $1.43 N/A N/A $1.64 N/A N/A $1.13 N/A N/A $1.43 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.23 N/A N/A $0.72 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.23 N/A N/A $1.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.05 $2.05 N/A 4400842 Pharmacy ibuprofen 200 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400615 Pharmacy ibuprofen 100 mg/5 mL Oral Susp [BCH] 250 $15.58 $- $4.05 $- $- $12.46 $- N/A $4.05 N/A N/A $5.89 N/A N/A $9.35 N/A N/A $7.79 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.66 N/A N/A $6.39 N/A N/A $10.91 N/A N/A $12.46 N/A N/A $8.57 N/A N/A $10.91 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.35 N/A N/A $5.45 N/A N/A $10.13 N/A N/A N/A N/A N/A $9.35 N/A N/A $10.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.58 $15.58 N/A 4400656 Pharmacy bacitracin-polymyxin B Top Oint [BCH] 250 $11.98 $- $3.11 $- $- $9.58 $- N/A $3.11 N/A N/A $4.53 N/A N/A $7.19 N/A N/A $5.99 N/A N/A N/A N/A N/A $8.15 N/A N/A $7.43 N/A N/A $4.91 N/A N/A $8.39 N/A N/A $9.58 N/A N/A $6.59 N/A N/A $8.39 N/A N/A $4.01 N/A N/A N/A N/A N/A $7.19 N/A N/A $4.19 N/A N/A $7.79 N/A N/A N/A N/A N/A $7.19 N/A N/A $8.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.98 $11.98 N/A 4401283 Pharmacy clotrimazole Top 1% Crm [BCH] 250 $14.98 $- $3.89 $- $- $11.98 $- N/A $3.89 N/A N/A $5.66 N/A N/A $8.99 N/A N/A $7.49 N/A N/A N/A N/A N/A $10.19 N/A N/A $9.29 N/A N/A $6.14 N/A N/A $10.49 N/A N/A $11.98 N/A N/A $8.24 N/A N/A $10.49 N/A N/A $5.02 N/A N/A N/A N/A N/A $8.99 N/A N/A $5.24 N/A N/A $9.74 N/A N/A N/A N/A N/A $8.99 N/A N/A $10.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.98 $14.98 N/A 4400917 Pharmacy piperonyl butoxide-pyrethrins topical 4%-0.33% Sha 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409747 Pharmacy sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 135 mL [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400696 Pharmacy loperamide 2 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400189 Pharmacy mineral oil 100% Rectal Enema 133 mL [BCH] 250 $4.78 $- $1.24 $- $- $3.82 $- N/A $1.24 N/A N/A $1.81 N/A N/A $2.87 N/A N/A $2.39 N/A N/A N/A N/A N/A $3.25 N/A N/A $2.96 N/A N/A $1.96 N/A N/A $3.35 N/A N/A $3.82 N/A N/A $2.63 N/A N/A $3.35 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.87 N/A N/A $1.67 N/A N/A $3.11 N/A N/A N/A N/A N/A $2.87 N/A N/A $3.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.78 $4.78 N/A 4400577 Pharmacy nicotine 2 mg Oral transmucosal Gum [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400613 Pharmacy menthol oral lozenge [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400130 Pharmacy magnesium citrate 1.745 g/30 mL Liq 250 $2.82 $- $0.73 $- $- $2.26 $- N/A $0.73 N/A N/A $1.07 N/A N/A $1.69 N/A N/A $1.41 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.75 N/A N/A $1.16 N/A N/A $1.97 N/A N/A $2.26 N/A N/A $1.55 N/A N/A $1.97 N/A N/A $0.94 N/A N/A N/A N/A N/A $1.69 N/A N/A $0.99 N/A N/A $1.83 N/A N/A N/A N/A N/A $1.69 N/A N/A $1.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.82 $2.82 N/A 4400031 Pharmacy simethicone 40 mg/0.6 mL Liq [BCH] 250 $16.38 $- $4.26 $- $- $13.10 $- N/A $4.26 N/A N/A $6.19 N/A N/A $9.83 N/A N/A $8.19 N/A N/A N/A N/A N/A $11.14 N/A N/A $10.16 N/A N/A $6.72 N/A N/A $11.47 N/A N/A $13.10 N/A N/A $9.01 N/A N/A $11.47 N/A N/A $5.49 N/A N/A N/A N/A N/A $9.83 N/A N/A $5.73 N/A N/A $10.65 N/A N/A N/A N/A N/A $9.83 N/A N/A $11.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.38 $16.38 N/A 4401253 Pharmacy famotidine 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409436 Pharmacy diphenhydramine-zinc acetate topical 2%-0.1% Cre [BCH] 250 $9.94 $- $2.58 $- $- $7.95 $- N/A $2.58 N/A N/A $3.76 N/A N/A $5.96 N/A N/A $4.97 N/A N/A N/A N/A N/A $6.76 N/A N/A $6.16 N/A N/A $4.08 N/A N/A $6.96 N/A N/A $7.95 N/A N/A $5.47 N/A N/A $6.96 N/A N/A $3.33 N/A N/A N/A N/A N/A $5.96 N/A N/A $3.48 N/A N/A $6.46 N/A N/A N/A N/A N/A $5.96 N/A N/A $6.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.94 $9.94 N/A 4400184 Pharmacy miconazole 2% Vag Crm w/Appl [BCH] 250 $16.58 $- $4.31 $- $- $13.26 $- N/A $4.31 N/A N/A $6.27 N/A N/A $9.95 N/A N/A $8.29 N/A N/A N/A N/A N/A $11.27 N/A N/A $10.28 N/A N/A $6.80 N/A N/A $11.61 N/A N/A $13.26 N/A N/A $9.12 N/A N/A $11.61 N/A N/A $5.55 N/A N/A N/A N/A N/A $9.95 N/A N/A $5.80 N/A N/A $10.78 N/A N/A N/A N/A N/A $9.95 N/A N/A $11.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.58 $16.58 N/A 4400189 Pharmacy mineral oil 100% Ene[BCH] 250 $4.58 $- $1.19 $- $- $3.66 $- N/A $1.19 N/A N/A $1.73 N/A N/A $2.75 N/A N/A $2.29 N/A N/A N/A N/A N/A $3.11 N/A N/A $2.84 N/A N/A $1.88 N/A N/A $3.21 N/A N/A $3.66 N/A N/A $2.52 N/A N/A $3.21 N/A N/A $1.53 N/A N/A N/A N/A N/A $2.75 N/A N/A $1.60 N/A N/A $2.98 N/A N/A N/A N/A N/A $2.75 N/A N/A $3.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.58 $4.58 N/A 4400234 Pharmacy polyethylene glycol 3350 Oral Pwdr for Recon [BCH] 250 $9.99 $- $2.60 $- $- $7.99 $- N/A $2.60 N/A N/A $3.78 N/A N/A $5.99 N/A N/A $4.99 N/A N/A N/A N/A N/A $6.79 N/A N/A $6.19 N/A N/A $4.09 N/A N/A $6.99 N/A N/A $7.99 N/A N/A $5.49 N/A N/A $6.99 N/A N/A $3.35 N/A N/A N/A N/A N/A $5.99 N/A N/A $3.50 N/A N/A $6.49 N/A N/A N/A N/A N/A $5.99 N/A N/A $6.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.99 $9.99 N/A 4408036 Pharmacy acetaminophen 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Oral EC Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4400723 Pharmacy paricalcitol 1 mcg Cap 250 $16.00 $- $4.16 $- $- $12.80 $- N/A $4.16 N/A N/A $6.05 N/A N/A $9.60 N/A N/A $8.00 N/A N/A N/A N/A N/A $10.88 N/A N/A $9.92 N/A N/A $6.56 N/A N/A $11.20 N/A N/A $12.80 N/A N/A $8.80 N/A N/A $11.20 N/A N/A $5.36 N/A N/A N/A N/A N/A $9.60 N/A N/A $5.60 N/A N/A $10.40 N/A N/A N/A N/A N/A $9.60 N/A N/A $11.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.00 $16.00 N/A 4408234 Pharmacy doxycycline monohydrate 100 mg Tab [BCH] 250 $9.46 $- $2.46 $- $- $7.57 $- N/A $2.46 N/A N/A $3.58 N/A N/A $5.67 N/A N/A $4.73 N/A N/A N/A N/A N/A $6.43 N/A N/A $5.86 N/A N/A $3.88 N/A N/A $6.62 N/A N/A $7.57 N/A N/A $5.20 N/A N/A $6.62 N/A N/A $3.17 N/A N/A N/A N/A N/A $5.67 N/A N/A $3.31 N/A N/A $6.15 N/A N/A N/A N/A N/A $5.67 N/A N/A $6.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.46 $9.46 N/A 4404159 Pharmacy labetalol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409450 Pharmacy calcitonin 200 intl units/inh Spr [BCH} 250 $237.08 $- $61.64 $- $- $189.66 $- N/A $61.64 N/A N/A $89.62 N/A N/A $142.25 N/A N/A $118.54 N/A N/A N/A N/A N/A $161.21 N/A N/A $146.99 N/A N/A $97.20 N/A N/A $165.96 N/A N/A $189.66 N/A N/A $130.39 N/A N/A $165.96 N/A N/A $79.42 N/A N/A N/A N/A N/A $142.25 N/A N/A $82.98 N/A N/A $154.10 N/A N/A N/A N/A N/A $142.25 N/A N/A $165.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $237.08 $237.08 N/A 4403292 Pharmacy minoxidil 2.5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400569 Pharmacy megestrol 40 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400749 Pharmacy risperiDONE 0.5 mg Dis Tab [BCH] 250 $9.83 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.88 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.88 N/A N/A $3.29 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.39 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.83 $9.83 N/A 4400748 Pharmacy risperiDONE 1 mg Dis Tab [BCH] 250 $11.49 $- $2.99 $- $- $9.19 $- N/A $2.99 N/A N/A $4.34 N/A N/A $6.89 N/A N/A $5.74 N/A N/A N/A N/A N/A $7.81 N/A N/A $7.12 N/A N/A $4.71 N/A N/A $8.04 N/A N/A $9.19 N/A N/A $6.32 N/A N/A $8.04 N/A N/A $3.85 N/A N/A N/A N/A N/A $6.89 N/A N/A $4.02 N/A N/A $7.47 N/A N/A N/A N/A N/A $6.89 N/A N/A $8.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.49 $11.49 N/A 4400117 Pharmacy OLANZapine 5 mg Tab [BCH] 250 $28.55 $- $7.42 $- $- $22.84 $- N/A $7.42 N/A N/A $10.79 N/A N/A $17.13 N/A N/A $14.27 N/A N/A N/A N/A N/A $19.41 N/A N/A $17.70 N/A N/A $11.70 N/A N/A $19.98 N/A N/A $22.84 N/A N/A $15.70 N/A N/A $19.98 N/A N/A $9.56 N/A N/A N/A N/A N/A $17.13 N/A N/A $9.99 N/A N/A $18.56 N/A N/A N/A N/A N/A $17.13 N/A N/A $19.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.55 $28.55 N/A 4400866 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $41.94 $- $10.91 $- $- $33.56 $- N/A $10.91 N/A N/A $15.86 N/A N/A $25.17 N/A N/A $20.97 N/A N/A N/A N/A N/A $28.52 N/A N/A $26.01 N/A N/A $17.20 N/A N/A $29.36 N/A N/A $33.56 N/A N/A $23.07 N/A N/A $29.36 N/A N/A $14.05 N/A N/A N/A N/A N/A $25.17 N/A N/A $14.68 N/A N/A $27.26 N/A N/A N/A N/A N/A $25.17 N/A N/A $29.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.94 $41.94 N/A 4400750 Pharmacy risperiDONE 2 mg Dis Tab [BCH] 250 $18.68 $- $4.86 $- $- $14.94 $- N/A $4.86 N/A N/A $7.06 N/A N/A $11.21 N/A N/A $9.34 N/A N/A N/A N/A N/A $12.70 N/A N/A $11.58 N/A N/A $7.66 N/A N/A $13.07 N/A N/A $14.94 N/A N/A $10.27 N/A N/A $13.07 N/A N/A $6.26 N/A N/A N/A N/A N/A $11.21 N/A N/A $6.54 N/A N/A $12.14 N/A N/A N/A N/A N/A $11.21 N/A N/A $13.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.68 $18.68 N/A 4400137 Pharmacy modafinil 100 mg Tab [BCH] 250 $44.13 $- $11.47 $- $- $35.31 $- N/A $11.47 N/A N/A $16.68 N/A N/A $26.48 N/A N/A $22.07 N/A N/A N/A N/A N/A $30.01 N/A N/A $27.36 N/A N/A $18.09 N/A N/A $30.89 N/A N/A $35.31 N/A N/A $24.27 N/A N/A $30.89 N/A N/A $14.78 N/A N/A N/A N/A N/A $26.48 N/A N/A $15.45 N/A N/A $28.69 N/A N/A N/A N/A N/A $26.48 N/A N/A $30.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.13 $44.13 N/A 4401941 Pharmacy metoclopramide 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404296 Pharmacy hydroxyurea 500 mg Cap [BCH] S0176 250 $2.55 $- $0.66 $- $- $2.04 $- N/A $0.66 N/A N/A Not Reimbursed N/A N/A $1.53 N/A N/A $1.28 N/A N/A N/A N/A N/A $1.74 N/A N/A $1.58 N/A N/A $1.05 N/A N/A $1.79 N/A N/A $2.04 N/A N/A $1.41 N/A N/A $1.79 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.53 N/A N/A $0.89 N/A N/A $1.66 N/A N/A N/A N/A N/A $1.53 N/A N/A $1.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.55 $2.55 N/A 4400231 Pharmacy dilTIAZem 240 mg/24 hours Cap [BCH] 250 $4.10 $- $1.07 $- $- $3.28 $- N/A $1.07 N/A N/A $1.55 N/A N/A $2.46 N/A N/A $2.05 N/A N/A N/A N/A N/A $2.79 N/A N/A $2.54 N/A N/A $1.68 N/A N/A $2.87 N/A N/A $3.28 N/A N/A $2.26 N/A N/A $2.87 N/A N/A $1.37 N/A N/A N/A N/A N/A $2.46 N/A N/A $1.44 N/A N/A $2.67 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.10 $4.10 N/A 4400754 Pharmacy Quetiapine 300 mg Tab-ER [BCH] 250 $46.00 $- $11.96 $- $- $36.80 $- N/A $11.96 N/A N/A $17.39 N/A N/A $27.60 N/A N/A $23.00 N/A N/A N/A N/A N/A $31.28 N/A N/A $28.52 N/A N/A $18.86 N/A N/A $32.20 N/A N/A $36.80 N/A N/A $25.30 N/A N/A $32.20 N/A N/A $15.41 N/A N/A N/A N/A N/A $27.60 N/A N/A $16.10 N/A N/A $29.90 N/A N/A N/A N/A N/A $27.60 N/A N/A $32.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $46.00 $46.00 N/A 4409744 Pharmacy megestrol 40 mg/mL Oral Susp [BCH] 250 $287.90 $- $74.85 $- $- $230.32 $- N/A $74.85 N/A N/A $108.83 N/A N/A $172.74 N/A N/A $143.95 N/A N/A N/A N/A N/A $195.77 N/A N/A $178.50 N/A N/A $118.04 N/A N/A $201.53 N/A N/A $230.32 N/A N/A $158.35 N/A N/A $201.53 N/A N/A $96.45 N/A N/A N/A N/A N/A $172.74 N/A N/A $100.77 N/A N/A $187.14 N/A N/A N/A N/A N/A $172.74 N/A N/A $201.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $287.90 $287.90 N/A 4400261 Pharmacy diclofenac topical 1% Gel [BCH} 250 $103.84 $- $27.00 $- $- $83.07 $- N/A $27.00 N/A N/A $39.25 N/A N/A $62.30 N/A N/A $51.92 N/A N/A N/A N/A N/A $70.61 N/A N/A $64.38 N/A N/A $42.57 N/A N/A $72.69 N/A N/A $83.07 N/A N/A $57.11 N/A N/A $72.69 N/A N/A $34.79 N/A N/A N/A N/A N/A $62.30 N/A N/A $36.34 N/A N/A $67.50 N/A N/A N/A N/A N/A $62.30 N/A N/A $72.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $103.84 $103.84 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400633 Pharmacy hydrALAZINE 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402829 Pharmacy metroNIDAZOLE 500 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403736 Pharmacy hydrALAZINE 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400654 Pharmacy traZODone 50 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4401909 Pharmacy traZODone 100 mg Tab [BCH] 250 $2.78 $- $0.72 $- $- $2.23 $- N/A $0.72 N/A N/A $1.05 N/A N/A $1.67 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.89 N/A N/A $1.73 N/A N/A $1.14 N/A N/A $1.95 N/A N/A $2.23 N/A N/A $1.53 N/A N/A $1.95 N/A N/A $0.93 N/A N/A N/A N/A N/A $1.67 N/A N/A $0.97 N/A N/A $1.81 N/A N/A N/A N/A N/A $1.67 N/A N/A $1.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.78 $2.78 N/A 4403595 Pharmacy oxybutynin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400899 Pharmacy theophylline 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400654 Pharmacy traZODone 50 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab [BCH] 250 $2.29 $- $0.60 $- $- $1.83 $- N/A $0.60 N/A N/A $0.87 N/A N/A $1.37 N/A N/A $1.15 N/A N/A N/A N/A N/A $1.56 N/A N/A $1.42 N/A N/A $0.94 N/A N/A $1.60 N/A N/A $1.83 N/A N/A $1.26 N/A N/A $1.60 N/A N/A $0.77 N/A N/A N/A N/A N/A $1.37 N/A N/A $0.80 N/A N/A $1.49 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.29 $2.29 N/A 4405095 Pharmacy FLUoxetine 10 mg Cap [BCH] 250 $5.20 $- $1.35 $- $- $4.16 $- N/A $1.35 N/A N/A $1.96 N/A N/A $3.12 N/A N/A $2.60 N/A N/A N/A N/A N/A $3.53 N/A N/A $3.22 N/A N/A $2.13 N/A N/A $3.64 N/A N/A $4.16 N/A N/A $2.86 N/A N/A $3.64 N/A N/A $1.74 N/A N/A N/A N/A N/A $3.12 N/A N/A $1.82 N/A N/A $3.38 N/A N/A N/A N/A N/A $3.12 N/A N/A $3.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.20 $5.20 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap 250 $5.34 $- $1.39 $- $- $4.27 $- N/A $1.39 N/A N/A $2.02 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.63 N/A N/A $3.31 N/A N/A $2.19 N/A N/A $3.74 N/A N/A $4.27 N/A N/A $2.93 N/A N/A $3.74 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.47 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.34 $5.34 N/A 4402019 Pharmacy azithromycin 250 mg Tab [BCH] 250 $15.57 $- $4.05 $- $- $12.45 $- N/A $4.05 N/A N/A $5.88 N/A N/A $9.34 N/A N/A $7.78 N/A N/A N/A N/A N/A $10.59 N/A N/A $9.65 N/A N/A $6.38 N/A N/A $10.90 N/A N/A $12.45 N/A N/A $8.56 N/A N/A $10.90 N/A N/A $5.22 N/A N/A N/A N/A N/A $9.34 N/A N/A $5.45 N/A N/A $10.12 N/A N/A N/A N/A N/A $9.34 N/A N/A $10.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.57 $15.57 N/A 4400898 Pharmacy torsemide 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406804 Pharmacy torsemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400391 Pharmacy "ergocalciferol 50,000 intl units Cap [BCH]" 250 $3.37 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.85 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.37 $3.37 N/A 4406253 Pharmacy alteplase 2 mg IV Inj [BCH] J2997 636 $314.02 $- $81.65 $- $- $251.22 $- N/A $81.65 N/A N/A Not Reimbursed N/A N/A $188.41 N/A N/A $157.01 N/A N/A N/A N/A N/A $213.53 N/A N/A $194.69 N/A N/A $128.75 N/A N/A $219.81 N/A N/A $251.22 N/A N/A $172.71 N/A N/A $219.81 N/A N/A $105.20 N/A N/A N/A N/A N/A $188.41 N/A N/A $109.91 N/A N/A $204.11 N/A N/A $87.89 N/A N/A $188.41 N/A N/A $219.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $314.02 $314.02 N/A 4409595 Pharmacy alteplase 100 mg IV Inj [BCH] J2997 636 "$21,120.86 " $- $87.89 $- $- "$16,896.69 " $- N/A "$5,491.42 " N/A N/A Not Reimbursed N/A N/A "$12,672.52 " N/A N/A "$10,560.43 " N/A N/A N/A N/A N/A "$14,362.18 " N/A N/A "$13,094.93 " N/A N/A "$8,659.55 " N/A N/A "$14,784.60 " N/A N/A "$16,896.69 " N/A N/A "$11,616.47 " N/A N/A "$14,784.60 " N/A N/A "$7,075.49 " N/A N/A N/A N/A N/A "$12,672.52 " N/A N/A "$7,392.30 " N/A N/A "$13,728.56 " N/A N/A $87.89 N/A N/A "$12,672.52 " N/A N/A "$14,784.60 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$21,120.86 " "$21,120.86 " N/A 4402387 Pharmacy tenecteplase 50 mg IV Inj [BCH] J3101 636 "$14,925.26 " $- $129.06 $- $- "$11,940.21 " $- N/A "$3,880.57 " N/A N/A Not Reimbursed N/A N/A "$8,955.16 " N/A N/A "$7,462.63 " N/A N/A N/A N/A N/A "$10,149.18 " N/A N/A "$9,253.66 " N/A N/A "$6,119.36 " N/A N/A "$10,447.68 " N/A N/A "$11,940.21 " N/A N/A "$8,208.89 " N/A N/A "$10,447.68 " N/A N/A "$4,999.96 " N/A N/A N/A N/A N/A "$8,955.16 " N/A N/A "$5,223.84 " N/A N/A "$9,701.42 " N/A N/A $129.06 N/A N/A "$8,955.16 " N/A N/A "$10,447.68 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$14,925.26 " "$14,925.26 " N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $59.85 $- $15.56 $- $- $47.88 $- N/A $15.56 N/A N/A $22.62 N/A N/A $35.91 N/A N/A $29.93 N/A N/A N/A N/A N/A $40.70 N/A N/A $37.11 N/A N/A $24.54 N/A N/A $41.90 N/A N/A $47.88 N/A N/A $32.92 N/A N/A $41.90 N/A N/A $20.05 N/A N/A N/A N/A N/A $35.91 N/A N/A $20.95 N/A N/A $38.90 N/A N/A N/A N/A N/A $35.91 N/A N/A $41.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $59.85 $59.85 N/A 4400520 Pharmacy atorvastatin 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab [BCH] 250 $3.03 $- $0.79 $- $- $2.42 $- N/A $0.79 N/A N/A $1.15 N/A N/A $1.82 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.06 N/A N/A $1.88 N/A N/A $1.24 N/A N/A $2.12 N/A N/A $2.42 N/A N/A $1.67 N/A N/A $2.12 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.82 N/A N/A $1.06 N/A N/A $1.97 N/A N/A N/A N/A N/A $1.82 N/A N/A $2.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.03 $3.03 N/A 4402112 Pharmacy bumetanide 1 mg Tab[BCH] 250 $3.00 $- $0.78 $- $- $2.40 $- N/A $0.78 N/A N/A $1.13 N/A N/A $1.80 N/A N/A $1.50 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.86 N/A N/A $1.23 N/A N/A $2.10 N/A N/A $2.40 N/A N/A $1.65 N/A N/A $2.10 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.05 N/A N/A $1.95 N/A N/A N/A N/A N/A $1.80 N/A N/A $2.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.00 $3.00 N/A 4403029 Pharmacy cephalexin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403045 Pharmacy cephalexin 500 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409022 Pharmacy celecoxib 100 mg Cap [BCH] 250 $8.73 $- $2.27 $- $- $6.99 $- N/A $2.27 N/A N/A $3.30 N/A N/A $5.24 N/A N/A $4.37 N/A N/A N/A N/A N/A $5.94 N/A N/A $5.41 N/A N/A $3.58 N/A N/A $6.11 N/A N/A $6.99 N/A N/A $4.80 N/A N/A $6.11 N/A N/A $2.93 N/A N/A N/A N/A N/A $5.24 N/A N/A $3.06 N/A N/A $5.68 N/A N/A N/A N/A N/A $5.24 N/A N/A $6.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.73 $8.73 N/A 4408966 Pharmacy celecoxib 200 mg Cap 250 $4.86 $- $1.26 $- $- $3.89 $- N/A $1.26 N/A N/A $1.84 N/A N/A $2.91 N/A N/A $2.43 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.01 N/A N/A $1.99 N/A N/A $3.40 N/A N/A $3.89 N/A N/A $2.67 N/A N/A $3.40 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.91 N/A N/A $1.70 N/A N/A $3.16 N/A N/A N/A N/A N/A $2.91 N/A N/A $3.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.86 $4.86 N/A 4409385 Pharmacy cilostazol 100 mg Tab 250 $4.50 $- $1.17 $- $- $3.60 $- N/A $1.17 N/A N/A $1.70 N/A N/A $2.70 N/A N/A $2.25 N/A N/A N/A N/A N/A $3.06 N/A N/A $2.79 N/A N/A $1.85 N/A N/A $3.15 N/A N/A $3.60 N/A N/A $2.48 N/A N/A $3.15 N/A N/A $1.51 N/A N/A N/A N/A N/A $2.70 N/A N/A $1.58 N/A N/A $2.93 N/A N/A N/A N/A N/A $2.70 N/A N/A $3.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.50 $4.50 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $11.85 $- $3.08 $- $- $9.48 $- N/A $3.08 N/A N/A $4.48 N/A N/A $7.11 N/A N/A $5.93 N/A N/A N/A N/A N/A $8.06 N/A N/A $7.35 N/A N/A $4.86 N/A N/A $8.30 N/A N/A $9.48 N/A N/A $6.52 N/A N/A $8.30 N/A N/A $3.97 N/A N/A N/A N/A N/A $7.11 N/A N/A $4.15 N/A N/A $7.70 N/A N/A N/A N/A N/A $7.11 N/A N/A $8.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.85 $11.85 N/A 4401253 Pharmacy famotidine 20 mg Tab [BCH] 250 $3.03 $- $0.79 $- $- $2.43 $- N/A $0.79 N/A N/A $1.15 N/A N/A $1.82 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.06 N/A N/A $1.88 N/A N/A $1.24 N/A N/A $2.12 N/A N/A $2.43 N/A N/A $1.67 N/A N/A $2.12 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.82 N/A N/A $1.06 N/A N/A $1.97 N/A N/A N/A N/A N/A $1.82 N/A N/A $2.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.03 $3.03 N/A 4400166 Pharmacy fenofibrate 48 mg Tab 250 $3.81 $- $0.99 $- $- $3.05 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.28 N/A N/A $1.90 N/A N/A N/A N/A N/A $2.59 N/A N/A $2.36 N/A N/A $1.56 N/A N/A $2.67 N/A N/A $3.05 N/A N/A $2.09 N/A N/A $2.67 N/A N/A $1.28 N/A N/A N/A N/A N/A $2.28 N/A N/A $1.33 N/A N/A $2.48 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.81 $3.81 N/A 4404125 Pharmacy fludrocortisone 0.1 mg Tab [BCH] 250 $3.20 $- $0.83 $- $- $2.56 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.98 N/A N/A $1.31 N/A N/A $2.24 N/A N/A $2.56 N/A N/A $1.76 N/A N/A $2.24 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.20 $3.20 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap 250 $4.90 $- $1.27 $- $- $3.92 $- N/A $1.27 N/A N/A $1.85 N/A N/A $2.94 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.33 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.43 N/A N/A $3.92 N/A N/A $2.69 N/A N/A $3.43 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.94 N/A N/A $1.71 N/A N/A $3.18 N/A N/A N/A N/A N/A $2.94 N/A N/A $3.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.90 $4.90 N/A 4400583 Pharmacy fluconazole 100 mg Tab [BCH] 250 $19.06 $- $4.96 $- $- $15.25 $- N/A $4.96 N/A N/A $7.21 N/A N/A $11.44 N/A N/A $9.53 N/A N/A N/A N/A N/A $12.96 N/A N/A $11.82 N/A N/A $7.82 N/A N/A $13.34 N/A N/A $15.25 N/A N/A $10.48 N/A N/A $13.34 N/A N/A $6.39 N/A N/A N/A N/A N/A $11.44 N/A N/A $6.67 N/A N/A $12.39 N/A N/A N/A N/A N/A $11.44 N/A N/A $13.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.06 $19.06 N/A 4404729 Pharmacy folic acid 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402233 Pharmacy gemfibrozil 600 mg Tab [BCH] 250 $2.33 $- $0.60 $- $- $1.86 $- N/A $0.60 N/A N/A $0.88 N/A N/A $1.40 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.58 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.63 N/A N/A $1.86 N/A N/A $1.28 N/A N/A $1.63 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.40 N/A N/A $0.81 N/A N/A $1.51 N/A N/A N/A N/A N/A $1.40 N/A N/A $1.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.33 $2.33 N/A 4408719 Pharmacy glimepiride 2 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405248 Pharmacy indomethacin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400708 Pharmacy isosorbide dinitrate 5 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.70 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.28 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.87 N/A N/A $1.49 N/A N/A $1.70 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.74 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4402688 Pharmacy isosorbide dinitrate 20 mg Tab 250 $2.40 $- $0.62 $- $- $1.92 $- N/A $0.62 N/A N/A $0.91 N/A N/A $1.44 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.63 N/A N/A $1.49 N/A N/A $0.99 N/A N/A $1.68 N/A N/A $1.92 N/A N/A $1.32 N/A N/A $1.68 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.44 N/A N/A $0.84 N/A N/A $1.56 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.40 $2.40 N/A 4400794 Pharmacy losartan 25 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400478 Pharmacy losartan 100 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402787 Pharmacy meclizine 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400351 Pharmacy meloxicam 15 mg Tab 250 $9.33 $- $2.42 $- $- $7.46 $- N/A $2.42 N/A N/A $3.53 N/A N/A $5.60 N/A N/A $4.66 N/A N/A N/A N/A N/A $6.34 N/A N/A $5.78 N/A N/A $3.82 N/A N/A $6.53 N/A N/A $7.46 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.12 N/A N/A N/A N/A N/A $5.60 N/A N/A $3.26 N/A N/A $6.06 N/A N/A N/A N/A N/A $5.60 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.33 $9.33 N/A 4402829 Pharmacy metroNIDAZOLE 500 mg Tab[BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400013 Pharmacy niacin 500 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409393 Pharmacy naproxen 250 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409770 Pharmacy nortriptyline 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401962 Pharmacy QUEtiapine 25 mg Tab [BCH] 250 $7.43 $- $1.93 $- $- $5.94 $- N/A $1.93 N/A N/A $2.81 N/A N/A $4.46 N/A N/A $3.71 N/A N/A N/A N/A N/A $5.05 N/A N/A $4.61 N/A N/A $3.05 N/A N/A $5.20 N/A N/A $5.94 N/A N/A $4.09 N/A N/A $5.20 N/A N/A $2.49 N/A N/A N/A N/A N/A $4.46 N/A N/A $2.60 N/A N/A $4.83 N/A N/A N/A N/A N/A $4.46 N/A N/A $5.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.43 $7.43 N/A 4400433 Pharmacy QUEtiapine 50 mg Tab [BCH] 250 $12.38 $- $3.22 $- $- $9.90 $- N/A $3.22 N/A N/A $4.68 N/A N/A $7.43 N/A N/A $6.19 N/A N/A N/A N/A N/A $8.42 N/A N/A $7.67 N/A N/A $5.07 N/A N/A $8.66 N/A N/A $9.90 N/A N/A $6.81 N/A N/A $8.66 N/A N/A $4.15 N/A N/A N/A N/A N/A $7.43 N/A N/A $4.33 N/A N/A $8.05 N/A N/A N/A N/A N/A $7.43 N/A N/A $8.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.38 $12.38 N/A 4400118 Pharmacy QUEtiapine 100 mg Tab [BCH] 250 $12.92 $- $3.36 $- $- $10.33 $- N/A $3.36 N/A N/A $4.88 N/A N/A $7.75 N/A N/A $6.46 N/A N/A N/A N/A N/A $8.78 N/A N/A $8.01 N/A N/A $5.30 N/A N/A $9.04 N/A N/A $10.33 N/A N/A $7.10 N/A N/A $9.04 N/A N/A $4.33 N/A N/A N/A N/A N/A $7.75 N/A N/A $4.52 N/A N/A $8.40 N/A N/A N/A N/A N/A $7.75 N/A N/A $9.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.92 $12.92 N/A 4400587 Pharmacy QUEtiapine 200 mg Tab [BCH] 250 "$1,217.34 " $- $316.51 $- $- $973.87 $- N/A $316.51 N/A N/A $460.15 N/A N/A $730.40 N/A N/A $608.67 N/A N/A N/A N/A N/A $827.79 N/A N/A $754.75 N/A N/A $499.11 N/A N/A $852.14 N/A N/A $973.87 N/A N/A $669.54 N/A N/A $852.14 N/A N/A $407.81 N/A N/A N/A N/A N/A $730.40 N/A N/A $426.07 N/A N/A $791.27 N/A N/A N/A N/A N/A $730.40 N/A N/A $852.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,217.34 " "$1,217.34 " N/A 4404635 Pharmacy primidone 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400898 Pharmacy torsemide 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406804 Pharmacy torsemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409754 Pharmacy tiZANidine 2 mg Tab [BCH] 250 $3.50 $- $0.91 $- $- $2.80 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.10 N/A N/A $1.75 N/A N/A N/A N/A N/A $2.38 N/A N/A $2.17 N/A N/A $1.44 N/A N/A $2.45 N/A N/A $2.80 N/A N/A $1.93 N/A N/A $2.45 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.10 N/A N/A $1.23 N/A N/A $2.28 N/A N/A N/A N/A N/A $2.10 N/A N/A $2.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.50 $3.50 N/A 4404791 Pharmacy terazosin 5 mg Cap[BCH] 250 $3.21 $- $0.83 $- $- $2.57 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.93 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.77 N/A N/A $2.25 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.93 N/A N/A $1.12 N/A N/A $2.09 N/A N/A N/A N/A N/A $1.93 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.21 $3.21 N/A 4406725 Pharmacy thiamine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400406 Pharmacy pyridoxine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400208 Pharmacy cholecalciferol 400 intl units Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400399 Pharmacy cholecalciferol 2000 intl units Cap 250 $40.52 $- $10.54 $- $- $32.42 $- N/A $10.54 N/A N/A $15.32 N/A N/A $24.31 N/A N/A $20.26 N/A N/A N/A N/A N/A $27.55 N/A N/A $25.12 N/A N/A $16.61 N/A N/A $28.36 N/A N/A $32.42 N/A N/A $22.29 N/A N/A $28.36 N/A N/A $13.57 N/A N/A N/A N/A N/A $24.31 N/A N/A $14.18 N/A N/A $26.34 N/A N/A N/A N/A N/A $24.31 N/A N/A $28.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.52 $40.52 N/A 4405632 Pharmacy prednisoLONE 15 mg/5 mL Syr J7510 250 $231.14 $- $0.12 $- $- $184.91 $- N/A $60.10 N/A N/A Not Reimbursed N/A N/A $138.68 N/A N/A $115.57 N/A N/A N/A N/A N/A $157.18 N/A N/A $143.31 N/A N/A $94.77 N/A N/A $161.80 N/A N/A $184.91 N/A N/A $127.13 N/A N/A $161.80 N/A N/A $77.43 N/A N/A N/A N/A N/A $138.68 N/A N/A $80.90 N/A N/A $150.24 N/A N/A $0.12 N/A N/A $138.68 N/A N/A $161.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $231.14 $231.14 N/A 4405632 Pharmacy prednisoLONE 15 mg/5 mL Syr[BCH] J7510 250 $185.01 $- $0.12 $- $- $148.01 $- N/A $48.10 N/A N/A Not Reimbursed N/A N/A $111.01 N/A N/A $92.51 N/A N/A N/A N/A N/A $125.81 N/A N/A $114.71 N/A N/A $75.85 N/A N/A $129.51 N/A N/A $148.01 N/A N/A $101.76 N/A N/A $129.51 N/A N/A $61.98 N/A N/A N/A N/A N/A $111.01 N/A N/A $64.75 N/A N/A $120.26 N/A N/A $0.12 N/A N/A $111.01 N/A N/A $129.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $185.01 $185.01 N/A 4409567 Pharmacy acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liq 120 mL [BCH 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406168 Pharmacy dorzolamide ophthalmic 2% Sol [BCH] 250 $133.60 $- $34.74 $- $- $106.88 $- N/A $34.74 N/A N/A $50.50 N/A N/A $80.16 N/A N/A $66.80 N/A N/A N/A N/A N/A $90.85 N/A N/A $82.83 N/A N/A $54.78 N/A N/A $93.52 N/A N/A $106.88 N/A N/A $73.48 N/A N/A $93.52 N/A N/A $44.76 N/A N/A N/A N/A N/A $80.16 N/A N/A $46.76 N/A N/A $86.84 N/A N/A N/A N/A N/A $80.16 N/A N/A $93.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $133.60 $133.60 N/A 4409730 Pharmacy ciprofloxacin Ophth 0.3% Sol [BCH] 250 $49.80 $- $12.95 $- $- $39.84 $- N/A $12.95 N/A N/A $18.82 N/A N/A $29.88 N/A N/A $24.90 N/A N/A N/A N/A N/A $33.86 N/A N/A $30.88 N/A N/A $20.42 N/A N/A $34.86 N/A N/A $39.84 N/A N/A $27.39 N/A N/A $34.86 N/A N/A $16.68 N/A N/A N/A N/A N/A $29.88 N/A N/A $17.43 N/A N/A $32.37 N/A N/A N/A N/A N/A $29.88 N/A N/A $34.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.80 $49.80 N/A 4409030 Pharmacy fluticasone nasal 50 mcg/inh Spr [BCH] 250 $168.64 $- $43.85 $- $- $134.91 $- N/A $43.85 N/A N/A $63.75 N/A N/A $101.18 N/A N/A $84.32 N/A N/A N/A N/A N/A $114.68 N/A N/A $104.56 N/A N/A $69.14 N/A N/A $118.05 N/A N/A $134.91 N/A N/A $92.75 N/A N/A $118.05 N/A N/A $56.49 N/A N/A N/A N/A N/A $101.18 N/A N/A $59.02 N/A N/A $109.62 N/A N/A N/A N/A N/A $101.18 N/A N/A $118.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $168.64 $168.64 N/A 4400578 Pharmacy lidocaine Top 2% viscous Sol 100 mL [BCH] 250 $26.40 $- $6.86 $- $- $21.12 $- N/A $6.86 N/A N/A $9.98 N/A N/A $15.84 N/A N/A $13.20 N/A N/A N/A N/A N/A $17.95 N/A N/A $16.37 N/A N/A $10.82 N/A N/A $18.48 N/A N/A $21.12 N/A N/A $14.52 N/A N/A $18.48 N/A N/A $8.84 N/A N/A N/A N/A N/A $15.84 N/A N/A $9.24 N/A N/A $17.16 N/A N/A N/A N/A N/A $15.84 N/A N/A $18.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.40 $26.40 N/A 4408432 Pharmacy lidocaine Top 2% viscous Sol 15 mL [BCH] 250 $2.16 $- $0.56 $- $- $1.73 $- N/A $0.56 N/A N/A $0.82 N/A N/A $1.30 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.34 N/A N/A $0.89 N/A N/A $1.51 N/A N/A $1.73 N/A N/A $1.19 N/A N/A $1.51 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.30 N/A N/A $0.76 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.30 N/A N/A $1.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.16 $2.16 N/A 4400721 Pharmacy lactulose 10 g/15 mL Syr UD [BCH] 250 $5.02 $- $1.31 $- $- $4.02 $- N/A $1.31 N/A N/A $1.90 N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.06 N/A N/A $3.52 N/A N/A $4.02 N/A N/A $2.76 N/A N/A $3.52 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.76 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.02 $5.02 N/A 4400369 Pharmacy lidocaine Top 2% Gel w/Appl [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408408 Pharmacy lidocaine Top 2% Gel w/Appl 30ml [BCH] 250 $33.34 $- $8.67 $- $- $26.67 $- N/A $8.67 N/A N/A $12.60 N/A N/A $20.00 N/A N/A $16.67 N/A N/A N/A N/A N/A $22.67 N/A N/A $20.67 N/A N/A $13.67 N/A N/A $23.34 N/A N/A $26.67 N/A N/A $18.34 N/A N/A $23.34 N/A N/A $11.17 N/A N/A N/A N/A N/A $20.00 N/A N/A $11.67 N/A N/A $21.67 N/A N/A N/A N/A N/A $20.00 N/A N/A $23.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.34 $33.34 N/A 4403850 Pharmacy codeine-promethazine 10 mg-6.25 mg/5 mL Syr [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407814 Pharmacy sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 47 250 $9.88 $- $2.57 $- $- $7.90 $- N/A $2.57 N/A N/A $3.73 N/A N/A $5.93 N/A N/A $4.94 N/A N/A N/A N/A N/A $6.72 N/A N/A $6.12 N/A N/A $4.05 N/A N/A $6.91 N/A N/A $7.90 N/A N/A $5.43 N/A N/A $6.91 N/A N/A $3.31 N/A N/A N/A N/A N/A $5.93 N/A N/A $3.46 N/A N/A $6.42 N/A N/A N/A N/A N/A $5.93 N/A N/A $6.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.88 $9.88 N/A 4400981 Pharmacy buprenorphine 8 mg Tab [BCH] J0571 250 $16.97 $- $4.41 $- $- $13.57 $- N/A $4.41 N/A N/A Not Reimbursed N/A N/A $10.18 N/A N/A $8.48 N/A N/A N/A N/A N/A $11.54 N/A N/A $10.52 N/A N/A $6.96 N/A N/A $11.88 N/A N/A $13.57 N/A N/A $9.33 N/A N/A $11.88 N/A N/A $5.68 N/A N/A N/A N/A N/A $10.18 N/A N/A $5.94 N/A N/A $11.03 N/A N/A N/A N/A N/A $10.18 N/A N/A $11.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.97 $16.97 N/A 4400645 Pharmacy lidocaine Top 5% Oint [BCH] 250 $600.00 $- $156.00 $- $- $480.00 $- N/A $156.00 N/A N/A $226.80 N/A N/A $360.00 N/A N/A $300.00 N/A N/A N/A N/A N/A $408.00 N/A N/A $372.00 N/A N/A $246.00 N/A N/A $420.00 N/A N/A $480.00 N/A N/A $330.00 N/A N/A $420.00 N/A N/A $201.00 N/A N/A N/A N/A N/A $360.00 N/A N/A $210.00 N/A N/A $390.00 N/A N/A N/A N/A N/A $360.00 N/A N/A $420.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $600.00 $600.00 N/A 4400860 Pharmacy paliperidone 3 mg Tab [BCH] 250 $74.72 $- $19.43 $- $- $59.78 $- N/A $19.43 N/A N/A $28.25 N/A N/A $44.83 N/A N/A $37.36 N/A N/A N/A N/A N/A $50.81 N/A N/A $46.33 N/A N/A $30.64 N/A N/A $52.31 N/A N/A $59.78 N/A N/A $41.10 N/A N/A $52.31 N/A N/A $25.03 N/A N/A N/A N/A N/A $44.83 N/A N/A $26.15 N/A N/A $48.57 N/A N/A N/A N/A N/A $44.83 N/A N/A $52.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $74.72 $74.72 N/A 4400920 Pharmacy paliperidone 117 mg/0.75 mL Sus [BCH] J2426 636 "$2,861.74 " $- $12.03 $- $- "$2,289.39 " $- N/A $744.05 N/A N/A Not Reimbursed N/A N/A "$1,717.04 " N/A N/A "$1,430.87 " N/A N/A N/A N/A N/A "$1,945.98 " N/A N/A "$1,774.28 " N/A N/A "$1,173.31 " N/A N/A "$2,003.22 " N/A N/A "$2,289.39 " N/A N/A "$1,573.96 " N/A N/A "$2,003.22 " N/A N/A $958.68 N/A N/A N/A N/A N/A "$1,717.04 " N/A N/A "$1,001.61 " N/A N/A "$1,860.13 " N/A N/A $12.03 N/A N/A "$1,717.04 " N/A N/A "$2,003.22 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,861.74 " "$2,861.74 " N/A 4400918 Pharmacy paliperidone 156 mg/mL Sus [BCH] J2426 636 "$3,815.84 " $- $12.03 $- $- "$3,052.67 " $- N/A $992.12 N/A N/A Not Reimbursed N/A N/A "$2,289.50 " N/A N/A "$1,907.92 " N/A N/A N/A N/A N/A "$2,594.77 " N/A N/A "$2,365.82 " N/A N/A "$1,564.49 " N/A N/A "$2,671.09 " N/A N/A "$3,052.67 " N/A N/A "$2,098.71 " N/A N/A "$2,671.09 " N/A N/A "$1,278.31 " N/A N/A N/A N/A N/A "$2,289.50 " N/A N/A "$1,335.54 " N/A N/A "$2,480.30 " N/A N/A $12.03 N/A N/A "$2,289.50 " N/A N/A "$2,671.09 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$3,815.84 " "$3,815.84 " N/A 4400930 Pharmacy paliperidone 234 mg/1.5 mL Sus [BCH] J2426 636 "$8,585.40 " $- $12.03 $- $- "$6,868.32 " $- N/A "$2,232.20 " N/A N/A Not Reimbursed N/A N/A "$5,151.24 " N/A N/A "$4,292.70 " N/A N/A N/A N/A N/A "$5,838.07 " N/A N/A "$5,322.95 " N/A N/A "$3,520.01 " N/A N/A "$6,009.78 " N/A N/A "$6,868.32 " N/A N/A "$4,721.97 " N/A N/A "$6,009.78 " N/A N/A "$2,876.11 " N/A N/A N/A N/A N/A "$5,151.24 " N/A N/A "$3,004.89 " N/A N/A "$5,580.51 " N/A N/A $12.03 N/A N/A "$5,151.24 " N/A N/A "$6,009.78 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$8,585.40 " "$8,585.40 " N/A 4400531 Pharmacy rivaroxaban 15 mg Tab [BCH] 250 $28.77 $- $7.48 $- $- $23.01 $- N/A $7.48 N/A N/A $10.87 N/A N/A $17.26 N/A N/A $14.38 N/A N/A N/A N/A N/A $19.56 N/A N/A $17.84 N/A N/A $11.80 N/A N/A $20.14 N/A N/A $23.01 N/A N/A $15.82 N/A N/A $20.14 N/A N/A $9.64 N/A N/A N/A N/A N/A $17.26 N/A N/A $10.07 N/A N/A $18.70 N/A N/A N/A N/A N/A $17.26 N/A N/A $20.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.77 $28.77 N/A 4400531 Pharmacy rivaroxaban 15 mg Tab 250 $33.53 $- $8.72 $- $- $26.82 $- N/A $8.72 N/A N/A $12.67 N/A N/A $20.12 N/A N/A $16.76 N/A N/A N/A N/A N/A $22.80 N/A N/A $20.79 N/A N/A $13.75 N/A N/A $23.47 N/A N/A $26.82 N/A N/A $18.44 N/A N/A $23.47 N/A N/A $11.23 N/A N/A N/A N/A N/A $20.12 N/A N/A $11.73 N/A N/A $21.79 N/A N/A N/A N/A N/A $20.12 N/A N/A $23.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.53 $33.53 N/A 4400530 Pharmacy rivaroxaban 10 mg Tab [BCH] 250 $39.40 $- $10.24 $- $- $31.52 $- N/A $10.24 N/A N/A $14.89 N/A N/A $23.64 N/A N/A $19.70 N/A N/A N/A N/A N/A $26.79 N/A N/A $24.43 N/A N/A $16.15 N/A N/A $27.58 N/A N/A $31.52 N/A N/A $21.67 N/A N/A $27.58 N/A N/A $13.20 N/A N/A N/A N/A N/A $23.64 N/A N/A $13.79 N/A N/A $25.61 N/A N/A N/A N/A N/A $23.64 N/A N/A $27.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.40 $39.40 N/A 4400530 Pharmacy rivaroxaban 10 mg Tab [BCH] 250 $28.77 $- $7.48 $- $- $23.01 $- N/A $7.48 N/A N/A $10.87 N/A N/A $17.26 N/A N/A $14.38 N/A N/A N/A N/A N/A $19.56 N/A N/A $17.84 N/A N/A $11.80 N/A N/A $20.14 N/A N/A $23.01 N/A N/A $15.82 N/A N/A $20.14 N/A N/A $9.64 N/A N/A N/A N/A N/A $17.26 N/A N/A $10.07 N/A N/A $18.70 N/A N/A N/A N/A N/A $17.26 N/A N/A $20.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.77 $28.77 N/A 4400309 Pharmacy risperiDONE 0.25 mg Tab [BCH] 250 $2.62 $- $0.68 $- $- $2.09 $- N/A $0.68 N/A N/A $0.99 N/A N/A $1.57 N/A N/A $1.31 N/A N/A N/A N/A N/A $1.78 N/A N/A $1.62 N/A N/A $1.07 N/A N/A $1.83 N/A N/A $2.09 N/A N/A $1.44 N/A N/A $1.83 N/A N/A $0.88 N/A N/A N/A N/A N/A $1.57 N/A N/A $0.92 N/A N/A $1.70 N/A N/A N/A N/A N/A $1.57 N/A N/A $1.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.62 $2.62 N/A 4400293 Pharmacy risperiDONE 0.5 mg Tab [BCH] 250 $2.87 $- $0.75 $- $- $2.30 $- N/A $0.75 N/A N/A $1.09 N/A N/A $1.72 N/A N/A $1.44 N/A N/A N/A N/A N/A $1.95 N/A N/A $1.78 N/A N/A $1.18 N/A N/A $2.01 N/A N/A $2.30 N/A N/A $1.58 N/A N/A $2.01 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.72 N/A N/A $1.00 N/A N/A $1.87 N/A N/A N/A N/A N/A $1.72 N/A N/A $2.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.87 $2.87 N/A 4405798 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $3.05 $- $0.79 $- $- $2.44 $- N/A $0.79 N/A N/A $1.15 N/A N/A $1.83 N/A N/A $1.53 N/A N/A N/A N/A N/A $2.08 N/A N/A $1.89 N/A N/A $1.25 N/A N/A $2.14 N/A N/A $2.44 N/A N/A $1.68 N/A N/A $2.14 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.07 N/A N/A $1.98 N/A N/A N/A N/A N/A $1.83 N/A N/A $2.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.05 $3.05 N/A 4400515 Pharmacy risperiDONE 1 mg/mL Oral Sol [BCH] 250 $292.28 $- $75.99 $- $- $233.82 $- N/A $75.99 N/A N/A $110.48 N/A N/A $175.37 N/A N/A $146.14 N/A N/A N/A N/A N/A $198.75 N/A N/A $181.21 N/A N/A $119.83 N/A N/A $204.60 N/A N/A $233.82 N/A N/A $160.75 N/A N/A $204.60 N/A N/A $97.91 N/A N/A N/A N/A N/A $175.37 N/A N/A $102.30 N/A N/A $189.98 N/A N/A N/A N/A N/A $175.37 N/A N/A $204.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $292.28 $292.28 N/A 4400749 Pharmacy risperiDONE 0.5 mg Dis Tab [BCH] 250 $9.42 $- $2.45 $- $- $7.53 $- N/A $2.45 N/A N/A $3.56 N/A N/A $5.65 N/A N/A $4.71 N/A N/A N/A N/A N/A $6.40 N/A N/A $5.84 N/A N/A $3.86 N/A N/A $6.59 N/A N/A $7.53 N/A N/A $5.18 N/A N/A $6.59 N/A N/A $3.16 N/A N/A N/A N/A N/A $5.65 N/A N/A $3.30 N/A N/A $6.12 N/A N/A N/A N/A N/A $5.65 N/A N/A $6.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.42 $9.42 N/A 4400748 Pharmacy risperiDONE 1 mg Dis Tab [BCH] 250 $11.01 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A $6.82 N/A N/A $4.51 N/A N/A $7.70 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.70 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A N/A N/A N/A $6.60 N/A N/A $7.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.01 $11.01 N/A 4400662 Pharmacy tapentadol 50 mg Tab [BCH] 250 $11.54 $- $3.00 $- $- $9.24 $- N/A $3.00 N/A N/A $4.36 N/A N/A $6.93 N/A N/A $5.77 N/A N/A N/A N/A N/A $7.85 N/A N/A $7.16 N/A N/A $4.73 N/A N/A $8.08 N/A N/A $9.24 N/A N/A $6.35 N/A N/A $8.08 N/A N/A $3.87 N/A N/A N/A N/A N/A $6.93 N/A N/A $4.04 N/A N/A $7.50 N/A N/A N/A N/A N/A $6.93 N/A N/A $8.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.54 $11.54 N/A 4400617 Pharmacy tapentadol ER 50 mg Tab [BCH] 250 $12.43 $- $3.23 $- $- $9.94 $- N/A $3.23 N/A N/A $4.70 N/A N/A $7.46 N/A N/A $6.22 N/A N/A N/A N/A N/A $8.45 N/A N/A $7.71 N/A N/A $5.10 N/A N/A $8.70 N/A N/A $9.94 N/A N/A $6.84 N/A N/A $8.70 N/A N/A $4.16 N/A N/A N/A N/A N/A $7.46 N/A N/A $4.35 N/A N/A $8.08 N/A N/A N/A N/A N/A $7.46 N/A N/A $8.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.43 $12.43 N/A 4402390 Pharmacy collagenase topical 250 units/g Ointment [BCH] 250 $491.52 $- $127.80 $- $- $393.22 $- N/A $127.80 N/A N/A $185.79 N/A N/A $294.91 N/A N/A $245.76 N/A N/A N/A N/A N/A $334.23 N/A N/A $304.74 N/A N/A $201.52 N/A N/A $344.06 N/A N/A $393.22 N/A N/A $270.34 N/A N/A $344.06 N/A N/A $164.66 N/A N/A N/A N/A N/A $294.91 N/A N/A $172.03 N/A N/A $319.49 N/A N/A N/A N/A N/A $294.91 N/A N/A $344.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $491.52 $491.52 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405699 Pharmacy diphenhydrAMINE 12.5 mg/5 mL Liq [BCH] Q0163 636 $8.29 $- $2.15 $- $- $6.63 $- N/A $2.15 N/A N/A Not Reimbursed N/A N/A $4.97 N/A N/A $4.14 N/A N/A N/A N/A N/A $5.64 N/A N/A $5.14 N/A N/A $3.40 N/A N/A $5.80 N/A N/A $6.63 N/A N/A $4.56 N/A N/A $5.80 N/A N/A $2.78 N/A N/A N/A N/A N/A $4.97 N/A N/A $2.90 N/A N/A $5.39 N/A N/A N/A N/A N/A $4.97 N/A N/A $5.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.29 $8.29 N/A 4409620 Pharmacy antivenin (Crotalidae) polyvalent Inj Sol [BCH] J0840 636 "$7,675.20 " $- "$1,995.55 " $- $- "$6,140.16 " $- N/A "$1,995.55 " N/A N/A Not Reimbursed N/A N/A "$4,605.12 " N/A N/A "$3,837.60 " N/A N/A N/A N/A N/A "$5,219.14 " N/A N/A "$4,758.62 " N/A N/A "$3,146.83 " N/A N/A "$5,372.64 " N/A N/A "$6,140.16 " N/A N/A "$4,221.36 " N/A N/A "$5,372.64 " N/A N/A "$2,571.19 " N/A N/A N/A N/A N/A "$4,605.12 " N/A N/A "$2,686.32 " N/A N/A "$4,988.88 " N/A N/A "$3,099.37 " N/A N/A "$4,605.12 " N/A N/A "$5,372.64 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$7,675.20 " "$7,675.20 " N/A 4409810 Pharmacy digoxin immune FAB 40 mg Inj [BCH] J1162 636 "$7,548.00 " $- "$1,962.48 " $- $- "$6,038.40 " $- N/A "$1,962.48 " N/A N/A Not Reimbursed N/A N/A "$4,528.80 " N/A N/A "$3,774.00 " N/A N/A N/A N/A N/A "$5,132.64 " N/A N/A "$4,679.76 " N/A N/A "$3,094.68 " N/A N/A "$5,283.60 " N/A N/A "$6,038.40 " N/A N/A "$4,151.40 " N/A N/A "$5,283.60 " N/A N/A "$2,528.58 " N/A N/A N/A N/A N/A "$4,528.80 " N/A N/A "$2,641.80 " N/A N/A "$4,906.20 " N/A N/A "$3,965.21 " N/A N/A "$4,528.80 " N/A N/A "$5,283.60 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$7,548.00 " "$7,548.00 " N/A 4400707 Pharmacy metoprolol succinate 25 mg Tab-24 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400789 Pharmacy lamiVUDine 150 mg Tab 250 $14.31 $- $3.72 $- $- $11.45 $- N/A $3.72 N/A N/A $5.41 N/A N/A $8.58 N/A N/A $7.15 N/A N/A N/A N/A N/A $9.73 N/A N/A $8.87 N/A N/A $5.87 N/A N/A $10.01 N/A N/A $11.45 N/A N/A $7.87 N/A N/A $10.01 N/A N/A $4.79 N/A N/A N/A N/A N/A $8.58 N/A N/A $5.01 N/A N/A $9.30 N/A N/A N/A N/A N/A $8.58 N/A N/A $10.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.31 $14.31 N/A 4403110 Pharmacy furosemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403736 Pharmacy hydrALAZINE 10 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400607 Pharmacy hydrOXYzine pamoate 25 mg Cap Q0177 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401338 Pharmacy spironolactone 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409603 Pharmacy amitriptyline 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405370 Pharmacy amitriptyline 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400707 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.34 $- $0.61 $- $- $1.87 $- N/A $0.61 N/A N/A $0.88 N/A N/A $1.40 N/A N/A $1.17 N/A N/A N/A N/A N/A $1.59 N/A N/A $1.45 N/A N/A $0.96 N/A N/A $1.64 N/A N/A $1.87 N/A N/A $1.29 N/A N/A $1.64 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.40 N/A N/A $0.82 N/A N/A $1.52 N/A N/A N/A N/A N/A $1.40 N/A N/A $1.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.34 $2.34 N/A 4400744 Pharmacy lithium 300 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405248 Pharmacy indomethacin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400698 Pharmacy fenofibric acid 135 mg Cap [BCH] 250 $10.67 $- $2.77 $- $- $8.54 $- N/A $2.77 N/A N/A $4.03 N/A N/A $6.40 N/A N/A $5.34 N/A N/A N/A N/A N/A $7.26 N/A N/A $6.62 N/A N/A $4.37 N/A N/A $7.47 N/A N/A $8.54 N/A N/A $5.87 N/A N/A $7.47 N/A N/A $3.57 N/A N/A N/A N/A N/A $6.40 N/A N/A $3.73 N/A N/A $6.94 N/A N/A N/A N/A N/A $6.40 N/A N/A $7.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.67 $10.67 N/A 4400054 Pharmacy metoprolol 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404387 Pharmacy propranolol 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408101 Pharmacy diazePAM 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400725 Pharmacy ziprasidone 60 mg Cap [BCH] 250 $21.75 $- $5.66 $- $- $17.40 $- N/A $5.66 N/A N/A $8.22 N/A N/A $13.05 N/A N/A $10.88 N/A N/A N/A N/A N/A $14.79 N/A N/A $13.49 N/A N/A $8.92 N/A N/A $15.23 N/A N/A $17.40 N/A N/A $11.97 N/A N/A $15.23 N/A N/A $7.29 N/A N/A N/A N/A N/A $13.05 N/A N/A $7.61 N/A N/A $14.14 N/A N/A N/A N/A N/A $13.05 N/A N/A $15.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.75 $21.75 N/A 4400657 Pharmacy doxepin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401945 Pharmacy levothyroxine 100 mcg (0.1 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405343 Pharmacy levothyroxine 150 mcg (0.15 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400492 Pharmacy midodrine 5 mg Tab [BCH] 250 $5.42 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.25 N/A N/A $2.71 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.36 N/A N/A $2.22 N/A N/A $3.79 N/A N/A $4.34 N/A N/A $2.98 N/A N/A $3.79 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.25 N/A N/A $1.90 N/A N/A $3.52 N/A N/A N/A N/A N/A $3.25 N/A N/A $3.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.42 $5.42 N/A 4400691 Pharmacy fluPHENAZine 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab 250 $8.32 $- $2.16 $- $- $6.66 $- N/A $2.16 N/A N/A $3.14 N/A N/A $4.99 N/A N/A $4.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $5.16 N/A N/A $3.41 N/A N/A $5.82 N/A N/A $6.66 N/A N/A $4.58 N/A N/A $5.82 N/A N/A $2.79 N/A N/A N/A N/A N/A $4.99 N/A N/A $2.91 N/A N/A $5.41 N/A N/A N/A N/A N/A $4.99 N/A N/A $5.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.32 $8.32 N/A 4400728 Pharmacy azaTHIOprine 50 mg Tab [BCH] J7500 636 $4.69 $- $0.68 $- $- $3.75 $- N/A $1.22 N/A N/A Not Reimbursed N/A N/A $2.81 N/A N/A $2.35 N/A N/A N/A N/A N/A $3.19 N/A N/A $2.91 N/A N/A $1.92 N/A N/A $3.28 N/A N/A $3.75 N/A N/A $2.58 N/A N/A $3.28 N/A N/A $1.57 N/A N/A N/A N/A N/A $2.81 N/A N/A $1.64 N/A N/A $3.05 N/A N/A $0.68 N/A N/A $2.81 N/A N/A $3.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.69 $4.69 N/A 4403797 Pharmacy prazosin 1 mg Cap[BCH] 250 $3.62 $- $0.94 $- $- $2.90 $- N/A $0.94 N/A N/A $1.37 N/A N/A $2.17 N/A N/A $1.81 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.25 N/A N/A $1.49 N/A N/A $2.54 N/A N/A $2.90 N/A N/A $1.99 N/A N/A $2.54 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.27 N/A N/A $2.36 N/A N/A N/A N/A N/A $2.17 N/A N/A $2.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.62 $3.62 N/A 4401910 Pharmacy methotrexate 2.5 mg Tab [BCH] J8610 636 $12.47 $- $0.22 $- $- $9.98 $- N/A $3.24 N/A N/A Not Reimbursed N/A N/A $7.48 N/A N/A $6.24 N/A N/A N/A N/A N/A $8.48 N/A N/A $7.73 N/A N/A $5.11 N/A N/A $8.73 N/A N/A $9.98 N/A N/A $6.86 N/A N/A $8.73 N/A N/A $4.18 N/A N/A N/A N/A N/A $7.48 N/A N/A $4.37 N/A N/A $8.11 N/A N/A $0.22 N/A N/A $7.48 N/A N/A $8.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.47 $12.47 N/A 4406543 Pharmacy atenolol 50 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400717 Pharmacy topiramate 100 mg Tab [BCH] 250 $13.93 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.36 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.75 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.75 N/A N/A $4.67 N/A N/A N/A N/A N/A $8.36 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.36 N/A N/A $9.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.93 $13.93 N/A 4402939 Pharmacy haloperidol 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404936 Pharmacy haloperidol 5 mg Tab 250 $2.18 $- $0.57 $- $- $1.75 $- N/A $0.57 N/A N/A $0.83 N/A N/A $1.31 N/A N/A $1.09 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.35 N/A N/A $0.90 N/A N/A $1.53 N/A N/A $1.75 N/A N/A $1.20 N/A N/A $1.53 N/A N/A $0.73 N/A N/A N/A N/A N/A $1.31 N/A N/A $0.76 N/A N/A $1.42 N/A N/A N/A N/A N/A $1.31 N/A N/A $1.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.18 $2.18 N/A 4400074 Pharmacy diltiazem 90 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402252 Pharmacy sucralfate 1 g Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408792 Pharmacy carvedilol 3.125 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400305 Pharmacy hydroCHLOROthiazide 12.5 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab [BCH] 250 $7.03 $- $1.83 $- $- $5.62 $- N/A $1.83 N/A N/A $2.66 N/A N/A $4.22 N/A N/A $3.51 N/A N/A N/A N/A N/A $4.78 N/A N/A $4.36 N/A N/A $2.88 N/A N/A $4.92 N/A N/A $5.62 N/A N/A $3.87 N/A N/A $4.92 N/A N/A $2.35 N/A N/A N/A N/A N/A $4.22 N/A N/A $2.46 N/A N/A $4.57 N/A N/A N/A N/A N/A $4.22 N/A N/A $4.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.03 $7.03 N/A 4409537 Pharmacy galantamine 4 mg Tab [BCH] 250 $8.44 $- $2.20 $- $- $6.76 $- N/A $2.20 N/A N/A $3.19 N/A N/A $5.07 N/A N/A $4.22 N/A N/A N/A N/A N/A $5.74 N/A N/A $5.24 N/A N/A $3.46 N/A N/A $5.91 N/A N/A $6.76 N/A N/A $4.64 N/A N/A $5.91 N/A N/A $2.83 N/A N/A N/A N/A N/A $5.07 N/A N/A $2.96 N/A N/A $5.49 N/A N/A N/A N/A N/A $5.07 N/A N/A $5.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.44 $8.44 N/A 4409881 Pharmacy metoclopramide 5 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400737 Pharmacy bumetanide 0.5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400977 Pharmacy cloZAPine 100 mg Tab 250 $6.86 $- $1.78 $- $- $5.48 $- N/A $1.78 N/A N/A $2.59 N/A N/A $4.11 N/A N/A $3.43 N/A N/A N/A N/A N/A $4.66 N/A N/A $4.25 N/A N/A $2.81 N/A N/A $4.80 N/A N/A $5.48 N/A N/A $3.77 N/A N/A $4.80 N/A N/A $2.30 N/A N/A N/A N/A N/A $4.11 N/A N/A $2.40 N/A N/A $4.46 N/A N/A N/A N/A N/A $4.11 N/A N/A $4.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.86 $6.86 N/A 4409815 Pharmacy hydrochlorothiazide-triamterene 25 mg-37.5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401253 Pharmacy famotidine 20 mg Tab 250 $3.48 $- $0.90 $- $- $2.78 $- N/A $0.90 N/A N/A $1.31 N/A N/A $2.09 N/A N/A $1.74 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.43 N/A N/A $2.78 N/A N/A $1.91 N/A N/A $2.43 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.26 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.48 $3.48 N/A 4400065 Pharmacy carbidopa-levodopa 25 mg-100[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409455 Pharmacy busPIRone 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407566 Pharmacy phentolamine 5 mg Pow [BCH] J2760 636 "$1,007.52 " $- $261.96 $- $- $806.02 $- N/A $261.96 N/A N/A Not Reimbursed N/A N/A $604.51 N/A N/A $503.76 N/A N/A N/A N/A N/A $685.11 N/A N/A $624.66 N/A N/A $413.08 N/A N/A $705.26 N/A N/A $806.02 N/A N/A $554.14 N/A N/A $705.26 N/A N/A $337.52 N/A N/A N/A N/A N/A $604.51 N/A N/A $352.63 N/A N/A $654.89 N/A N/A $374.74 N/A N/A $604.51 N/A N/A $705.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,007.52 " "$1,007.52 " N/A 4400532 Pharmacy solifenacin 5 mg Tab [BCH] 250 $23.10 $- $6.01 $- $- $18.48 $- N/A $6.01 N/A N/A $8.73 N/A N/A $13.86 N/A N/A $11.55 N/A N/A N/A N/A N/A $15.71 N/A N/A $14.32 N/A N/A $9.47 N/A N/A $16.17 N/A N/A $18.48 N/A N/A $12.71 N/A N/A $16.17 N/A N/A $7.74 N/A N/A N/A N/A N/A $13.86 N/A N/A $8.09 N/A N/A $15.02 N/A N/A N/A N/A N/A $13.86 N/A N/A $16.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.10 $23.10 N/A Pharmacy methIMAzole 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400759 Pharmacy methIMAzole 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400827 Pharmacy nystatin-triamcinolone topical 100000 units/g-0.1% Cre 15gm [BCH] 250 $223.88 $- $58.21 $- $- $179.10 $- N/A $58.21 N/A N/A $84.63 N/A N/A $134.33 N/A N/A $111.94 N/A N/A N/A N/A N/A $152.24 N/A N/A $138.81 N/A N/A $91.79 N/A N/A $156.72 N/A N/A $179.10 N/A N/A $123.13 N/A N/A $156.72 N/A N/A $75.00 N/A N/A N/A N/A N/A $134.33 N/A N/A $78.36 N/A N/A $145.52 N/A N/A N/A N/A N/A $134.33 N/A N/A $156.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $223.88 $223.88 N/A 4401904 Pharmacy nystatin-triamcinolone Top Oint [BCH] 250 $223.88 $- $58.21 $- $- $179.10 $- N/A $58.21 N/A N/A $84.63 N/A N/A $134.33 N/A N/A $111.94 N/A N/A N/A N/A N/A $152.24 N/A N/A $138.81 N/A N/A $91.79 N/A N/A $156.72 N/A N/A $179.10 N/A N/A $123.13 N/A N/A $156.72 N/A N/A $75.00 N/A N/A N/A N/A N/A $134.33 N/A N/A $78.36 N/A N/A $145.52 N/A N/A N/A N/A N/A $134.33 N/A N/A $156.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $223.88 $223.88 N/A 4407760 Pharmacy "nystatin Top 100,000 units/g Crm [BCH]" 250 $35.10 $- $9.13 $- $- $28.08 $- N/A $9.13 N/A N/A $13.27 N/A N/A $21.06 N/A N/A $17.55 N/A N/A N/A N/A N/A $23.87 N/A N/A $21.76 N/A N/A $14.39 N/A N/A $24.57 N/A N/A $28.08 N/A N/A $19.31 N/A N/A $24.57 N/A N/A $11.76 N/A N/A N/A N/A N/A $21.06 N/A N/A $12.29 N/A N/A $22.82 N/A N/A N/A N/A N/A $21.06 N/A N/A $24.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.10 $35.10 N/A 4402404 Pharmacy mupirocin Top 2% Oint [BCH] 250 $219.24 $- $57.00 $- $- $175.39 $- N/A $57.00 N/A N/A $82.87 N/A N/A $131.54 N/A N/A $109.62 N/A N/A N/A N/A N/A $149.08 N/A N/A $135.93 N/A N/A $89.89 N/A N/A $153.47 N/A N/A $175.39 N/A N/A $120.58 N/A N/A $153.47 N/A N/A $73.44 N/A N/A N/A N/A N/A $131.54 N/A N/A $76.73 N/A N/A $142.51 N/A N/A N/A N/A N/A $131.54 N/A N/A $153.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $219.24 $219.24 N/A 4401283 Pharmacy clotrimazole topical 1% Cre [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4401367 Pharmacy acetaminophen 325 mg Sup 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400430 Pharmacy bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin [BCH] 250 $23.03 $- $5.99 $- $- $18.42 $- N/A $5.99 N/A N/A $8.70 N/A N/A $13.82 N/A N/A $11.51 N/A N/A N/A N/A N/A $15.66 N/A N/A $14.28 N/A N/A $9.44 N/A N/A $16.12 N/A N/A $18.42 N/A N/A $12.67 N/A N/A $16.12 N/A N/A $7.71 N/A N/A N/A N/A N/A $13.82 N/A N/A $8.06 N/A N/A $14.97 N/A N/A N/A N/A N/A $13.82 N/A N/A $16.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.03 $23.03 N/A 4409770 Pharmacy nortriptyline 25 mg Cap 250 $2.93 $- $0.76 $- $- $2.35 $- N/A $0.76 N/A N/A $1.11 N/A N/A $1.76 N/A N/A $1.47 N/A N/A N/A N/A N/A $1.99 N/A N/A $1.82 N/A N/A $1.20 N/A N/A $2.05 N/A N/A $2.35 N/A N/A $1.61 N/A N/A $2.05 N/A N/A $0.98 N/A N/A N/A N/A N/A $1.76 N/A N/A $1.03 N/A N/A $1.91 N/A N/A N/A N/A N/A $1.76 N/A N/A $2.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.93 $2.93 N/A 4409770 Pharmacy nortriptyline 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400312 Pharmacy etodolac 300 mg Cap [BCH] 250 $3.23 $- $0.84 $- $- $2.59 $- N/A $0.84 N/A N/A $1.22 N/A N/A $1.94 N/A N/A $1.62 N/A N/A N/A N/A N/A $2.20 N/A N/A $2.00 N/A N/A $1.33 N/A N/A $2.26 N/A N/A $2.59 N/A N/A $1.78 N/A N/A $2.26 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.94 N/A N/A $1.13 N/A N/A $2.10 N/A N/A N/A N/A N/A $1.94 N/A N/A $2.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.23 $3.23 N/A 4400603 Pharmacy acetaZOLAMIDE 250 mg Tab [BCH] 250 $5.77 $- $1.50 $- $- $4.61 $- N/A $1.50 N/A N/A $2.18 N/A N/A $3.46 N/A N/A $2.88 N/A N/A N/A N/A N/A $3.92 N/A N/A $3.58 N/A N/A $2.36 N/A N/A $4.04 N/A N/A $4.61 N/A N/A $3.17 N/A N/A $4.04 N/A N/A $1.93 N/A N/A N/A N/A N/A $3.46 N/A N/A $2.02 N/A N/A $3.75 N/A N/A N/A N/A N/A $3.46 N/A N/A $4.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.77 $5.77 N/A 4404480 Pharmacy amiodarone 200 mg Tab [BCH] 250 $6.61 $- $1.72 $- $- $5.28 $- N/A $1.72 N/A N/A $2.50 N/A N/A $3.96 N/A N/A $3.30 N/A N/A N/A N/A N/A $4.49 N/A N/A $4.10 N/A N/A $2.71 N/A N/A $4.62 N/A N/A $5.28 N/A N/A $3.63 N/A N/A $4.62 N/A N/A $2.21 N/A N/A N/A N/A N/A $3.96 N/A N/A $2.31 N/A N/A $4.29 N/A N/A N/A N/A N/A $3.96 N/A N/A $4.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.61 $6.61 N/A 4400675 Pharmacy warfarin 4 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405277 Pharmacy carBAMazepine 100 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400368 Pharmacy betamethasone-clotrimazole Top 0.05%-1% Crm [BCH] 250 $61.44 $- $15.97 $- $- $49.15 $- N/A $15.97 N/A N/A $23.22 N/A N/A $36.86 N/A N/A $30.72 N/A N/A N/A N/A N/A $41.78 N/A N/A $38.09 N/A N/A $25.19 N/A N/A $43.01 N/A N/A $49.15 N/A N/A $33.79 N/A N/A $43.01 N/A N/A $20.58 N/A N/A N/A N/A N/A $36.86 N/A N/A $21.50 N/A N/A $39.94 N/A N/A N/A N/A N/A $36.86 N/A N/A $43.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $61.44 $61.44 N/A 4405965 Pharmacy phenytoin 100 mg ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab 250 $9.00 $- $2.34 $- $- $7.20 $- N/A $2.34 N/A N/A $3.40 N/A N/A $5.40 N/A N/A $4.50 N/A N/A N/A N/A N/A $6.12 N/A N/A $5.58 N/A N/A $3.69 N/A N/A $6.30 N/A N/A $7.20 N/A N/A $4.95 N/A N/A $6.30 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.40 N/A N/A $3.15 N/A N/A $5.85 N/A N/A N/A N/A N/A $5.40 N/A N/A $6.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.00 $9.00 N/A 4409995 Pharmacy glycopyrrolate 0.2 mg/mL preservative-free Sol J7642 250 $- $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400619 Pharmacy pramoxine topical 1% Foa[BCH] 250 $104.86 $- $27.26 $- $- $83.89 $- N/A $27.26 N/A N/A $39.64 N/A N/A $62.92 N/A N/A $52.43 N/A N/A N/A N/A N/A $71.30 N/A N/A $65.01 N/A N/A $42.99 N/A N/A $73.40 N/A N/A $83.89 N/A N/A $57.67 N/A N/A $73.40 N/A N/A $35.13 N/A N/A N/A N/A N/A $62.92 N/A N/A $36.70 N/A N/A $68.16 N/A N/A N/A N/A N/A $62.92 N/A N/A $73.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $104.86 $104.86 N/A 4403722 Pharmacy methylergonovine 0.2 mg/mL Sol [BCH} J2210 636 $33.73 $- $8.77 $- $- $26.98 $- N/A $8.77 N/A N/A Not Reimbursed N/A N/A $20.24 N/A N/A $16.86 N/A N/A N/A N/A N/A $22.93 N/A N/A $20.91 N/A N/A $13.83 N/A N/A $23.61 N/A N/A $26.98 N/A N/A $18.55 N/A N/A $23.61 N/A N/A $11.30 N/A N/A N/A N/A N/A $20.24 N/A N/A $11.80 N/A N/A $21.92 N/A N/A $19.41 N/A N/A $20.24 N/A N/A $23.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.73 $33.73 N/A 4400309 Pharmacy risperiDONE 0.25 mg Tab [BCH] 250 $7.80 $- $2.03 $- $- $6.24 $- N/A $2.03 N/A N/A $2.95 N/A N/A $4.68 N/A N/A $3.90 N/A N/A N/A N/A N/A $5.31 N/A N/A $4.84 N/A N/A $3.20 N/A N/A $5.46 N/A N/A $6.24 N/A N/A $4.29 N/A N/A $5.46 N/A N/A $2.61 N/A N/A N/A N/A N/A $4.68 N/A N/A $2.73 N/A N/A $5.07 N/A N/A N/A N/A N/A $4.68 N/A N/A $5.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.80 $7.80 N/A 4400293 Pharmacy risperiDONE 0.5 mg Tab [BCH] 250 $8.56 $- $2.23 $- $- $6.85 $- N/A $2.23 N/A N/A $3.24 N/A N/A $5.14 N/A N/A $4.28 N/A N/A N/A N/A N/A $5.82 N/A N/A $5.31 N/A N/A $3.51 N/A N/A $5.99 N/A N/A $6.85 N/A N/A $4.71 N/A N/A $5.99 N/A N/A $2.87 N/A N/A N/A N/A N/A $5.14 N/A N/A $3.00 N/A N/A $5.57 N/A N/A N/A N/A N/A $5.14 N/A N/A $5.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.56 $8.56 N/A 4405798 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $9.10 $- $2.37 $- $- $7.28 $- N/A $2.37 N/A N/A $3.44 N/A N/A $5.46 N/A N/A $4.55 N/A N/A N/A N/A N/A $6.19 N/A N/A $5.64 N/A N/A $3.73 N/A N/A $6.37 N/A N/A $7.28 N/A N/A $5.01 N/A N/A $6.37 N/A N/A $3.05 N/A N/A N/A N/A N/A $5.46 N/A N/A $3.19 N/A N/A $5.92 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.10 $9.10 N/A 4400316 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $15.21 $- $3.96 $- $- $12.17 $- N/A $3.96 N/A N/A $5.75 N/A N/A $9.13 N/A N/A $7.61 N/A N/A N/A N/A N/A $10.35 N/A N/A $9.43 N/A N/A $6.24 N/A N/A $10.65 N/A N/A $12.17 N/A N/A $8.37 N/A N/A $10.65 N/A N/A $5.10 N/A N/A N/A N/A N/A $9.13 N/A N/A $5.32 N/A N/A $9.89 N/A N/A N/A N/A N/A $9.13 N/A N/A $10.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.21 $15.21 N/A 4409645 Pharmacy Vitamin B Complex with Folic Acid Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400704 Pharmacy terbinafine 250 mg Tab [BCH] 250 $26.15 $- $6.80 $- $- $20.92 $- N/A $6.80 N/A N/A $9.88 N/A N/A $15.69 N/A N/A $13.08 N/A N/A N/A N/A N/A $17.78 N/A N/A $16.21 N/A N/A $10.72 N/A N/A $18.31 N/A N/A $20.92 N/A N/A $14.38 N/A N/A $18.31 N/A N/A $8.76 N/A N/A N/A N/A N/A $15.69 N/A N/A $9.15 N/A N/A $17.00 N/A N/A N/A N/A N/A $15.69 N/A N/A $18.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.15 $26.15 N/A 4400704 Pharmacy terbinafine 250 mg Tab [BCH] 250 $26.15 $- $6.80 $- $- $20.92 $- N/A $6.80 N/A N/A $9.88 N/A N/A $15.69 N/A N/A $13.08 N/A N/A N/A N/A N/A $17.78 N/A N/A $16.21 N/A N/A $10.72 N/A N/A $18.31 N/A N/A $20.92 N/A N/A $14.38 N/A N/A $18.31 N/A N/A $8.76 N/A N/A N/A N/A N/A $15.69 N/A N/A $9.15 N/A N/A $17.00 N/A N/A N/A N/A N/A $15.69 N/A N/A $18.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.15 $26.15 N/A 4409418 Pharmacy rivastigmine 1.5 mg Cap [BCH] 250 $9.32 $- $2.42 $- $- $7.46 $- N/A $2.42 N/A N/A $3.52 N/A N/A $5.59 N/A N/A $4.66 N/A N/A N/A N/A N/A $6.34 N/A N/A $5.78 N/A N/A $3.82 N/A N/A $6.53 N/A N/A $7.46 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.12 N/A N/A N/A N/A N/A $5.59 N/A N/A $3.26 N/A N/A $6.06 N/A N/A N/A N/A N/A $5.59 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.32 $9.32 N/A 4400951 Pharmacy fidaxomicin 200 mg Tab [BCH] 250 $441.79 $- $114.87 $- $- $353.43 $- N/A $114.87 N/A N/A $167.00 N/A N/A $265.08 N/A N/A $220.90 N/A N/A N/A N/A N/A $300.42 N/A N/A $273.91 N/A N/A $181.13 N/A N/A $309.25 N/A N/A $353.43 N/A N/A $242.99 N/A N/A $309.25 N/A N/A $148.00 N/A N/A N/A N/A N/A $265.08 N/A N/A $154.63 N/A N/A $287.16 N/A N/A N/A N/A N/A $265.08 N/A N/A $309.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $441.79 $441.79 N/A 4400945 Pharmacy theophylline 100 mg/24 hours Cap [BCH] 250 $3.97 $- $1.03 $- $- $3.18 $- N/A $1.03 N/A N/A $1.50 N/A N/A $2.38 N/A N/A $1.99 N/A N/A N/A N/A N/A $2.70 N/A N/A $2.46 N/A N/A $1.63 N/A N/A $2.78 N/A N/A $3.18 N/A N/A $2.18 N/A N/A $2.78 N/A N/A $1.33 N/A N/A N/A N/A N/A $2.38 N/A N/A $1.39 N/A N/A $2.58 N/A N/A N/A N/A N/A $2.38 N/A N/A $2.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.97 $3.97 N/A 4400203 Pharmacy polyethylene glycol 3350 with electrolytes Oral Pwdr for Sol 4000 mL [BCH] 250 $46.40 $- $12.06 $- $- $37.12 $- N/A $12.06 N/A N/A $17.54 N/A N/A $27.84 N/A N/A $23.20 N/A N/A N/A N/A N/A $31.55 N/A N/A $28.77 N/A N/A $19.02 N/A N/A $32.48 N/A N/A $37.12 N/A N/A $25.52 N/A N/A $32.48 N/A N/A $15.54 N/A N/A N/A N/A N/A $27.84 N/A N/A $16.24 N/A N/A $30.16 N/A N/A N/A N/A N/A $27.84 N/A N/A $32.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $46.40 $46.40 N/A 4400235 Pharmacy hydrogen peroxide topical 3% Sol [BCH] 250 $6.68 $- $1.74 $- $- $5.35 $- N/A $1.74 N/A N/A $2.53 N/A N/A $4.01 N/A N/A $3.34 N/A N/A N/A N/A N/A $4.54 N/A N/A $4.14 N/A N/A $2.74 N/A N/A $4.68 N/A N/A $5.35 N/A N/A $3.67 N/A N/A $4.68 N/A N/A $2.24 N/A N/A N/A N/A N/A $4.01 N/A N/A $2.34 N/A N/A $4.34 N/A N/A N/A N/A N/A $4.01 N/A N/A $4.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.68 $6.68 N/A 4402456 Pharmacy erythromycin 250 mg Tab [BCH] 250 $24.93 $- $6.48 $- $- $19.94 $- N/A $6.48 N/A N/A $9.42 N/A N/A $14.96 N/A N/A $12.46 N/A N/A N/A N/A N/A $16.95 N/A N/A $15.45 N/A N/A $10.22 N/A N/A $17.45 N/A N/A $19.94 N/A N/A $13.71 N/A N/A $17.45 N/A N/A $8.35 N/A N/A N/A N/A N/A $14.96 N/A N/A $8.72 N/A N/A $16.20 N/A N/A N/A N/A N/A $14.96 N/A N/A $17.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.93 $24.93 N/A 4405172 Pharmacy iron dextran 50 mg/mL Inj Sol [BCH] J1750 636 $57.73 $- $15.01 $- $- $46.19 $- N/A $15.01 N/A N/A Not Reimbursed N/A N/A $34.64 N/A N/A $28.87 N/A N/A N/A N/A N/A $39.26 N/A N/A $35.79 N/A N/A $23.67 N/A N/A $40.41 N/A N/A $46.19 N/A N/A $31.75 N/A N/A $40.41 N/A N/A $19.34 N/A N/A N/A N/A N/A $34.64 N/A N/A $20.21 N/A N/A $37.53 N/A N/A $15.02 N/A N/A $34.64 N/A N/A $40.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $57.73 $57.73 N/A 4405172 Pharmacy iron dextran 50 mg/mL Inj Sol [BCH] J1750 636 $90.00 $- $15.02 $- $- $72.00 $- N/A $23.40 N/A N/A Not Reimbursed N/A N/A $54.00 N/A N/A $45.00 N/A N/A N/A N/A N/A $61.20 N/A N/A $55.80 N/A N/A $36.90 N/A N/A $63.00 N/A N/A $72.00 N/A N/A $49.50 N/A N/A $63.00 N/A N/A $30.15 N/A N/A N/A N/A N/A $54.00 N/A N/A $31.50 N/A N/A $58.50 N/A N/A $15.02 N/A N/A $54.00 N/A N/A $63.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $90.00 $90.00 N/A 4401626 Pharmacy gentamicin topical 0.1% Oin [BCH] 250 $98.76 $- $25.68 $- $- $79.01 $- N/A $25.68 N/A N/A $37.33 N/A N/A $59.26 N/A N/A $49.38 N/A N/A N/A N/A N/A $67.16 N/A N/A $61.23 N/A N/A $40.49 N/A N/A $69.13 N/A N/A $79.01 N/A N/A $54.32 N/A N/A $69.13 N/A N/A $33.08 N/A N/A N/A N/A N/A $59.26 N/A N/A $34.57 N/A N/A $64.19 N/A N/A N/A N/A N/A $59.26 N/A N/A $69.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $98.76 $98.76 N/A 4402880 Pharmacy glyBURIDE 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407927 Pharmacy cyproheptadine 4 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.71 $- N/A $0.55 N/A N/A $0.81 N/A N/A $1.28 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.88 N/A N/A $1.49 N/A N/A $1.71 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4400050 Pharmacy vitamin A & D topical - Ointment 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407541 Pharmacy quiNIDine 324 mg ER Tab [BCH] 250 $18.13 $- $4.71 $- $- $14.50 $- N/A $4.71 N/A N/A $6.85 N/A N/A $10.88 N/A N/A $9.06 N/A N/A N/A N/A N/A $12.33 N/A N/A $11.24 N/A N/A $7.43 N/A N/A $12.69 N/A N/A $14.50 N/A N/A $9.97 N/A N/A $12.69 N/A N/A $6.07 N/A N/A N/A N/A N/A $10.88 N/A N/A $6.34 N/A N/A $11.78 N/A N/A N/A N/A N/A $10.88 N/A N/A $12.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.13 $18.13 N/A 4401338 Pharmacy spironolactone 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403292 Pharmacy minoxidil 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400060 Pharmacy temazepam 7.5 mg Cap [BCH] 250 $19.88 $- $5.17 $- $- $15.90 $- N/A $5.17 N/A N/A $7.51 N/A N/A $11.93 N/A N/A $9.94 N/A N/A N/A N/A N/A $13.52 N/A N/A $12.33 N/A N/A $8.15 N/A N/A $13.92 N/A N/A $15.90 N/A N/A $10.93 N/A N/A $13.92 N/A N/A $6.66 N/A N/A N/A N/A N/A $11.93 N/A N/A $6.96 N/A N/A $12.92 N/A N/A N/A N/A N/A $11.93 N/A N/A $13.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.88 $19.88 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.68 $- $0.70 $- $- $2.15 $- N/A $0.70 N/A N/A $1.01 N/A N/A $1.61 N/A N/A $1.34 N/A N/A N/A N/A N/A $1.82 N/A N/A $1.66 N/A N/A $1.10 N/A N/A $1.88 N/A N/A $2.15 N/A N/A $1.48 N/A N/A $1.88 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.61 N/A N/A $0.94 N/A N/A $1.74 N/A N/A N/A N/A N/A $1.61 N/A N/A $1.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.68 $2.68 N/A 4400227 Pharmacy acetaminophen-HYDROcodone 325 mg-5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400062 Pharmacy acetaminophen-oxyCODONE 325 mg-10 mg Tab [BCH] 250 $7.10 $- $1.85 $- $- $5.68 $- N/A $1.85 N/A N/A $2.68 N/A N/A $4.26 N/A N/A $3.55 N/A N/A N/A N/A N/A $4.83 N/A N/A $4.40 N/A N/A $2.91 N/A N/A $4.97 N/A N/A $5.68 N/A N/A $3.91 N/A N/A $4.97 N/A N/A $2.38 N/A N/A N/A N/A N/A $4.26 N/A N/A $2.49 N/A N/A $4.62 N/A N/A N/A N/A N/A $4.26 N/A N/A $4.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.10 $7.10 N/A 4406069 Pharmacy metFORMIN 500 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4405685 Pharmacy ibuprofen 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405693 Pharmacy ibuprofen 600 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401338 Pharmacy spironolactone 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404635 Pharmacy primidone 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405750 Pharmacy primidone 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A Pharmacy mesalamine 250 mg Cap $6.62 $- $1.72 $- $- $5.30 $- N/A $1.72 N/A N/A $2.50 N/A N/A $3.97 N/A N/A $3.31 N/A N/A N/A N/A N/A $4.50 N/A N/A $4.11 N/A N/A $2.72 N/A N/A $4.64 N/A N/A $5.30 N/A N/A $3.64 N/A N/A $4.64 N/A N/A $2.22 N/A N/A N/A N/A N/A $3.97 N/A N/A $2.32 N/A N/A $4.31 N/A N/A N/A N/A N/A $3.97 N/A N/A $4.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.62 $6.62 N/A 4400050 Pharmacy vitamin A & D Top Oint [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400809 Pharmacy senna 8.8 mg/5 mL Oral Syrup [BCH] 250 $25.54 $- $6.64 $- $- $20.43 $- N/A $6.64 N/A N/A $9.65 N/A N/A $15.32 N/A N/A $12.77 N/A N/A N/A N/A N/A $17.37 N/A N/A $15.83 N/A N/A $10.47 N/A N/A $17.88 N/A N/A $20.43 N/A N/A $14.05 N/A N/A $17.88 N/A N/A $8.56 N/A N/A N/A N/A N/A $15.32 N/A N/A $8.94 N/A N/A $16.60 N/A N/A N/A N/A N/A $15.32 N/A N/A $17.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.54 $25.54 N/A 4404209 Pharmacy dibucaine Top 1% Oint [BCH] 250 $16.95 $- $4.41 $- $- $13.56 $- N/A $4.41 N/A N/A $6.41 N/A N/A $10.17 N/A N/A $8.48 N/A N/A N/A N/A N/A $11.53 N/A N/A $10.51 N/A N/A $6.95 N/A N/A $11.87 N/A N/A $13.56 N/A N/A $9.32 N/A N/A $11.87 N/A N/A $5.68 N/A N/A N/A N/A N/A $10.17 N/A N/A $5.93 N/A N/A $11.02 N/A N/A N/A N/A N/A $10.17 N/A N/A $11.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.95 $16.95 N/A 4400905 Pharmacy sorbitol 70% Liq [BCH] 250 $9.22 $- $2.40 $- $- $7.38 $- N/A $2.40 N/A N/A $3.49 N/A N/A $5.53 N/A N/A $4.61 N/A N/A N/A N/A N/A $6.27 N/A N/A $5.72 N/A N/A $3.78 N/A N/A $6.46 N/A N/A $7.38 N/A N/A $5.07 N/A N/A $6.46 N/A N/A $3.09 N/A N/A N/A N/A N/A $5.53 N/A N/A $3.23 N/A N/A $6.00 N/A N/A N/A N/A N/A $5.53 N/A N/A $6.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.22 $9.22 N/A 4400816 Pharmacy benzocaine topical 20% Gel [BCH] 250 $5.88 $- $1.53 $- $- $4.70 $- N/A $1.53 N/A N/A $2.22 N/A N/A $3.53 N/A N/A $2.94 N/A N/A N/A N/A N/A $4.00 N/A N/A $3.65 N/A N/A $2.41 N/A N/A $4.12 N/A N/A $4.70 N/A N/A $3.23 N/A N/A $4.12 N/A N/A $1.97 N/A N/A N/A N/A N/A $3.53 N/A N/A $2.06 N/A N/A $3.82 N/A N/A N/A N/A N/A $3.53 N/A N/A $4.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.88 $5.88 N/A 4404548 Pharmacy EPINEPHrine 1 mg/mL Sol [BCH] J0171 636 $35.00 $- $0.91 $- $- $28.00 $- N/A $9.10 N/A N/A Not Reimbursed N/A N/A $21.00 N/A N/A $17.50 N/A N/A N/A N/A N/A $23.80 N/A N/A $21.70 N/A N/A $14.35 N/A N/A $24.50 N/A N/A $28.00 N/A N/A $19.25 N/A N/A $24.50 N/A N/A $11.73 N/A N/A N/A N/A N/A $21.00 N/A N/A $12.25 N/A N/A $22.75 N/A N/A $0.91 N/A N/A $21.00 N/A N/A $24.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.00 $35.00 N/A 4400677 Pharmacy cholecalciferol 1000 intl units Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403383 Pharmacy Multiple Vitamins IV Sol 10 mL [BCH] 250 $48.55 $- $12.62 $- $- $38.84 $- N/A $12.62 N/A N/A $18.35 N/A N/A $29.13 N/A N/A $24.27 N/A N/A N/A N/A N/A $33.01 N/A N/A $30.10 N/A N/A $19.90 N/A N/A $33.98 N/A N/A $38.84 N/A N/A $26.70 N/A N/A $33.98 N/A N/A $16.26 N/A N/A N/A N/A N/A $29.13 N/A N/A $16.99 N/A N/A $31.56 N/A N/A N/A N/A N/A $29.13 N/A N/A $33.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.55 $48.55 N/A 4403383 Pharmacy multivitamin Multiple Vitamins Sol 636 $24.28 $- $6.31 $- $- $19.42 $- N/A $6.31 N/A N/A $9.18 N/A N/A $14.57 N/A N/A $12.14 N/A N/A N/A N/A N/A $16.51 N/A N/A $15.05 N/A N/A $9.95 N/A N/A $16.99 N/A N/A $19.42 N/A N/A $13.35 N/A N/A $16.99 N/A N/A $8.13 N/A N/A N/A N/A N/A $14.57 N/A N/A $8.50 N/A N/A $15.78 N/A N/A N/A N/A N/A $14.57 N/A N/A $16.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.28 $24.28 N/A 4400076 Pharmacy Multiple Vitamins Oral Liq 237 mL [BCH] 250 $12.20 $- $3.17 $- $- $9.76 $- N/A $3.17 N/A N/A $4.61 N/A N/A $7.32 N/A N/A $6.10 N/A N/A N/A N/A N/A $8.30 N/A N/A $7.56 N/A N/A $5.00 N/A N/A $8.54 N/A N/A $9.76 N/A N/A $6.71 N/A N/A $8.54 N/A N/A $4.09 N/A N/A N/A N/A N/A $7.32 N/A N/A $4.27 N/A N/A $7.93 N/A N/A N/A N/A N/A $7.32 N/A N/A $8.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.20 $12.20 N/A 4400415 Pharmacy haloperidol 2 mg/mL Con 250 $18.11 $- $4.71 $- $- $14.49 $- N/A $4.71 N/A N/A $6.84 N/A N/A $10.86 N/A N/A $9.05 N/A N/A N/A N/A N/A $12.31 N/A N/A $11.23 N/A N/A $7.42 N/A N/A $12.67 N/A N/A $14.49 N/A N/A $9.96 N/A N/A $12.67 N/A N/A $6.07 N/A N/A N/A N/A N/A $10.86 N/A N/A $6.34 N/A N/A $11.77 N/A N/A N/A N/A N/A $10.86 N/A N/A $12.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.11 $18.11 N/A 4400998 Pharmacy dextromethorphan-guaifenesin 10 mg-100 mg/5 mL Liq [BCH] 250 $13.83 $- $3.60 $- $- $11.06 $- N/A $3.60 N/A N/A $5.23 N/A N/A $8.30 N/A N/A $6.92 N/A N/A N/A N/A N/A $9.41 N/A N/A $8.58 N/A N/A $5.67 N/A N/A $9.68 N/A N/A $11.06 N/A N/A $7.61 N/A N/A $9.68 N/A N/A $4.63 N/A N/A N/A N/A N/A $8.30 N/A N/A $4.84 N/A N/A $8.99 N/A N/A N/A N/A N/A $8.30 N/A N/A $9.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.83 $13.83 N/A 4400678 Pharmacy atorvastatin 40 mg Tab [BCH] 250 $10.99 $- $2.86 $- $- $8.79 $- N/A $2.86 N/A N/A $4.15 N/A N/A $6.59 N/A N/A $5.49 N/A N/A N/A N/A N/A $7.47 N/A N/A $6.81 N/A N/A $4.50 N/A N/A $7.69 N/A N/A $8.79 N/A N/A $6.04 N/A N/A $7.69 N/A N/A $3.68 N/A N/A N/A N/A N/A $6.59 N/A N/A $3.84 N/A N/A $7.14 N/A N/A N/A N/A N/A $6.59 N/A N/A $7.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.99 $10.99 N/A 4403028 Pharmacy ciprofloxacin 250 mg Tab 250 $8.87 $- $2.31 $- $- $7.10 $- N/A $2.31 N/A N/A $3.35 N/A N/A $5.32 N/A N/A $4.44 N/A N/A N/A N/A N/A $6.03 N/A N/A $5.50 N/A N/A $3.64 N/A N/A $6.21 N/A N/A $7.10 N/A N/A $4.88 N/A N/A $6.21 N/A N/A $2.97 N/A N/A N/A N/A N/A $5.32 N/A N/A $3.10 N/A N/A $5.77 N/A N/A N/A N/A N/A $5.32 N/A N/A $6.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.87 $8.87 N/A 4400583 Pharmacy fluconazole 100 mg Tab 250 $17.51 $- $4.55 $- $- $14.01 $- N/A $4.55 N/A N/A $6.62 N/A N/A $10.50 N/A N/A $8.75 N/A N/A N/A N/A N/A $11.91 N/A N/A $10.85 N/A N/A $7.18 N/A N/A $12.26 N/A N/A $14.01 N/A N/A $9.63 N/A N/A $12.26 N/A N/A $5.87 N/A N/A N/A N/A N/A $10.50 N/A N/A $6.13 N/A N/A $11.38 N/A N/A N/A N/A N/A $10.50 N/A N/A $12.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.51 $17.51 N/A 4400730 Pharmacy fluconazole 150 mg Tab [BCH] 250 $27.87 $- $7.25 $- $- $22.29 $- N/A $7.25 N/A N/A $10.53 N/A N/A $16.72 N/A N/A $13.93 N/A N/A N/A N/A N/A $18.95 N/A N/A $17.28 N/A N/A $11.43 N/A N/A $19.51 N/A N/A $22.29 N/A N/A $15.33 N/A N/A $19.51 N/A N/A $9.34 N/A N/A N/A N/A N/A $16.72 N/A N/A $9.75 N/A N/A $18.11 N/A N/A N/A N/A N/A $16.72 N/A N/A $19.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.87 $27.87 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $49.55 $- $0.02 $- $- $39.64 $- N/A $12.88 N/A N/A Not Reimbursed N/A N/A $29.73 N/A N/A $24.78 N/A N/A N/A N/A N/A $33.70 N/A N/A $30.72 N/A N/A $20.32 N/A N/A $34.69 N/A N/A $39.64 N/A N/A $27.25 N/A N/A $34.69 N/A N/A $16.60 N/A N/A N/A N/A N/A $29.73 N/A N/A $17.34 N/A N/A $32.21 N/A N/A $0.02 N/A N/A $29.73 N/A N/A $34.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.55 $49.55 N/A 4407778 Pharmacy OLANZapine 2.5 mg Tab 250 $22.38 $- $5.82 $- $- $17.90 $- N/A $5.82 N/A N/A $8.46 N/A N/A $13.43 N/A N/A $11.19 N/A N/A N/A N/A N/A $15.22 N/A N/A $13.88 N/A N/A $9.18 N/A N/A $15.67 N/A N/A $17.90 N/A N/A $12.31 N/A N/A $15.67 N/A N/A $7.50 N/A N/A N/A N/A N/A $13.43 N/A N/A $7.83 N/A N/A $14.55 N/A N/A N/A N/A N/A $13.43 N/A N/A $15.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.38 $22.38 N/A 4409754 Pharmacy tiZANidine 2 mg Tab [BCH] 250 $2.44 $- $0.64 $- $- $1.95 $- N/A $0.64 N/A N/A $0.92 N/A N/A $1.47 N/A N/A $1.22 N/A N/A N/A N/A N/A $1.66 N/A N/A $1.52 N/A N/A $1.00 N/A N/A $1.71 N/A N/A $1.95 N/A N/A $1.34 N/A N/A $1.71 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.47 N/A N/A $0.86 N/A N/A $1.59 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.44 $2.44 N/A 4407265 Pharmacy clopidogrel 75 mg Tab [BCH] 250 $13.92 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.35 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.75 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.75 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.35 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.35 N/A N/A $9.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.92 $13.92 N/A 4400163 Pharmacy ziprasidone 40 mg Cap [BCH] 250 $17.73 $- $4.61 $- $- $14.18 $- N/A $4.61 N/A N/A $6.70 N/A N/A $10.64 N/A N/A $8.86 N/A N/A N/A N/A N/A $12.05 N/A N/A $10.99 N/A N/A $7.27 N/A N/A $12.41 N/A N/A $14.18 N/A N/A $9.75 N/A N/A $12.41 N/A N/A $5.94 N/A N/A N/A N/A N/A $10.64 N/A N/A $6.20 N/A N/A $11.52 N/A N/A N/A N/A N/A $10.64 N/A N/A $12.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.73 $17.73 N/A 4400725 Pharmacy ziprasidone 60 mg Cap [BCH] 250 $21.51 $- $5.59 $- $- $17.21 $- N/A $5.59 N/A N/A $8.13 N/A N/A $12.91 N/A N/A $10.76 N/A N/A N/A N/A N/A $14.63 N/A N/A $13.34 N/A N/A $8.82 N/A N/A $15.06 N/A N/A $17.21 N/A N/A $11.83 N/A N/A $15.06 N/A N/A $7.21 N/A N/A N/A N/A N/A $12.91 N/A N/A $7.53 N/A N/A $13.98 N/A N/A N/A N/A N/A $12.91 N/A N/A $15.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.51 $21.51 N/A 4400117 Pharmacy OLANZapine 5 mg Dis Tab [BCH] 250 $28.23 $- $7.34 $- $- $22.59 $- N/A $7.34 N/A N/A $10.67 N/A N/A $16.94 N/A N/A $14.12 N/A N/A N/A N/A N/A $19.20 N/A N/A $17.50 N/A N/A $11.57 N/A N/A $19.76 N/A N/A $22.59 N/A N/A $15.53 N/A N/A $19.76 N/A N/A $9.46 N/A N/A N/A N/A N/A $16.94 N/A N/A $9.88 N/A N/A $18.35 N/A N/A N/A N/A N/A $16.94 N/A N/A $19.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.23 $28.23 N/A 4400866 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $41.48 $- $10.79 $- $- $33.19 $- N/A $10.79 N/A N/A $15.68 N/A N/A $24.89 N/A N/A $20.74 N/A N/A N/A N/A N/A $28.21 N/A N/A $25.72 N/A N/A $17.01 N/A N/A $29.04 N/A N/A $33.19 N/A N/A $22.81 N/A N/A $29.04 N/A N/A $13.90 N/A N/A N/A N/A N/A $24.89 N/A N/A $14.52 N/A N/A $26.96 N/A N/A N/A N/A N/A $24.89 N/A N/A $29.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.48 $41.48 N/A 4400966 Pharmacy donepezil 23 mg Tab [BCH] 250 $22.71 $- $5.91 $- $- $18.17 $- N/A $5.91 N/A N/A $8.59 N/A N/A $13.63 N/A N/A $11.36 N/A N/A N/A N/A N/A $15.45 N/A N/A $14.08 N/A N/A $9.31 N/A N/A $15.90 N/A N/A $18.17 N/A N/A $12.49 N/A N/A $15.90 N/A N/A $7.61 N/A N/A N/A N/A N/A $13.63 N/A N/A $7.95 N/A N/A $14.76 N/A N/A N/A N/A N/A $13.63 N/A N/A $15.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.71 $22.71 N/A 4409594 Pharmacy pantoprazole 40 mg Tab [BCH] 250 $8.18 $- $2.13 $- $- $6.55 $- N/A $2.13 N/A N/A $3.09 N/A N/A $4.91 N/A N/A $4.09 N/A N/A N/A N/A N/A $5.56 N/A N/A $5.07 N/A N/A $3.35 N/A N/A $5.73 N/A N/A $6.55 N/A N/A $4.50 N/A N/A $5.73 N/A N/A $2.74 N/A N/A N/A N/A N/A $4.91 N/A N/A $2.86 N/A N/A $5.32 N/A N/A N/A N/A N/A $4.91 N/A N/A $5.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.18 $8.18 N/A 4409418 Pharmacy rivastigmine 1.5 mg Cap [BCH] 250 $8.49 $- $2.21 $- $- $6.79 $- N/A $2.21 N/A N/A $3.21 N/A N/A $5.09 N/A N/A $4.24 N/A N/A N/A N/A N/A $5.77 N/A N/A $5.26 N/A N/A $3.48 N/A N/A $5.94 N/A N/A $6.79 N/A N/A $4.67 N/A N/A $5.94 N/A N/A $2.84 N/A N/A N/A N/A N/A $5.09 N/A N/A $2.97 N/A N/A $5.52 N/A N/A N/A N/A N/A $5.09 N/A N/A $5.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.49 $8.49 N/A 4400707 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.11 $- $0.55 $- $- $1.69 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.31 N/A N/A $0.86 N/A N/A $1.48 N/A N/A $1.69 N/A N/A $1.16 N/A N/A $1.48 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.74 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.26 N/A N/A $1.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.11 $2.11 N/A 4402118 Pharmacy metoprolol 50 mg ER Tab [BCH] 250 $2.11 $- $0.55 $- $- $1.69 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.26 N/A N/A $1.05 N/A N/A N/A N/A N/A $1.43 N/A N/A $1.31 N/A N/A $0.86 N/A N/A $1.48 N/A N/A $1.69 N/A N/A $1.16 N/A N/A $1.48 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.26 N/A N/A $0.74 N/A N/A $1.37 N/A N/A N/A N/A N/A $1.26 N/A N/A $1.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.11 $2.11 N/A 4406515 Pharmacy divalproex sodium 125 mg Oral EC Cap [BCH] 250 $2.24 $- $0.58 $- $- $1.79 $- N/A $0.58 N/A N/A $0.85 N/A N/A $1.34 N/A N/A $1.12 N/A N/A N/A N/A N/A $1.52 N/A N/A $1.39 N/A N/A $0.92 N/A N/A $1.57 N/A N/A $1.79 N/A N/A $1.23 N/A N/A $1.57 N/A N/A $0.75 N/A N/A N/A N/A N/A $1.34 N/A N/A $0.78 N/A N/A $1.46 N/A N/A N/A N/A N/A $1.34 N/A N/A $1.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.24 $2.24 N/A 4400131 Pharmacy divalproex sodium 250 mg ER Tab [BCH] 250 $4.91 $- $1.28 $- $- $3.93 $- N/A $1.28 N/A N/A $1.86 N/A N/A $2.95 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.44 N/A N/A $3.93 N/A N/A $2.70 N/A N/A $3.44 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.95 N/A N/A $1.72 N/A N/A $3.19 N/A N/A N/A N/A N/A $2.95 N/A N/A $3.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.91 $4.91 N/A 4400131 Pharmacy divalproex sodium 250 mg Tab [BCH] 250 $4.91 $- $1.28 $- $- $3.93 $- N/A $1.28 N/A N/A $1.86 N/A N/A $2.95 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.44 N/A N/A $3.93 N/A N/A $2.70 N/A N/A $3.44 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.95 N/A N/A $1.72 N/A N/A $3.19 N/A N/A N/A N/A N/A $2.95 N/A N/A $3.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.91 $4.91 N/A 4400854 Pharmacy divalproex sodium 500 mg Tab [BCH] 258 $5.71 $- $1.48 $- $- $4.57 $- N/A $1.48 N/A N/A $2.16 N/A N/A $3.43 N/A N/A $2.86 N/A N/A N/A N/A N/A $3.88 N/A N/A $3.54 N/A N/A $2.34 N/A N/A $4.00 N/A N/A $4.57 N/A N/A $3.14 N/A N/A $4.00 N/A N/A $1.91 N/A N/A N/A N/A N/A $3.43 N/A N/A $2.00 N/A N/A $3.71 N/A N/A N/A N/A N/A $3.43 N/A N/A $4.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.71 $5.71 N/A 4400907 Pharmacy memantine 5 mg Tab [BCH] 250 $12.19 $- $3.17 $- $- $9.75 $- N/A $3.17 N/A N/A $4.61 N/A N/A $7.32 N/A N/A $6.10 N/A N/A N/A N/A N/A $8.29 N/A N/A $7.56 N/A N/A $5.00 N/A N/A $8.53 N/A N/A $9.75 N/A N/A $6.71 N/A N/A $8.53 N/A N/A $4.08 N/A N/A N/A N/A N/A $7.32 N/A N/A $4.27 N/A N/A $7.92 N/A N/A N/A N/A N/A $7.32 N/A N/A $8.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.19 $12.19 N/A 4400921 Pharmacy memantine 10 mg Tab [BCH] 250 $12.19 $- $3.17 $- $- $9.75 $- N/A $3.17 N/A N/A $4.61 N/A N/A $7.32 N/A N/A $6.10 N/A N/A N/A N/A N/A $8.29 N/A N/A $7.56 N/A N/A $5.00 N/A N/A $8.53 N/A N/A $9.75 N/A N/A $6.71 N/A N/A $8.53 N/A N/A $4.08 N/A N/A N/A N/A N/A $7.32 N/A N/A $4.27 N/A N/A $7.93 N/A N/A N/A N/A N/A $7.32 N/A N/A $8.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.19 $12.19 N/A 4400723 Pharmacy paricalcitol 1 mcg Cap [BCH] 250 $22.18 $- $5.77 $- $- $17.75 $- N/A $5.77 N/A N/A $8.38 N/A N/A $13.31 N/A N/A $11.09 N/A N/A N/A N/A N/A $15.08 N/A N/A $13.75 N/A N/A $9.09 N/A N/A $15.53 N/A N/A $17.75 N/A N/A $12.20 N/A N/A $15.53 N/A N/A $7.43 N/A N/A N/A N/A N/A $13.31 N/A N/A $7.76 N/A N/A $14.42 N/A N/A N/A N/A N/A $13.31 N/A N/A $15.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.18 $22.18 N/A 4400223 Pharmacy zoledronic acid 5 mg/100 mL IV Sol [BCH] J3489 636 "$2,008.84 " $- $11.39 $- $- "$1,607.07 " $- N/A $522.30 N/A N/A Not Reimbursed N/A N/A "$1,205.30 " N/A N/A "$1,004.42 " N/A N/A N/A N/A N/A "$1,366.01 " N/A N/A "$1,245.48 " N/A N/A $823.62 N/A N/A "$1,406.19 " N/A N/A "$1,607.07 " N/A N/A "$1,104.86 " N/A N/A "$1,406.19 " N/A N/A $672.96 N/A N/A N/A N/A N/A "$1,205.30 " N/A N/A $703.09 N/A N/A "$1,305.75 " N/A N/A $11.39 N/A N/A "$1,205.30 " N/A N/A "$1,406.19 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,008.84 " "$2,008.84 " N/A 4407273 Pharmacy montelukast 10 mg Tab [BCH] 250 $11.31 $- $2.94 $- $- $9.05 $- N/A $2.94 N/A N/A $4.28 N/A N/A $6.79 N/A N/A $5.66 N/A N/A N/A N/A N/A $7.69 N/A N/A $7.01 N/A N/A $4.64 N/A N/A $7.92 N/A N/A $9.05 N/A N/A $6.22 N/A N/A $7.92 N/A N/A $3.79 N/A N/A N/A N/A N/A $6.79 N/A N/A $3.96 N/A N/A $7.35 N/A N/A N/A N/A N/A $6.79 N/A N/A $7.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.31 $11.31 N/A 4408564 Pharmacy allopurinol 100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400526 Pharmacy allopurinol 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406964 Pharmacy ampicillin-sulbactam 1 g-0.5 g Inj [BCH] J0295 636 $28.00 $- $2.76 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.76 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400177 Pharmacy ampicillin-sulbactam 2 g-1 g Inj [BCH] J0295 636 $29.20 $- $2.76 $- $- $23.36 $- N/A $7.59 N/A N/A Not Reimbursed N/A N/A $17.52 N/A N/A $14.60 N/A N/A N/A N/A N/A $19.86 N/A N/A $18.10 N/A N/A $11.97 N/A N/A $20.44 N/A N/A $23.36 N/A N/A $16.06 N/A N/A $20.44 N/A N/A $9.78 N/A N/A N/A N/A N/A $17.52 N/A N/A $10.22 N/A N/A $18.98 N/A N/A $2.76 N/A N/A $17.52 N/A N/A $20.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.20 $29.20 N/A 4408347 Pharmacy oxacillin 1 g Pow [BCH] J2700 636 $29.00 $- $1.13 $- $- $23.20 $- N/A $7.54 N/A N/A Not Reimbursed N/A N/A $17.40 N/A N/A $14.50 N/A N/A N/A N/A N/A $19.72 N/A N/A $17.98 N/A N/A $11.89 N/A N/A $20.30 N/A N/A $23.20 N/A N/A $15.95 N/A N/A $20.30 N/A N/A $9.72 N/A N/A N/A N/A N/A $17.40 N/A N/A $10.15 N/A N/A $18.85 N/A N/A $1.13 N/A N/A $17.40 N/A N/A $20.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.00 $29.00 N/A 4400941 Pharmacy oxacillin 2 g Pow [BCH] J2700 636 $56.55 $- $1.13 $- $- $45.24 $- N/A $14.70 N/A N/A Not Reimbursed N/A N/A $33.93 N/A N/A $28.28 N/A N/A N/A N/A N/A $38.45 N/A N/A $35.06 N/A N/A $23.19 N/A N/A $39.59 N/A N/A $45.24 N/A N/A $31.10 N/A N/A $39.59 N/A N/A $18.94 N/A N/A N/A N/A N/A $33.93 N/A N/A $19.79 N/A N/A $36.76 N/A N/A $1.13 N/A N/A $33.93 N/A N/A $39.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $56.55 $56.55 N/A 4400806 Pharmacy oxacillin 10 g Inj [BCH] J2700 636 $276.00 $- $1.13 $- $- $220.80 $- N/A $71.76 N/A N/A Not Reimbursed N/A N/A $165.60 N/A N/A $138.00 N/A N/A N/A N/A N/A $187.68 N/A N/A $171.12 N/A N/A $113.16 N/A N/A $193.20 N/A N/A $220.80 N/A N/A $151.80 N/A N/A $193.20 N/A N/A $92.46 N/A N/A N/A N/A N/A $165.60 N/A N/A $96.60 N/A N/A $179.40 N/A N/A $1.13 N/A N/A $165.60 N/A N/A $193.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $276.00 $276.00 N/A 4400265 Pharmacy bupivacaine 0.25% preservative-free Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402373 Pharmacy SUMAtriptan 6 mg/0.5 mL [BCH] J3030 636 $170.00 $- $44.20 $- $- $136.00 $- N/A $44.20 N/A N/A Not Reimbursed N/A N/A $102.00 N/A N/A $85.00 N/A N/A N/A N/A N/A $115.60 N/A N/A $105.40 N/A N/A $69.70 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A N/A N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A N/A N/A N/A $102.00 N/A N/A $119.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $170.00 $170.00 N/A 4402373 Pharmacy SUMAtriptan 6 mg/0.5 mL Sol [BCH] J3030 636 $170.00 $- $44.20 $- $- $136.00 $- N/A $44.20 N/A N/A Not Reimbursed N/A N/A $102.00 N/A N/A $85.00 N/A N/A N/A N/A N/A $115.60 N/A N/A $105.40 N/A N/A $69.70 N/A N/A $119.00 N/A N/A $136.00 N/A N/A $93.50 N/A N/A $119.00 N/A N/A $56.95 N/A N/A N/A N/A N/A $102.00 N/A N/A $59.50 N/A N/A $110.50 N/A N/A N/A N/A N/A $102.00 N/A N/A $119.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $170.00 $170.00 N/A 4409518 Pharmacy niCARdipine 2.5 mg/mL Sol[BCH] 258 $50.97 $- $13.25 $- $- $40.77 $- N/A $13.25 N/A N/A $19.27 N/A N/A $30.58 N/A N/A $25.48 N/A N/A N/A N/A N/A $34.66 N/A N/A $31.60 N/A N/A $20.90 N/A N/A $35.68 N/A N/A $40.77 N/A N/A $28.03 N/A N/A $35.68 N/A N/A $17.07 N/A N/A N/A N/A N/A $30.58 N/A N/A $17.84 N/A N/A $33.13 N/A N/A N/A N/A N/A $30.58 N/A N/A $35.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.97 $50.97 N/A 4409538 Pharmacy pantoprazole 40 mg Pow S0164 636 $17.00 $- $4.42 $- $- $13.60 $- N/A $4.42 N/A N/A Not Reimbursed N/A N/A $10.20 N/A N/A $8.50 N/A N/A N/A N/A N/A $11.56 N/A N/A $10.54 N/A N/A $6.97 N/A N/A $11.90 N/A N/A $13.60 N/A N/A $9.35 N/A N/A $11.90 N/A N/A $5.70 N/A N/A N/A N/A N/A $10.20 N/A N/A $5.95 N/A N/A $11.05 N/A N/A N/A N/A N/A $10.20 N/A N/A $11.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.00 $17.00 N/A 4401913 Pharmacy eptifibatide 2 mg/mL IV Sol [BCH] J1327 636 $450.00 $- $117.00 $- $- $360.00 $- N/A $117.00 N/A N/A Not Reimbursed N/A N/A $270.00 N/A N/A $225.00 N/A N/A N/A N/A N/A $306.00 N/A N/A $279.00 N/A N/A $184.50 N/A N/A $315.00 N/A N/A $360.00 N/A N/A $247.50 N/A N/A $315.00 N/A N/A $150.75 N/A N/A N/A N/A N/A $270.00 N/A N/A $157.50 N/A N/A $292.50 N/A N/A N/A N/A N/A $270.00 N/A N/A $315.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $450.00 $450.00 N/A 4401771 Pharmacy etomidate 2 mg/mL Sol 250 $19.20 $- $4.99 $- $- $15.36 $- N/A $4.99 N/A N/A $7.26 N/A N/A $11.52 N/A N/A $9.60 N/A N/A N/A N/A N/A $13.06 N/A N/A $11.90 N/A N/A $7.87 N/A N/A $13.44 N/A N/A $15.36 N/A N/A $10.56 N/A N/A $13.44 N/A N/A $6.43 N/A N/A N/A N/A N/A $11.52 N/A N/A $6.72 N/A N/A $12.48 N/A N/A N/A N/A N/A $11.52 N/A N/A $13.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.20 $19.20 N/A 4409680 Pharmacy vecuronium 10 mg Pow [BCH] 636 $13.20 $- $3.43 $- $- $10.56 $- N/A $3.43 N/A N/A $4.99 N/A N/A $7.92 N/A N/A $6.60 N/A N/A N/A N/A N/A $8.98 N/A N/A $8.18 N/A N/A $5.41 N/A N/A $9.24 N/A N/A $10.56 N/A N/A $7.26 N/A N/A $9.24 N/A N/A $4.42 N/A N/A N/A N/A N/A $7.92 N/A N/A $4.62 N/A N/A $8.58 N/A N/A N/A N/A N/A $7.92 N/A N/A $9.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.20 $13.20 N/A 4402746 Pharmacy lidocaine 2% Sol [BCH] J2001 636 $12.00 $- $0.02 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.02 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409695 Pharmacy ertapenem 1 g Pow [BCH] J1335 636 $300.00 $- $35.33 $- $- $240.00 $- N/A $78.00 N/A N/A Not Reimbursed N/A N/A $180.00 N/A N/A $150.00 N/A N/A N/A N/A N/A $204.00 N/A N/A $186.00 N/A N/A $123.00 N/A N/A $210.00 N/A N/A $240.00 N/A N/A $165.00 N/A N/A $210.00 N/A N/A $100.50 N/A N/A N/A N/A N/A $180.00 N/A N/A $105.00 N/A N/A $195.00 N/A N/A $35.33 N/A N/A $180.00 N/A N/A $210.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $300.00 $300.00 N/A 4402228 Pharmacy chlorproMAZINE 25 mg/mL Sol [BCH] J3230 636 $39.72 $- $10.33 $- $- $33.29 $- N/A $10.33 N/A N/A Not Reimbursed N/A N/A $23.83 N/A N/A $19.86 N/A N/A N/A N/A N/A $27.01 N/A N/A $24.63 N/A N/A $16.29 N/A N/A $27.80 N/A N/A $31.78 N/A N/A $21.85 N/A N/A $27.80 N/A N/A $13.31 N/A N/A N/A N/A N/A $23.83 N/A N/A $13.90 N/A N/A $25.82 N/A N/A $33.29 N/A N/A $23.83 N/A N/A $27.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.72 $39.72 N/A 4404886 Pharmacy glucagon recombinant 1 mg Inj [BCH] J1610 636 $411.84 $- $107.08 $- $- $329.47 $- N/A $107.08 N/A N/A Not Reimbursed N/A N/A $247.10 N/A N/A $205.92 N/A N/A N/A N/A N/A $280.05 N/A N/A $255.34 N/A N/A $168.85 N/A N/A $288.29 N/A N/A $329.47 N/A N/A $226.51 N/A N/A $288.29 N/A N/A $137.97 N/A N/A N/A N/A N/A $247.10 N/A N/A $144.14 N/A N/A $267.70 N/A N/A $199.13 N/A N/A $247.10 N/A N/A $288.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $411.84 $411.84 N/A 4409337 Pharmacy valproic acid 100 mg/mL Sol [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404080 Pharmacy esmolol 10 mg/mL IV Sol [BCH] 250 $12.48 $- $3.24 $- $- $9.98 $- N/A $3.24 N/A N/A $4.72 N/A N/A $7.49 N/A N/A $6.24 N/A N/A N/A N/A N/A $8.49 N/A N/A $7.74 N/A N/A $5.12 N/A N/A $8.74 N/A N/A $9.98 N/A N/A $6.86 N/A N/A $8.74 N/A N/A $4.18 N/A N/A N/A N/A N/A $7.49 N/A N/A $4.37 N/A N/A $8.11 N/A N/A N/A N/A N/A $7.49 N/A N/A $8.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.48 $12.48 N/A 4409345 Pharmacy prochlorperazine 5 mg/mL Inj Sol [BCH] J0780 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $6.43 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407566 Pharmacy phentolamine 5 mg Inj [BCH] J2760 636 "$1,020.00 " $- $265.20 $- $- $816.00 $- N/A $265.20 N/A N/A Not Reimbursed N/A N/A $612.00 N/A N/A $510.00 N/A N/A N/A N/A N/A $693.60 N/A N/A $632.40 N/A N/A $418.20 N/A N/A $714.00 N/A N/A $816.00 N/A N/A $561.00 N/A N/A $714.00 N/A N/A $341.70 N/A N/A N/A N/A N/A $612.00 N/A N/A $357.00 N/A N/A $663.00 N/A N/A $374.74 N/A N/A $612.00 N/A N/A $714.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,020.00 " "$1,020.00 " N/A 4405803 Pharmacy octreotide 100 mcg/mL Inj Sol [BCH] J2354 636 $24.00 $- $0.83 $- $- $19.20 $- N/A $6.24 N/A N/A Not Reimbursed N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A $14.88 N/A N/A $9.84 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A $0.83 N/A N/A $14.40 N/A N/A $16.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.00 $24.00 N/A 4400401 Pharmacy amikacin 250 mg/mL IV Sol [BCH] J0278 636 $28.00 $- $1.39 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.39 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400429 Pharmacy diltiazem 5 mg/mL IV Sol 25mL [BCH] 258 $25.00 $- $6.50 $- $- $20.00 $- N/A $6.50 N/A N/A $9.45 N/A N/A $15.00 N/A N/A $12.50 N/A N/A N/A N/A N/A $17.00 N/A N/A $15.50 N/A N/A $10.25 N/A N/A $17.50 N/A N/A $20.00 N/A N/A $13.75 N/A N/A $17.50 N/A N/A $8.38 N/A N/A N/A N/A N/A $15.00 N/A N/A $8.75 N/A N/A $16.25 N/A N/A N/A N/A N/A $15.00 N/A N/A $17.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.00 $25.00 N/A 4400968 Pharmacy filgrastim 480 mcg/0.8 mL Sol [BCH] J1442 636 "$1,275.44 " $- $0.92 $- $- "$1,020.35 " $- N/A $331.61 N/A N/A Not Reimbursed N/A N/A $765.26 N/A N/A $637.72 N/A N/A N/A N/A N/A $867.30 N/A N/A $790.77 N/A N/A $522.93 N/A N/A $892.81 N/A N/A "$1,020.35 " N/A N/A $701.49 N/A N/A $892.81 N/A N/A $427.27 N/A N/A N/A N/A N/A $765.26 N/A N/A $446.40 N/A N/A $829.04 N/A N/A $0.92 N/A N/A $765.26 N/A N/A $892.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,275.44 " "$1,275.44 " N/A 4400463 Pharmacy filgrastim 300 mcg/mL Inj Sol [BCH] J1442 636 $734.30 $- $0.92 $- $- $587.44 $- N/A $190.92 N/A N/A Not Reimbursed N/A N/A $440.58 N/A N/A $367.15 N/A N/A N/A N/A N/A $499.33 N/A N/A $455.27 N/A N/A $301.06 N/A N/A $514.01 N/A N/A $587.44 N/A N/A $403.87 N/A N/A $514.01 N/A N/A $245.99 N/A N/A N/A N/A N/A $440.58 N/A N/A $257.01 N/A N/A $477.30 N/A N/A $0.92 N/A N/A $440.58 N/A N/A $514.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $734.30 $734.30 N/A 4409395 Pharmacy filgrastim 480 mcg/1.6 mL Inj Sol [BCH] J1442 636 "$1,169.28 " $- $0.92 $- $- $935.42 $- N/A $304.01 N/A N/A Not Reimbursed N/A N/A $701.57 N/A N/A $584.64 N/A N/A N/A N/A N/A $795.11 N/A N/A $724.95 N/A N/A $479.40 N/A N/A $818.50 N/A N/A $935.42 N/A N/A $643.10 N/A N/A $818.50 N/A N/A $391.71 N/A N/A N/A N/A N/A $701.57 N/A N/A $409.25 N/A N/A $760.03 N/A N/A $0.92 N/A N/A $701.57 N/A N/A $818.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,169.28 " "$1,169.28 " N/A 4400458 Pharmacy denosumab 60 mg/mL Sol [BCH] J0897 636 "$2,465.28 " $- $19.90 $- $- "$1,972.22 " $- N/A $640.97 N/A N/A Not Reimbursed N/A N/A "$1,479.17 " N/A N/A "$1,232.64 " N/A N/A N/A N/A N/A "$1,676.39 " N/A N/A "$1,528.47 " N/A N/A "$1,010.76 " N/A N/A "$1,725.70 " N/A N/A "$1,972.22 " N/A N/A "$1,355.90 " N/A N/A "$1,725.70 " N/A N/A $825.87 N/A N/A N/A N/A N/A "$1,479.17 " N/A N/A $862.85 N/A N/A "$1,602.43 " N/A N/A $19.90 N/A N/A "$1,479.17 " N/A N/A "$1,725.70 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,465.28 " "$2,465.28 " N/A 4400845 Pharmacy desmopressin 4 mcg/mL Sol [BCH] J2597 636 $110.97 $- $11.06 $- $- $88.78 $- N/A $28.85 N/A N/A Not Reimbursed N/A N/A $66.58 N/A N/A $55.49 N/A N/A N/A N/A N/A $75.46 N/A N/A $68.80 N/A N/A $45.50 N/A N/A $77.68 N/A N/A $88.78 N/A N/A $61.04 N/A N/A $77.68 N/A N/A $37.18 N/A N/A N/A N/A N/A $66.58 N/A N/A $38.84 N/A N/A $72.13 N/A N/A $11.06 N/A N/A $66.58 N/A N/A $77.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $110.97 $110.97 N/A 4409204 Pharmacy tamsulosin 0.4 mg Cap [BCH] 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.22 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.63 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4400688 Pharmacy DULoxetine 20 mg Cap [BCH] 250 $14.00 $- $3.64 $- $- $11.20 $- N/A $3.64 N/A N/A $5.29 N/A N/A $8.40 N/A N/A $7.00 N/A N/A N/A N/A N/A $9.52 N/A N/A $8.68 N/A N/A $5.74 N/A N/A $9.80 N/A N/A $11.20 N/A N/A $7.70 N/A N/A $9.80 N/A N/A $4.69 N/A N/A N/A N/A N/A $8.40 N/A N/A $4.90 N/A N/A $9.10 N/A N/A N/A N/A N/A $8.40 N/A N/A $9.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.00 $14.00 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4400680 Pharmacy DULoxetine 60 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4407053 Pharmacy Penicillin V Potassium 250 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403002 Pharmacy cefuroxime 250 mg Tab 250 $8.80 $- $2.29 $- $- $7.04 $- N/A $2.29 N/A N/A $3.33 N/A N/A $5.28 N/A N/A $4.40 N/A N/A N/A N/A N/A $5.98 N/A N/A $5.45 N/A N/A $3.61 N/A N/A $6.16 N/A N/A $7.04 N/A N/A $4.84 N/A N/A $6.16 N/A N/A $2.95 N/A N/A N/A N/A N/A $5.28 N/A N/A $3.08 N/A N/A $5.72 N/A N/A N/A N/A N/A $5.28 N/A N/A $6.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.80 $8.80 N/A 4408556 Pharmacy alfuzosin 10 mg ER Tab [BCH] 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.22 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.63 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4405602 Pharmacy warfarin 2.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405673 Pharmacy ramipril 2.5 mg Cap 250 $3.61 $- $0.94 $- $- $2.89 $- N/A $0.94 N/A N/A $1.37 N/A N/A $2.17 N/A N/A $1.81 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.24 N/A N/A $1.48 N/A N/A $2.53 N/A N/A $2.89 N/A N/A $1.99 N/A N/A $2.53 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.26 N/A N/A $2.35 N/A N/A N/A N/A N/A $2.17 N/A N/A $2.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.61 $3.61 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404712 Pharmacy ferrous sulfate 325 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405338 Pharmacy verapamil 120 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402084 Pharmacy verapamil 180 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400629 Pharmacy metoprolol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403850 Pharmacy codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup 118 mL [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400973 Pharmacy cloZAPine 50 mg Tab [BCH] 250 $3.30 $- $0.86 $- $- $2.64 $- N/A $0.86 N/A N/A $1.25 N/A N/A $1.98 N/A N/A $1.65 N/A N/A N/A N/A N/A $2.24 N/A N/A $2.05 N/A N/A $1.35 N/A N/A $2.31 N/A N/A $2.64 N/A N/A $1.82 N/A N/A $2.31 N/A N/A $1.11 N/A N/A N/A N/A N/A $1.98 N/A N/A $1.16 N/A N/A $2.15 N/A N/A N/A N/A N/A $1.98 N/A N/A $2.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.30 $3.30 N/A 4400977 Pharmacy cloZAPine 100 mg Tab [BCH] 250 $6.72 $- $1.75 $- $- $5.37 $- N/A $1.75 N/A N/A $2.54 N/A N/A $4.03 N/A N/A $3.36 N/A N/A N/A N/A N/A $4.57 N/A N/A $4.16 N/A N/A $2.75 N/A N/A $4.70 N/A N/A $5.37 N/A N/A $3.69 N/A N/A $4.70 N/A N/A $2.25 N/A N/A N/A N/A N/A $4.03 N/A N/A $2.35 N/A N/A $4.37 N/A N/A N/A N/A N/A $4.03 N/A N/A $4.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.72 $6.72 N/A 4405707 Pharmacy traMADol 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405681 Pharmacy metFORMIN 850 mg Tab [BCH] 250 $2.39 $- $0.62 $- $- $1.92 $- N/A $0.62 N/A N/A $0.90 N/A N/A $1.44 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.63 N/A N/A $1.48 N/A N/A $0.98 N/A N/A $1.68 N/A N/A $1.92 N/A N/A $1.32 N/A N/A $1.68 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.44 N/A N/A $0.84 N/A N/A $1.56 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.39 $2.39 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409754 Pharmacy tiZANidine 2 mg Tab [BCH] 250 $2.44 $- $0.64 $- $- $1.95 $- N/A $0.64 N/A N/A $0.92 N/A N/A $1.47 N/A N/A $1.22 N/A N/A N/A N/A N/A $1.66 N/A N/A $1.51 N/A N/A $1.00 N/A N/A $1.71 N/A N/A $1.95 N/A N/A $1.34 N/A N/A $1.71 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.47 N/A N/A $0.86 N/A N/A $1.59 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.44 $2.44 N/A 4400419 Pharmacy citalopram 20 mg Tab [BCH] 250 $5.11 $- $1.33 $- $- $4.09 $- N/A $1.33 N/A N/A $1.93 N/A N/A $3.07 N/A N/A $2.56 N/A N/A N/A N/A N/A $3.47 N/A N/A $3.17 N/A N/A $2.10 N/A N/A $3.58 N/A N/A $4.09 N/A N/A $2.81 N/A N/A $3.58 N/A N/A $1.71 N/A N/A N/A N/A N/A $3.07 N/A N/A $1.79 N/A N/A $3.32 N/A N/A N/A N/A N/A $3.07 N/A N/A $3.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.11 $5.11 N/A 4400298 Pharmacy citalopram 40 mg Tab [BCH] 250 $5.31 $- $1.38 $- $- $4.25 $- N/A $1.38 N/A N/A $2.01 N/A N/A $3.19 N/A N/A $2.66 N/A N/A N/A N/A N/A $3.61 N/A N/A $3.29 N/A N/A $2.18 N/A N/A $3.72 N/A N/A $4.25 N/A N/A $2.92 N/A N/A $3.72 N/A N/A $1.78 N/A N/A N/A N/A N/A $3.19 N/A N/A $1.86 N/A N/A $3.45 N/A N/A N/A N/A N/A $3.19 N/A N/A $3.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.31 $5.31 N/A 4409631 Pharmacy acetaminophen-tramadol 325 mg-37.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408941 Pharmacy chlorthalidone 25 mg Tab 250 $2.41 $- $0.63 $- $- $1.93 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.45 N/A N/A $1.21 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.50 N/A N/A $0.99 N/A N/A $1.69 N/A N/A $1.93 N/A N/A $1.33 N/A N/A $1.69 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.45 N/A N/A $0.84 N/A N/A $1.57 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $8.18 $- $2.13 $- $- $6.54 $- N/A $2.13 N/A N/A $3.09 N/A N/A $4.91 N/A N/A $4.09 N/A N/A N/A N/A N/A $5.56 N/A N/A $5.07 N/A N/A $3.35 N/A N/A $5.72 N/A N/A $6.54 N/A N/A $4.50 N/A N/A $5.72 N/A N/A $2.74 N/A N/A N/A N/A N/A $4.91 N/A N/A $2.86 N/A N/A $5.31 N/A N/A N/A N/A N/A $4.91 N/A N/A $5.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.18 $8.18 N/A 4400489 Pharmacy inFLIXimab 100 mg IV Inj [BCH] J1745 636 "$2,802.76 " $- $51.20 $- $- "$2,242.21 " $- N/A $728.72 N/A N/A Not Reimbursed N/A N/A "$1,681.66 " N/A N/A "$1,401.38 " N/A N/A N/A N/A N/A "$1,905.88 " N/A N/A "$1,737.71 " N/A N/A "$1,149.13 " N/A N/A "$1,961.93 " N/A N/A "$2,242.21 " N/A N/A "$1,541.52 " N/A N/A "$1,961.93 " N/A N/A $938.92 N/A N/A N/A N/A N/A "$1,681.66 " N/A N/A $980.97 N/A N/A "$1,821.79 " N/A N/A $51.20 N/A N/A "$1,681.66 " N/A N/A "$1,961.93 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,802.76 " "$2,802.76 " N/A 4408036 Pharmacy acetaminophen 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401957 Pharmacy bacitracin topical zinc 500 units/g Oin [BCH] 250 $2.55 $- $0.66 $- $- $2.04 $- N/A $0.66 N/A N/A $0.96 N/A N/A $1.53 N/A N/A $1.28 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.58 N/A N/A $1.05 N/A N/A $1.79 N/A N/A $2.04 N/A N/A $1.40 N/A N/A $1.79 N/A N/A $0.85 N/A N/A N/A N/A N/A $1.53 N/A N/A $0.89 N/A N/A $1.66 N/A N/A N/A N/A N/A $1.53 N/A N/A $1.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.55 $2.55 N/A 4400050 Pharmacy vitamin A and D topical - Oin [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407521 Pharmacy ocular lubricant preserved Sol 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403952 Pharmacy acetaminophen 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409686 Pharmacy docusate-senna 50 mg-8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404172 Pharmacy carbamide peroxide otic 6.5% Sol [BCH] 250 $59.40 $- $15.44 $- $- $47.52 $- N/A $15.44 N/A N/A $22.45 N/A N/A $35.64 N/A N/A $29.70 N/A N/A N/A N/A N/A $40.39 N/A N/A $36.83 N/A N/A $24.35 N/A N/A $41.58 N/A N/A $47.52 N/A N/A $32.67 N/A N/A $41.58 N/A N/A $19.90 N/A N/A N/A N/A N/A $35.64 N/A N/A $20.79 N/A N/A $38.61 N/A N/A N/A N/A N/A $35.64 N/A N/A $41.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $59.40 $59.40 N/A 4402340 Pharmacy bisacodyl 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400809 Pharmacy senna 8.8 mg/5 mL Syr [BCH] 250 $24.48 $- $6.36 $- $- $19.58 $- N/A $6.36 N/A N/A $9.25 N/A N/A $14.69 N/A N/A $12.24 N/A N/A N/A N/A N/A $16.64 N/A N/A $15.18 N/A N/A $10.04 N/A N/A $17.13 N/A N/A $19.58 N/A N/A $13.46 N/A N/A $17.13 N/A N/A $8.20 N/A N/A N/A N/A N/A $14.69 N/A N/A $8.57 N/A N/A $15.91 N/A N/A N/A N/A N/A $14.69 N/A N/A $17.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.48 $24.48 N/A 4400043 Pharmacy multivitamin Multiple Vitamins Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400043 Pharmacy Multiple Vitamins Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401973 Pharmacy diphenhydrAMINE 25 mg Tab [BCH] Q0163 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400891 Pharmacy aspirin 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403838 Pharmacy hepatitis B adult vaccine 20 mcg/mL Sus [BCH] 636 $129.43 $- $33.65 $- $- $103.54 $- N/A $33.65 N/A N/A $48.92 N/A N/A $77.66 N/A N/A $64.71 N/A N/A N/A N/A N/A $88.01 N/A N/A $80.25 N/A N/A $53.07 N/A N/A $90.60 N/A N/A $103.54 N/A N/A $71.19 N/A N/A $90.60 N/A N/A $43.36 N/A N/A N/A N/A N/A $77.66 N/A N/A $45.30 N/A N/A $84.13 N/A N/A N/A N/A N/A $77.66 N/A N/A $90.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $129.43 $129.43 N/A 4403838 Pharmacy hepatitis B adult vaccine 20 mcg/mL Sus [BCH] 250 $129.43 $- $33.65 $- $- $103.54 $- N/A $33.65 N/A N/A $48.92 N/A N/A $77.66 N/A N/A $64.71 N/A N/A N/A N/A N/A $88.01 N/A N/A $80.25 N/A N/A $53.07 N/A N/A $90.60 N/A N/A $103.54 N/A N/A $71.19 N/A N/A $90.60 N/A N/A $43.36 N/A N/A N/A N/A N/A $77.66 N/A N/A $45.30 N/A N/A $84.13 N/A N/A N/A N/A N/A $77.66 N/A N/A $90.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $129.43 $129.43 N/A 4409469 Pharmacy hepatitis A adult vaccine 1440 units/mL PF IM Susp [BCH] 636 $152.64 $- $39.69 $- $- $122.11 $- N/A $39.69 N/A N/A $57.70 N/A N/A $91.58 N/A N/A $76.32 N/A N/A N/A N/A N/A $103.79 N/A N/A $94.64 N/A N/A $62.58 N/A N/A $106.85 N/A N/A $122.11 N/A N/A $83.95 N/A N/A $106.85 N/A N/A $51.13 N/A N/A N/A N/A N/A $91.58 N/A N/A $53.42 N/A N/A $99.21 N/A N/A N/A N/A N/A $91.58 N/A N/A $106.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $152.64 $152.64 N/A 4400257 Pharmacy "tetanus/diphtheria/pertussis, (Tdap) 5 units-2.5 units-18.5 mcg/0.5 mL IM Susp 0 mL [BCH]" 90715 636 $91.76 $- $23.86 $- $- $73.41 $- N/A $23.86 N/A N/A $34.69 N/A N/A $55.06 N/A N/A $45.88 N/A N/A N/A N/A N/A $62.40 N/A N/A $56.89 N/A N/A $37.62 N/A N/A $64.23 N/A N/A $73.41 N/A N/A $50.47 N/A N/A $64.23 N/A N/A $30.74 N/A N/A N/A N/A N/A $55.06 N/A N/A $32.12 N/A N/A $59.65 N/A N/A N/A N/A N/A $55.06 N/A N/A $64.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $91.76 $91.76 N/A 4400940 Pharmacy "influenza virus vaccine, inactivated preservative-free quadrivalent Sus [BCH]" 90686 636 $87.02 $- $22.63 $- $- $69.62 $- N/A $22.63 N/A N/A $32.90 N/A N/A $52.21 N/A N/A $43.51 N/A N/A N/A N/A N/A $59.18 N/A N/A $53.95 N/A N/A $35.68 N/A N/A $60.92 N/A N/A $69.62 N/A N/A $47.86 N/A N/A $60.92 N/A N/A $29.15 N/A N/A N/A N/A N/A $52.21 N/A N/A $30.46 N/A N/A $56.57 N/A N/A N/A N/A N/A $52.21 N/A N/A $60.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $87.02 $87.02 N/A 4400940 Pharmacy "influenza virus vaccine, inactivated preservative-free quadrivalent Sus [BCH]" 90686 636 $80.14 $- $20.84 $- $- $64.11 $- N/A $20.84 N/A N/A $30.29 N/A N/A $48.08 N/A N/A $40.07 N/A N/A N/A N/A N/A $54.49 N/A N/A $49.68 N/A N/A $32.86 N/A N/A $56.10 N/A N/A $64.11 N/A N/A $44.07 N/A N/A $56.10 N/A N/A $26.85 N/A N/A N/A N/A N/A $48.08 N/A N/A $28.05 N/A N/A $52.09 N/A N/A N/A N/A N/A $48.08 N/A N/A $56.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.14 $80.14 N/A 4400940 Pharmacy "influenzavirus vaccine, inactivated quad preservative-free quadrivalent Syringe[BCH]" 90686 636 $40.07 $- $10.42 $- $- $32.05 $- N/A $10.42 N/A N/A $15.15 N/A N/A $24.04 N/A N/A $20.03 N/A N/A N/A N/A N/A $27.25 N/A N/A $24.84 N/A N/A $16.43 N/A N/A $28.05 N/A N/A $32.05 N/A N/A $22.04 N/A N/A $28.05 N/A N/A $13.42 N/A N/A N/A N/A N/A $24.04 N/A N/A $14.02 N/A N/A $26.04 N/A N/A N/A N/A N/A $24.04 N/A N/A $28.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.07 $40.07 N/A 4401011 Pharmacy "rabies vaccine, purified chick embryo cell 2.5 intl units Pow [BCH]" 90675 636 $- $- $216.60 $- $- $666.45 $- N/A $216.60 N/A N/A $314.90 N/A N/A $499.84 N/A N/A $416.53 N/A N/A N/A N/A N/A $566.48 N/A N/A $516.50 N/A N/A $341.56 N/A N/A $583.14 N/A N/A $666.45 N/A N/A $458.19 N/A N/A $583.14 N/A N/A $279.08 N/A N/A N/A N/A N/A $499.84 N/A N/A $291.57 N/A N/A $541.49 N/A N/A N/A N/A N/A $499.84 N/A N/A $583.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4401938 Pharmacy bacitracin/neomycin/polymyxin B topical 400 units-3.5 mg-5000 units/g Oin 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400666 Pharmacy sevelamer carbonate 800 mg Tab [BCH] 250 $13.55 $- $3.52 $- $- $10.84 $- N/A $3.52 N/A N/A $5.12 N/A N/A $8.13 N/A N/A $6.77 N/A N/A N/A N/A N/A $9.21 N/A N/A $8.40 N/A N/A $5.55 N/A N/A $9.48 N/A N/A $10.84 N/A N/A $7.45 N/A N/A $9.48 N/A N/A $4.54 N/A N/A N/A N/A N/A $8.13 N/A N/A $4.74 N/A N/A $8.80 N/A N/A N/A N/A N/A $8.13 N/A N/A $9.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.55 $13.55 N/A 4400670 Pharmacy sevelamer carbonate 0.8 g Pow [BCH] 250 $40.64 $- $10.57 $- $- $32.51 $- N/A $10.57 N/A N/A $15.36 N/A N/A $24.38 N/A N/A $20.32 N/A N/A N/A N/A N/A $27.64 N/A N/A $25.20 N/A N/A $16.66 N/A N/A $28.45 N/A N/A $32.51 N/A N/A $22.35 N/A N/A $28.45 N/A N/A $13.61 N/A N/A N/A N/A N/A $24.38 N/A N/A $14.22 N/A N/A $26.42 N/A N/A N/A N/A N/A $24.38 N/A N/A $28.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.64 $40.64 N/A 4409483 Pharmacy olopatadine ophthalmic 0.1% Sol[BCH] 250 $18.24 $- $4.74 $- $- $14.59 $- N/A $4.74 N/A N/A $6.89 N/A N/A $10.94 N/A N/A $9.12 N/A N/A N/A N/A N/A $12.40 N/A N/A $11.31 N/A N/A $7.48 N/A N/A $12.77 N/A N/A $14.59 N/A N/A $10.03 N/A N/A $12.77 N/A N/A $6.11 N/A N/A N/A N/A N/A $10.94 N/A N/A $6.38 N/A N/A $11.86 N/A N/A N/A N/A N/A $10.94 N/A N/A $12.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.24 $18.24 N/A 4400133 Pharmacy codeine-guaifenesin 10 mg-100 mg/5 mL Syr [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400971 Pharmacy haloperidol 20 mg Tab 250 $5.51 $- $1.43 $- $- $4.41 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.31 N/A N/A $2.76 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.42 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.41 N/A N/A $3.03 N/A N/A $3.86 N/A N/A $1.85 N/A N/A N/A N/A N/A $3.31 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.51 $5.51 N/A 4402013 Pharmacy dicyclomine 10 mg/mL Inj Sol [BCH] J0500 636 $147.82 $- $38.43 $- $- $118.26 $- N/A $38.43 N/A N/A Not Reimbursed N/A N/A $88.69 N/A N/A $73.91 N/A N/A N/A N/A N/A $100.52 N/A N/A $91.65 N/A N/A $60.61 N/A N/A $103.48 N/A N/A $118.26 N/A N/A $81.30 N/A N/A $103.48 N/A N/A $49.52 N/A N/A N/A N/A N/A $88.69 N/A N/A $51.74 N/A N/A $96.09 N/A N/A $40.65 N/A N/A $88.69 N/A N/A $103.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $147.82 $147.82 N/A 4402252 Pharmacy sucralfate 1 g Tab [BCH} 250 $7.78 $- $2.02 $- $- $6.22 $- N/A $2.02 N/A N/A $2.94 N/A N/A $4.67 N/A N/A $3.89 N/A N/A N/A N/A N/A $5.29 N/A N/A $4.82 N/A N/A $3.19 N/A N/A $5.44 N/A N/A $6.22 N/A N/A $4.28 N/A N/A $5.44 N/A N/A $2.61 N/A N/A N/A N/A N/A $4.67 N/A N/A $2.72 N/A N/A $5.05 N/A N/A N/A N/A N/A $4.67 N/A N/A $5.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.78 $7.78 N/A 4409493 Pharmacy oxyCODONE 10 mg ER Tab [BCH] 250 $7.36 $- $1.91 $- $- $5.89 $- N/A $1.91 N/A N/A $2.78 N/A N/A $4.41 N/A N/A $3.68 N/A N/A N/A N/A N/A $5.00 N/A N/A $4.56 N/A N/A $3.02 N/A N/A $5.15 N/A N/A $5.89 N/A N/A $4.05 N/A N/A $5.15 N/A N/A $2.46 N/A N/A N/A N/A N/A $4.41 N/A N/A $2.57 N/A N/A $4.78 N/A N/A N/A N/A N/A $4.41 N/A N/A $5.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.36 $7.36 N/A 4409493 Pharmacy oxyCODONE 10 mg ER Tab [BCH] 250 $7.55 $- $1.96 $- $- $6.04 $- N/A $1.96 N/A N/A $2.86 N/A N/A $4.53 N/A N/A $3.78 N/A N/A N/A N/A N/A $5.14 N/A N/A $4.68 N/A N/A $3.10 N/A N/A $5.29 N/A N/A $6.04 N/A N/A $4.15 N/A N/A $5.29 N/A N/A $2.53 N/A N/A N/A N/A N/A $4.53 N/A N/A $2.64 N/A N/A $4.91 N/A N/A N/A N/A N/A $4.53 N/A N/A $5.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.55 $7.55 N/A 4406846 Pharmacy oxyCODONE 20 mg ER Tab [BCH] 250 $13.72 $- $3.57 $- $- $10.98 $- N/A $3.57 N/A N/A $5.19 N/A N/A $8.23 N/A N/A $6.86 N/A N/A N/A N/A N/A $9.33 N/A N/A $8.51 N/A N/A $5.63 N/A N/A $9.60 N/A N/A $10.98 N/A N/A $7.55 N/A N/A $9.60 N/A N/A $4.60 N/A N/A N/A N/A N/A $8.23 N/A N/A $4.80 N/A N/A $8.92 N/A N/A N/A N/A N/A $8.23 N/A N/A $9.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.72 $13.72 N/A 4406846 Pharmacy oxyCODONE 20 mg ER Tab [BCH] 250 $14.07 $- $3.66 $- $- $11.26 $- N/A $3.66 N/A N/A $5.32 N/A N/A $8.44 N/A N/A $7.04 N/A N/A N/A N/A N/A $9.57 N/A N/A $8.72 N/A N/A $5.77 N/A N/A $9.85 N/A N/A $11.26 N/A N/A $7.74 N/A N/A $9.85 N/A N/A $4.71 N/A N/A N/A N/A N/A $8.44 N/A N/A $4.92 N/A N/A $9.15 N/A N/A N/A N/A N/A $8.44 N/A N/A $9.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.07 $14.07 N/A 4400997 Pharmacy oxyCODONE 30 mg Tab [BCH] 250 $25.05 $- $6.51 $- $- $20.04 $- N/A $6.51 N/A N/A $9.47 N/A N/A $15.03 N/A N/A $12.53 N/A N/A N/A N/A N/A $17.04 N/A N/A $15.53 N/A N/A $10.27 N/A N/A $17.54 N/A N/A $20.04 N/A N/A $13.78 N/A N/A $17.54 N/A N/A $8.39 N/A N/A N/A N/A N/A $15.03 N/A N/A $8.77 N/A N/A $16.28 N/A N/A N/A N/A N/A $15.03 N/A N/A $17.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.05 $25.05 N/A 4400568 Pharmacy oxyCODONE 40 mg ER Tab [BCH] 250 $23.50 $- $6.11 $- $- $18.80 $- N/A $6.11 N/A N/A $8.88 N/A N/A $14.10 N/A N/A $11.75 N/A N/A N/A N/A N/A $15.98 N/A N/A $14.57 N/A N/A $9.63 N/A N/A $16.45 N/A N/A $18.80 N/A N/A $12.92 N/A N/A $16.45 N/A N/A $7.87 N/A N/A N/A N/A N/A $14.10 N/A N/A $8.22 N/A N/A $15.27 N/A N/A N/A N/A N/A $14.10 N/A N/A $16.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.50 $23.50 N/A 4400568 Pharmacy oxyCODONE 40 mg ER Tab [BCH] 250 $24.09 $- $6.26 $- $- $19.27 $- N/A $6.26 N/A N/A $9.11 N/A N/A $14.45 N/A N/A $12.05 N/A N/A N/A N/A N/A $16.38 N/A N/A $14.94 N/A N/A $9.88 N/A N/A $16.86 N/A N/A $19.27 N/A N/A $13.25 N/A N/A $16.86 N/A N/A $8.07 N/A N/A N/A N/A N/A $14.45 N/A N/A $8.43 N/A N/A $15.66 N/A N/A N/A N/A N/A $14.45 N/A N/A $16.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.09 $24.09 N/A 4400835 Pharmacy oxyCODONE 60 mg Tab [BCH] 250 $33.27 $- $8.65 $- $- $26.61 $- N/A $8.65 N/A N/A $12.58 N/A N/A $19.96 N/A N/A $16.63 N/A N/A N/A N/A N/A $22.62 N/A N/A $20.63 N/A N/A $13.64 N/A N/A $23.29 N/A N/A $26.61 N/A N/A $18.30 N/A N/A $23.29 N/A N/A $11.14 N/A N/A N/A N/A N/A $19.96 N/A N/A $11.64 N/A N/A $21.62 N/A N/A N/A N/A N/A $19.96 N/A N/A $23.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.27 $33.27 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $71.36 $- $18.55 $- $- $57.09 $- N/A $18.55 N/A N/A $26.97 N/A N/A $42.81 N/A N/A $35.68 N/A N/A N/A N/A N/A $48.52 N/A N/A $44.24 N/A N/A $29.26 N/A N/A $49.95 N/A N/A $57.09 N/A N/A $39.25 N/A N/A $49.95 N/A N/A $23.90 N/A N/A N/A N/A N/A $42.81 N/A N/A $24.98 N/A N/A $46.38 N/A N/A N/A N/A N/A $42.81 N/A N/A $49.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $71.36 $71.36 N/A 4400863 Pharmacy ARIPiprazole 400 mg PWD [BCH] J0401 636 "$6,127.84 " $- $5.70 $- $- "$4,902.27 " $- N/A "$1,593.24 " N/A N/A Not Reimbursed N/A N/A "$3,676.70 " N/A N/A "$3,063.92 " N/A N/A N/A N/A N/A "$4,166.93 " N/A N/A "$3,799.26 " N/A N/A "$2,512.41 " N/A N/A "$4,289.49 " N/A N/A "$4,902.27 " N/A N/A "$3,370.31 " N/A N/A "$4,289.49 " N/A N/A "$2,052.83 " N/A N/A N/A N/A N/A "$3,676.70 " N/A N/A "$2,144.74 " N/A N/A "$3,983.10 " N/A N/A $5.70 N/A N/A "$3,676.70 " N/A N/A "$4,289.49 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$6,127.84 " "$6,127.84 " N/A 4400485 Pharmacy tolvaptan 15 mg Tab [BCH] 250 $858.74 $- $223.27 $- $- $686.99 $- N/A $223.27 N/A N/A $324.60 N/A N/A $515.24 N/A N/A $429.37 N/A N/A N/A N/A N/A $583.94 N/A N/A $532.42 N/A N/A $352.08 N/A N/A $601.12 N/A N/A $686.99 N/A N/A $472.31 N/A N/A $601.12 N/A N/A $287.68 N/A N/A N/A N/A N/A $515.24 N/A N/A $300.56 N/A N/A $558.18 N/A N/A N/A N/A N/A $515.24 N/A N/A $601.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $858.74 $858.74 N/A 440933 Pharmacy brexpiprazole 1 mg Tab [BCH] 250 $80.76 $- $21.00 $- $- $64.61 $- N/A $21.00 N/A N/A $30.53 N/A N/A $48.46 N/A N/A $40.38 N/A N/A N/A N/A N/A $54.92 N/A N/A $50.07 N/A N/A $33.11 N/A N/A $56.53 N/A N/A $64.61 N/A N/A $44.42 N/A N/A $56.53 N/A N/A $27.06 N/A N/A N/A N/A N/A $48.46 N/A N/A $28.27 N/A N/A $52.49 N/A N/A N/A N/A N/A $48.46 N/A N/A $56.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.76 $80.76 N/A 440934 Pharmacy brexpiprazole 2 mg Tab [BCH] 250 $80.76 $- $21.00 $- $- $64.61 $- N/A $21.00 N/A N/A $30.53 N/A N/A $48.46 N/A N/A $40.38 N/A N/A N/A N/A N/A $54.92 N/A N/A $50.07 N/A N/A $33.11 N/A N/A $56.53 N/A N/A $64.61 N/A N/A $44.42 N/A N/A $56.53 N/A N/A $27.06 N/A N/A N/A N/A N/A $48.46 N/A N/A $28.27 N/A N/A $52.49 N/A N/A N/A N/A N/A $48.46 N/A N/A $56.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.76 $80.76 N/A 440935 Pharmacy brexpiprazole 3 mg Tab [BCH] 250 $80.76 $- $21.00 $- $- $64.61 $- N/A $21.00 N/A N/A $30.53 N/A N/A $48.46 N/A N/A $40.38 N/A N/A N/A N/A N/A $54.92 N/A N/A $50.07 N/A N/A $33.11 N/A N/A $56.53 N/A N/A $64.61 N/A N/A $44.42 N/A N/A $56.53 N/A N/A $27.06 N/A N/A N/A N/A N/A $48.46 N/A N/A $28.27 N/A N/A $52.49 N/A N/A N/A N/A N/A $48.46 N/A N/A $56.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.76 $80.76 N/A 440936 Pharmacy brexpiprazole 4 mg Tab [BCH] 250 $80.76 $- $21.00 $- $- $64.61 $- N/A $21.00 N/A N/A $30.53 N/A N/A $48.46 N/A N/A $40.38 N/A N/A N/A N/A N/A $54.92 N/A N/A $50.07 N/A N/A $33.11 N/A N/A $56.53 N/A N/A $64.61 N/A N/A $44.42 N/A N/A $56.53 N/A N/A $27.06 N/A N/A N/A N/A N/A $48.46 N/A N/A $28.27 N/A N/A $52.49 N/A N/A N/A N/A N/A $48.46 N/A N/A $56.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.76 $80.76 N/A 4400863 Pharmacy ARIPiprazole 400 mg PWD [BCH] J0401 636 "$5,199.38 " $- $5.70 $- $- "$4,159.50 " $- N/A "$1,351.84 " N/A N/A Not Reimbursed N/A N/A "$3,119.63 " N/A N/A "$2,599.69 " N/A N/A N/A N/A N/A "$3,535.58 " N/A N/A "$3,223.62 " N/A N/A "$2,131.75 " N/A N/A "$3,639.57 " N/A N/A "$4,159.50 " N/A N/A "$2,859.66 " N/A N/A "$3,639.57 " N/A N/A "$1,741.79 " N/A N/A N/A N/A N/A "$3,119.63 " N/A N/A "$1,819.78 " N/A N/A "$3,379.60 " N/A N/A $5.70 N/A N/A "$3,119.63 " N/A N/A "$3,639.57 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$5,199.38 " "$5,199.38 " N/A 4400035 Pharmacy atropine/hyoscyamine/PB/scopolamine Oral Elix 480 mL [BCH] 250 $86.59 $- $22.51 $- $- $69.27 $- N/A $22.51 N/A N/A $32.73 N/A N/A $51.96 N/A N/A $43.30 N/A N/A N/A N/A N/A $58.88 N/A N/A $53.69 N/A N/A $35.50 N/A N/A $60.61 N/A N/A $69.27 N/A N/A $47.63 N/A N/A $60.61 N/A N/A $29.01 N/A N/A N/A N/A N/A $51.96 N/A N/A $30.31 N/A N/A $56.28 N/A N/A N/A N/A N/A $51.96 N/A N/A $60.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $86.59 $86.59 N/A 4409725 Pharmacy albuterol CFC free 90 mcg/inh Inh Aer w/Adapt [BCH] 250 $127.24 $- $33.08 $- $- $101.79 $- N/A $33.08 N/A N/A $48.10 N/A N/A $76.34 N/A N/A $63.62 N/A N/A N/A N/A N/A $86.52 N/A N/A $78.89 N/A N/A $52.17 N/A N/A $89.07 N/A N/A $101.79 N/A N/A $69.98 N/A N/A $89.07 N/A N/A $42.63 N/A N/A N/A N/A N/A $76.34 N/A N/A $44.53 N/A N/A $82.71 N/A N/A N/A N/A N/A $76.34 N/A N/A $89.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $127.24 $127.24 N/A 4409710 Pharmacy ezetimibe 10 mg Tab [BCH] 250 $20.56 $- $5.35 $- $- $16.45 $- N/A $5.35 N/A N/A $7.77 N/A N/A $12.34 N/A N/A $10.28 N/A N/A N/A N/A N/A $13.98 N/A N/A $12.75 N/A N/A $8.43 N/A N/A $14.39 N/A N/A $16.45 N/A N/A $11.31 N/A N/A $14.39 N/A N/A $6.89 N/A N/A N/A N/A N/A $12.34 N/A N/A $7.20 N/A N/A $13.37 N/A N/A N/A N/A N/A $12.34 N/A N/A $14.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.56 $20.56 N/A 4409408 Pharmacy azelastine nasal 137 mcg/inh Spr 250 $210.48 $- $54.72 $- $- $168.38 $- N/A $54.72 N/A N/A $79.56 N/A N/A $126.29 N/A N/A $105.24 N/A N/A N/A N/A N/A $143.13 N/A N/A $130.50 N/A N/A $86.30 N/A N/A $147.34 N/A N/A $168.38 N/A N/A $115.76 N/A N/A $147.34 N/A N/A $70.51 N/A N/A N/A N/A N/A $126.29 N/A N/A $73.67 N/A N/A $136.81 N/A N/A N/A N/A N/A $126.29 N/A N/A $147.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $210.48 $210.48 N/A 4403280 Pharmacy propafenone 150 mg Tab [BCH] 250 $3.27 $- $0.85 $- $- $2.62 $- N/A $0.85 N/A N/A $1.24 N/A N/A $1.96 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.22 N/A N/A $2.03 N/A N/A $1.34 N/A N/A $2.29 N/A N/A $2.62 N/A N/A $1.80 N/A N/A $2.29 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.96 N/A N/A $1.15 N/A N/A $2.13 N/A N/A N/A N/A N/A $1.96 N/A N/A $2.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.27 $3.27 N/A 4407661 Pharmacy "epoetin alfa 20,000 units/mL Inj Sol [BCH]" J0886 636 "$1,123.20 " $- $292.03 $- $- $898.56 $- N/A $292.03 N/A N/A Not Reimbursed N/A N/A $673.92 N/A N/A $561.60 N/A N/A N/A N/A N/A $763.78 N/A N/A $696.38 N/A N/A $460.51 N/A N/A $786.24 N/A N/A $898.56 N/A N/A $617.76 N/A N/A $786.24 N/A N/A $376.27 N/A N/A N/A N/A N/A $673.92 N/A N/A $393.12 N/A N/A $730.08 N/A N/A N/A N/A N/A $673.92 N/A N/A $786.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,123.20 " "$1,123.20 " N/A 4403607 Pharmacy methylPREDNISolone 4 mg Tab J7509 636 $5.00 $- $0.34 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.34 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400749 Pharmacy risperiDONE 0.5 mg Tab 250 $9.83 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.88 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.88 N/A N/A $3.29 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.39 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.83 $9.83 N/A 4400748 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $11.01 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A $6.82 N/A N/A $4.51 N/A N/A $7.70 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.70 N/A N/A $3.69 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A N/A N/A N/A $6.60 N/A N/A $7.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.01 $11.01 N/A 4400750 Pharmacy risperiDONE 2 mg Tab [BCH] 250 $17.89 $- $4.65 $- $- $14.31 $- N/A $4.65 N/A N/A $6.76 N/A N/A $10.74 N/A N/A $8.95 N/A N/A N/A N/A N/A $12.17 N/A N/A $11.09 N/A N/A $7.34 N/A N/A $12.52 N/A N/A $14.31 N/A N/A $9.84 N/A N/A $12.52 N/A N/A $5.99 N/A N/A N/A N/A N/A $10.74 N/A N/A $6.26 N/A N/A $11.63 N/A N/A N/A N/A N/A $10.74 N/A N/A $12.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.89 $17.89 N/A 4400757 Pharmacy risperiDONE 3 mg Tab [BCH] 250 $22.58 $- $5.87 $- $- $18.06 $- N/A $5.87 N/A N/A $8.54 N/A N/A $13.55 N/A N/A $11.29 N/A N/A N/A N/A N/A $15.35 N/A N/A $14.00 N/A N/A $9.26 N/A N/A $15.81 N/A N/A $18.06 N/A N/A $12.42 N/A N/A $15.81 N/A N/A $7.56 N/A N/A N/A N/A N/A $13.55 N/A N/A $7.90 N/A N/A $14.68 N/A N/A N/A N/A N/A $13.55 N/A N/A $15.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.58 $22.58 N/A 4402575 Pharmacy prochlorperazine 5 mg Tab [BCH] Q0164 250 $2.00 $- $0.23 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A $0.23 N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402787 Pharmacy meclizine 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408453 Pharmacy predniSONE 10 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408446 Pharmacy predniSONE 20 mg Tab [BCH] J7506 250 $3.00 $- $0.78 $- $- $2.40 $- N/A $0.78 N/A N/A Not Reimbursed N/A N/A $1.80 N/A N/A $1.50 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.86 N/A N/A $1.23 N/A N/A $2.10 N/A N/A $2.40 N/A N/A $1.65 N/A N/A $2.10 N/A N/A $1.01 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.05 N/A N/A $1.95 N/A N/A N/A N/A N/A $1.80 N/A N/A $2.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.00 $3.00 N/A 4400886 Pharmacy Olanzapine ODT 10 mg Tab [BCH] 250 $41.94 $- $10.90 $- $- $33.55 $- N/A $10.90 N/A N/A $15.85 N/A N/A $25.16 N/A N/A $20.97 N/A N/A N/A N/A N/A $28.52 N/A N/A $26.00 N/A N/A $17.20 N/A N/A $29.36 N/A N/A $33.55 N/A N/A $23.07 N/A N/A $29.36 N/A N/A $14.05 N/A N/A N/A N/A N/A $25.16 N/A N/A $14.68 N/A N/A $27.26 N/A N/A N/A N/A N/A $25.16 N/A N/A $29.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.94 $41.94 N/A 4400866 Pharmacy OLANZapine 10 mg Tab 250 $41.95 $- $10.91 $- $- $33.56 $- N/A $10.91 N/A N/A $15.86 N/A N/A $25.17 N/A N/A $20.97 N/A N/A N/A N/A N/A $28.52 N/A N/A $26.01 N/A N/A $17.20 N/A N/A $29.36 N/A N/A $33.56 N/A N/A $23.07 N/A N/A $29.36 N/A N/A $14.05 N/A N/A N/A N/A N/A $25.17 N/A N/A $14.68 N/A N/A $27.27 N/A N/A N/A N/A N/A $25.17 N/A N/A $29.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.95 $41.95 N/A 4400305 Pharmacy hydrochlorothiazide 12.5 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402988 Pharmacy terazosin 1 mg Cap [BCH] 250 $3.21 $- $0.83 $- $- $2.57 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.93 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.77 N/A N/A $2.25 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.93 N/A N/A $1.12 N/A N/A $2.09 N/A N/A N/A N/A N/A $1.93 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.21 $3.21 N/A 4404791 Pharmacy terazosin 5 mg Cap [BCH] 250 $3.21 $- $0.83 $- $- $2.57 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.93 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.18 N/A N/A $1.99 N/A N/A $1.32 N/A N/A $2.25 N/A N/A $2.57 N/A N/A $1.77 N/A N/A $2.25 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.93 N/A N/A $1.12 N/A N/A $2.09 N/A N/A N/A N/A N/A $1.93 N/A N/A $2.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.21 $3.21 N/A 4400644 Pharmacy hydrocortisone 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400520 Pharmacy atorvastatin 10 mg Tab [BCH] 250 $7.71 $- $2.00 $- $- $6.17 $- N/A $2.00 N/A N/A $2.91 N/A N/A $4.63 N/A N/A $3.85 N/A N/A N/A N/A N/A $5.24 N/A N/A $4.78 N/A N/A $3.16 N/A N/A $5.40 N/A N/A $6.17 N/A N/A $4.24 N/A N/A $5.40 N/A N/A $2.58 N/A N/A N/A N/A N/A $4.63 N/A N/A $2.70 N/A N/A $5.01 N/A N/A N/A N/A N/A $4.63 N/A N/A $5.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.71 $7.71 N/A 4400678 Pharmacy atorvastatin 40 mg Tab [BCH] 250 $11.00 $- $2.86 $- $- $8.80 $- N/A $2.86 N/A N/A $4.16 N/A N/A $6.60 N/A N/A $5.50 N/A N/A N/A N/A N/A $7.48 N/A N/A $6.82 N/A N/A $4.51 N/A N/A $7.70 N/A N/A $8.80 N/A N/A $6.05 N/A N/A $7.70 N/A N/A $3.68 N/A N/A N/A N/A N/A $6.60 N/A N/A $3.85 N/A N/A $7.15 N/A N/A N/A N/A N/A $6.60 N/A N/A $7.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.00 $11.00 N/A 4407872 Pharmacy venlafaxine 37.5 mg ERCap [BCH] 250 $8.33 $- $2.17 $- $- $6.66 $- N/A $2.17 N/A N/A $3.15 N/A N/A $5.00 N/A N/A $4.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $5.16 N/A N/A $3.41 N/A N/A $5.83 N/A N/A $6.66 N/A N/A $4.58 N/A N/A $5.83 N/A N/A $2.79 N/A N/A N/A N/A N/A $5.00 N/A N/A $2.91 N/A N/A $5.41 N/A N/A N/A N/A N/A $5.00 N/A N/A $5.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.33 $8.33 N/A 4409523 Pharmacy venlafaxine 75 mg ERCap [BCH] 250 $9.33 $- $2.43 $- $- $7.46 $- N/A $2.43 N/A N/A $3.53 N/A N/A $5.60 N/A N/A $4.67 N/A N/A N/A N/A N/A $6.35 N/A N/A $5.79 N/A N/A $3.83 N/A N/A $6.53 N/A N/A $7.46 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.13 N/A N/A N/A N/A N/A $5.60 N/A N/A $3.27 N/A N/A $6.07 N/A N/A N/A N/A N/A $5.60 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.33 $9.33 N/A 4409394 Pharmacy latanoprost ophthalmic 0.005% Sol[BCH] 250 $190.54 $- $49.54 $- $- $152.43 $- N/A $49.54 N/A N/A $72.02 N/A N/A $114.32 N/A N/A $95.27 N/A N/A N/A N/A N/A $129.57 N/A N/A $118.13 N/A N/A $78.12 N/A N/A $133.38 N/A N/A $152.43 N/A N/A $104.80 N/A N/A $133.38 N/A N/A $63.83 N/A N/A N/A N/A N/A $114.32 N/A N/A $66.69 N/A N/A $123.85 N/A N/A N/A N/A N/A $114.32 N/A N/A $133.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $190.54 $190.54 N/A 4400679 Pharmacy glipiZIDE 2.5 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407384 Pharmacy NIFEdipine 10 mg Cap [BCH] 250 $2.17 $- $0.56 $- $- $1.73 $- N/A $0.56 N/A N/A $0.82 N/A N/A $1.30 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.34 N/A N/A $0.89 N/A N/A $1.52 N/A N/A $1.73 N/A N/A $1.19 N/A N/A $1.52 N/A N/A $0.73 N/A N/A N/A N/A N/A $1.30 N/A N/A $0.76 N/A N/A $1.41 N/A N/A N/A N/A N/A $1.30 N/A N/A $1.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.17 $2.17 N/A 4400163 Pharmacy ziprasidone 40 mg Cap [BCH] 250 $17.73 $- $4.61 $- $- $14.18 $- N/A $4.61 N/A N/A $6.70 N/A N/A $10.64 N/A N/A $8.86 N/A N/A N/A N/A N/A $12.05 N/A N/A $10.99 N/A N/A $7.27 N/A N/A $12.41 N/A N/A $14.18 N/A N/A $9.75 N/A N/A $12.41 N/A N/A $5.94 N/A N/A N/A N/A N/A $10.64 N/A N/A $6.20 N/A N/A $11.52 N/A N/A N/A N/A N/A $10.64 N/A N/A $12.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.73 $17.73 N/A 4406913 Pharmacy doxazosin 2 mg Tab [BCH] 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.48 N/A N/A $1.89 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4402019 Pharmacy azithromycin 250 mg Tab [BCH] 250 $15.55 $- $4.04 $- $- $12.44 $- N/A $4.04 N/A N/A $5.88 N/A N/A $9.33 N/A N/A $7.78 N/A N/A N/A N/A N/A $10.57 N/A N/A $9.64 N/A N/A $6.38 N/A N/A $10.89 N/A N/A $12.44 N/A N/A $8.55 N/A N/A $10.89 N/A N/A $5.21 N/A N/A N/A N/A N/A $9.33 N/A N/A $5.44 N/A N/A $10.11 N/A N/A N/A N/A N/A $9.33 N/A N/A $10.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.55 $15.55 N/A 4400355 Pharmacy azithromycin 200 mg/5 mL Oral Liq [BCH] Q0144 250 $69.77 $- $18.14 $- $- $55.81 $- N/A $18.14 N/A N/A Not Reimbursed N/A N/A $41.86 N/A N/A $34.88 N/A N/A N/A N/A N/A $47.44 N/A N/A $43.25 N/A N/A $28.60 N/A N/A $48.84 N/A N/A $55.81 N/A N/A $38.37 N/A N/A $48.84 N/A N/A $23.37 N/A N/A N/A N/A N/A $41.86 N/A N/A $24.42 N/A N/A $45.35 N/A N/A N/A N/A N/A $41.86 N/A N/A $48.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.77 $69.77 N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404577 Pharmacy ALPRAZolam 1 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403607 Pharmacy methylPREDNISolone 4 mg Tab [BCH] J7509 636 $5.00 $- $0.34 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.34 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400345 Pharmacy sertraline 100 mg Tab [BCH] 250 $5.42 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.25 N/A N/A $2.71 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.36 N/A N/A $2.22 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.98 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.25 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.25 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.42 $5.42 N/A 4400240 Pharmacy sulfaSALAzine 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400240 Pharmacy sulfaSALAzine 500 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4400477 Pharmacy potassium phosphate-sodium phosphate 250 mg-280 mg-160 mg Pow UD [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409509 Pharmacy multivitamin Vitamin B Complex with C and Folic Acid Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400600 Pharmacy iron polysaccharide 150 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400623 Pharmacy calcitriol 0.25 mcg Oral Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400902 Pharmacy bicalutamide 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402369 Pharmacy lactulose 10 g/15 mL Oral Syrup [BCH] 250 $27.82 $- $7.23 $- $- $22.26 $- N/A $7.23 N/A N/A $10.52 N/A N/A $16.69 N/A N/A $13.91 N/A N/A N/A N/A N/A $18.92 N/A N/A $17.25 N/A N/A $11.41 N/A N/A $19.48 N/A N/A $22.26 N/A N/A $15.30 N/A N/A $19.48 N/A N/A $9.32 N/A N/A N/A N/A N/A $16.69 N/A N/A $9.74 N/A N/A $18.09 N/A N/A N/A N/A N/A $16.69 N/A N/A $19.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.82 $27.82 N/A 4409030 Pharmacy fluticasone Nasal 0.05 mg/inh Spry [BCH] 250 $170.52 $- $44.34 $- $- $136.42 $- N/A $44.34 N/A N/A $64.46 N/A N/A $102.31 N/A N/A $85.26 N/A N/A N/A N/A N/A $115.95 N/A N/A $105.72 N/A N/A $69.91 N/A N/A $119.36 N/A N/A $136.42 N/A N/A $93.79 N/A N/A $119.36 N/A N/A $57.12 N/A N/A N/A N/A N/A $102.31 N/A N/A $59.68 N/A N/A $110.84 N/A N/A N/A N/A N/A $102.31 N/A N/A $119.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $170.52 $170.52 N/A 4400128 Pharmacy dexamethasone 0.5 mg/5 mL Liq [BCH] J8540 636 $128.99 $- $0.10 $- $- $103.19 $- N/A $33.54 N/A N/A Not Reimbursed N/A N/A $77.39 N/A N/A $64.50 N/A N/A N/A N/A N/A $87.71 N/A N/A $79.97 N/A N/A $52.89 N/A N/A $90.29 N/A N/A $103.19 N/A N/A $70.94 N/A N/A $90.29 N/A N/A $43.21 N/A N/A N/A N/A N/A $77.39 N/A N/A $45.15 N/A N/A $83.84 N/A N/A $0.10 N/A N/A $77.39 N/A N/A $90.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $128.99 $128.99 N/A 4404084 Pharmacy nystatin 100000 units/mL Sus 473 mL [BCH] 250 $2.45 $- $0.64 $- $- $1.96 $- N/A $0.64 N/A N/A $0.93 N/A N/A $1.47 N/A N/A $1.23 N/A N/A N/A N/A N/A $1.67 N/A N/A $1.52 N/A N/A $1.01 N/A N/A $1.72 N/A N/A $1.96 N/A N/A $1.35 N/A N/A $1.72 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.47 N/A N/A $0.86 N/A N/A $1.60 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.45 $2.45 N/A 4400802 Pharmacy "nystatin 100,000 units/mL Oral Susp [BCH]" 250 $33.88 $- $8.81 $- $- $27.10 $- N/A $8.81 N/A N/A $12.81 N/A N/A $20.33 N/A N/A $16.94 N/A N/A N/A N/A N/A $23.04 N/A N/A $21.01 N/A N/A $13.89 N/A N/A $23.72 N/A N/A $27.10 N/A N/A $18.63 N/A N/A $23.72 N/A N/A $11.35 N/A N/A N/A N/A N/A $20.33 N/A N/A $11.86 N/A N/A $22.02 N/A N/A N/A N/A N/A $20.33 N/A N/A $23.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.88 $33.88 N/A 4400388 Pharmacy triamcinolone Top 0.025% Lotion [BCH] 250 $75.58 $- $19.65 $- $- $60.46 $- N/A $19.65 N/A N/A $28.57 N/A N/A $45.35 N/A N/A $37.79 N/A N/A N/A N/A N/A $51.39 N/A N/A $46.86 N/A N/A $30.99 N/A N/A $52.91 N/A N/A $60.46 N/A N/A $41.57 N/A N/A $52.91 N/A N/A $25.32 N/A N/A N/A N/A N/A $45.35 N/A N/A $26.45 N/A N/A $49.13 N/A N/A N/A N/A N/A $45.35 N/A N/A $52.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.58 $75.58 N/A 4406865 Pharmacy pentoxifylline 400 mg ER Tab [BCH] 250 $2.28 $- $0.59 $- $- $1.82 $- N/A $0.59 N/A N/A $0.86 N/A N/A $1.37 N/A N/A $1.14 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.41 N/A N/A $0.94 N/A N/A $1.60 N/A N/A $1.82 N/A N/A $1.25 N/A N/A $1.60 N/A N/A $0.76 N/A N/A N/A N/A N/A $1.37 N/A N/A $0.80 N/A N/A $1.48 N/A N/A N/A N/A N/A $1.37 N/A N/A $1.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.28 $2.28 N/A 4401975 Pharmacy selegiline 5 mg Cap [BCH] 250 $4.60 $- $1.20 $- $- $3.68 $- N/A $1.20 N/A N/A $1.74 N/A N/A $2.76 N/A N/A $2.30 N/A N/A N/A N/A N/A $3.13 N/A N/A $2.85 N/A N/A $1.89 N/A N/A $3.22 N/A N/A $3.68 N/A N/A $2.53 N/A N/A $3.22 N/A N/A $1.54 N/A N/A N/A N/A N/A $2.76 N/A N/A $1.61 N/A N/A $2.99 N/A N/A N/A N/A N/A $2.76 N/A N/A $3.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.60 $4.60 N/A 4400170 Pharmacy sotalol 80 mg Tab [BCH] 250 $5.12 $- $1.33 $- $- $4.10 $- N/A $1.33 N/A N/A $1.94 N/A N/A $3.07 N/A N/A $2.56 N/A N/A N/A N/A N/A $3.48 N/A N/A $3.18 N/A N/A $2.10 N/A N/A $3.59 N/A N/A $4.10 N/A N/A $2.82 N/A N/A $3.59 N/A N/A $1.72 N/A N/A N/A N/A N/A $3.07 N/A N/A $1.79 N/A N/A $3.33 N/A N/A N/A N/A N/A $3.07 N/A N/A $3.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.12 $5.12 N/A 4406913 Pharmacy doxazosin 2 mg Tab [BCH] 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.48 N/A N/A $1.89 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4400539 Pharmacy PARoxetine 40 mg Tab [BCH] 250 $5.95 $- $1.55 $- $- $4.76 $- N/A $1.55 N/A N/A $2.25 N/A N/A $3.57 N/A N/A $2.97 N/A N/A N/A N/A N/A $4.04 N/A N/A $3.69 N/A N/A $2.44 N/A N/A $4.16 N/A N/A $4.76 N/A N/A $3.27 N/A N/A $4.16 N/A N/A $1.99 N/A N/A N/A N/A N/A $3.57 N/A N/A $2.08 N/A N/A $3.86 N/A N/A N/A N/A N/A $3.57 N/A N/A $4.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.95 $5.95 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.84 N/A N/A $1.68 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.49 N/A N/A $1.89 N/A N/A $0.91 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.95 N/A N/A $1.76 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.66 $- $0.69 $- $- $2.13 $- N/A $0.69 N/A N/A $1.01 N/A N/A $1.60 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.81 N/A N/A $1.65 N/A N/A $1.09 N/A N/A $1.86 N/A N/A $2.13 N/A N/A $1.46 N/A N/A $1.86 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.60 N/A N/A $0.93 N/A N/A $1.73 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.66 $2.66 N/A 4402566 Pharmacy glipiZIDE 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400611 Pharmacy buPROPion 75 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406804 Pharmacy torsemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409754 Pharmacy tiZANidine 2 mg Tab [BCH] 250 $2.44 $- $0.64 $- $- $1.96 $- N/A $0.64 N/A N/A $0.92 N/A N/A $1.47 N/A N/A $1.22 N/A N/A N/A N/A N/A $1.66 N/A N/A $1.52 N/A N/A $1.00 N/A N/A $1.71 N/A N/A $1.96 N/A N/A $1.34 N/A N/A $1.71 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.47 N/A N/A $0.86 N/A N/A $1.59 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.44 $2.44 N/A 4407265 Pharmacy clopidogrel 75 mg Tab [BCH] 250 $13.92 $- $3.62 $- $- $11.14 $- N/A $3.62 N/A N/A $5.26 N/A N/A $8.35 N/A N/A $6.96 N/A N/A N/A N/A N/A $9.47 N/A N/A $8.63 N/A N/A $5.71 N/A N/A $9.75 N/A N/A $11.14 N/A N/A $7.66 N/A N/A $9.75 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.35 N/A N/A $4.87 N/A N/A $9.05 N/A N/A N/A N/A N/A $8.35 N/A N/A $9.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.92 $13.92 N/A 4409483 Pharmacy olopatadine Ophth 0.1% Sol [BCH] 250 $513.00 $- $133.38 $- $- $410.40 $- N/A $133.38 N/A N/A $193.91 N/A N/A $307.80 N/A N/A $256.50 N/A N/A N/A N/A N/A $348.84 N/A N/A $318.06 N/A N/A $210.33 N/A N/A $359.10 N/A N/A $410.40 N/A N/A $282.15 N/A N/A $359.10 N/A N/A $171.86 N/A N/A N/A N/A N/A $307.80 N/A N/A $179.55 N/A N/A $333.45 N/A N/A N/A N/A N/A $307.80 N/A N/A $359.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $513.00 $513.00 N/A 4409637 Pharmacy travoprost ophthalmic 0.004% Sol [BCH] 250 $419.22 $- $109.00 $- $- $335.38 $- N/A $109.00 N/A N/A $158.47 N/A N/A $251.53 N/A N/A $209.61 N/A N/A N/A N/A N/A $285.07 N/A N/A $259.92 N/A N/A $171.88 N/A N/A $293.45 N/A N/A $335.38 N/A N/A $230.57 N/A N/A $293.45 N/A N/A $140.44 N/A N/A N/A N/A N/A $251.53 N/A N/A $146.73 N/A N/A $272.49 N/A N/A N/A N/A N/A $251.53 N/A N/A $293.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $419.22 $419.22 N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $80.72 $- $1.93 $- $- $64.58 $- N/A $20.99 N/A N/A Not Reimbursed N/A N/A $48.43 N/A N/A $40.36 N/A N/A N/A N/A N/A $54.89 N/A N/A $50.05 N/A N/A $33.10 N/A N/A $56.50 N/A N/A $64.58 N/A N/A $44.40 N/A N/A $56.50 N/A N/A $27.04 N/A N/A N/A N/A N/A $48.43 N/A N/A $28.25 N/A N/A $52.47 N/A N/A $1.93 N/A N/A $48.43 N/A N/A $56.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.72 $80.72 N/A 4409647 Pharmacy piperacillin-tazobactam 2 g-0.25 g IV Inj [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4403306 Pharmacy ceFAZolin 1 g Inj [BCH] J0690 636 $28.00 $- $0.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4407723 Pharmacy cefTRIAXone 250 mg Inj [BCH] J0696 636 $29.64 $- $0.53 $- $- $23.71 $- N/A $7.71 N/A N/A Not Reimbursed N/A N/A $17.78 N/A N/A $14.82 N/A N/A N/A N/A N/A $20.16 N/A N/A $18.38 N/A N/A $12.15 N/A N/A $20.75 N/A N/A $23.71 N/A N/A $16.30 N/A N/A $20.75 N/A N/A $9.93 N/A N/A N/A N/A N/A $17.78 N/A N/A $10.37 N/A N/A $19.27 N/A N/A $0.53 N/A N/A $17.78 N/A N/A $20.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.64 $29.64 N/A 4400880 Pharmacy cefTRIAXone 1 g Inj [BCH] J0696 636 $91.98 $- $0.53 $- $- $73.58 $- N/A $23.91 N/A N/A Not Reimbursed N/A N/A $55.19 N/A N/A $45.99 N/A N/A N/A N/A N/A $62.55 N/A N/A $57.03 N/A N/A $37.71 N/A N/A $64.39 N/A N/A $73.58 N/A N/A $50.59 N/A N/A $64.39 N/A N/A $30.81 N/A N/A N/A N/A N/A $55.19 N/A N/A $32.19 N/A N/A $59.79 N/A N/A $0.53 N/A N/A $55.19 N/A N/A $64.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $91.98 $91.98 N/A 4409450 Pharmacy calcitonin 200 intl units/inh Nasal Spry [BCH] 250 $237.08 $- $61.64 $- $- $189.66 $- N/A $61.64 N/A N/A $89.62 N/A N/A $142.25 N/A N/A $118.54 N/A N/A N/A N/A N/A $161.21 N/A N/A $146.99 N/A N/A $97.20 N/A N/A $165.96 N/A N/A $189.66 N/A N/A $130.39 N/A N/A $165.96 N/A N/A $79.42 N/A N/A N/A N/A N/A $142.25 N/A N/A $82.98 N/A N/A $154.10 N/A N/A N/A N/A N/A $142.25 N/A N/A $165.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $237.08 $237.08 N/A 4400795 Pharmacy ipratropium nasal 21 mcg/inh Spr 250 $7.44 $- $1.94 $- $- $5.96 $- N/A $1.94 N/A N/A $2.81 N/A N/A $4.47 N/A N/A $3.72 N/A N/A N/A N/A N/A $5.06 N/A N/A $4.62 N/A N/A $3.05 N/A N/A $5.21 N/A N/A $5.96 N/A N/A $4.09 N/A N/A $5.21 N/A N/A $2.49 N/A N/A N/A N/A N/A $4.47 N/A N/A $2.61 N/A N/A $4.84 N/A N/A N/A N/A N/A $4.47 N/A N/A $5.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.44 $7.44 N/A 4409505 Pharmacy ipratropium nasal 42 mcg/inh Spr [BCH] 250 $191.42 $- $49.77 $- $- $153.14 $- N/A $49.77 N/A N/A $72.36 N/A N/A $114.85 N/A N/A $95.71 N/A N/A N/A N/A N/A $130.17 N/A N/A $118.68 N/A N/A $78.48 N/A N/A $133.99 N/A N/A $153.14 N/A N/A $105.28 N/A N/A $133.99 N/A N/A $64.13 N/A N/A N/A N/A N/A $114.85 N/A N/A $67.00 N/A N/A $124.42 N/A N/A N/A N/A N/A $114.85 N/A N/A $133.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $191.42 $191.42 N/A 4409030 Pharmacy fluticasone Nasal 0.05 mg/inh Spry [BCH] 250 $170.52 $- $44.34 $- $- $136.42 $- N/A $44.34 N/A N/A $64.46 N/A N/A $102.31 N/A N/A $85.26 N/A N/A N/A N/A N/A $115.95 N/A N/A $105.72 N/A N/A $69.91 N/A N/A $119.36 N/A N/A $136.42 N/A N/A $93.79 N/A N/A $119.36 N/A N/A $57.12 N/A N/A N/A N/A N/A $102.31 N/A N/A $59.68 N/A N/A $110.84 N/A N/A N/A N/A N/A $102.31 N/A N/A $119.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $170.52 $170.52 N/A 4409408 Pharmacy azelastine Nasal 137 mcg/inh Spry [BCH] 250 $210.48 $- $54.72 $- $- $168.38 $- N/A $54.72 N/A N/A $79.56 N/A N/A $126.29 N/A N/A $105.24 N/A N/A N/A N/A N/A $143.13 N/A N/A $130.50 N/A N/A $86.30 N/A N/A $147.34 N/A N/A $168.38 N/A N/A $115.76 N/A N/A $147.34 N/A N/A $70.51 N/A N/A N/A N/A N/A $126.29 N/A N/A $73.67 N/A N/A $136.81 N/A N/A N/A N/A N/A $126.29 N/A N/A $147.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $210.48 $210.48 N/A 4409522 Pharmacy cefepime 1 g Pow [BCH] J0692 636 $40.66 $- $1.93 $- $- $32.53 $- N/A $10.57 N/A N/A Not Reimbursed N/A N/A $24.40 N/A N/A $20.33 N/A N/A N/A N/A N/A $27.65 N/A N/A $25.21 N/A N/A $16.67 N/A N/A $28.46 N/A N/A $32.53 N/A N/A $22.36 N/A N/A $28.46 N/A N/A $13.62 N/A N/A N/A N/A N/A $24.40 N/A N/A $14.23 N/A N/A $26.43 N/A N/A $1.93 N/A N/A $24.40 N/A N/A $28.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.66 $40.66 N/A 4400492 Pharmacy midodrine 5 mg Tab [BCH] 250 $4.86 $- $1.26 $- $- $3.89 $- N/A $1.26 N/A N/A $1.84 N/A N/A $2.92 N/A N/A $2.43 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.01 N/A N/A $1.99 N/A N/A $3.40 N/A N/A $3.89 N/A N/A $2.67 N/A N/A $3.40 N/A N/A $1.63 N/A N/A N/A N/A N/A $2.92 N/A N/A $1.70 N/A N/A $3.16 N/A N/A N/A N/A N/A $2.92 N/A N/A $3.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.86 $4.86 N/A 4400137 Pharmacy modafinil 100 mg Tab [BCH] 250 $52.75 $- $13.72 $- $- $42.20 $- N/A $13.72 N/A N/A $19.94 N/A N/A $31.65 N/A N/A $26.38 N/A N/A N/A N/A N/A $35.87 N/A N/A $32.71 N/A N/A $21.63 N/A N/A $36.93 N/A N/A $42.20 N/A N/A $29.01 N/A N/A $36.93 N/A N/A $17.67 N/A N/A N/A N/A N/A $31.65 N/A N/A $18.46 N/A N/A $34.29 N/A N/A N/A N/A N/A $31.65 N/A N/A $36.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.75 $52.75 N/A 4400725 Pharmacy ziprasidone 60 mg Cap [BCH] 250 $21.76 $- $5.66 $- $- $17.40 $- N/A $5.66 N/A N/A $8.22 N/A N/A $13.05 N/A N/A $10.88 N/A N/A N/A N/A N/A $14.79 N/A N/A $13.49 N/A N/A $8.92 N/A N/A $15.23 N/A N/A $17.40 N/A N/A $11.97 N/A N/A $15.23 N/A N/A $7.29 N/A N/A N/A N/A N/A $13.05 N/A N/A $7.61 N/A N/A $14.14 N/A N/A N/A N/A N/A $13.05 N/A N/A $15.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.76 $21.76 N/A 4409537 Pharmacy galantamine 4 mg Tab [BCH] 250 $6.36 $- $1.65 $- $- $5.09 $- N/A $1.65 N/A N/A $2.41 N/A N/A $3.82 N/A N/A $3.18 N/A N/A N/A N/A N/A $4.33 N/A N/A $3.95 N/A N/A $2.61 N/A N/A $4.46 N/A N/A $5.09 N/A N/A $3.50 N/A N/A $4.46 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.82 N/A N/A $2.23 N/A N/A $4.14 N/A N/A N/A N/A N/A $3.82 N/A N/A $4.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.36 $6.36 N/A 4400520 Pharmacy atorvastatin 10 mg Tab [BCH] 250 $8.10 $- $2.10 $- $- $6.48 $- N/A $2.10 N/A N/A $3.06 N/A N/A $4.86 N/A N/A $4.05 N/A N/A N/A N/A N/A $5.50 N/A N/A $5.02 N/A N/A $3.32 N/A N/A $5.67 N/A N/A $6.48 N/A N/A $4.45 N/A N/A $5.67 N/A N/A $2.71 N/A N/A N/A N/A N/A $4.86 N/A N/A $2.83 N/A N/A $5.26 N/A N/A N/A N/A N/A $4.86 N/A N/A $5.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.10 $8.10 N/A 4400519 Pharmacy atorvastatin 20 mg Tab [BCH] 250 $11.55 $- $3.00 $- $- $9.24 $- N/A $3.00 N/A N/A $4.36 N/A N/A $6.93 N/A N/A $5.77 N/A N/A N/A N/A N/A $7.85 N/A N/A $7.16 N/A N/A $4.73 N/A N/A $8.08 N/A N/A $9.24 N/A N/A $6.35 N/A N/A $8.08 N/A N/A $3.87 N/A N/A N/A N/A N/A $6.93 N/A N/A $4.04 N/A N/A $7.51 N/A N/A N/A N/A N/A $6.93 N/A N/A $8.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.55 $11.55 N/A 4400678 Pharmacy atorvastatin 40 mg Tab [BCH] 250 $11.55 $- $3.00 $- $- $9.24 $- N/A $3.00 N/A N/A $4.36 N/A N/A $6.93 N/A N/A $5.77 N/A N/A N/A N/A N/A $7.85 N/A N/A $7.16 N/A N/A $4.73 N/A N/A $8.08 N/A N/A $9.24 N/A N/A $6.35 N/A N/A $8.08 N/A N/A $3.87 N/A N/A N/A N/A N/A $6.93 N/A N/A $4.04 N/A N/A $7.51 N/A N/A N/A N/A N/A $6.93 N/A N/A $8.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.55 $11.55 N/A 4400654 Pharmacy traZODone 50 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4400143 Pharmacy atorvastatin 80 mg Tab [BCH] 250 $11.55 $- $3.00 $- $- $9.24 $- N/A $3.00 N/A N/A $4.36 N/A N/A $6.93 N/A N/A $5.77 N/A N/A N/A N/A N/A $7.85 N/A N/A $7.16 N/A N/A $4.73 N/A N/A $8.08 N/A N/A $9.24 N/A N/A $6.35 N/A N/A $8.08 N/A N/A $3.87 N/A N/A N/A N/A N/A $6.93 N/A N/A $4.04 N/A N/A $7.51 N/A N/A N/A N/A N/A $6.93 N/A N/A $8.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.55 $11.55 N/A 4409769 Pharmacy ARIPiprazole 5 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4400883 Pharmacy ARIPiprazole 10 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4408556 Pharmacy alfuzosin 10 mg ER Tab [BCH] 250 $8.44 $- $2.19 $- $- $6.75 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.22 N/A N/A N/A N/A N/A $5.74 N/A N/A $5.23 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.75 N/A N/A $4.64 N/A N/A $5.90 N/A N/A $2.83 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.44 $8.44 N/A 4400892 Pharmacy anastrozole 1 mg Tab [BCH] 250 $29.76 $- $7.74 $- $- $23.81 $- N/A $7.74 N/A N/A $11.25 N/A N/A $17.85 N/A N/A $14.88 N/A N/A N/A N/A N/A $20.23 N/A N/A $18.45 N/A N/A $12.20 N/A N/A $20.83 N/A N/A $23.81 N/A N/A $16.37 N/A N/A $20.83 N/A N/A $9.97 N/A N/A N/A N/A N/A $17.85 N/A N/A $10.42 N/A N/A $19.34 N/A N/A N/A N/A N/A $17.85 N/A N/A $20.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.76 $29.76 N/A 4400680 Pharmacy DULoxetine 60 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4407778 Pharmacy OLANZapine 2.5 mg Tab [BCH] 250 $22.39 $- $5.82 $- $- $17.92 $- N/A $5.82 N/A N/A $8.47 N/A N/A $13.44 N/A N/A $11.20 N/A N/A N/A N/A N/A $15.23 N/A N/A $13.88 N/A N/A $9.18 N/A N/A $15.68 N/A N/A $17.92 N/A N/A $12.32 N/A N/A $15.68 N/A N/A $7.50 N/A N/A N/A N/A N/A $13.44 N/A N/A $7.84 N/A N/A $14.56 N/A N/A N/A N/A N/A $13.44 N/A N/A $15.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.39 $22.39 N/A 4407778 Pharmacy OLANZapine 2.5 mg Tab [BCH] 250 $22.39 $- $5.82 $- $- $17.92 $- N/A $5.82 N/A N/A $8.47 N/A N/A $13.44 N/A N/A $11.20 N/A N/A N/A N/A N/A $15.23 N/A N/A $13.88 N/A N/A $9.18 N/A N/A $15.68 N/A N/A $17.92 N/A N/A $12.32 N/A N/A $15.68 N/A N/A $7.50 N/A N/A N/A N/A N/A $13.44 N/A N/A $7.84 N/A N/A $14.56 N/A N/A N/A N/A N/A $13.44 N/A N/A $15.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.39 $22.39 N/A 4400974 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $39.83 $- $10.36 $- $- $31.87 $- N/A $10.36 N/A N/A $15.06 N/A N/A $23.90 N/A N/A $19.92 N/A N/A N/A N/A N/A $27.09 N/A N/A $24.70 N/A N/A $16.33 N/A N/A $27.88 N/A N/A $31.87 N/A N/A $21.91 N/A N/A $27.88 N/A N/A $13.34 N/A N/A N/A N/A N/A $23.90 N/A N/A $13.94 N/A N/A $25.89 N/A N/A N/A N/A N/A $23.90 N/A N/A $27.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.83 $39.83 N/A 4400322 Pharmacy QUEtiapine 300 mg Tab [BCH] 250 $33.92 $- $8.82 $- $- $27.14 $- N/A $8.82 N/A N/A $12.82 N/A N/A $20.35 N/A N/A $16.96 N/A N/A N/A N/A N/A $23.07 N/A N/A $21.03 N/A N/A $13.91 N/A N/A $23.75 N/A N/A $27.14 N/A N/A $18.66 N/A N/A $23.75 N/A N/A $11.36 N/A N/A N/A N/A N/A $20.35 N/A N/A $11.87 N/A N/A $22.05 N/A N/A N/A N/A N/A $20.35 N/A N/A $23.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.92 $33.92 N/A 4405285 Pharmacy famciclovir 500 mg Tab [BCH] 250 $27.90 $- $7.25 $- $- $22.32 $- N/A $7.25 N/A N/A $10.55 N/A N/A $16.74 N/A N/A $13.95 N/A N/A N/A N/A N/A $18.97 N/A N/A $17.30 N/A N/A $11.44 N/A N/A $19.53 N/A N/A $22.32 N/A N/A $15.35 N/A N/A $19.53 N/A N/A $9.35 N/A N/A N/A N/A N/A $16.74 N/A N/A $9.77 N/A N/A $18.14 N/A N/A N/A N/A N/A $16.74 N/A N/A $19.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.90 $27.90 N/A 4400789 Pharmacy lamiVUDine 150 mg Tab [BCH] 250 $14.36 $- $3.73 $- $- $11.49 $- N/A $3.73 N/A N/A $5.43 N/A N/A $8.62 N/A N/A $7.18 N/A N/A N/A N/A N/A $9.77 N/A N/A $8.90 N/A N/A $5.89 N/A N/A $10.05 N/A N/A $11.49 N/A N/A $7.90 N/A N/A $10.05 N/A N/A $4.81 N/A N/A N/A N/A N/A $8.62 N/A N/A $5.03 N/A N/A $9.34 N/A N/A N/A N/A N/A $8.62 N/A N/A $10.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.36 $14.36 N/A 4400117 Pharmacy OLANZapine 5 mg Dis Tab [BCH] 250 $28.55 $- $7.42 $- $- $22.84 $- N/A $7.42 N/A N/A $10.79 N/A N/A $17.13 N/A N/A $14.27 N/A N/A N/A N/A N/A $19.41 N/A N/A $17.70 N/A N/A $11.70 N/A N/A $19.98 N/A N/A $22.84 N/A N/A $15.70 N/A N/A $19.98 N/A N/A $9.56 N/A N/A N/A N/A N/A $17.13 N/A N/A $9.99 N/A N/A $18.56 N/A N/A N/A N/A N/A $17.13 N/A N/A $19.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.55 $28.55 N/A 4400866 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $41.95 $- $10.91 $- $- $33.56 $- N/A $10.91 N/A N/A $15.86 N/A N/A $25.17 N/A N/A $20.97 N/A N/A N/A N/A N/A $28.52 N/A N/A $26.01 N/A N/A $17.20 N/A N/A $29.36 N/A N/A $33.56 N/A N/A $23.07 N/A N/A $29.36 N/A N/A $14.05 N/A N/A N/A N/A N/A $25.17 N/A N/A $14.68 N/A N/A $27.27 N/A N/A N/A N/A N/A $25.17 N/A N/A $29.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $41.95 $41.95 N/A 4400627 Pharmacy sildenafil 20 mg oral tablet [BCH] 250 $40.45 $- $10.52 $- $- $32.36 $- N/A $10.52 N/A N/A $15.29 N/A N/A $24.27 N/A N/A $20.23 N/A N/A N/A N/A N/A $27.51 N/A N/A $25.08 N/A N/A $16.59 N/A N/A $28.32 N/A N/A $32.36 N/A N/A $22.25 N/A N/A $28.32 N/A N/A $13.55 N/A N/A N/A N/A N/A $24.27 N/A N/A $14.16 N/A N/A $26.30 N/A N/A N/A N/A N/A $24.27 N/A N/A $28.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.45 $40.45 N/A 4401515 Pharmacy azithromycin 500 mg Pow [BCH] J0456 636 $39.60 $- $3.42 $- $- $31.68 $- N/A $10.30 N/A N/A Not Reimbursed N/A N/A $23.76 N/A N/A $19.80 N/A N/A N/A N/A N/A $26.93 N/A N/A $24.55 N/A N/A $16.24 N/A N/A $27.72 N/A N/A $31.68 N/A N/A $21.78 N/A N/A $27.72 N/A N/A $13.27 N/A N/A N/A N/A N/A $23.76 N/A N/A $13.86 N/A N/A $25.74 N/A N/A $3.42 N/A N/A $23.76 N/A N/A $27.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.60 $39.60 N/A 4409522 Pharmacy cefepime 1 g Pow J0692 636 $40.67 $- $1.93 $- $- $32.53 $- N/A $10.57 N/A N/A Not Reimbursed N/A N/A $24.40 N/A N/A $20.33 N/A N/A N/A N/A N/A $27.65 N/A N/A $25.21 N/A N/A $16.67 N/A N/A $28.47 N/A N/A $32.53 N/A N/A $22.37 N/A N/A $28.47 N/A N/A $13.62 N/A N/A N/A N/A N/A $24.40 N/A N/A $14.23 N/A N/A $26.43 N/A N/A $1.93 N/A N/A $24.40 N/A N/A $28.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.67 $40.67 N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $80.71 $- $1.93 $- $- $64.57 $- N/A $20.99 N/A N/A Not Reimbursed N/A N/A $48.43 N/A N/A $40.36 N/A N/A N/A N/A N/A $54.88 N/A N/A $50.04 N/A N/A $33.09 N/A N/A $56.50 N/A N/A $64.57 N/A N/A $44.39 N/A N/A $56.50 N/A N/A $27.04 N/A N/A N/A N/A N/A $48.43 N/A N/A $28.25 N/A N/A $52.46 N/A N/A $1.93 N/A N/A $48.43 N/A N/A $56.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.71 $80.71 N/A 4409522 Pharmacy cefepime 1 g Pow [BCH] J0692 636 $40.67 $- $1.93 $- $- $32.53 $- N/A $10.57 N/A N/A Not Reimbursed N/A N/A $24.40 N/A N/A $20.33 N/A N/A N/A N/A N/A $27.65 N/A N/A $25.21 N/A N/A $16.67 N/A N/A $28.47 N/A N/A $32.53 N/A N/A $22.37 N/A N/A $28.47 N/A N/A $13.62 N/A N/A N/A N/A N/A $24.40 N/A N/A $14.23 N/A N/A $26.43 N/A N/A $1.93 N/A N/A $24.40 N/A N/A $28.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.67 $40.67 N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $80.71 $- $1.93 $- $- $64.57 $- N/A $20.99 N/A N/A Not Reimbursed N/A N/A $48.43 N/A N/A $40.36 N/A N/A N/A N/A N/A $54.88 N/A N/A $50.04 N/A N/A $33.09 N/A N/A $56.50 N/A N/A $64.57 N/A N/A $44.39 N/A N/A $56.50 N/A N/A $27.04 N/A N/A N/A N/A N/A $48.43 N/A N/A $28.25 N/A N/A $52.46 N/A N/A $1.93 N/A N/A $48.43 N/A N/A $56.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $80.71 $80.71 N/A 4409026 Pharmacy fentaNYL 100 mcg/hr Transderm ER Film [BCH] 250 $157.42 $- $40.93 $- $- $125.94 $- N/A $40.93 N/A N/A $59.51 N/A N/A $94.45 N/A N/A $78.71 N/A N/A N/A N/A N/A $107.05 N/A N/A $97.60 N/A N/A $64.54 N/A N/A $110.20 N/A N/A $125.94 N/A N/A $86.58 N/A N/A $110.20 N/A N/A $52.74 N/A N/A N/A N/A N/A $94.45 N/A N/A $55.10 N/A N/A $102.33 N/A N/A N/A N/A N/A $94.45 N/A N/A $110.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $157.42 $157.42 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404159 Pharmacy labetalol 100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405681 Pharmacy metFORMIN 850 mg Tab[BCH] 250 $2.41 $- $0.63 $- $- $1.93 $- N/A $0.63 N/A N/A $0.91 N/A N/A $1.44 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.64 N/A N/A $1.49 N/A N/A $0.99 N/A N/A $1.68 N/A N/A $1.93 N/A N/A $1.32 N/A N/A $1.68 N/A N/A $0.81 N/A N/A N/A N/A N/A $1.44 N/A N/A $0.84 N/A N/A $1.56 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.41 $2.41 N/A 4404936 Pharmacy haloperidol 5 mg Tab [BCH] 250 $2.18 $- $0.57 $- $- $1.75 $- N/A $0.57 N/A N/A $0.83 N/A N/A $1.31 N/A N/A $1.09 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.35 N/A N/A $0.90 N/A N/A $1.53 N/A N/A $1.75 N/A N/A $1.20 N/A N/A $1.53 N/A N/A $0.73 N/A N/A N/A N/A N/A $1.31 N/A N/A $0.76 N/A N/A $1.42 N/A N/A N/A N/A N/A $1.31 N/A N/A $1.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.18 $2.18 N/A 4403045 Pharmacy cephalexin 500 mg Cap[BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400907 Pharmacy memantine 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400921 Pharmacy memantine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401714 Pharmacy dilTIAZem 180 mg/24 hours Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400929 Pharmacy loperamide 2 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400557 Pharmacy sertraline 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401987 Pharmacy sertraline 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400345 Pharmacy sertraline 100 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403002 Pharmacy cefuroxime 250 mg Tab[BCH] 250 $8.25 $- $2.15 $- $- $6.60 $- N/A $2.15 N/A N/A $3.12 N/A N/A $4.95 N/A N/A $4.13 N/A N/A N/A N/A N/A $5.61 N/A N/A $5.12 N/A N/A $3.38 N/A N/A $5.78 N/A N/A $6.60 N/A N/A $4.54 N/A N/A $5.78 N/A N/A $2.76 N/A N/A N/A N/A N/A $4.95 N/A N/A $2.89 N/A N/A $5.36 N/A N/A N/A N/A N/A $4.95 N/A N/A $5.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.25 $8.25 N/A 4402019 Pharmacy azithromycin 250 mg Tab 250 $8.43 $- $2.19 $- $- $6.74 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.22 N/A N/A N/A N/A N/A $5.73 N/A N/A $5.23 N/A N/A $3.46 N/A N/A $5.90 N/A N/A $6.74 N/A N/A $4.64 N/A N/A $5.90 N/A N/A $2.82 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.48 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.43 $8.43 N/A 4400288 Pharmacy donepezil 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407182 Pharmacy donepezil 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400906 Pharmacy captopril 12.5 mg Tab [BCH] 250 $3.40 $- $0.88 $- $- $2.72 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.04 N/A N/A $1.70 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.11 N/A N/A $1.39 N/A N/A $2.38 N/A N/A $2.72 N/A N/A $1.87 N/A N/A $2.38 N/A N/A $1.14 N/A N/A N/A N/A N/A $2.04 N/A N/A $1.19 N/A N/A $2.21 N/A N/A N/A N/A N/A $2.04 N/A N/A $2.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.40 $3.40 N/A 4404387 Pharmacy propranolol 20 mg Tab 250 $2.32 $- $0.60 $- $- $1.86 $- N/A $0.60 N/A N/A $0.88 N/A N/A $1.39 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.58 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.63 N/A N/A $1.86 N/A N/A $1.28 N/A N/A $1.63 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.39 N/A N/A $0.81 N/A N/A $1.51 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.32 $2.32 N/A 4408234 Pharmacy doxycycline monohydrate 100 mg Tab [BCH] 250 $4.80 $- $1.25 $- $- $3.84 $- N/A $1.25 N/A N/A $1.81 N/A N/A $2.88 N/A N/A $2.40 N/A N/A N/A N/A N/A $3.26 N/A N/A $2.97 N/A N/A $1.97 N/A N/A $3.36 N/A N/A $3.84 N/A N/A $2.64 N/A N/A $3.36 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.88 N/A N/A $1.68 N/A N/A $3.12 N/A N/A N/A N/A N/A $2.88 N/A N/A $3.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.80 $4.80 N/A 4400623 Pharmacy calcitriol 0.25 mcg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A Pharmacy methIMAzole 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402542 Pharmacy Colchicine 0.6 mg Cap [BCH] 250 $13.34 $- $3.47 $- $- $10.67 $- N/A $3.47 N/A N/A $5.04 N/A N/A $8.00 N/A N/A $6.67 N/A N/A N/A N/A N/A $9.07 N/A N/A $8.27 N/A N/A $5.47 N/A N/A $9.34 N/A N/A $10.67 N/A N/A $7.34 N/A N/A $9.34 N/A N/A $4.47 N/A N/A N/A N/A N/A $8.00 N/A N/A $4.67 N/A N/A $8.67 N/A N/A N/A N/A N/A $8.00 N/A N/A $9.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.34 $13.34 N/A 4402518 Pharmacy benztropine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400759 Pharmacy methIMAzole 10 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400455 Pharmacy pioglitazone 15 mg Tab [BCH] 250 $2.52 $- $0.66 $- $- $2.02 $- N/A $0.66 N/A N/A $0.95 N/A N/A $1.51 N/A N/A $1.26 N/A N/A N/A N/A N/A $1.71 N/A N/A $1.56 N/A N/A $1.03 N/A N/A $1.76 N/A N/A $2.02 N/A N/A $1.39 N/A N/A $1.76 N/A N/A $0.84 N/A N/A N/A N/A N/A $1.51 N/A N/A $0.88 N/A N/A $1.64 N/A N/A N/A N/A N/A $1.51 N/A N/A $1.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.52 $2.52 N/A 4409603 Pharmacy amitriptyline 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400654 Pharmacy traZODone 50 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405685 Pharmacy ibuprofen 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400942 Pharmacy levothyroxine 25 mcg (0.025 mg) Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403090 Pharmacy levothyroxine 50 mcg (0.05 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400641 Pharmacy pregabalin 100 mg Cap[BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4402712 Pharmacy levothyroxine 125 mcg (0.125 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403280 Pharmacy propafenone 150 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400396 Pharmacy ranolazine 500 mg Tab [BCH] 250 $3.36 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.08 N/A N/A $1.38 N/A N/A $2.35 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.35 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.36 $3.36 N/A 4402829 Pharmacy metroNIDAZOLE 500 mg Tab 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400413 Pharmacy pramipexole 0.5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.75 $- $0.72 $- $- $2.20 $- N/A $0.72 N/A N/A $1.04 N/A N/A $1.65 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.87 N/A N/A $1.71 N/A N/A $1.13 N/A N/A $1.93 N/A N/A $2.20 N/A N/A $1.51 N/A N/A $1.93 N/A N/A $0.92 N/A N/A N/A N/A N/A $1.65 N/A N/A $0.96 N/A N/A $1.79 N/A N/A N/A N/A N/A $1.65 N/A N/A $1.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.75 $2.75 N/A 4404778 Pharmacy hydroCHLOROthiazide 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400166 Pharmacy fenofibrate 48 mg Tab [BCH] 250 $3.82 $- $0.99 $- $- $3.06 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.29 N/A N/A $1.91 N/A N/A N/A N/A N/A $2.60 N/A N/A $2.37 N/A N/A $1.57 N/A N/A $2.67 N/A N/A $3.06 N/A N/A $2.10 N/A N/A $2.67 N/A N/A $1.28 N/A N/A N/A N/A N/A $2.29 N/A N/A $1.34 N/A N/A $2.48 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.82 $3.82 N/A 4400819 Pharmacy sulfacetamide sodium ophthalmic 10% Sol [BCH] 250 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A $28.35 N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4403652 Pharmacy levobunolol ophthalmic 0.5% Sol [BCH] 250 $11.16 $- $2.90 $- $- $8.93 $- N/A $2.90 N/A N/A $4.22 N/A N/A $6.70 N/A N/A $5.58 N/A N/A N/A N/A N/A $7.59 N/A N/A $6.92 N/A N/A $4.58 N/A N/A $7.81 N/A N/A $8.93 N/A N/A $6.14 N/A N/A $7.81 N/A N/A $3.74 N/A N/A N/A N/A N/A $6.70 N/A N/A $3.91 N/A N/A $7.25 N/A N/A N/A N/A N/A $6.70 N/A N/A $7.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.16 $11.16 N/A 4400289 Pharmacy prednisoLONE Ophth acetate 1% Susp [BCH] 250 $105.60 $- $27.46 $- $- $84.48 $- N/A $27.46 N/A N/A $39.92 N/A N/A $63.36 N/A N/A $52.80 N/A N/A N/A N/A N/A $71.81 N/A N/A $65.47 N/A N/A $43.30 N/A N/A $73.92 N/A N/A $84.48 N/A N/A $58.08 N/A N/A $73.92 N/A N/A $35.38 N/A N/A N/A N/A N/A $63.36 N/A N/A $36.96 N/A N/A $68.64 N/A N/A N/A N/A N/A $63.36 N/A N/A $73.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.60 $105.60 N/A 4408057 Pharmacy gentamicin ophthalmic 0.3% Sol [BCH] 250 $38.36 $- $9.97 $- $- $30.69 $- N/A $9.97 N/A N/A $14.50 N/A N/A $23.02 N/A N/A $19.18 N/A N/A N/A N/A N/A $26.08 N/A N/A $23.78 N/A N/A $15.73 N/A N/A $26.85 N/A N/A $30.69 N/A N/A $21.10 N/A N/A $26.85 N/A N/A $12.85 N/A N/A N/A N/A N/A $23.02 N/A N/A $13.43 N/A N/A $24.93 N/A N/A N/A N/A N/A $23.02 N/A N/A $26.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.36 $38.36 N/A 4408689 Pharmacy timolol ophthalmic maleate 0.5% Sol [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400164 Pharmacy metaxalone 800 mg Tab [BCH] 250 $18.61 $- $4.84 $- $- $14.89 $- N/A $4.84 N/A N/A $7.04 N/A N/A $11.17 N/A N/A $9.31 N/A N/A N/A N/A N/A $12.66 N/A N/A $11.54 N/A N/A $7.63 N/A N/A $13.03 N/A N/A $14.89 N/A N/A $10.24 N/A N/A $13.03 N/A N/A $6.24 N/A N/A N/A N/A N/A $11.17 N/A N/A $6.52 N/A N/A $12.10 N/A N/A N/A N/A N/A $11.17 N/A N/A $13.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.61 $18.61 N/A 4400517 Pharmacy thrombin topical bovine 5000 intl units Pow [BCH] 636 $172.24 $- $44.78 $- $- $137.79 $- N/A $44.78 N/A N/A $65.11 N/A N/A $103.34 N/A N/A $86.12 N/A N/A N/A N/A N/A $117.12 N/A N/A $106.79 N/A N/A $70.62 N/A N/A $120.57 N/A N/A $137.79 N/A N/A $94.73 N/A N/A $120.57 N/A N/A $57.70 N/A N/A N/A N/A N/A $103.34 N/A N/A $60.28 N/A N/A $111.96 N/A N/A N/A N/A N/A $103.34 N/A N/A $120.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $172.24 $172.24 N/A 4400272 Pharmacy "penicillin G benzathine 1,200,000 units/2 mL Sus [BCH]" J0561 636 $288.13 $- $15.03 $- $- $230.51 $- N/A $74.91 N/A N/A Not Reimbursed N/A N/A $172.88 N/A N/A $144.07 N/A N/A N/A N/A N/A $195.93 N/A N/A $178.64 N/A N/A $118.13 N/A N/A $201.69 N/A N/A $230.51 N/A N/A $158.47 N/A N/A $201.69 N/A N/A $96.52 N/A N/A N/A N/A N/A $172.88 N/A N/A $100.85 N/A N/A $187.29 N/A N/A $15.03 N/A N/A $172.88 N/A N/A $201.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $288.13 $288.13 N/A 4401920 Pharmacy morphine 15 mg ER Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400647 Pharmacy pralidoxime 1 g Pow [BCH] J2730 636 $208.08 $- $54.10 $- $- $166.46 $- N/A $54.10 N/A N/A Not Reimbursed N/A N/A $124.85 N/A N/A $104.04 N/A N/A N/A N/A N/A $141.49 N/A N/A $129.01 N/A N/A $85.31 N/A N/A $145.66 N/A N/A $166.46 N/A N/A $114.44 N/A N/A $145.66 N/A N/A $69.71 N/A N/A N/A N/A N/A $124.85 N/A N/A $72.83 N/A N/A $135.25 N/A N/A N/A N/A N/A $124.85 N/A N/A $145.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $208.08 $208.08 N/A 4401957 Pharmacy bacitracin topical zinc 500 units/g Oin [BCH] 250 $6.38 $- $1.66 $- $- $5.10 $- N/A $1.66 N/A N/A $2.41 N/A N/A $3.83 N/A N/A $3.19 N/A N/A N/A N/A N/A $4.34 N/A N/A $3.95 N/A N/A $2.61 N/A N/A $4.46 N/A N/A $5.10 N/A N/A $3.51 N/A N/A $4.46 N/A N/A $2.14 N/A N/A N/A N/A N/A $3.83 N/A N/A $2.23 N/A N/A $4.14 N/A N/A N/A N/A N/A $3.83 N/A N/A $4.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.38 $6.38 N/A 4402269 Pharmacy miconazole topical 2% Cream 250 $77.56 $- $20.17 $- $- $62.05 $- N/A $20.17 N/A N/A $29.32 N/A N/A $46.54 N/A N/A $38.78 N/A N/A N/A N/A N/A $52.74 N/A N/A $48.09 N/A N/A $31.80 N/A N/A $54.29 N/A N/A $62.05 N/A N/A $42.66 N/A N/A $54.29 N/A N/A $25.98 N/A N/A N/A N/A N/A $46.54 N/A N/A $27.15 N/A N/A $50.41 N/A N/A N/A N/A N/A $46.54 N/A N/A $54.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $77.56 $77.56 N/A 4408594 Pharmacy trifluridine Ophth 1% Sol [BCH] 250 $356.56 $- $92.71 $- $- $285.25 $- N/A $92.71 N/A N/A $134.78 N/A N/A $213.94 N/A N/A $178.28 N/A N/A N/A N/A N/A $242.46 N/A N/A $221.07 N/A N/A $146.19 N/A N/A $249.59 N/A N/A $285.25 N/A N/A $196.11 N/A N/A $249.59 N/A N/A $119.45 N/A N/A N/A N/A N/A $213.94 N/A N/A $124.80 N/A N/A $231.76 N/A N/A N/A N/A N/A $213.94 N/A N/A $249.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $356.56 $356.56 N/A 4409700 Pharmacy ketorolac ophthalmic 0.5% Sol [BCH] 250 $211.00 $- $54.86 $- $- $168.80 $- N/A $54.86 N/A N/A $79.76 N/A N/A $126.60 N/A N/A $105.50 N/A N/A N/A N/A N/A $143.48 N/A N/A $130.82 N/A N/A $86.51 N/A N/A $147.70 N/A N/A $168.80 N/A N/A $116.05 N/A N/A $147.70 N/A N/A $70.69 N/A N/A N/A N/A N/A $126.60 N/A N/A $73.85 N/A N/A $137.15 N/A N/A N/A N/A N/A $126.60 N/A N/A $147.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $211.00 $211.00 N/A 4409501 Pharmacy brimonidine ophthalmic 0.2% Sol [BCH] 250 $65.30 $- $16.98 $- $- $52.24 $- N/A $16.98 N/A N/A $24.68 N/A N/A $39.18 N/A N/A $32.65 N/A N/A N/A N/A N/A $44.40 N/A N/A $40.49 N/A N/A $26.77 N/A N/A $45.71 N/A N/A $52.24 N/A N/A $35.92 N/A N/A $45.71 N/A N/A $21.88 N/A N/A N/A N/A N/A $39.18 N/A N/A $22.86 N/A N/A $42.45 N/A N/A N/A N/A N/A $39.18 N/A N/A $45.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $65.30 $65.30 N/A 4400562 Pharmacy brimonidine Ophth 0.15% Sol [BCH] 250 $260.60 $- $67.76 $- $- $208.48 $- N/A $67.76 N/A N/A $98.51 N/A N/A $156.36 N/A N/A $130.30 N/A N/A N/A N/A N/A $177.21 N/A N/A $161.57 N/A N/A $106.85 N/A N/A $182.42 N/A N/A $208.48 N/A N/A $143.33 N/A N/A $182.42 N/A N/A $87.30 N/A N/A N/A N/A N/A $156.36 N/A N/A $91.21 N/A N/A $169.39 N/A N/A N/A N/A N/A $156.36 N/A N/A $182.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $260.60 $260.60 N/A 4400070 Pharmacy pilocarpine Ophth 1% Sol [BCH] 250 $197.12 $- $51.25 $- $- $157.70 $- N/A $51.25 N/A N/A $74.51 N/A N/A $118.27 N/A N/A $98.56 N/A N/A N/A N/A N/A $134.04 N/A N/A $122.21 N/A N/A $80.82 N/A N/A $137.98 N/A N/A $157.70 N/A N/A $108.42 N/A N/A $137.98 N/A N/A $66.04 N/A N/A N/A N/A N/A $118.27 N/A N/A $68.99 N/A N/A $128.13 N/A N/A N/A N/A N/A $118.27 N/A N/A $137.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $197.12 $197.12 N/A 4408671 Pharmacy timolol Ophth 0.25% Sol [BCH] 250 $30.00 $- $7.80 $- $- $24.00 $- N/A $7.80 N/A N/A $11.34 N/A N/A $18.00 N/A N/A $15.00 N/A N/A N/A N/A N/A $20.40 N/A N/A $18.60 N/A N/A $12.30 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A N/A N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A N/A N/A N/A $18.00 N/A N/A $21.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.00 $30.00 N/A 4408689 Pharmacy timolol Ophth 0.5% Sol [BCH] 250 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A $21.08 N/A N/A $13.94 N/A N/A $23.80 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $23.80 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A N/A N/A N/A $20.40 N/A N/A $23.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.00 $34.00 N/A 4409577 Pharmacy tropicamide Ophth 1% Sol [BCH] 250 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409394 Pharmacy latanoprost Ophth 0.005% Sol [BCH] 250 $190.00 $- $49.40 $- $- $152.00 $- N/A $49.40 N/A N/A $71.82 N/A N/A $114.00 N/A N/A $95.00 N/A N/A N/A N/A N/A $129.20 N/A N/A $117.80 N/A N/A $77.90 N/A N/A $133.00 N/A N/A $152.00 N/A N/A $104.50 N/A N/A $133.00 N/A N/A $63.65 N/A N/A N/A N/A N/A $114.00 N/A N/A $66.50 N/A N/A $123.50 N/A N/A N/A N/A N/A $114.00 N/A N/A $133.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $190.00 $190.00 N/A 4400798 Pharmacy polymyxin B-trimethoprim ophthalmic 10000 units-1 mg/mL Sol 250 $34.84 $- $9.06 $- $- $27.87 $- N/A $9.06 N/A N/A $13.17 N/A N/A $20.90 N/A N/A $17.42 N/A N/A N/A N/A N/A $23.69 N/A N/A $21.60 N/A N/A $14.28 N/A N/A $24.39 N/A N/A $27.87 N/A N/A $19.16 N/A N/A $24.39 N/A N/A $11.67 N/A N/A N/A N/A N/A $20.90 N/A N/A $12.19 N/A N/A $22.65 N/A N/A N/A N/A N/A $20.90 N/A N/A $24.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.84 $34.84 N/A 4402383 Pharmacy dexamethasone/neomycin/polymyxin B ophthalmic 1 mg-3.5 mg-10000 units/mL Sus [BCH] 250 $88.00 $- $22.88 $- $- $70.40 $- N/A $22.88 N/A N/A $33.26 N/A N/A $52.80 N/A N/A $44.00 N/A N/A N/A N/A N/A $59.84 N/A N/A $54.56 N/A N/A $36.08 N/A N/A $61.60 N/A N/A $70.40 N/A N/A $48.40 N/A N/A $61.60 N/A N/A $29.48 N/A N/A N/A N/A N/A $52.80 N/A N/A $30.80 N/A N/A $57.20 N/A N/A N/A N/A N/A $52.80 N/A N/A $61.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $88.00 $88.00 N/A 4400004 Pharmacy dexamethasone/neomycin/polymyxin B Ophth Oint [BCH] 250 $88.00 $- $22.88 $- $- $70.40 $- N/A $22.88 N/A N/A $33.26 N/A N/A $52.80 N/A N/A $44.00 N/A N/A N/A N/A N/A $59.84 N/A N/A $54.56 N/A N/A $36.08 N/A N/A $61.60 N/A N/A $70.40 N/A N/A $48.40 N/A N/A $61.60 N/A N/A $29.48 N/A N/A N/A N/A N/A $52.80 N/A N/A $30.80 N/A N/A $57.20 N/A N/A N/A N/A N/A $52.80 N/A N/A $61.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $88.00 $88.00 N/A 4408057 Pharmacy gentamicin Ophth 0.3% Sol [BCH] 250 $43.40 $- $11.28 $- $- $34.72 $- N/A $11.28 N/A N/A $16.41 N/A N/A $26.04 N/A N/A $21.70 N/A N/A N/A N/A N/A $29.51 N/A N/A $26.91 N/A N/A $17.79 N/A N/A $30.38 N/A N/A $34.72 N/A N/A $23.87 N/A N/A $30.38 N/A N/A $14.54 N/A N/A N/A N/A N/A $26.04 N/A N/A $15.19 N/A N/A $28.21 N/A N/A N/A N/A N/A $26.04 N/A N/A $30.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $43.40 $43.40 N/A 4400289 Pharmacy prednisoLONE Ophth acetate 1% Susp [BCH] 250 $110.64 $- $28.77 $- $- $88.51 $- N/A $28.77 N/A N/A $41.82 N/A N/A $66.38 N/A N/A $55.32 N/A N/A N/A N/A N/A $75.24 N/A N/A $68.60 N/A N/A $45.36 N/A N/A $77.45 N/A N/A $88.51 N/A N/A $60.85 N/A N/A $77.45 N/A N/A $37.06 N/A N/A N/A N/A N/A $66.38 N/A N/A $38.72 N/A N/A $71.92 N/A N/A N/A N/A N/A $66.38 N/A N/A $77.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $110.64 $110.64 N/A 4408982 Pharmacy hydrocortisone/neomycin/polymyxin B Ophth Susp [BCH] 250 $282.94 $- $73.56 $- $- $226.35 $- N/A $73.56 N/A N/A $106.95 N/A N/A $169.76 N/A N/A $141.47 N/A N/A N/A N/A N/A $192.40 N/A N/A $175.42 N/A N/A $116.01 N/A N/A $198.06 N/A N/A $226.35 N/A N/A $155.62 N/A N/A $198.06 N/A N/A $94.78 N/A N/A N/A N/A N/A $169.76 N/A N/A $99.03 N/A N/A $183.91 N/A N/A N/A N/A N/A $169.76 N/A N/A $198.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $282.94 $282.94 N/A 4403804 Pharmacy tobramycin Ophth 0.3% Sol [BCH] 250 $68.00 $- $17.68 $- $- $54.40 $- N/A $17.68 N/A N/A $25.70 N/A N/A $40.80 N/A N/A $34.00 N/A N/A N/A N/A N/A $46.24 N/A N/A $42.16 N/A N/A $27.88 N/A N/A $47.60 N/A N/A $54.40 N/A N/A $37.40 N/A N/A $47.60 N/A N/A $22.78 N/A N/A N/A N/A N/A $40.80 N/A N/A $23.80 N/A N/A $44.20 N/A N/A N/A N/A N/A $40.80 N/A N/A $47.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $68.00 $68.00 N/A 4409605 Pharmacy hydrocortisone/neomycin/polymyxin B otic 1%-0.35%-10000 units/mL Sol [BCH] 250 $209.76 $- $54.54 $- $- $167.81 $- N/A $54.54 N/A N/A $79.29 N/A N/A $125.86 N/A N/A $104.88 N/A N/A N/A N/A N/A $142.64 N/A N/A $130.05 N/A N/A $86.00 N/A N/A $146.83 N/A N/A $167.81 N/A N/A $115.37 N/A N/A $146.83 N/A N/A $70.27 N/A N/A N/A N/A N/A $125.86 N/A N/A $73.42 N/A N/A $136.34 N/A N/A N/A N/A N/A $125.86 N/A N/A $146.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $209.76 $209.76 N/A 4406283 Pharmacy dexamethasone-tobramycin Ophth 0.1%-0.3% Susp [BCH] 250 $130.62 $- $33.96 $- $- $104.50 $- N/A $33.96 N/A N/A $49.37 N/A N/A $78.37 N/A N/A $65.31 N/A N/A N/A N/A N/A $88.82 N/A N/A $80.98 N/A N/A $53.55 N/A N/A $91.43 N/A N/A $104.50 N/A N/A $71.84 N/A N/A $91.43 N/A N/A $43.76 N/A N/A N/A N/A N/A $78.37 N/A N/A $45.72 N/A N/A $84.90 N/A N/A N/A N/A N/A $78.37 N/A N/A $91.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $130.62 $130.62 N/A 4409730 Pharmacy ciprofloxacin ophthalmic 0.3% Sol [BCH] 250 $47.22 $- $12.28 $- $- $37.78 $- N/A $12.28 N/A N/A $17.85 N/A N/A $28.33 N/A N/A $23.61 N/A N/A N/A N/A N/A $32.11 N/A N/A $29.28 N/A N/A $19.36 N/A N/A $33.05 N/A N/A $37.78 N/A N/A $25.97 N/A N/A $33.05 N/A N/A $15.82 N/A N/A N/A N/A N/A $28.33 N/A N/A $16.53 N/A N/A $30.69 N/A N/A N/A N/A N/A $28.33 N/A N/A $33.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.22 $47.22 N/A 4401253 Pharmacy famotidine 20 mg Tab [BCH] 250 $4.15 $- $1.08 $- $- $3.32 $- N/A $1.08 N/A N/A $1.57 N/A N/A $2.49 N/A N/A $2.08 N/A N/A N/A N/A N/A $2.82 N/A N/A $2.57 N/A N/A $1.70 N/A N/A $2.91 N/A N/A $3.32 N/A N/A $2.28 N/A N/A $2.91 N/A N/A $1.39 N/A N/A N/A N/A N/A $2.49 N/A N/A $1.45 N/A N/A $2.70 N/A N/A N/A N/A N/A $2.49 N/A N/A $2.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.15 $4.15 N/A 4400351 Pharmacy meloxicam 15 mg Tab 250 $8.52 $- $2.21 $- $- $6.81 $- N/A $2.21 N/A N/A $3.22 N/A N/A $5.11 N/A N/A $4.26 N/A N/A N/A N/A N/A $5.79 N/A N/A $5.28 N/A N/A $3.49 N/A N/A $5.96 N/A N/A $6.81 N/A N/A $4.68 N/A N/A $5.96 N/A N/A $2.85 N/A N/A N/A N/A N/A $5.11 N/A N/A $2.98 N/A N/A $5.54 N/A N/A N/A N/A N/A $5.11 N/A N/A $5.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.52 $8.52 N/A 4404001 Pharmacy neomycin-polymyxin B sulfate Top Sol 1 mL [BCH] 250 $73.26 $- $19.05 $- $- $58.60 $- N/A $19.05 N/A N/A $27.69 N/A N/A $43.95 N/A N/A $36.63 N/A N/A N/A N/A N/A $49.81 N/A N/A $45.42 N/A N/A $30.03 N/A N/A $51.28 N/A N/A $58.60 N/A N/A $40.29 N/A N/A $51.28 N/A N/A $24.54 N/A N/A N/A N/A N/A $43.95 N/A N/A $25.64 N/A N/A $47.62 N/A N/A N/A N/A N/A $43.95 N/A N/A $51.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $73.26 $73.26 N/A 4405940 Pharmacy silver sulfADIAZINE topical 1% Cre 250 $17.88 $- $4.65 $- $- $14.30 $- N/A $4.65 N/A N/A $6.76 N/A N/A $10.73 N/A N/A $8.94 N/A N/A N/A N/A N/A $12.16 N/A N/A $11.09 N/A N/A $7.33 N/A N/A $12.52 N/A N/A $14.30 N/A N/A $9.83 N/A N/A $12.52 N/A N/A $5.99 N/A N/A N/A N/A N/A $10.73 N/A N/A $6.26 N/A N/A $11.62 N/A N/A N/A N/A N/A $10.73 N/A N/A $12.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.88 $17.88 N/A 4400210 Pharmacy pamidronate 3 mg/mL IV Sol [BCH] J2430 636 $34.63 $- $9.00 $- $- $27.71 $- N/A $9.00 N/A N/A Not Reimbursed N/A N/A $20.78 N/A N/A $17.32 N/A N/A N/A N/A N/A $23.55 N/A N/A $21.47 N/A N/A $14.20 N/A N/A $24.24 N/A N/A $27.71 N/A N/A $19.05 N/A N/A $24.24 N/A N/A $11.60 N/A N/A N/A N/A N/A $20.78 N/A N/A $12.12 N/A N/A $22.51 N/A N/A $12.63 N/A N/A $20.78 N/A N/A $24.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.63 $34.63 N/A 4400897 Pharmacy rifAMPin 300 mg Cap[BCH] 250 $4.04 $- $1.05 $- $- $3.23 $- N/A $1.05 N/A N/A $1.53 N/A N/A $2.42 N/A N/A $2.02 N/A N/A N/A N/A N/A $2.74 N/A N/A $2.50 N/A N/A $1.65 N/A N/A $2.82 N/A N/A $3.23 N/A N/A $2.22 N/A N/A $2.82 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.42 N/A N/A $1.41 N/A N/A $2.62 N/A N/A N/A N/A N/A $2.42 N/A N/A $2.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.04 $4.04 N/A 4400897 Pharmacy rifampin 300 mg Cap [BCH] 250 $4.02 $- $1.05 $- $- $3.22 $- N/A $1.05 N/A N/A $1.52 N/A N/A $2.41 N/A N/A $2.01 N/A N/A N/A N/A N/A $2.73 N/A N/A $2.49 N/A N/A $1.65 N/A N/A $2.82 N/A N/A $3.22 N/A N/A $2.21 N/A N/A $2.82 N/A N/A $1.35 N/A N/A N/A N/A N/A $2.41 N/A N/A $1.41 N/A N/A $2.61 N/A N/A N/A N/A N/A $2.41 N/A N/A $2.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.02 $4.02 N/A 4400998 Pharmacy dextromethorphan-guaifenesin 10 mg-100 mg/5 mL Liq [BCH] 250 $8.54 $- $2.22 $- $- $6.83 $- N/A $2.22 N/A N/A $3.23 N/A N/A $5.12 N/A N/A $4.27 N/A N/A N/A N/A N/A $5.81 N/A N/A $5.30 N/A N/A $3.50 N/A N/A $5.98 N/A N/A $6.83 N/A N/A $4.70 N/A N/A $5.98 N/A N/A $2.86 N/A N/A N/A N/A N/A $5.12 N/A N/A $2.99 N/A N/A $5.55 N/A N/A N/A N/A N/A $5.12 N/A N/A $5.98 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.54 $8.54 N/A 4400659 Pharmacy emtricitabine-tenofovir 200 mg-300 mg Tab [BCH] 250 $117.32 $- $30.50 $- $- $93.85 $- N/A $30.50 N/A N/A $44.35 N/A N/A $70.39 N/A N/A $58.66 N/A N/A N/A N/A N/A $79.77 N/A N/A $72.74 N/A N/A $48.10 N/A N/A $82.12 N/A N/A $93.85 N/A N/A $64.52 N/A N/A $82.12 N/A N/A $39.30 N/A N/A N/A N/A N/A $70.39 N/A N/A $41.06 N/A N/A $76.26 N/A N/A N/A N/A N/A $70.39 N/A N/A $82.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $117.32 $117.32 N/A 4400396 Pharmacy ranolazine 500 mg oral ER Tab [BCH] 250 $12.15 $- $3.16 $- $- $9.72 $- N/A $3.16 N/A N/A $4.59 N/A N/A $7.29 N/A N/A $6.08 N/A N/A N/A N/A N/A $8.26 N/A N/A $7.53 N/A N/A $4.98 N/A N/A $8.51 N/A N/A $9.72 N/A N/A $6.68 N/A N/A $8.51 N/A N/A $4.07 N/A N/A N/A N/A N/A $7.29 N/A N/A $4.25 N/A N/A $7.90 N/A N/A N/A N/A N/A $7.29 N/A N/A $8.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.15 $12.15 N/A 4400231 Pharmacy dilTIAZem 240 mg/24 hours Cap 250 $4.10 $- $1.07 $- $- $3.28 $- N/A $1.07 N/A N/A $1.55 N/A N/A $2.46 N/A N/A $2.05 N/A N/A N/A N/A N/A $2.79 N/A N/A $2.54 N/A N/A $1.68 N/A N/A $2.87 N/A N/A $3.28 N/A N/A $2.26 N/A N/A $2.87 N/A N/A $1.37 N/A N/A N/A N/A N/A $2.46 N/A N/A $1.44 N/A N/A $2.67 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.10 $4.10 N/A 4403520 Pharmacy diltiazem 120 mg/24 hours ERCap [BCH] 250 $2.07 $- $0.54 $- $- $1.66 $- N/A $0.54 N/A N/A $0.78 N/A N/A $1.24 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.41 N/A N/A $1.29 N/A N/A $0.85 N/A N/A $1.45 N/A N/A $1.66 N/A N/A $1.14 N/A N/A $1.45 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.24 N/A N/A $0.73 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.24 N/A N/A $1.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.07 $2.07 N/A 4401714 Pharmacy diltiazem 180 mg/24 hours ERCap [BCH] 250 $2.50 $- $0.65 $- $- $2.00 $- N/A $0.65 N/A N/A $0.95 N/A N/A $1.50 N/A N/A $1.25 N/A N/A N/A N/A N/A $1.70 N/A N/A $1.55 N/A N/A $1.03 N/A N/A $1.75 N/A N/A $2.00 N/A N/A $1.38 N/A N/A $1.75 N/A N/A $0.84 N/A N/A N/A N/A N/A $1.50 N/A N/A $0.88 N/A N/A $1.63 N/A N/A N/A N/A N/A $1.50 N/A N/A $1.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.50 $2.50 N/A 4400653 Pharmacy dilTIAZem 360 mg/24 hours Cap 250 $5.18 $- $1.35 $- $- $4.14 $- N/A $1.35 N/A N/A $1.96 N/A N/A $3.11 N/A N/A $2.59 N/A N/A N/A N/A N/A $3.52 N/A N/A $3.21 N/A N/A $2.12 N/A N/A $3.63 N/A N/A $4.14 N/A N/A $2.85 N/A N/A $3.63 N/A N/A $1.74 N/A N/A N/A N/A N/A $3.11 N/A N/A $1.81 N/A N/A $3.37 N/A N/A N/A N/A N/A $3.11 N/A N/A $3.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.18 $5.18 N/A 4400653 Pharmacy diltiazem 360 mg/24 hours ERCap [BCH] 250 $4.69 $- $1.22 $- $- $3.75 $- N/A $1.22 N/A N/A $1.77 N/A N/A $2.81 N/A N/A $2.35 N/A N/A N/A N/A N/A $3.19 N/A N/A $2.91 N/A N/A $1.92 N/A N/A $3.28 N/A N/A $3.75 N/A N/A $2.58 N/A N/A $3.28 N/A N/A $1.57 N/A N/A N/A N/A N/A $2.81 N/A N/A $1.64 N/A N/A $3.05 N/A N/A N/A N/A N/A $2.81 N/A N/A $3.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.69 $4.69 N/A 4406671 Pharmacy enoxaparin 30 mg/0.3 mL SC Sol [BCH] J1650 636 $48.84 $- $0.69 $- $- $39.07 $- N/A $12.70 N/A N/A Not Reimbursed N/A N/A $29.31 N/A N/A $24.42 N/A N/A N/A N/A N/A $33.21 N/A N/A $30.28 N/A N/A $20.03 N/A N/A $34.19 N/A N/A $39.07 N/A N/A $26.86 N/A N/A $34.19 N/A N/A $16.36 N/A N/A N/A N/A N/A $29.31 N/A N/A $17.09 N/A N/A $31.75 N/A N/A $0.69 N/A N/A $29.31 N/A N/A $34.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.84 $48.84 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL SC Sol [BCH] J1650 636 $65.13 $- $0.69 $- $- $52.10 $- N/A $16.93 N/A N/A Not Reimbursed N/A N/A $39.08 N/A N/A $32.56 N/A N/A N/A N/A N/A $44.29 N/A N/A $40.38 N/A N/A $26.70 N/A N/A $45.59 N/A N/A $52.10 N/A N/A $35.82 N/A N/A $45.59 N/A N/A $21.82 N/A N/A N/A N/A N/A $39.08 N/A N/A $22.79 N/A N/A $42.33 N/A N/A $0.69 N/A N/A $39.08 N/A N/A $45.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $65.13 $65.13 N/A 4400291 Pharmacy potassium chloride 20 mEq ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403028 Pharmacy ciprofloxacin 250 mg Tab [BCH] 250 $8.87 $- $2.31 $- $- $7.10 $- N/A $2.31 N/A N/A $3.35 N/A N/A $5.32 N/A N/A $4.44 N/A N/A N/A N/A N/A $6.03 N/A N/A $5.50 N/A N/A $3.64 N/A N/A $6.21 N/A N/A $7.10 N/A N/A $4.88 N/A N/A $6.21 N/A N/A $2.97 N/A N/A N/A N/A N/A $5.32 N/A N/A $3.10 N/A N/A $5.77 N/A N/A N/A N/A N/A $5.32 N/A N/A $6.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.87 $8.87 N/A 4401950 Pharmacy oxybutynin 5 mg ER Tab [BCH] 250 $6.15 $- $1.60 $- $- $4.92 $- N/A $1.60 N/A N/A $2.32 N/A N/A $3.69 N/A N/A $3.07 N/A N/A N/A N/A N/A $4.18 N/A N/A $3.81 N/A N/A $2.52 N/A N/A $4.30 N/A N/A $4.92 N/A N/A $3.38 N/A N/A $4.30 N/A N/A $2.06 N/A N/A N/A N/A N/A $3.69 N/A N/A $2.15 N/A N/A $3.99 N/A N/A N/A N/A N/A $3.69 N/A N/A $4.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.15 $6.15 N/A 4409594 Pharmacy pantoprazole 40 mg Tab 250 $8.11 $- $2.11 $- $- $6.49 $- N/A $2.11 N/A N/A $3.07 N/A N/A $4.87 N/A N/A $4.06 N/A N/A N/A N/A N/A $5.52 N/A N/A $5.03 N/A N/A $3.33 N/A N/A $5.68 N/A N/A $6.49 N/A N/A $4.46 N/A N/A $5.68 N/A N/A $2.72 N/A N/A N/A N/A N/A $4.87 N/A N/A $2.84 N/A N/A $5.27 N/A N/A N/A N/A N/A $4.87 N/A N/A $5.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.11 $8.11 N/A 4400899 Pharmacy theophylline 300 mg Tab [BCH] 250 $6.18 $- $1.61 $- $- $4.95 $- N/A $1.61 N/A N/A $2.34 N/A N/A $3.71 N/A N/A $3.09 N/A N/A N/A N/A N/A $4.20 N/A N/A $3.83 N/A N/A $2.53 N/A N/A $4.33 N/A N/A $4.95 N/A N/A $3.40 N/A N/A $4.33 N/A N/A $2.07 N/A N/A N/A N/A N/A $3.71 N/A N/A $2.16 N/A N/A $4.02 N/A N/A N/A N/A N/A $3.71 N/A N/A $4.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.18 $6.18 N/A 4409668 Pharmacy rOPINIRole 1 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.67 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400641 Pharmacy pregabalin 100 mg Cap [BCH] 250 $11.70 $- $3.04 $- $- $9.36 $- N/A $3.04 N/A N/A $4.42 N/A N/A $7.02 N/A N/A $5.85 N/A N/A N/A N/A N/A $7.96 N/A N/A $7.26 N/A N/A $4.80 N/A N/A $8.19 N/A N/A $9.36 N/A N/A $6.44 N/A N/A $8.19 N/A N/A $3.92 N/A N/A N/A N/A N/A $7.02 N/A N/A $4.10 N/A N/A $7.61 N/A N/A N/A N/A N/A $7.02 N/A N/A $8.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.70 $11.70 N/A 4409022 Pharmacy celecoxib 100 mg Cap 250 $9.24 $- $2.40 $- $- $7.39 $- N/A $2.40 N/A N/A $3.49 N/A N/A $5.54 N/A N/A $4.62 N/A N/A N/A N/A N/A $6.28 N/A N/A $5.73 N/A N/A $3.79 N/A N/A $6.47 N/A N/A $7.39 N/A N/A $5.08 N/A N/A $6.47 N/A N/A $3.10 N/A N/A N/A N/A N/A $5.54 N/A N/A $3.23 N/A N/A $6.01 N/A N/A N/A N/A N/A $5.54 N/A N/A $6.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.24 $9.24 N/A 4400972 Pharmacy febuxostat 80 mg Tab [BCH] 250 $24.75 $- $6.44 $- $- $19.80 $- N/A $6.44 N/A N/A $9.36 N/A N/A $14.85 N/A N/A $12.38 N/A N/A N/A N/A N/A $16.83 N/A N/A $15.35 N/A N/A $10.15 N/A N/A $17.33 N/A N/A $19.80 N/A N/A $13.61 N/A N/A $17.33 N/A N/A $8.29 N/A N/A N/A N/A N/A $14.85 N/A N/A $8.66 N/A N/A $16.09 N/A N/A N/A N/A N/A $14.85 N/A N/A $17.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.75 $24.75 N/A 4401601 Pharmacy amantadine 100 mg Cap 250 $3.88 $- $1.01 $- $- $3.10 $- N/A $1.01 N/A N/A $1.47 N/A N/A $2.33 N/A N/A $1.94 N/A N/A N/A N/A N/A $2.64 N/A N/A $2.40 N/A N/A $1.59 N/A N/A $2.71 N/A N/A $3.10 N/A N/A $2.13 N/A N/A $2.71 N/A N/A $1.30 N/A N/A N/A N/A N/A $2.33 N/A N/A $1.36 N/A N/A $2.52 N/A N/A N/A N/A N/A $2.33 N/A N/A $2.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.88 $3.88 N/A 4409798 Pharmacy moxifloxacin ophthalmic 0.5% Sol [BCH] 250 $334.64 $- $87.01 $- $- $267.71 $- N/A $87.01 N/A N/A $126.49 N/A N/A $200.78 N/A N/A $167.32 N/A N/A N/A N/A N/A $227.56 N/A N/A $207.48 N/A N/A $137.20 N/A N/A $234.25 N/A N/A $267.71 N/A N/A $184.05 N/A N/A $234.25 N/A N/A $112.10 N/A N/A N/A N/A N/A $200.78 N/A N/A $117.12 N/A N/A $217.52 N/A N/A N/A N/A N/A $200.78 N/A N/A $234.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $334.64 $334.64 N/A 4402609 Pharmacy hydrocortisone 100 mg/60 mL Rectal Susp [BCH] 250 $21.33 $- $5.55 $- $- $17.06 $- N/A $5.55 N/A N/A $8.06 N/A N/A $12.80 N/A N/A $10.67 N/A N/A N/A N/A N/A $14.51 N/A N/A $13.23 N/A N/A $8.75 N/A N/A $14.93 N/A N/A $17.06 N/A N/A $11.73 N/A N/A $14.93 N/A N/A $7.15 N/A N/A N/A N/A N/A $12.80 N/A N/A $7.47 N/A N/A $13.87 N/A N/A N/A N/A N/A $12.80 N/A N/A $14.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.33 $21.33 N/A 4400312 Pharmacy etodolac 300 mg Cap [BCH] 250 $3.10 $- $0.81 $- $- $2.48 $- N/A $0.81 N/A N/A $1.17 N/A N/A $1.86 N/A N/A $1.55 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.92 N/A N/A $1.27 N/A N/A $2.17 N/A N/A $2.48 N/A N/A $1.71 N/A N/A $2.17 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.86 N/A N/A $1.09 N/A N/A $2.02 N/A N/A N/A N/A N/A $1.86 N/A N/A $2.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.10 $3.10 N/A 4403284 Pharmacy atropine-diphenoxylate 0.025 mg-2.5 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4403342 Pharmacy indapamide 2.5 mg Tab 250 $3.10 $- $0.81 $- $- $2.48 $- N/A $0.81 N/A N/A $1.17 N/A N/A $1.86 N/A N/A $1.55 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.92 N/A N/A $1.27 N/A N/A $2.17 N/A N/A $2.48 N/A N/A $1.70 N/A N/A $2.17 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.86 N/A N/A $1.08 N/A N/A $2.01 N/A N/A N/A N/A N/A $1.86 N/A N/A $2.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.10 $3.10 N/A 4400712 Pharmacy oxcarbazepine 300 mg Tab [BCH] 250 $5.51 $- $1.43 $- $- $4.41 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.31 N/A N/A $2.75 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.42 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.41 N/A N/A $3.03 N/A N/A $3.86 N/A N/A $1.85 N/A N/A N/A N/A N/A $3.31 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.51 $5.51 N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403326 Pharmacy metoprolol 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400629 Pharmacy metoprolol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404729 Pharmacy folic acid 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405610 Pharmacy warfarin 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405803 Pharmacy octreotide 100 mcg/mL Inj Sol [BCH] J2354 636 $42.85 $- $0.83 $- $- $34.28 $- N/A $11.14 N/A N/A Not Reimbursed N/A N/A $25.71 N/A N/A $21.43 N/A N/A N/A N/A N/A $29.14 N/A N/A $26.57 N/A N/A $17.57 N/A N/A $30.00 N/A N/A $34.28 N/A N/A $23.57 N/A N/A $30.00 N/A N/A $14.35 N/A N/A N/A N/A N/A $25.71 N/A N/A $15.00 N/A N/A $27.85 N/A N/A $0.83 N/A N/A $25.71 N/A N/A $30.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.85 $42.85 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $3.20 $- $0.83 $- $- $2.56 $- N/A $0.83 N/A N/A $1.21 N/A N/A $1.92 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.98 N/A N/A $1.31 N/A N/A $2.24 N/A N/A $2.56 N/A N/A $1.76 N/A N/A $2.24 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.92 N/A N/A $1.12 N/A N/A $2.08 N/A N/A N/A N/A N/A $1.92 N/A N/A $2.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.20 $3.20 N/A 4409418 Pharmacy rivastigmine 1.5 mg Cap [BCH] 250 $8.44 $- $2.19 $- $- $6.75 $- N/A $2.19 N/A N/A $3.19 N/A N/A $5.06 N/A N/A $4.22 N/A N/A N/A N/A N/A $5.74 N/A N/A $5.23 N/A N/A $3.46 N/A N/A $5.91 N/A N/A $6.75 N/A N/A $4.64 N/A N/A $5.91 N/A N/A $2.83 N/A N/A N/A N/A N/A $5.06 N/A N/A $2.95 N/A N/A $5.49 N/A N/A N/A N/A N/A $5.06 N/A N/A $5.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.44 $8.44 N/A 4409660 Pharmacy oxcarbazepine 150 mg Tab [BCH] 250 $2.89 $- $0.75 $- $- $2.31 $- N/A $0.75 N/A N/A $1.09 N/A N/A $1.73 N/A N/A $1.45 N/A N/A N/A N/A N/A $1.97 N/A N/A $1.79 N/A N/A $1.19 N/A N/A $2.02 N/A N/A $2.31 N/A N/A $1.59 N/A N/A $2.02 N/A N/A $0.97 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.01 N/A N/A $1.88 N/A N/A N/A N/A N/A $1.73 N/A N/A $2.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.89 $2.89 N/A 4400712 Pharmacy oxcarbazepine 300 mg Tab [BCH] 250 $5.28 $- $1.37 $- $- $4.22 $- N/A $1.37 N/A N/A $2.00 N/A N/A $3.17 N/A N/A $2.64 N/A N/A N/A N/A N/A $3.59 N/A N/A $3.27 N/A N/A $2.16 N/A N/A $3.70 N/A N/A $4.22 N/A N/A $2.90 N/A N/A $3.70 N/A N/A $1.77 N/A N/A N/A N/A N/A $3.17 N/A N/A $1.85 N/A N/A $3.43 N/A N/A N/A N/A N/A $3.17 N/A N/A $3.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.28 $5.28 N/A 4400719 Pharmacy ondansetron 4 mg Dis Tab [BCH] Q0162 250 $44.50 $- $0.02 $- $- $35.60 $- N/A $11.57 N/A N/A Not Reimbursed N/A N/A $26.70 N/A N/A $22.25 N/A N/A N/A N/A N/A $30.26 N/A N/A $27.59 N/A N/A $18.25 N/A N/A $31.15 N/A N/A $35.60 N/A N/A $24.48 N/A N/A $31.15 N/A N/A $14.91 N/A N/A N/A N/A N/A $26.70 N/A N/A $15.58 N/A N/A $28.93 N/A N/A $0.02 N/A N/A $26.70 N/A N/A $31.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.50 $44.50 N/A 4407182 Pharmacy donepezil 10 mg Tab [BCH] 250 $17.30 $- $4.50 $- $- $13.84 $- N/A $4.50 N/A N/A $6.54 N/A N/A $10.38 N/A N/A $8.65 N/A N/A N/A N/A N/A $11.77 N/A N/A $10.73 N/A N/A $7.09 N/A N/A $12.11 N/A N/A $13.84 N/A N/A $9.52 N/A N/A $12.11 N/A N/A $5.80 N/A N/A N/A N/A N/A $10.38 N/A N/A $6.06 N/A N/A $11.25 N/A N/A N/A N/A N/A $10.38 N/A N/A $12.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.30 $17.30 N/A 4407939 Pharmacy carisoprodol 350 mg Tab [BCH] 250 $- $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400065 Pharmacy carbidopa-levodopa 25 mg-100 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408762 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400464 Pharmacy carbidopa-levodopa 25 mg-250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409551 Pharmacy topiramate 25 mg Tab [BCH] 250 $5.11 $- $1.33 $- $- $4.09 $- N/A $1.33 N/A N/A $1.93 N/A N/A $3.07 N/A N/A $2.55 N/A N/A N/A N/A N/A $3.47 N/A N/A $3.17 N/A N/A $2.09 N/A N/A $3.58 N/A N/A $4.09 N/A N/A $2.81 N/A N/A $3.58 N/A N/A $1.71 N/A N/A N/A N/A N/A $3.07 N/A N/A $1.79 N/A N/A $3.32 N/A N/A N/A N/A N/A $3.07 N/A N/A $3.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.11 $5.11 N/A 4400717 Pharmacy topiramate 100 mg Tab [BCH] 250 $13.90 $- $3.61 $- $- $11.12 $- N/A $3.61 N/A N/A $5.25 N/A N/A $8.34 N/A N/A $6.95 N/A N/A N/A N/A N/A $9.45 N/A N/A $8.62 N/A N/A $5.70 N/A N/A $9.73 N/A N/A $11.12 N/A N/A $7.65 N/A N/A $9.73 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.34 N/A N/A $4.87 N/A N/A $9.04 N/A N/A N/A N/A N/A $8.34 N/A N/A $9.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.90 $13.90 N/A 4403713 Pharmacy divalproex sodium 250 mg Tab 250 $3.49 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.09 N/A N/A $1.74 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.44 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.44 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.49 $3.49 N/A 4403713 Pharmacy divalproex sodium 250 mg DR Oral EC Tab [BCH] 250 $3.49 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.09 N/A N/A $1.74 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.44 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.44 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.49 $3.49 N/A 4409447 Pharmacy SUMAtriptan 50 mg Tab [BCH] 250 $50.28 $- $13.07 $- $- $40.22 $- N/A $13.07 N/A N/A $19.01 N/A N/A $30.17 N/A N/A $25.14 N/A N/A N/A N/A N/A $34.19 N/A N/A $31.17 N/A N/A $20.61 N/A N/A $35.20 N/A N/A $40.22 N/A N/A $27.65 N/A N/A $35.20 N/A N/A $16.84 N/A N/A N/A N/A N/A $30.17 N/A N/A $17.60 N/A N/A $32.68 N/A N/A N/A N/A N/A $30.17 N/A N/A $35.20 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.28 $50.28 N/A 4403785 Pharmacy hydroxychloroquine 200 mg Tab [BCH] 250 $8.18 $- $2.13 $- $- $6.54 $- N/A $2.13 N/A N/A $3.09 N/A N/A $4.91 N/A N/A $4.09 N/A N/A N/A N/A N/A $5.56 N/A N/A $5.07 N/A N/A $3.35 N/A N/A $5.72 N/A N/A $6.54 N/A N/A $4.50 N/A N/A $5.72 N/A N/A $2.74 N/A N/A N/A N/A N/A $4.91 N/A N/A $2.86 N/A N/A $5.31 N/A N/A N/A N/A N/A $4.91 N/A N/A $5.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.18 $8.18 N/A 4401920 Pharmacy morphine 15 mg/8 hr Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400629 Pharmacy metoprolol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403110 Pharmacy furosemide 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403128 Pharmacy furosemide 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407463 Pharmacy clindamycin 150 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400231 Pharmacy dilTIAZem 240 mg/24 hours Cap 250 $4.10 $- $1.07 $- $- $3.28 $- N/A $1.07 N/A N/A $1.55 N/A N/A $2.46 N/A N/A $2.05 N/A N/A N/A N/A N/A $2.79 N/A N/A $2.54 N/A N/A $1.68 N/A N/A $2.87 N/A N/A $3.28 N/A N/A $2.26 N/A N/A $2.87 N/A N/A $1.37 N/A N/A N/A N/A N/A $2.46 N/A N/A $1.44 N/A N/A $2.67 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.10 $4.10 N/A 4400015 Pharmacy valACYclovir 500 mg Tab [BCH] 250 $14.45 $- $3.76 $- $- $11.56 $- N/A $3.76 N/A N/A $5.46 N/A N/A $8.67 N/A N/A $7.22 N/A N/A N/A N/A N/A $9.82 N/A N/A $8.96 N/A N/A $5.92 N/A N/A $10.11 N/A N/A $11.56 N/A N/A $7.95 N/A N/A $10.11 N/A N/A $4.84 N/A N/A N/A N/A N/A $8.67 N/A N/A $5.06 N/A N/A $9.39 N/A N/A N/A N/A N/A $8.67 N/A N/A $10.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.45 $14.45 N/A 4404752 Pharmacy gentamicin 40 mg/mL Inj Sol [BCH] J1580 636 $12.00 $- $1.94 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $1.94 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407194 Pharmacy oxytocin 10 intl units/mL Inj Sol [BCH] J2590 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4406733 Pharmacy thiamine 100 mg/mL Sol [BCH] J3411 636 $24.88 $- $2.76 $- $- $19.90 $- N/A $6.47 N/A N/A Not Reimbursed N/A N/A $14.93 N/A N/A $12.44 N/A N/A N/A N/A N/A $16.92 N/A N/A $15.42 N/A N/A $10.20 N/A N/A $17.41 N/A N/A $19.90 N/A N/A $13.68 N/A N/A $17.41 N/A N/A $8.33 N/A N/A N/A N/A N/A $14.93 N/A N/A $8.71 N/A N/A $16.17 N/A N/A $2.76 N/A N/A $14.93 N/A N/A $17.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.88 $24.88 N/A 4400306 Pharmacy cyanocobalamin 1000 mcg/mL Inj Sol [BCH] J3420 636 $16.58 $- $1.72 $- $- $13.27 $- N/A $4.31 N/A N/A Not Reimbursed N/A N/A $9.95 N/A N/A $8.29 N/A N/A N/A N/A N/A $11.28 N/A N/A $10.28 N/A N/A $6.80 N/A N/A $11.61 N/A N/A $13.27 N/A N/A $9.12 N/A N/A $11.61 N/A N/A $5.56 N/A N/A N/A N/A N/A $9.95 N/A N/A $5.80 N/A N/A $10.78 N/A N/A $1.72 N/A N/A $9.95 N/A N/A $11.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.58 $16.58 N/A 4409396 Pharmacy magnesium sulfate 50% Inj Sol 2 mL [BCH] J3475 636 $12.00 $- $0.64 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.64 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409396 Pharmacy magnesium sulfate 50% Sol [BCH] J3475 636 $12.00 $- $0.64 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.64 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400439 Pharmacy magnesium sulfate 50% Inj Sol 10 mL [BCH] J3475 636 $12.00 $- $0.64 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.64 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400439 Pharmacy magnesium sulfate 50% Sol J3475 636 $12.00 $- $0.64 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.64 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409396 Pharmacy magnesium sulfate 50% Sol [BCH] J3475 636 $12.00 $- $0.64 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.64 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407992 Pharmacy doxycycline 100 mg IV Inj [BCH] 250 $57.98 $- $15.08 $- $- $46.39 $- N/A $15.08 N/A N/A $21.92 N/A N/A $34.79 N/A N/A $28.99 N/A N/A N/A N/A N/A $39.43 N/A N/A $35.95 N/A N/A $23.77 N/A N/A $40.59 N/A N/A $46.39 N/A N/A $31.89 N/A N/A $40.59 N/A N/A $19.42 N/A N/A N/A N/A N/A $34.79 N/A N/A $20.29 N/A N/A $37.69 N/A N/A N/A N/A N/A $34.79 N/A N/A $40.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $57.98 $57.98 N/A 4405874 Pharmacy ketorolac 30 mg/mL Sol [BCH] J1885 636 $12.00 $- $0.58 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.58 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4405874 Pharmacy ketorolac 30 mg/mL Sol [BCH] J1885 636 $12.00 $- $0.58 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.58 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409121 Pharmacy dexamethasone 4 mg/mL Inj Sol [BCH] J1100 636 $12.00 $- $0.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.12 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400412 Pharmacy dexamethasone 4 mg/mL Inj Sol [BCH] J1100 636 $68.26 $- $0.12 $- $- $54.61 $- N/A $17.75 N/A N/A Not Reimbursed N/A N/A $40.96 N/A N/A $34.13 N/A N/A N/A N/A N/A $46.42 N/A N/A $42.32 N/A N/A $27.99 N/A N/A $47.78 N/A N/A $54.61 N/A N/A $37.54 N/A N/A $47.78 N/A N/A $22.87 N/A N/A N/A N/A N/A $40.96 N/A N/A $23.89 N/A N/A $44.37 N/A N/A $0.12 N/A N/A $40.96 N/A N/A $47.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $68.26 $68.26 N/A 4400088 Pharmacy sodium phosphate 3 mmol/mL Sol [BCH] 636 $116.21 $- $30.21 $- $- $92.97 $- N/A $30.21 N/A N/A $43.93 N/A N/A $69.72 N/A N/A $58.10 N/A N/A N/A N/A N/A $79.02 N/A N/A $72.05 N/A N/A $47.65 N/A N/A $81.35 N/A N/A $92.97 N/A N/A $63.91 N/A N/A $81.35 N/A N/A $38.93 N/A N/A N/A N/A N/A $69.72 N/A N/A $40.67 N/A N/A $75.54 N/A N/A N/A N/A N/A $69.72 N/A N/A $81.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $116.21 $116.21 N/A 4400088 Pharmacy sodium phosphate 3 mmol/mL Inj Sol [BCH] 636 $79.22 $- $20.60 $- $- $63.38 $- N/A $20.60 N/A N/A $29.95 N/A N/A $47.53 N/A N/A $39.61 N/A N/A N/A N/A N/A $53.87 N/A N/A $49.12 N/A N/A $32.48 N/A N/A $55.46 N/A N/A $63.38 N/A N/A $43.57 N/A N/A $55.46 N/A N/A $26.54 N/A N/A N/A N/A N/A $47.53 N/A N/A $27.73 N/A N/A $51.50 N/A N/A N/A N/A N/A $47.53 N/A N/A $55.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $79.22 $79.22 N/A 4404711 Pharmacy folic acid 5 mg/mL Inj Sol [BCH] 250 $108.28 $- $28.15 $- $- $86.62 $- N/A $28.15 N/A N/A $40.93 N/A N/A $64.97 N/A N/A $54.14 N/A N/A N/A N/A N/A $73.63 N/A N/A $67.13 N/A N/A $44.39 N/A N/A $75.80 N/A N/A $86.62 N/A N/A $59.55 N/A N/A $75.80 N/A N/A $36.27 N/A N/A N/A N/A N/A $64.97 N/A N/A $37.90 N/A N/A $70.38 N/A N/A N/A N/A N/A $64.97 N/A N/A $75.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $108.28 $108.28 N/A 4400559 Pharmacy sodium chloride 0.9% Sol 250 $- $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400075 Pharmacy lidocaine 1% Sol [BCH] J2001 636 $12.00 $- $0.02 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.02 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400387 Pharmacy vancomycin 750 mg Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4407475 Pharmacy protamine 10 mg/mL Sol J2720 636 $108.00 $- $0.88 $- $- $86.40 $- N/A $28.08 N/A N/A Not Reimbursed N/A N/A $64.80 N/A N/A $54.00 N/A N/A N/A N/A N/A $73.44 N/A N/A $66.96 N/A N/A $44.28 N/A N/A $75.60 N/A N/A $86.40 N/A N/A $59.40 N/A N/A $75.60 N/A N/A $36.18 N/A N/A N/A N/A N/A $64.80 N/A N/A $37.80 N/A N/A $70.20 N/A N/A $0.88 N/A N/A $64.80 N/A N/A $75.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $108.00 $108.00 N/A 4407475 Pharmacy protamine 10 mg/mL Inj Sol [BCH] J2720 636 $84.24 $- $0.88 $- $- $67.39 $- N/A $21.90 N/A N/A Not Reimbursed N/A N/A $50.54 N/A N/A $42.12 N/A N/A N/A N/A N/A $57.28 N/A N/A $52.23 N/A N/A $34.54 N/A N/A $58.97 N/A N/A $67.39 N/A N/A $46.33 N/A N/A $58.97 N/A N/A $28.22 N/A N/A N/A N/A N/A $50.54 N/A N/A $29.48 N/A N/A $54.76 N/A N/A $0.88 N/A N/A $50.54 N/A N/A $58.97 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $84.24 $84.24 N/A 4400110 Pharmacy mineral oil 100% Oral Liq 10 mL [BCH] 250 $33.41 $- $8.69 $- $- $26.73 $- N/A $8.69 N/A N/A $12.63 N/A N/A $20.04 N/A N/A $16.70 N/A N/A N/A N/A N/A $22.72 N/A N/A $20.71 N/A N/A $13.70 N/A N/A $23.39 N/A N/A $26.73 N/A N/A $18.37 N/A N/A $23.39 N/A N/A $11.19 N/A N/A N/A N/A N/A $20.04 N/A N/A $11.69 N/A N/A $21.72 N/A N/A N/A N/A N/A $20.04 N/A N/A $23.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.41 $33.41 N/A 4405016 Pharmacy heparin 5000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407756 Pharmacy scopolamine 0.4 mg/mL Inj Sol [BCH] 250 $19.08 $- $4.96 $- $- $15.26 $- N/A $4.96 N/A N/A $7.21 N/A N/A $11.45 N/A N/A $9.54 N/A N/A N/A N/A N/A $12.97 N/A N/A $11.83 N/A N/A $7.82 N/A N/A $13.36 N/A N/A $15.26 N/A N/A $10.49 N/A N/A $13.36 N/A N/A $6.39 N/A N/A N/A N/A N/A $11.45 N/A N/A $6.68 N/A N/A $12.40 N/A N/A N/A N/A N/A $11.45 N/A N/A $13.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.08 $19.08 N/A 4409915 Pharmacy propofol 10 mg/mL IV 100ml Emul [BCH] S0144 250 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4409915 Pharmacy propofol 10 mg/mL EMU S0144 636 $75.00 $- $19.50 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A N/A N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400124 Pharmacy fluPHENAZine decanoate 25 mg/mL Inj Sol [BCH] J2680 636 $371.92 $- $11.45 $- $- $297.54 $- N/A $96.70 N/A N/A Not Reimbursed N/A N/A $223.15 N/A N/A $185.96 N/A N/A N/A N/A N/A $252.91 N/A N/A $230.59 N/A N/A $152.49 N/A N/A $260.34 N/A N/A $297.54 N/A N/A $204.56 N/A N/A $260.34 N/A N/A $124.59 N/A N/A N/A N/A N/A $223.15 N/A N/A $130.17 N/A N/A $241.75 N/A N/A $11.45 N/A N/A $223.15 N/A N/A $260.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $371.92 $371.92 N/A 4402373 Pharmacy SUMAtriptan 6 mg/0.5 mL SubQ Sol [BCH] J3030 636 $122.50 $- $31.85 $- $- $98.00 $- N/A $31.85 N/A N/A Not Reimbursed N/A N/A $73.50 N/A N/A $61.25 N/A N/A N/A N/A N/A $83.30 N/A N/A $75.95 N/A N/A $50.23 N/A N/A $85.75 N/A N/A $98.00 N/A N/A $67.38 N/A N/A $85.75 N/A N/A $41.04 N/A N/A N/A N/A N/A $73.50 N/A N/A $42.88 N/A N/A $79.63 N/A N/A N/A N/A N/A $73.50 N/A N/A $85.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $122.50 $122.50 N/A 4400695 Pharmacy fluPHENAZine 2.5 mg/mL Inj Sol [BCH] 250 $439.00 $- $114.14 $- $- $351.20 $- N/A $114.14 N/A N/A $165.94 N/A N/A $263.40 N/A N/A $219.50 N/A N/A N/A N/A N/A $298.52 N/A N/A $272.18 N/A N/A $179.99 N/A N/A $307.30 N/A N/A $351.20 N/A N/A $241.45 N/A N/A $307.30 N/A N/A $147.07 N/A N/A N/A N/A N/A $263.40 N/A N/A $153.65 N/A N/A $285.35 N/A N/A N/A N/A N/A $263.40 N/A N/A $307.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $439.00 $439.00 N/A 4405346 Pharmacy vancomycin 1 g Pow [BCH] J3370 636 $32.50 $- $2.77 $- $- $26.00 $- N/A $8.45 N/A N/A Not Reimbursed N/A N/A $19.50 N/A N/A $16.25 N/A N/A N/A N/A N/A $22.10 N/A N/A $20.15 N/A N/A $13.33 N/A N/A $22.75 N/A N/A $26.00 N/A N/A $17.88 N/A N/A $22.75 N/A N/A $10.89 N/A N/A N/A N/A N/A $19.50 N/A N/A $11.38 N/A N/A $21.13 N/A N/A $2.77 N/A N/A $19.50 N/A N/A $22.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.50 $32.50 N/A 4400552 Pharmacy ropivacaine 0.5% Inj Sol 30 mL [BCH] J2795 636 $52.10 $- $0.08 $- $- $41.68 $- N/A $13.55 N/A N/A Not Reimbursed N/A N/A $31.26 N/A N/A $26.05 N/A N/A N/A N/A N/A $35.43 N/A N/A $32.30 N/A N/A $21.36 N/A N/A $36.47 N/A N/A $41.68 N/A N/A $28.66 N/A N/A $36.47 N/A N/A $17.45 N/A N/A N/A N/A N/A $31.26 N/A N/A $18.24 N/A N/A $33.87 N/A N/A $0.08 N/A N/A $31.26 N/A N/A $36.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.10 $52.10 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g IV Inj [BCH] J2543 636 $33.29 $- $1.68 $- $- $26.63 $- N/A $8.65 N/A N/A Not Reimbursed N/A N/A $19.97 N/A N/A $16.64 N/A N/A N/A N/A N/A $22.64 N/A N/A $20.64 N/A N/A $13.65 N/A N/A $23.30 N/A N/A $26.63 N/A N/A $18.31 N/A N/A $23.30 N/A N/A $11.15 N/A N/A N/A N/A N/A $19.97 N/A N/A $11.65 N/A N/A $21.64 N/A N/A $1.68 N/A N/A $19.97 N/A N/A $23.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.29 $33.29 N/A 4409000 Pharmacy tobramycin 40 mg/mL Inj Sol [BCH] J3260 636 $28.00 $- $3.45 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.45 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400207 Pharmacy calcium gluconate 100 mg/mL Inj Sol [BCH] J0610 636 $12.96 $- $3.37 $- $- $10.37 $- N/A $3.37 N/A N/A Not Reimbursed N/A N/A $7.78 N/A N/A $6.48 N/A N/A N/A N/A N/A $8.81 N/A N/A $8.04 N/A N/A $5.31 N/A N/A $9.07 N/A N/A $10.37 N/A N/A $7.13 N/A N/A $9.07 N/A N/A $4.34 N/A N/A N/A N/A N/A $7.78 N/A N/A $4.54 N/A N/A $8.42 N/A N/A $4.19 N/A N/A $7.78 N/A N/A $9.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.96 $12.96 N/A 4400207 Pharmacy calcium gluconate 100 mg/mL Inj Sol [BCH] J0610 636 $16.85 $- $4.19 $- $- $13.48 $- N/A $4.38 N/A N/A Not Reimbursed N/A N/A $10.11 N/A N/A $8.42 N/A N/A N/A N/A N/A $11.46 N/A N/A $10.45 N/A N/A $6.91 N/A N/A $11.79 N/A N/A $13.48 N/A N/A $9.27 N/A N/A $11.79 N/A N/A $5.64 N/A N/A N/A N/A N/A $10.11 N/A N/A $5.90 N/A N/A $10.95 N/A N/A $4.19 N/A N/A $10.11 N/A N/A $11.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.85 $16.85 N/A 4401961 Pharmacy imipenem-cilastatin 500 mg-500 mg Pow J0743 636 $60.00 $- $5.77 $- $- $48.00 $- N/A $15.60 N/A N/A Not Reimbursed N/A N/A $36.00 N/A N/A $30.00 N/A N/A N/A N/A N/A $40.80 N/A N/A $37.20 N/A N/A $24.60 N/A N/A $42.00 N/A N/A $48.00 N/A N/A $33.00 N/A N/A $42.00 N/A N/A $20.10 N/A N/A N/A N/A N/A $36.00 N/A N/A $21.00 N/A N/A $39.00 N/A N/A $5.77 N/A N/A $36.00 N/A N/A $42.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $60.00 $60.00 N/A 4401961 Pharmacy imipenem-cilastatin 500 mg-500 mg Pow [BCH] J0743 636 $30.00 $- $5.77 $- $- $24.00 $- N/A $7.80 N/A N/A Not Reimbursed N/A N/A $18.00 N/A N/A $15.00 N/A N/A N/A N/A N/A $20.40 N/A N/A $18.60 N/A N/A $12.30 N/A N/A $21.00 N/A N/A $24.00 N/A N/A $16.50 N/A N/A $21.00 N/A N/A $10.05 N/A N/A N/A N/A N/A $18.00 N/A N/A $10.50 N/A N/A $19.50 N/A N/A $5.77 N/A N/A $18.00 N/A N/A $21.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.00 $30.00 N/A 4401528 Pharmacy acyclovir 50 mg/mL IV Sol [BCH] J0133 636 $45.12 $- $0.07 $- $- $36.10 $- N/A $11.73 N/A N/A Not Reimbursed N/A N/A $27.07 N/A N/A $22.56 N/A N/A N/A N/A N/A $30.68 N/A N/A $27.97 N/A N/A $18.50 N/A N/A $31.58 N/A N/A $36.10 N/A N/A $24.82 N/A N/A $31.58 N/A N/A $15.12 N/A N/A N/A N/A N/A $27.07 N/A N/A $15.79 N/A N/A $29.33 N/A N/A $0.07 N/A N/A $27.07 N/A N/A $31.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.12 $45.12 N/A 4400722 Pharmacy cefepime 2 g Pow [BCH] J0692 636 $28.00 $- $1.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400650 Pharmacy cefTRIAXone 2 g Inj [BCH] J0696 636 $28.00 $- $0.53 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.53 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400207 Pharmacy calcium gluconate 100 mg/mL Sol [BCH] J0610 636 $21.96 $- $4.19 $- $- $17.57 $- N/A $5.71 N/A N/A Not Reimbursed N/A N/A $13.18 N/A N/A $10.98 N/A N/A N/A N/A N/A $14.93 N/A N/A $13.62 N/A N/A $9.00 N/A N/A $15.37 N/A N/A $17.57 N/A N/A $12.08 N/A N/A $15.37 N/A N/A $7.36 N/A N/A N/A N/A N/A $13.18 N/A N/A $7.69 N/A N/A $14.27 N/A N/A $4.19 N/A N/A $13.18 N/A N/A $15.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.96 $21.96 N/A 4400177 Pharmacy ampicillin-sulbactam 2 g-1 g Inj [BCH] J0295 636 $28.00 $- $2.76 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.76 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405803 Pharmacy octreotide 100 mcg/mL Sol [BCH] J2354 636 $23.86 $- $0.83 $- $- $19.08 $- N/A $6.20 N/A N/A Not Reimbursed N/A N/A $14.31 N/A N/A $11.93 N/A N/A N/A N/A N/A $16.22 N/A N/A $14.79 N/A N/A $9.78 N/A N/A $16.70 N/A N/A $19.08 N/A N/A $13.12 N/A N/A $16.70 N/A N/A $7.99 N/A N/A N/A N/A N/A $14.31 N/A N/A $8.35 N/A N/A $15.51 N/A N/A $0.83 N/A N/A $14.31 N/A N/A $16.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $23.86 $23.86 N/A 4409224 Pharmacy ampicillin 1 g Inj [BCH] J0290 636 $28.00 $- $0.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4401515 Pharmacy azithromycin 500 mg IV Inj [BCH] J0456 636 $28.00 $- $3.42 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.42 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400443 Pharmacy aztreonam 1 g Inj [BCH] 250 $79.08 $- $20.56 $- $- $63.26 $- N/A $20.56 N/A N/A $29.89 N/A N/A $47.45 N/A N/A $39.54 N/A N/A N/A N/A N/A $53.77 N/A N/A $49.03 N/A N/A $32.42 N/A N/A $55.36 N/A N/A $63.26 N/A N/A $43.49 N/A N/A $55.36 N/A N/A $26.49 N/A N/A N/A N/A N/A $47.45 N/A N/A $27.68 N/A N/A $51.40 N/A N/A N/A N/A N/A $47.45 N/A N/A $55.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $79.08 $79.08 N/A 4400443 Pharmacy aztreonam 1 g Pow [BCH] 636 $79.08 $- $20.56 $- $- $63.26 $- N/A $20.56 N/A N/A $29.89 N/A N/A $47.45 N/A N/A $39.54 N/A N/A N/A N/A N/A $53.77 N/A N/A $49.03 N/A N/A $32.42 N/A N/A $55.36 N/A N/A $63.26 N/A N/A $43.49 N/A N/A $55.36 N/A N/A $26.49 N/A N/A N/A N/A N/A $47.45 N/A N/A $27.68 N/A N/A $51.40 N/A N/A N/A N/A N/A $47.45 N/A N/A $55.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $79.08 $79.08 N/A 4408218 Pharmacy midazolam 5 mg/mL Inj Sol [BCH] J2250 636 $22.00 $- $0.11 $- $- $17.60 $- N/A $5.72 N/A N/A Not Reimbursed N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A $0.11 N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4404593 Pharmacy flumazenil 0.1 mg/mL IV Sol [BCH] 258 $16.28 $- $4.23 $- $- $13.02 $- N/A $4.23 N/A N/A $6.15 N/A N/A $9.77 N/A N/A $8.14 N/A N/A N/A N/A N/A $11.07 N/A N/A $10.09 N/A N/A $6.67 N/A N/A $11.40 N/A N/A $13.02 N/A N/A $8.95 N/A N/A $11.40 N/A N/A $5.45 N/A N/A N/A N/A N/A $9.77 N/A N/A $5.70 N/A N/A $10.58 N/A N/A N/A N/A N/A $9.77 N/A N/A $11.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.28 $16.28 N/A 4403249 Pharmacy "bupivacaine-EPINEPHrine 0.75%-1:200,000 PF Inj Sol 30 mL [BCH]" 250 $22.34 $- $5.81 $- $- $17.88 $- N/A $5.81 N/A N/A $8.45 N/A N/A $13.41 N/A N/A $11.17 N/A N/A N/A N/A N/A $15.19 N/A N/A $13.85 N/A N/A $9.16 N/A N/A $15.64 N/A N/A $17.88 N/A N/A $12.29 N/A N/A $15.64 N/A N/A $7.49 N/A N/A N/A N/A N/A $13.41 N/A N/A $7.82 N/A N/A $14.52 N/A N/A N/A N/A N/A $13.41 N/A N/A $15.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.34 $22.34 N/A 4400993 Pharmacy "bupivacaine-epinephrine 0.25%-1:200,000 Sol" 636 $32.30 $- $8.40 $- $- $25.84 $- N/A $8.40 N/A N/A $12.21 N/A N/A $19.38 N/A N/A $16.15 N/A N/A N/A N/A N/A $21.97 N/A N/A $20.03 N/A N/A $13.24 N/A N/A $22.61 N/A N/A $25.84 N/A N/A $17.77 N/A N/A $22.61 N/A N/A $10.82 N/A N/A N/A N/A N/A $19.38 N/A N/A $11.31 N/A N/A $21.00 N/A N/A N/A N/A N/A $19.38 N/A N/A $22.61 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.30 $32.30 N/A 4400268 Pharmacy "bupivacaine-EPINEPHrine 0.5%-1:200,000 PF Inj Sol 10 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400549 Pharmacy bupivacaine 0.25% PF Inj Sol 30 mL [BCH] 250 $14.40 $- $3.74 $- $- $11.52 $- N/A $3.74 N/A N/A $5.44 N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A N/A N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400266 Pharmacy "bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Sol 10 mL [BCH]" 250 $32.40 $- $8.42 $- $- $25.92 $- N/A $8.42 N/A N/A $12.25 N/A N/A $19.44 N/A N/A $16.20 N/A N/A N/A N/A N/A $22.03 N/A N/A $20.09 N/A N/A $13.28 N/A N/A $22.68 N/A N/A $25.92 N/A N/A $17.82 N/A N/A $22.68 N/A N/A $10.85 N/A N/A N/A N/A N/A $19.44 N/A N/A $11.34 N/A N/A $21.06 N/A N/A N/A N/A N/A $19.44 N/A N/A $22.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.40 $32.40 N/A 4400123 Pharmacy haloperidol decanoate 100 mg/mL Inj Sol [BCH] J1631 636 $123.56 $- $15.65 $- $- $98.85 $- N/A $32.13 N/A N/A Not Reimbursed N/A N/A $74.14 N/A N/A $61.78 N/A N/A N/A N/A N/A $84.02 N/A N/A $76.61 N/A N/A $50.66 N/A N/A $86.49 N/A N/A $98.85 N/A N/A $67.96 N/A N/A $86.49 N/A N/A $41.39 N/A N/A N/A N/A N/A $74.14 N/A N/A $43.25 N/A N/A $80.31 N/A N/A $15.65 N/A N/A $74.14 N/A N/A $86.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $123.56 $123.56 N/A 4404944 Pharmacy haloperidol 5 mg/mL Inj Sol [BCH] J1630 636 $14.38 $- $0.99 $- $- $11.50 $- N/A $3.74 N/A N/A Not Reimbursed N/A N/A $8.63 N/A N/A $7.19 N/A N/A N/A N/A N/A $9.78 N/A N/A $8.92 N/A N/A $5.90 N/A N/A $10.07 N/A N/A $11.50 N/A N/A $7.91 N/A N/A $10.07 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.63 N/A N/A $5.03 N/A N/A $9.35 N/A N/A $0.99 N/A N/A $8.63 N/A N/A $10.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.38 $14.38 N/A 4403710 Pharmacy chloroprocaine 3% PF Inj Sol 20 mL [BCH] J2400 636 $53.71 $- $13.97 $- $- $42.97 $- N/A $13.97 N/A N/A Not Reimbursed N/A N/A $32.23 N/A N/A $26.86 N/A N/A N/A N/A N/A $36.52 N/A N/A $33.30 N/A N/A $22.02 N/A N/A $37.60 N/A N/A $42.97 N/A N/A $29.54 N/A N/A $37.60 N/A N/A $17.99 N/A N/A N/A N/A N/A $32.23 N/A N/A $18.80 N/A N/A $34.91 N/A N/A $19.25 N/A N/A $32.23 N/A N/A $37.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $53.71 $53.71 N/A 4409998 Pharmacy "EPINEPHrine-lidocaine 1:100,000-1% Inj Sol 20 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409117 Pharmacy "EPINEPHrine-lidocaine 1:100,000-2% Inj Sol 20 mL [BCH]" 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402746 Pharmacy lidocaine 2% Sol [BCH] J2001 636 $14.40 $- $0.02 $- $- $11.52 $- N/A $3.74 N/A N/A Not Reimbursed N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A $0.02 N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4400825 Pharmacy lidocaine 1% PF Inj Sol 30 mL [BCH] J2001 636 $24.60 $- $0.02 $- $- $19.68 $- N/A $6.40 N/A N/A Not Reimbursed N/A N/A $14.76 N/A N/A $12.30 N/A N/A N/A N/A N/A $16.73 N/A N/A $15.25 N/A N/A $10.09 N/A N/A $17.22 N/A N/A $19.68 N/A N/A $13.53 N/A N/A $17.22 N/A N/A $8.24 N/A N/A N/A N/A N/A $14.76 N/A N/A $8.61 N/A N/A $15.99 N/A N/A $0.02 N/A N/A $14.76 N/A N/A $17.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.60 $24.60 N/A 4400825 Pharmacy lidocaine 1% PF Inj Sol 30 mL [BCH] J2001 636 $37.20 $- $0.02 $- $- $29.76 $- N/A $9.67 N/A N/A Not Reimbursed N/A N/A $22.32 N/A N/A $18.60 N/A N/A N/A N/A N/A $25.30 N/A N/A $23.06 N/A N/A $15.25 N/A N/A $26.04 N/A N/A $29.76 N/A N/A $20.46 N/A N/A $26.04 N/A N/A $12.46 N/A N/A N/A N/A N/A $22.32 N/A N/A $13.02 N/A N/A $24.18 N/A N/A $0.02 N/A N/A $22.32 N/A N/A $26.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.20 $37.20 N/A 4409337 Pharmacy valproic acid 100 mg/mL Sol [BCH] 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400558 Pharmacy lidocaine 2% PF Inj Sol 10 mL [BCH] J2001 636 $14.47 $- $0.02 $- $- $11.58 $- N/A $3.76 N/A N/A Not Reimbursed N/A N/A $8.68 N/A N/A $7.24 N/A N/A N/A N/A N/A $9.84 N/A N/A $8.97 N/A N/A $5.93 N/A N/A $10.13 N/A N/A $11.58 N/A N/A $7.96 N/A N/A $10.13 N/A N/A $4.85 N/A N/A N/A N/A N/A $8.68 N/A N/A $5.07 N/A N/A $9.41 N/A N/A $0.02 N/A N/A $8.68 N/A N/A $10.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.47 $14.47 N/A 4400870 Pharmacy dexamethasone 10 mg/mL preservative-free Sol [BCH] J1100 636 $12.60 $- $0.12 $- $- $10.08 $- N/A $3.28 N/A N/A Not Reimbursed N/A N/A $7.56 N/A N/A $6.30 N/A N/A N/A N/A N/A $8.57 N/A N/A $7.81 N/A N/A $5.17 N/A N/A $8.82 N/A N/A $10.08 N/A N/A $6.93 N/A N/A $8.82 N/A N/A $4.22 N/A N/A N/A N/A N/A $7.56 N/A N/A $4.41 N/A N/A $8.19 N/A N/A $0.12 N/A N/A $7.56 N/A N/A $8.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.60 $12.60 N/A 4400446 Pharmacy meropenem 500 mg IV Inj [BCH] J2185 636 $28.00 $- $0.79 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.79 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400446 Pharmacy meropenem 500 mg Pow [BCH] J2185 636 $28.00 $- $0.79 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.79 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400714 Pharmacy meropenem 1000 mg Pow [BCH] J2185 636 $48.00 $- $0.79 $- $- $38.40 $- N/A $12.48 N/A N/A Not Reimbursed N/A N/A $28.80 N/A N/A $24.00 N/A N/A N/A N/A N/A $32.64 N/A N/A $29.76 N/A N/A $19.68 N/A N/A $33.60 N/A N/A $38.40 N/A N/A $26.40 N/A N/A $33.60 N/A N/A $16.08 N/A N/A N/A N/A N/A $28.80 N/A N/A $16.80 N/A N/A $31.20 N/A N/A $0.79 N/A N/A $28.80 N/A N/A $33.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.00 $48.00 N/A 4400714 Pharmacy meropenem 1000 mg Pow [BCH] J2185 636 $48.00 $- $0.79 $- $- $38.40 $- N/A $12.48 N/A N/A Not Reimbursed N/A N/A $28.80 N/A N/A $24.00 N/A N/A N/A N/A N/A $32.64 N/A N/A $29.76 N/A N/A $19.68 N/A N/A $33.60 N/A N/A $38.40 N/A N/A $26.40 N/A N/A $33.60 N/A N/A $16.08 N/A N/A N/A N/A N/A $28.80 N/A N/A $16.80 N/A N/A $31.20 N/A N/A $0.79 N/A N/A $28.80 N/A N/A $33.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.00 $48.00 N/A 4400820 Pharmacy dexamethasone 10 mg/mL Inj Sol [BCH] J1100 636 $25.99 $- $0.12 $- $- $20.79 $- N/A $6.76 N/A N/A Not Reimbursed N/A N/A $15.60 N/A N/A $13.00 N/A N/A N/A N/A N/A $17.67 N/A N/A $16.12 N/A N/A $10.66 N/A N/A $18.19 N/A N/A $20.79 N/A N/A $14.30 N/A N/A $18.19 N/A N/A $8.71 N/A N/A N/A N/A N/A $15.60 N/A N/A $9.10 N/A N/A $16.89 N/A N/A $0.12 N/A N/A $15.60 N/A N/A $18.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.99 $25.99 N/A 4400451 Pharmacy heparin 50 units/mL-D5% Sol [BCH] J1644 636 $527.62 $- $0.25 $- $- $422.10 $- N/A $137.18 N/A N/A Not Reimbursed N/A N/A $316.57 N/A N/A $263.81 N/A N/A N/A N/A N/A $358.78 N/A N/A $327.12 N/A N/A $216.32 N/A N/A $369.33 N/A N/A $422.10 N/A N/A $290.19 N/A N/A $369.33 N/A N/A $176.75 N/A N/A N/A N/A N/A $316.57 N/A N/A $184.67 N/A N/A $342.95 N/A N/A $0.25 N/A N/A $316.57 N/A N/A $369.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $527.62 $527.62 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $38.16 $- $0.69 $- $- $30.53 $- N/A $9.92 N/A N/A Not Reimbursed N/A N/A $22.90 N/A N/A $19.08 N/A N/A N/A N/A N/A $25.95 N/A N/A $23.66 N/A N/A $15.65 N/A N/A $26.71 N/A N/A $30.53 N/A N/A $20.99 N/A N/A $26.71 N/A N/A $12.78 N/A N/A N/A N/A N/A $22.90 N/A N/A $13.36 N/A N/A $24.80 N/A N/A $0.69 N/A N/A $22.90 N/A N/A $26.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.16 $38.16 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $19.27 $- $0.69 $- $- $15.42 $- N/A $5.01 N/A N/A Not Reimbursed N/A N/A $11.56 N/A N/A $9.64 N/A N/A N/A N/A N/A $13.10 N/A N/A $11.95 N/A N/A $7.90 N/A N/A $13.49 N/A N/A $15.42 N/A N/A $10.60 N/A N/A $13.49 N/A N/A $6.46 N/A N/A N/A N/A N/A $11.56 N/A N/A $6.75 N/A N/A $12.53 N/A N/A $0.69 N/A N/A $11.56 N/A N/A $13.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.27 $19.27 N/A 4406671 Pharmacy enoxaparin 30 mg/0.3 mL Sol [BCH] J1650 636 $12.00 $- $0.69 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.69 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol [BCH] J1650 636 $19.06 $- $0.69 $- $- $15.24 $- N/A $4.95 N/A N/A Not Reimbursed N/A N/A $11.43 N/A N/A $9.53 N/A N/A N/A N/A N/A $12.96 N/A N/A $11.81 N/A N/A $7.81 N/A N/A $13.34 N/A N/A $15.24 N/A N/A $10.48 N/A N/A $13.34 N/A N/A $6.38 N/A N/A N/A N/A N/A $11.43 N/A N/A $6.67 N/A N/A $12.39 N/A N/A $0.69 N/A N/A $11.43 N/A N/A $13.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.06 $19.06 N/A 4400172 Pharmacy heparin 1000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408965 Pharmacy enoxaparin 100 mg/mL Sol [BCH] J1650 636 $47.71 $- $0.69 $- $- $38.17 $- N/A $12.41 N/A N/A Not Reimbursed N/A N/A $28.63 N/A N/A $23.86 N/A N/A N/A N/A N/A $32.44 N/A N/A $29.58 N/A N/A $19.56 N/A N/A $33.40 N/A N/A $38.17 N/A N/A $26.24 N/A N/A $33.40 N/A N/A $15.98 N/A N/A N/A N/A N/A $28.63 N/A N/A $16.70 N/A N/A $31.01 N/A N/A $0.69 N/A N/A $28.63 N/A N/A $33.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.71 $47.71 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol [BCH] J1650 636 $19.06 $- $0.69 $- $- $15.24 $- N/A $4.95 N/A N/A Not Reimbursed N/A N/A $11.43 N/A N/A $9.53 N/A N/A N/A N/A N/A $12.96 N/A N/A $11.81 N/A N/A $7.81 N/A N/A $13.34 N/A N/A $15.24 N/A N/A $10.48 N/A N/A $13.34 N/A N/A $6.38 N/A N/A N/A N/A N/A $11.43 N/A N/A $6.67 N/A N/A $12.39 N/A N/A $0.69 N/A N/A $11.43 N/A N/A $13.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.06 $19.06 N/A 4400111 Pharmacy enoxaparin 60 mg/0.6 mL Sol J1650 636 $28.63 $- $0.69 $- $- $22.91 $- N/A $7.44 N/A N/A Not Reimbursed N/A N/A $17.18 N/A N/A $14.32 N/A N/A N/A N/A N/A $19.47 N/A N/A $17.75 N/A N/A $11.74 N/A N/A $20.04 N/A N/A $22.91 N/A N/A $15.75 N/A N/A $20.04 N/A N/A $9.59 N/A N/A N/A N/A N/A $17.18 N/A N/A $10.02 N/A N/A $18.61 N/A N/A $0.69 N/A N/A $17.18 N/A N/A $20.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.63 $28.63 N/A 4409303 Pharmacy enoxaparin 80 mg/0.8 mL Sol [BCH] J1650 636 $38.16 $- $0.69 $- $- $30.53 $- N/A $9.92 N/A N/A Not Reimbursed N/A N/A $22.90 N/A N/A $19.08 N/A N/A N/A N/A N/A $25.95 N/A N/A $23.66 N/A N/A $15.65 N/A N/A $26.71 N/A N/A $30.53 N/A N/A $20.99 N/A N/A $26.71 N/A N/A $12.78 N/A N/A N/A N/A N/A $22.90 N/A N/A $13.36 N/A N/A $24.80 N/A N/A $0.69 N/A N/A $22.90 N/A N/A $26.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.16 $38.16 N/A 4406671 Pharmacy enoxaparin 30 mg/0.3 mL Sol [BCH] J1650 636 $14.33 $- $0.69 $- $- $11.46 $- N/A $3.73 N/A N/A Not Reimbursed N/A N/A $8.60 N/A N/A $7.16 N/A N/A N/A N/A N/A $9.74 N/A N/A $8.88 N/A N/A $5.87 N/A N/A $10.03 N/A N/A $11.46 N/A N/A $7.88 N/A N/A $10.03 N/A N/A $4.80 N/A N/A N/A N/A N/A $8.60 N/A N/A $5.01 N/A N/A $9.31 N/A N/A $0.69 N/A N/A $8.60 N/A N/A $10.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.33 $14.33 N/A 4400111 Pharmacy enoxaparin 60 mg/0.6 mL Sol [BCH] J1650 636 $28.63 $- $0.69 $- $- $22.91 $- N/A $7.44 N/A N/A Not Reimbursed N/A N/A $17.18 N/A N/A $14.32 N/A N/A N/A N/A N/A $19.47 N/A N/A $17.75 N/A N/A $11.74 N/A N/A $20.04 N/A N/A $22.91 N/A N/A $15.75 N/A N/A $20.04 N/A N/A $9.59 N/A N/A N/A N/A N/A $17.18 N/A N/A $10.02 N/A N/A $18.61 N/A N/A $0.69 N/A N/A $17.18 N/A N/A $20.04 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.63 $28.63 N/A 4400198 Pharmacy propranolol 1 mg/mL IV Sol [BCH] J1800 636 $24.17 $- $2.44 $- $- $19.33 $- N/A $6.28 N/A N/A Not Reimbursed N/A N/A $14.50 N/A N/A $12.08 N/A N/A N/A N/A N/A $16.43 N/A N/A $14.98 N/A N/A $9.91 N/A N/A $16.92 N/A N/A $19.33 N/A N/A $13.29 N/A N/A $16.92 N/A N/A $8.10 N/A N/A N/A N/A N/A $14.50 N/A N/A $8.46 N/A N/A $15.71 N/A N/A $2.44 N/A N/A $14.50 N/A N/A $16.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.17 $24.17 N/A 4400111 Pharmacy enoxaparin 60 mg / 0.6 mL Injection J1650 636 $12.00 $- $0.69 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.69 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4401676 Pharmacy hydrALAZINE 20 mg/mL Inj Sol [BCH] J0360 636 $28.80 $- $2.88 $- $- $23.04 $- N/A $7.49 N/A N/A Not Reimbursed N/A N/A $17.28 N/A N/A $14.40 N/A N/A N/A N/A N/A $19.58 N/A N/A $17.86 N/A N/A $11.81 N/A N/A $20.16 N/A N/A $23.04 N/A N/A $15.84 N/A N/A $20.16 N/A N/A $9.65 N/A N/A N/A N/A N/A $17.28 N/A N/A $10.08 N/A N/A $18.72 N/A N/A $2.88 N/A N/A $17.28 N/A N/A $20.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.80 $28.80 N/A 4401676 Pharmacy hydrALAZINE 20 mg/mL Sol [BCH] J0360 636 $28.80 $- $2.88 $- $- $23.04 $- N/A $7.49 N/A N/A Not Reimbursed N/A N/A $17.28 N/A N/A $14.40 N/A N/A N/A N/A N/A $19.58 N/A N/A $17.86 N/A N/A $11.81 N/A N/A $20.16 N/A N/A $23.04 N/A N/A $15.84 N/A N/A $20.16 N/A N/A $9.65 N/A N/A N/A N/A N/A $17.28 N/A N/A $10.08 N/A N/A $18.72 N/A N/A $2.88 N/A N/A $17.28 N/A N/A $20.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.80 $28.80 N/A 4409429 Pharmacy amiodarone 50 mg/mL Sol [BCH] J0280 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $7.31 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400428 Pharmacy Sodium Chloride 0.9% IV Sol 500 mL [BCH] J7040 636 $75.00 $- $1.28 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $1.28 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4401276 Pharmacy levothyroxine 100 mcg (0.1 mg) Pow [BCH] 250 $253.40 $- $65.88 $- $- $202.72 $- N/A $65.88 N/A N/A $95.79 N/A N/A $152.04 N/A N/A $126.70 N/A N/A N/A N/A N/A $172.31 N/A N/A $157.11 N/A N/A $103.89 N/A N/A $177.38 N/A N/A $202.72 N/A N/A $139.37 N/A N/A $177.38 N/A N/A $84.89 N/A N/A N/A N/A N/A $152.04 N/A N/A $88.69 N/A N/A $164.71 N/A N/A N/A N/A N/A $152.04 N/A N/A $177.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $253.40 $253.40 N/A 4402394 Pharmacy adenosine 3 mg/mL IV Sol vl[BCH] J0150 258 $26.28 $- $6.83 $- $- $21.02 $- N/A $6.83 N/A N/A Not Reimbursed N/A N/A $15.77 N/A N/A $13.14 N/A N/A N/A N/A N/A $17.87 N/A N/A $16.29 N/A N/A $10.77 N/A N/A $18.40 N/A N/A $21.02 N/A N/A $14.45 N/A N/A $18.40 N/A N/A $8.80 N/A N/A N/A N/A N/A $15.77 N/A N/A $9.20 N/A N/A $17.08 N/A N/A N/A N/A N/A $15.77 N/A N/A $18.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.28 $26.28 N/A 4402394 Pharmacy adenosine 3 mg/mL Sol [BCH] J0150 636 $38.16 $- $9.92 $- $- $30.53 $- N/A $9.92 N/A N/A Not Reimbursed N/A N/A $22.90 N/A N/A $19.08 N/A N/A N/A N/A N/A $25.95 N/A N/A $23.66 N/A N/A $15.65 N/A N/A $26.71 N/A N/A $30.53 N/A N/A $20.99 N/A N/A $26.71 N/A N/A $12.78 N/A N/A N/A N/A N/A $22.90 N/A N/A $13.36 N/A N/A $24.80 N/A N/A N/A N/A N/A $22.90 N/A N/A $26.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.16 $38.16 N/A 4404080 Pharmacy esmolol 10 mg/mL Sol [BCH] 636 $34.51 $- $8.97 $- $- $27.61 $- N/A $8.97 N/A N/A $13.05 N/A N/A $20.71 N/A N/A $17.26 N/A N/A N/A N/A N/A $23.47 N/A N/A $21.40 N/A N/A $14.15 N/A N/A $24.16 N/A N/A $27.61 N/A N/A $18.98 N/A N/A $24.16 N/A N/A $11.56 N/A N/A N/A N/A N/A $20.71 N/A N/A $12.08 N/A N/A $22.43 N/A N/A N/A N/A N/A $20.71 N/A N/A $24.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.51 $34.51 N/A 4400165 Pharmacy diphenhydrAMINE 50 mg/mL Inj Sol [BCH] J1200 636 $12.00 $- $0.72 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.72 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407323 Pharmacy acetylcysteine 20% Inh Sol 30 mL [BCH] J7608 636 $50.01 $- $5.48 $- $- $40.01 $- N/A $13.00 N/A N/A Not Reimbursed N/A N/A $30.01 N/A N/A $25.01 N/A N/A N/A N/A N/A $34.01 N/A N/A $31.01 N/A N/A $20.51 N/A N/A $35.01 N/A N/A $40.01 N/A N/A $27.51 N/A N/A $35.01 N/A N/A $16.75 N/A N/A N/A N/A N/A $30.01 N/A N/A $17.50 N/A N/A $32.51 N/A N/A $5.48 N/A N/A $30.01 N/A N/A $35.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $50.01 $50.01 N/A 4400840 Pharmacy acetylcysteine 20% Sol [BCH] J7608 636 $29.16 $- $5.48 $- $- $23.33 $- N/A $7.58 N/A N/A Not Reimbursed N/A N/A $17.50 N/A N/A $14.58 N/A N/A N/A N/A N/A $19.83 N/A N/A $18.08 N/A N/A $11.96 N/A N/A $20.41 N/A N/A $23.33 N/A N/A $16.04 N/A N/A $20.41 N/A N/A $9.77 N/A N/A N/A N/A N/A $17.50 N/A N/A $10.21 N/A N/A $18.95 N/A N/A $5.48 N/A N/A $17.50 N/A N/A $20.41 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $29.16 $29.16 N/A 4403861 Pharmacy famotidine 10 mg/mL IV Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409821 Pharmacy DAPTOmycin 500 mg Pow [BCH] J0878 636 "$1,008.00 " $- $0.14 $- $- $806.40 $- N/A $262.08 N/A N/A Not Reimbursed N/A N/A $604.80 N/A N/A $504.00 N/A N/A N/A N/A N/A $685.44 N/A N/A $624.96 N/A N/A $413.28 N/A N/A $705.60 N/A N/A $806.40 N/A N/A $554.40 N/A N/A $705.60 N/A N/A $337.68 N/A N/A N/A N/A N/A $604.80 N/A N/A $352.80 N/A N/A $655.20 N/A N/A $0.14 N/A N/A $604.80 N/A N/A $705.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,008.00 " "$1,008.00 " N/A 4401136 Pharmacy benztropine 1 mg/mL Sol [BCH] J0515 636 $660.00 $- $15.52 $- $- $528.00 $- N/A $171.60 N/A N/A Not Reimbursed N/A N/A $396.00 N/A N/A $330.00 N/A N/A N/A N/A N/A $448.80 N/A N/A $409.20 N/A N/A $270.60 N/A N/A $462.00 N/A N/A $528.00 N/A N/A $363.00 N/A N/A $462.00 N/A N/A $221.10 N/A N/A N/A N/A N/A $396.00 N/A N/A $231.00 N/A N/A $429.00 N/A N/A $15.52 N/A N/A $396.00 N/A N/A $462.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $660.00 $660.00 N/A 4409647 Pharmacy piperacillin-tazobactam 2 g-0.25 g Pow [BCH] J2543 636 $28.00 $- $1.68 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $1.68 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g Pow J2543 636 $33.29 $- $1.68 $- $- $26.63 $- N/A $8.65 N/A N/A Not Reimbursed N/A N/A $19.97 N/A N/A $16.64 N/A N/A N/A N/A N/A $22.64 N/A N/A $20.64 N/A N/A $13.65 N/A N/A $23.30 N/A N/A $26.63 N/A N/A $18.31 N/A N/A $23.30 N/A N/A $11.15 N/A N/A N/A N/A N/A $19.97 N/A N/A $11.65 N/A N/A $21.64 N/A N/A $1.68 N/A N/A $19.97 N/A N/A $23.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.29 $33.29 N/A 4400638 Pharmacy lurasidone 40 mg Tab 250 $97.87 $- $25.45 $- $- $78.30 $- N/A $25.45 N/A N/A $37.00 N/A N/A $58.72 N/A N/A $48.94 N/A N/A N/A N/A N/A $66.55 N/A N/A $60.68 N/A N/A $40.13 N/A N/A $68.51 N/A N/A $78.30 N/A N/A $53.83 N/A N/A $68.51 N/A N/A $32.79 N/A N/A N/A N/A N/A $58.72 N/A N/A $34.26 N/A N/A $63.62 N/A N/A N/A N/A N/A $58.72 N/A N/A $68.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $97.87 $97.87 N/A 4400638 Pharmacy lurasidone 40 mg Tab [BCH] 250 $89.06 $- $23.16 $- $- $71.25 $- N/A $23.16 N/A N/A $33.67 N/A N/A $53.44 N/A N/A $44.53 N/A N/A N/A N/A N/A $60.56 N/A N/A $55.22 N/A N/A $36.52 N/A N/A $62.34 N/A N/A $71.25 N/A N/A $48.99 N/A N/A $62.34 N/A N/A $29.84 N/A N/A N/A N/A N/A $53.44 N/A N/A $31.17 N/A N/A $57.89 N/A N/A N/A N/A N/A $53.44 N/A N/A $62.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $89.06 $89.06 N/A 4400454 Pharmacy levalbuterol CFC free 45 mcg/inh Inh Aer w/adapter [BCH] 250 $163.78 $- $42.58 $- $- $131.02 $- N/A $42.58 N/A N/A $61.91 N/A N/A $98.27 N/A N/A $81.89 N/A N/A N/A N/A N/A $111.37 N/A N/A $101.54 N/A N/A $67.15 N/A N/A $114.65 N/A N/A $131.02 N/A N/A $90.08 N/A N/A $114.65 N/A N/A $54.87 N/A N/A N/A N/A N/A $98.27 N/A N/A $57.32 N/A N/A $106.46 N/A N/A N/A N/A N/A $98.27 N/A N/A $114.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $163.78 $163.78 N/A 4409671 Pharmacy levalbuterol 0.31 mg/3 mL Inh Sol [BCH] J7614 636 $21.60 $- $0.06 $- $- $17.28 $- N/A $5.62 N/A N/A Not Reimbursed N/A N/A $12.96 N/A N/A $10.80 N/A N/A N/A N/A N/A $14.69 N/A N/A $13.39 N/A N/A $8.86 N/A N/A $15.12 N/A N/A $17.28 N/A N/A $11.88 N/A N/A $15.12 N/A N/A $7.24 N/A N/A N/A N/A N/A $12.96 N/A N/A $7.56 N/A N/A $14.04 N/A N/A $0.06 N/A N/A $12.96 N/A N/A $15.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.60 $21.60 N/A 4409873 Pharmacy levalbuterol 0.63 mg/3 mL Inh Sol [BCH] J7614 636 $19.64 $- $0.06 $- $- $15.71 $- N/A $5.11 N/A N/A Not Reimbursed N/A N/A $11.78 N/A N/A $9.82 N/A N/A N/A N/A N/A $13.36 N/A N/A $12.18 N/A N/A $8.05 N/A N/A $13.75 N/A N/A $15.71 N/A N/A $10.80 N/A N/A $13.75 N/A N/A $6.58 N/A N/A N/A N/A N/A $11.78 N/A N/A $6.87 N/A N/A $12.77 N/A N/A $0.06 N/A N/A $11.78 N/A N/A $13.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.64 $19.64 N/A 4401954 Pharmacy levalbuterol 1.25 mg/3 mL Inh Sol [BCH] J7614 636 $19.64 $- $0.06 $- $- $15.71 $- N/A $5.11 N/A N/A Not Reimbursed N/A N/A $11.78 N/A N/A $9.82 N/A N/A N/A N/A N/A $13.36 N/A N/A $12.18 N/A N/A $8.05 N/A N/A $13.75 N/A N/A $15.71 N/A N/A $10.80 N/A N/A $13.75 N/A N/A $6.58 N/A N/A N/A N/A N/A $11.78 N/A N/A $6.87 N/A N/A $12.77 N/A N/A $0.06 N/A N/A $11.78 N/A N/A $13.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $19.64 $19.64 N/A 4400832 Pharmacy armodafinil 150 mg Tab [BCH] 250 $48.64 $- $12.65 $- $- $38.91 $- N/A $12.65 N/A N/A $18.39 N/A N/A $29.18 N/A N/A $24.32 N/A N/A N/A N/A N/A $33.08 N/A N/A $30.16 N/A N/A $19.94 N/A N/A $34.05 N/A N/A $38.91 N/A N/A $26.75 N/A N/A $34.05 N/A N/A $16.29 N/A N/A N/A N/A N/A $29.18 N/A N/A $17.02 N/A N/A $31.62 N/A N/A N/A N/A N/A $29.18 N/A N/A $34.05 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.64 $48.64 N/A 4400261 Pharmacy diclofenac topical 1% Gel[BCH] 250 $115.40 $- $30.00 $- $- $92.32 $- N/A $30.00 N/A N/A $43.62 N/A N/A $69.24 N/A N/A $57.70 N/A N/A N/A N/A N/A $78.47 N/A N/A $71.55 N/A N/A $47.31 N/A N/A $80.78 N/A N/A $92.32 N/A N/A $63.47 N/A N/A $80.78 N/A N/A $38.66 N/A N/A N/A N/A N/A $69.24 N/A N/A $40.39 N/A N/A $75.01 N/A N/A N/A N/A N/A $69.24 N/A N/A $80.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $115.40 $115.40 N/A 4409666 Pharmacy lidocaine Top 5% film [BCH] 250 $28.75 $- $7.47 $- $- $23.00 $- N/A $7.47 N/A N/A $10.87 N/A N/A $17.25 N/A N/A $14.37 N/A N/A N/A N/A N/A $19.55 N/A N/A $17.82 N/A N/A $11.79 N/A N/A $20.12 N/A N/A $23.00 N/A N/A $15.81 N/A N/A $20.12 N/A N/A $9.63 N/A N/A N/A N/A N/A $17.25 N/A N/A $10.06 N/A N/A $18.69 N/A N/A N/A N/A N/A $17.25 N/A N/A $20.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.75 $28.75 N/A 4400793 Pharmacy oxymorphone 40 mg oral ER Tab [BCH] 250 $37.86 $- $9.84 $- $- $30.28 $- N/A $9.84 N/A N/A $14.31 N/A N/A $22.71 N/A N/A $18.93 N/A N/A N/A N/A N/A $25.74 N/A N/A $23.47 N/A N/A $15.52 N/A N/A $26.50 N/A N/A $30.28 N/A N/A $20.82 N/A N/A $26.50 N/A N/A $12.68 N/A N/A N/A N/A N/A $22.71 N/A N/A $13.25 N/A N/A $24.61 N/A N/A N/A N/A N/A $22.71 N/A N/A $26.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.86 $37.86 N/A 4409444 Pharmacy ketoconazole topical 2% Sha [BCH] 250 $47.85 $- $12.44 $- $- $38.28 $- N/A $12.44 N/A N/A $18.09 N/A N/A $28.71 N/A N/A $23.92 N/A N/A N/A N/A N/A $32.54 N/A N/A $29.66 N/A N/A $19.62 N/A N/A $33.49 N/A N/A $38.28 N/A N/A $26.32 N/A N/A $33.49 N/A N/A $16.03 N/A N/A N/A N/A N/A $28.71 N/A N/A $16.75 N/A N/A $31.10 N/A N/A N/A N/A N/A $28.71 N/A N/A $33.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.85 $47.85 N/A 4400807 Pharmacy phenol topical 14.5 mg Loz [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400864 Pharmacy levETIRAcetam 100 mg/mL Sol [BCH] 250 $6.56 $- $1.71 $- $- $5.25 $- N/A $1.71 N/A N/A $2.48 N/A N/A $3.94 N/A N/A $3.28 N/A N/A N/A N/A N/A $4.46 N/A N/A $4.07 N/A N/A $2.69 N/A N/A $4.59 N/A N/A $5.25 N/A N/A $3.61 N/A N/A $4.59 N/A N/A $2.20 N/A N/A N/A N/A N/A $3.94 N/A N/A $2.30 N/A N/A $4.27 N/A N/A N/A N/A N/A $3.94 N/A N/A $4.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.56 $6.56 N/A 4407463 Pharmacy clindamycin 150 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4404750 Pharmacy cloNIDine 0.1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402260 Pharmacy dilTIAZem 30 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407307 Pharmacy mirtazapine 15 mg Tab 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4409587 Pharmacy mirtazapine 30 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409881 Pharmacy metoclopramide 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402880 Pharmacy glyBURIDE 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400633 Pharmacy hydrALAZINE 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404778 Pharmacy hydroCHLOROthiazide 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400569 Pharmacy megestrol 40 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400032 Pharmacy simethicone 80 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402393 Pharmacy tamoxifen 10 mg Tab[BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401941 Pharmacy metoclopramide 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400537 Pharmacy hydrALAZINE 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400633 Pharmacy hydrALAZINE 50 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab 250 $2.47 $- $0.64 $- $- $1.98 $- N/A $0.64 N/A N/A $0.93 N/A N/A $1.48 N/A N/A $1.24 N/A N/A N/A N/A N/A $1.68 N/A N/A $1.53 N/A N/A $1.01 N/A N/A $1.73 N/A N/A $1.98 N/A N/A $1.36 N/A N/A $1.73 N/A N/A $0.83 N/A N/A N/A N/A N/A $1.48 N/A N/A $0.87 N/A N/A $1.61 N/A N/A N/A N/A N/A $1.48 N/A N/A $1.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.47 $2.47 N/A 4404361 Pharmacy lisinopril 20 mg Tab [BCH] 250 $2.65 $- $0.69 $- $- $2.12 $- N/A $0.69 N/A N/A $1.00 N/A N/A $1.59 N/A N/A $1.32 N/A N/A N/A N/A N/A $1.80 N/A N/A $1.64 N/A N/A $1.09 N/A N/A $1.85 N/A N/A $2.12 N/A N/A $1.46 N/A N/A $1.85 N/A N/A $0.89 N/A N/A N/A N/A N/A $1.59 N/A N/A $0.93 N/A N/A $1.72 N/A N/A N/A N/A N/A $1.59 N/A N/A $1.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.65 $2.65 N/A 4402413 Pharmacy magnesium oxide 400 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402413 Pharmacy magnesium oxide 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407307 Pharmacy mirtazapine 15 mg Tab [BCH] 250 $6.79 $- $1.76 $- $- $5.43 $- N/A $1.76 N/A N/A $2.57 N/A N/A $4.07 N/A N/A $3.39 N/A N/A N/A N/A N/A $4.62 N/A N/A $4.21 N/A N/A $2.78 N/A N/A $4.75 N/A N/A $5.43 N/A N/A $3.73 N/A N/A $4.75 N/A N/A $2.27 N/A N/A N/A N/A N/A $4.07 N/A N/A $2.38 N/A N/A $4.41 N/A N/A N/A N/A N/A $4.07 N/A N/A $4.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.79 $6.79 N/A 4402688 Pharmacy isosorbide dinitrate 20 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404480 Pharmacy amiodarone 200 mg Tab 250 $6.76 $- $1.76 $- $- $5.41 $- N/A $1.76 N/A N/A $2.56 N/A N/A $4.06 N/A N/A $3.38 N/A N/A N/A N/A N/A $4.60 N/A N/A $4.19 N/A N/A $2.77 N/A N/A $4.73 N/A N/A $5.41 N/A N/A $3.72 N/A N/A $4.73 N/A N/A $2.26 N/A N/A N/A N/A N/A $4.06 N/A N/A $2.37 N/A N/A $4.39 N/A N/A N/A N/A N/A $4.06 N/A N/A $4.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.76 $6.76 N/A 4408564 Pharmacy allopurinol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400323 Pharmacy levETIRAcetam 500 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409686 Pharmacy docusate-senna 50 mg-8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408945 Pharmacy aspirin 81 mg Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408036 Pharmacy acetaminophen 325 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407364 Pharmacy baclofen 10 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408453 Pharmacy predniSONE 10 mg Tab [BCH] J7506 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405814 Pharmacy aspirin 81 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400015 Pharmacy valACYclovir 500 mg Tab [BCH] 250 $14.45 $- $3.76 $- $- $11.56 $- N/A $3.76 N/A N/A $5.46 N/A N/A $8.67 N/A N/A $7.22 N/A N/A N/A N/A N/A $9.82 N/A N/A $8.96 N/A N/A $5.92 N/A N/A $10.11 N/A N/A $11.56 N/A N/A $7.95 N/A N/A $10.11 N/A N/A $4.84 N/A N/A N/A N/A N/A $8.67 N/A N/A $5.06 N/A N/A $9.39 N/A N/A N/A N/A N/A $8.67 N/A N/A $10.11 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.45 $14.45 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404729 Pharmacy folic acid 1 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400864 Pharmacy levETIRAcetam 100 mg/mL Sol [BCH] 250 $5.51 $- $1.43 $- $- $4.41 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.31 N/A N/A $2.76 N/A N/A N/A N/A N/A $3.75 N/A N/A $3.42 N/A N/A $2.26 N/A N/A $3.86 N/A N/A $4.41 N/A N/A $3.03 N/A N/A $3.86 N/A N/A $1.85 N/A N/A N/A N/A N/A $3.31 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.31 N/A N/A $3.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.51 $5.51 N/A 4401338 Pharmacy spironolactone 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409594 Pharmacy pantoprazole 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409204 Pharmacy tamsulosin 0.4 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406457 Pharmacy simvastatin 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402019 Pharmacy azithromycin 250 mg Tab [BCH] 250 $5.33 $- $1.39 $- $- $4.27 $- N/A $1.39 N/A N/A $2.02 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.63 N/A N/A $3.31 N/A N/A $2.19 N/A N/A $3.73 N/A N/A $4.27 N/A N/A $2.93 N/A N/A $3.73 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.47 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.33 $5.33 N/A 4409418 Pharmacy rivastigmine 1.5 mg Cap [BCH] 250 $8.07 $- $2.10 $- $- $6.45 $- N/A $2.10 N/A N/A $3.05 N/A N/A $4.84 N/A N/A $4.03 N/A N/A N/A N/A N/A $5.49 N/A N/A $5.00 N/A N/A $3.31 N/A N/A $5.65 N/A N/A $6.45 N/A N/A $4.44 N/A N/A $5.65 N/A N/A $2.70 N/A N/A N/A N/A N/A $4.84 N/A N/A $2.82 N/A N/A $5.24 N/A N/A N/A N/A N/A $4.84 N/A N/A $5.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.07 $8.07 N/A 4406366 Pharmacy gabapentin 100 mg Cap [bch] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401253 Pharmacy famotidine 20 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405685 Pharmacy ibuprofen 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405685 Pharmacy ibuprofen 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400794 Pharmacy losartan 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405693 Pharmacy ibuprofen 600 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400066 Pharmacy losartan 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400478 Pharmacy losartan 100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400526 Pharmacy allopurinol 300 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400370 Pharmacy niMODipine 30 mg Cap 250 $6.90 $- $1.79 $- $- $5.52 $- N/A $1.79 N/A N/A $2.61 N/A N/A $4.14 N/A N/A $3.45 N/A N/A N/A N/A N/A $4.69 N/A N/A $4.28 N/A N/A $2.83 N/A N/A $4.83 N/A N/A $5.52 N/A N/A $3.79 N/A N/A $4.83 N/A N/A $2.31 N/A N/A N/A N/A N/A $4.14 N/A N/A $2.41 N/A N/A $4.48 N/A N/A N/A N/A N/A $4.14 N/A N/A $4.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.90 $6.90 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406366 Pharmacy gabapentin 100 mg Cap BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409642 Pharmacy gabapentin 400 mg Cap[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402252 Pharmacy sucralfate 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405016 Pharmacy heparin 5000 units/mL Sol [BCH] J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400291 Pharmacy potassium chloride 20 mEq Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409642 Pharmacy gabapentin 400 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $6.68 $- $1.74 $- $- $5.34 $- N/A $1.74 N/A N/A $2.52 N/A N/A $4.01 N/A N/A $3.34 N/A N/A N/A N/A N/A $4.54 N/A N/A $4.14 N/A N/A $2.74 N/A N/A $4.67 N/A N/A $5.34 N/A N/A $3.67 N/A N/A $4.67 N/A N/A $2.24 N/A N/A N/A N/A N/A $4.01 N/A N/A $2.34 N/A N/A $4.34 N/A N/A N/A N/A N/A $4.01 N/A N/A $4.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.68 $6.68 N/A 4409950 Pharmacy lidocaine topical 4% Sol [BCH] 250 $89.26 $- $23.21 $- $- $71.41 $- N/A $23.21 N/A N/A $33.74 N/A N/A $53.56 N/A N/A $44.63 N/A N/A N/A N/A N/A $60.70 N/A N/A $55.34 N/A N/A $36.60 N/A N/A $62.48 N/A N/A $71.41 N/A N/A $49.09 N/A N/A $62.48 N/A N/A $29.90 N/A N/A N/A N/A N/A $53.56 N/A N/A $31.24 N/A N/A $58.02 N/A N/A N/A N/A N/A $53.56 N/A N/A $62.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $89.26 $89.26 N/A 4400823 Pharmacy sodium chloride 0.9% Sol [BCH] 258 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409767 Pharmacy guaiFENesin 600 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409767 Pharmacy guaiFENesin 600 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409767 Pharmacy guaiFENesin 600 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402571 Pharmacy dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402571 Pharmacy dextromethorphan-guaiFENesin 30 mg-600 mg ER Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402377 Pharmacy benzocaine-menthol topical 15 mg-3.6 mg Loz [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402377 Pharmacy benzocaine-menthol topical 15 mg-3.6 mg Loz 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400134 Pharmacy heparin flush 100 units/mL Sol [BCH] J1642 636 $- $- $0.01 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.01 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400391 Pharmacy "ergocalciferol 50,000 intl units Cap" 250 $3.94 $- $1.03 $- $- $3.16 $- N/A $1.03 N/A N/A $1.49 N/A N/A $2.37 N/A N/A $1.97 N/A N/A N/A N/A N/A $2.68 N/A N/A $2.45 N/A N/A $1.62 N/A N/A $2.76 N/A N/A $3.16 N/A N/A $2.17 N/A N/A $2.76 N/A N/A $1.32 N/A N/A N/A N/A N/A $2.37 N/A N/A $1.38 N/A N/A $2.56 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.94 $3.94 N/A 4409455 Pharmacy busPIRone 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400956 Pharmacy dextromethorphan-quinidine 20 mg-10 mg Cap [BCH] 250 $43.93 $- $11.42 $- $- $35.14 $- N/A $11.42 N/A N/A $16.60 N/A N/A $26.36 N/A N/A $21.96 N/A N/A N/A N/A N/A $29.87 N/A N/A $27.24 N/A N/A $18.01 N/A N/A $30.75 N/A N/A $35.14 N/A N/A $24.16 N/A N/A $30.75 N/A N/A $14.72 N/A N/A N/A N/A N/A $26.36 N/A N/A $15.37 N/A N/A $28.55 N/A N/A N/A N/A N/A $26.36 N/A N/A $30.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $43.93 $43.93 N/A 4409518 Pharmacy niCARdipine 2.5 mg/mL Sol 10mL [BCH] 250 $208.48 $- $54.20 $- $- $166.78 $- N/A $54.20 N/A N/A $78.81 N/A N/A $125.09 N/A N/A $104.24 N/A N/A N/A N/A N/A $141.77 N/A N/A $129.26 N/A N/A $85.48 N/A N/A $145.94 N/A N/A $166.78 N/A N/A $114.66 N/A N/A $145.94 N/A N/A $69.84 N/A N/A N/A N/A N/A $125.09 N/A N/A $72.97 N/A N/A $135.51 N/A N/A N/A N/A N/A $125.09 N/A N/A $145.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $208.48 $208.48 N/A 4403102 Pharmacy furosemide 10 mg/mL Sol [BCH] J1940 636 $12.00 $- $0.60 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.60 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4403002 Pharmacy cefuroxime 250 mg Tab [BCH] 250 $8.79 $- $2.28 $- $- $7.03 $- N/A $2.28 N/A N/A $3.32 N/A N/A $5.27 N/A N/A $4.39 N/A N/A N/A N/A N/A $5.98 N/A N/A $5.45 N/A N/A $3.60 N/A N/A $6.15 N/A N/A $7.03 N/A N/A $4.83 N/A N/A $6.15 N/A N/A $2.94 N/A N/A N/A N/A N/A $5.27 N/A N/A $3.08 N/A N/A $5.71 N/A N/A N/A N/A N/A $5.27 N/A N/A $6.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.79 $8.79 N/A 4400546 Pharmacy bethanechol 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400858 Pharmacy amphetamine-dextroamphetamine 10 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400726 Pharmacy amphetamine-dextroamphetamine 30 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400164 Pharmacy metaxalone 800 mg Tab [BCH] 250 $9.78 $- $2.54 $- $- $7.83 $- N/A $2.54 N/A N/A $3.70 N/A N/A $5.87 N/A N/A $4.89 N/A N/A N/A N/A N/A $6.65 N/A N/A $6.06 N/A N/A $4.01 N/A N/A $6.85 N/A N/A $7.83 N/A N/A $5.38 N/A N/A $6.85 N/A N/A $3.28 N/A N/A N/A N/A N/A $5.87 N/A N/A $3.42 N/A N/A $6.36 N/A N/A N/A N/A N/A $5.87 N/A N/A $6.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.78 $9.78 N/A 4400612 Pharmacy lubiprostone 8 mcg Cap [BCH] 250 $13.21 $- $3.43 $- $- $10.57 $- N/A $3.43 N/A N/A $4.99 N/A N/A $7.93 N/A N/A $6.61 N/A N/A N/A N/A N/A $8.98 N/A N/A $8.19 N/A N/A $5.42 N/A N/A $9.25 N/A N/A $10.57 N/A N/A $7.27 N/A N/A $9.25 N/A N/A $4.43 N/A N/A N/A N/A N/A $7.93 N/A N/A $4.62 N/A N/A $8.59 N/A N/A N/A N/A N/A $7.93 N/A N/A $9.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.21 $13.21 N/A 4402542 Pharmacy colchicine 0.6 mg Tab [BCH] 250 $15.79 $- $4.11 $- $- $12.63 $- N/A $4.11 N/A N/A $5.97 N/A N/A $9.48 N/A N/A $7.90 N/A N/A N/A N/A N/A $10.74 N/A N/A $9.79 N/A N/A $6.48 N/A N/A $11.06 N/A N/A $12.63 N/A N/A $8.69 N/A N/A $11.06 N/A N/A $5.29 N/A N/A N/A N/A N/A $9.48 N/A N/A $5.53 N/A N/A $10.27 N/A N/A N/A N/A N/A $9.48 N/A N/A $11.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.79 $15.79 N/A 4400972 Pharmacy febuxostat 80 mg Tab [BCH] 250 $26.40 $- $6.86 $- $- $21.12 $- N/A $6.86 N/A N/A $9.98 N/A N/A $15.84 N/A N/A $13.20 N/A N/A N/A N/A N/A $17.95 N/A N/A $16.37 N/A N/A $10.83 N/A N/A $18.48 N/A N/A $21.12 N/A N/A $14.52 N/A N/A $18.48 N/A N/A $8.84 N/A N/A N/A N/A N/A $15.84 N/A N/A $9.24 N/A N/A $17.16 N/A N/A N/A N/A N/A $15.84 N/A N/A $18.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.40 $26.40 N/A 4400960 Pharmacy febuxostat 40 mg Tab [BCH] 250 $25.63 $- $6.66 $- $- $20.51 $- N/A $6.66 N/A N/A $9.69 N/A N/A $15.38 N/A N/A $12.82 N/A N/A N/A N/A N/A $17.43 N/A N/A $15.89 N/A N/A $10.51 N/A N/A $17.94 N/A N/A $20.51 N/A N/A $14.10 N/A N/A $17.94 N/A N/A $8.59 N/A N/A N/A N/A N/A $15.38 N/A N/A $8.97 N/A N/A $16.66 N/A N/A N/A N/A N/A $15.38 N/A N/A $17.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.63 $25.63 N/A 4400579 Pharmacy lactobacillus acidophilus and bulgaricus Chew Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400403 Pharmacy lactobacillus acidophilus and bulgaricus Oral Gran [BCH] 250 $4.06 $- $1.06 $- $- $3.25 $- N/A $1.06 N/A N/A $1.54 N/A N/A $2.44 N/A N/A $2.03 N/A N/A N/A N/A N/A $2.76 N/A N/A $2.52 N/A N/A $1.67 N/A N/A $2.84 N/A N/A $3.25 N/A N/A $2.24 N/A N/A $2.84 N/A N/A $1.36 N/A N/A N/A N/A N/A $2.44 N/A N/A $1.42 N/A N/A $2.64 N/A N/A N/A N/A N/A $2.44 N/A N/A $2.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.06 $4.06 N/A 4400546 Pharmacy bethanechol 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400679 Pharmacy glipiZIDE 2.5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409818 Pharmacy hydrocortisone 2.5% Rectal Crm w/Appl [BCH] 250 $174.66 $- $45.41 $- $- $139.73 $- N/A $45.41 N/A N/A $66.02 N/A N/A $104.80 N/A N/A $87.33 N/A N/A N/A N/A N/A $118.77 N/A N/A $108.29 N/A N/A $71.61 N/A N/A $122.26 N/A N/A $139.73 N/A N/A $96.06 N/A N/A $122.26 N/A N/A $58.51 N/A N/A N/A N/A N/A $104.80 N/A N/A $61.13 N/A N/A $113.53 N/A N/A N/A N/A N/A $104.80 N/A N/A $122.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $174.66 $174.66 N/A 4403827 Pharmacy triamcinolone Top 0.1% Paste [BCH] 250 $161.18 $- $41.91 $- $- $128.94 $- N/A $41.91 N/A N/A $60.93 N/A N/A $96.71 N/A N/A $80.59 N/A N/A N/A N/A N/A $109.60 N/A N/A $99.93 N/A N/A $66.08 N/A N/A $112.83 N/A N/A $128.94 N/A N/A $88.65 N/A N/A $112.83 N/A N/A $54.00 N/A N/A N/A N/A N/A $96.71 N/A N/A $56.41 N/A N/A $104.77 N/A N/A N/A N/A N/A $96.71 N/A N/A $112.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $161.18 $161.18 N/A 4401004 Pharmacy hydrocortisone topical 2.5% Cre [BCH] 250 $- $- $42.91 $- $- $132.04 $- N/A $42.91 N/A N/A $62.39 N/A N/A $99.03 N/A N/A $82.53 N/A N/A N/A N/A N/A $112.24 N/A N/A $102.33 N/A N/A $67.67 N/A N/A $115.54 N/A N/A $132.04 N/A N/A $90.78 N/A N/A $115.54 N/A N/A $55.29 N/A N/A N/A N/A N/A $99.03 N/A N/A $57.77 N/A N/A $107.28 N/A N/A N/A N/A N/A $99.03 N/A N/A $115.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4402413 Pharmacy magnesium oxide 400 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408689 Pharmacy timolol ophthalmic maleate 0.5% Sol [BCH] 250 $34.00 $- $8.84 $- $- $27.20 $- N/A $8.84 N/A N/A $12.85 N/A N/A $20.40 N/A N/A $17.00 N/A N/A N/A N/A N/A $23.12 N/A N/A $21.08 N/A N/A $13.94 N/A N/A $23.80 N/A N/A $27.20 N/A N/A $18.70 N/A N/A $23.80 N/A N/A $11.39 N/A N/A N/A N/A N/A $20.40 N/A N/A $11.90 N/A N/A $22.10 N/A N/A N/A N/A N/A $20.40 N/A N/A $23.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.00 $34.00 N/A 4405939 Pharmacy oxyCODONE 5 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400419 Pharmacy citalopram 20 mg Tab 250 $5.24 $- $1.36 $- $- $4.19 $- N/A $1.36 N/A N/A $1.98 N/A N/A $3.14 N/A N/A $2.62 N/A N/A N/A N/A N/A $3.56 N/A N/A $3.25 N/A N/A $2.15 N/A N/A $3.67 N/A N/A $4.19 N/A N/A $2.88 N/A N/A $3.67 N/A N/A $1.75 N/A N/A N/A N/A N/A $3.14 N/A N/A $1.83 N/A N/A $3.40 N/A N/A N/A N/A N/A $3.14 N/A N/A $3.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.24 $5.24 N/A 4400298 Pharmacy citalopram 40 mg Tab [BCH] 250 $5.48 $- $1.42 $- $- $4.38 $- N/A $1.42 N/A N/A $2.07 N/A N/A $3.29 N/A N/A $2.74 N/A N/A N/A N/A N/A $3.73 N/A N/A $3.40 N/A N/A $2.25 N/A N/A $3.84 N/A N/A $4.38 N/A N/A $3.01 N/A N/A $3.84 N/A N/A $1.84 N/A N/A N/A N/A N/A $3.29 N/A N/A $1.92 N/A N/A $3.56 N/A N/A N/A N/A N/A $3.29 N/A N/A $3.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.48 $5.48 N/A 4409393 Pharmacy naproxen 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409776 Pharmacy acetaminophen-oxyCODONE 325 mg-7.5 mg Tab [BCH] 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4404729 Pharmacy folic acid 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400761 Pharmacy buprenorphine-naloxone 8 mg-2 mg Tab[BCH] 250 $20.84 $- $5.42 $- $- $16.67 $- N/A $5.42 N/A N/A $7.88 N/A N/A $12.51 N/A N/A $10.42 N/A N/A N/A N/A N/A $14.17 N/A N/A $12.92 N/A N/A $8.55 N/A N/A $14.59 N/A N/A $16.67 N/A N/A $11.46 N/A N/A $14.59 N/A N/A $6.98 N/A N/A N/A N/A N/A $12.51 N/A N/A $7.29 N/A N/A $13.55 N/A N/A N/A N/A N/A $12.51 N/A N/A $14.59 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.84 $20.84 N/A 4402787 Pharmacy meclizine 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400447 Pharmacy salsalate 500 mg Tab [BCH] 250 $3.80 $- $0.99 $- $- $3.04 $- N/A $0.99 N/A N/A $1.44 N/A N/A $2.28 N/A N/A $1.90 N/A N/A N/A N/A N/A $2.58 N/A N/A $2.36 N/A N/A $1.56 N/A N/A $2.66 N/A N/A $3.04 N/A N/A $2.09 N/A N/A $2.66 N/A N/A $1.27 N/A N/A N/A N/A N/A $2.28 N/A N/A $1.33 N/A N/A $2.47 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.66 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.80 $3.80 N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.70 $- N/A $0.55 N/A N/A $0.80 N/A N/A $1.28 N/A N/A $1.06 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.87 N/A N/A $1.49 N/A N/A $1.70 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.71 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.38 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $5.01 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4404635 Pharmacy primidone 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405750 Pharmacy primidone 250 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409252 Pharmacy demeclocycline 150 mg Tab [BCH] 250 $18.80 $- $4.89 $- $- $15.04 $- N/A $4.89 N/A N/A $7.11 N/A N/A $11.28 N/A N/A $9.40 N/A N/A N/A N/A N/A $12.79 N/A N/A $11.66 N/A N/A $7.71 N/A N/A $13.16 N/A N/A $15.04 N/A N/A $10.34 N/A N/A $13.16 N/A N/A $6.30 N/A N/A N/A N/A N/A $11.28 N/A N/A $6.58 N/A N/A $12.22 N/A N/A N/A N/A N/A $11.28 N/A N/A $13.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.80 $18.80 N/A 4400546 Pharmacy bethanechol 5 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400515 Pharmacy risperiDONE 1 mg/mL Sol [BCH] 250 "$1,689.60 " $- $439.30 $- $- "$1,351.68 " $- N/A $439.30 N/A N/A $638.67 N/A N/A "$1,013.76 " N/A N/A $844.80 N/A N/A N/A N/A N/A "$1,148.93 " N/A N/A "$1,047.55 " N/A N/A $692.74 N/A N/A "$1,182.72 " N/A N/A "$1,351.68 " N/A N/A $929.28 N/A N/A "$1,182.72 " N/A N/A $566.02 N/A N/A N/A N/A N/A "$1,013.76 " N/A N/A $591.36 N/A N/A "$1,098.24 " N/A N/A N/A N/A N/A "$1,013.76 " N/A N/A "$1,182.72 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,689.60 " "$1,689.60 " N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $5.40 $- $1.40 $- $- $4.32 $- N/A $1.40 N/A N/A $2.04 N/A N/A $3.24 N/A N/A $2.70 N/A N/A N/A N/A N/A $3.67 N/A N/A $3.35 N/A N/A $2.21 N/A N/A $3.78 N/A N/A $4.32 N/A N/A $2.97 N/A N/A $3.78 N/A N/A $1.81 N/A N/A N/A N/A N/A $3.24 N/A N/A $1.89 N/A N/A $3.51 N/A N/A N/A N/A N/A $3.24 N/A N/A $3.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.40 $5.40 N/A 4400131 Pharmacy divalproex sodium 250 mg ER Tab [BCH] 250 $4.91 $- $1.28 $- $- $3.93 $- N/A $1.28 N/A N/A $1.86 N/A N/A $2.95 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.44 N/A N/A $3.93 N/A N/A $2.70 N/A N/A $3.44 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.95 N/A N/A $1.72 N/A N/A $3.19 N/A N/A N/A N/A N/A $2.95 N/A N/A $3.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.91 $4.91 N/A 4409755 Pharmacy linezolid 600 mg Tab [BCH] 250 $366.94 $- $95.40 $- $- $293.55 $- N/A $95.40 N/A N/A $138.70 N/A N/A $220.16 N/A N/A $183.47 N/A N/A N/A N/A N/A $249.52 N/A N/A $227.50 N/A N/A $150.44 N/A N/A $256.86 N/A N/A $293.55 N/A N/A $201.82 N/A N/A $256.86 N/A N/A $122.92 N/A N/A N/A N/A N/A $220.16 N/A N/A $128.43 N/A N/A $238.51 N/A N/A N/A N/A N/A $220.16 N/A N/A $256.86 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $366.94 $366.94 N/A 4408909 Pharmacy mometasone nasal 50 mcg/inh Spr [BCH] 250 $533.86 $- $138.80 $- $- $427.09 $- N/A $138.80 N/A N/A $201.80 N/A N/A $320.32 N/A N/A $266.93 N/A N/A N/A N/A N/A $363.02 N/A N/A $330.99 N/A N/A $218.88 N/A N/A $373.70 N/A N/A $427.09 N/A N/A $293.62 N/A N/A $373.70 N/A N/A $178.84 N/A N/A N/A N/A N/A $320.32 N/A N/A $186.85 N/A N/A $347.01 N/A N/A N/A N/A N/A $320.32 N/A N/A $373.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $533.86 $533.86 N/A 4400883 Pharmacy ARIPiprazole 10 mg Tab 250 $64.15 $- $16.68 $- $- $51.32 $- N/A $16.68 N/A N/A $24.25 N/A N/A $38.49 N/A N/A $32.08 N/A N/A N/A N/A N/A $43.62 N/A N/A $39.77 N/A N/A $26.30 N/A N/A $44.91 N/A N/A $51.32 N/A N/A $35.28 N/A N/A $44.91 N/A N/A $21.49 N/A N/A N/A N/A N/A $38.49 N/A N/A $22.45 N/A N/A $41.70 N/A N/A N/A N/A N/A $38.49 N/A N/A $44.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.15 $64.15 N/A 4400736 Pharmacy vancomycin 50 mg/mL Pow [BCH] 250 $209.34 $- $54.43 $- $- $167.47 $- N/A $54.43 N/A N/A $79.13 N/A N/A $125.60 N/A N/A $104.67 N/A N/A N/A N/A N/A $142.35 N/A N/A $129.79 N/A N/A $85.83 N/A N/A $146.54 N/A N/A $167.47 N/A N/A $115.14 N/A N/A $146.54 N/A N/A $70.13 N/A N/A N/A N/A N/A $125.60 N/A N/A $73.27 N/A N/A $136.07 N/A N/A N/A N/A N/A $125.60 N/A N/A $146.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $209.34 $209.34 N/A 4400975 Pharmacy vancomycin 25 mg/mL Pow 250 $226.48 $- $58.88 $- $- $181.18 $- N/A $58.88 N/A N/A $85.61 N/A N/A $135.89 N/A N/A $113.24 N/A N/A N/A N/A N/A $154.01 N/A N/A $140.42 N/A N/A $92.86 N/A N/A $158.54 N/A N/A $181.18 N/A N/A $124.56 N/A N/A $158.54 N/A N/A $75.87 N/A N/A N/A N/A N/A $135.89 N/A N/A $79.27 N/A N/A $147.21 N/A N/A N/A N/A N/A $135.89 N/A N/A $158.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $226.48 $226.48 N/A 4400739 Pharmacy rifaximin 550 mg Tab [BCH] 250 $73.30 $- $19.06 $- $- $58.64 $- N/A $19.06 N/A N/A $27.71 N/A N/A $43.98 N/A N/A $36.65 N/A N/A N/A N/A N/A $49.84 N/A N/A $45.45 N/A N/A $30.05 N/A N/A $51.31 N/A N/A $58.64 N/A N/A $40.32 N/A N/A $51.31 N/A N/A $24.56 N/A N/A N/A N/A N/A $43.98 N/A N/A $25.66 N/A N/A $47.65 N/A N/A N/A N/A N/A $43.98 N/A N/A $51.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $73.30 $73.30 N/A 4400739 Pharmacy rifaximin 550 mg Tab [BCH] 250 $73.30 $- $19.06 $- $- $58.64 $- N/A $19.06 N/A N/A $27.71 N/A N/A $43.98 N/A N/A $36.65 N/A N/A N/A N/A N/A $49.84 N/A N/A $45.45 N/A N/A $30.05 N/A N/A $51.31 N/A N/A $58.64 N/A N/A $40.32 N/A N/A $51.31 N/A N/A $24.56 N/A N/A N/A N/A N/A $43.98 N/A N/A $25.66 N/A N/A $47.65 N/A N/A N/A N/A N/A $43.98 N/A N/A $51.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $73.30 $73.30 N/A 4400502 Pharmacy methylnaltrexone 12 mg/0.6 mL SC Sol [BCH] J2212 636 $218.16 $- $56.72 $- $- $174.53 $- N/A $56.72 N/A N/A Not Reimbursed N/A N/A $130.90 N/A N/A $109.08 N/A N/A N/A N/A N/A $148.35 N/A N/A $135.26 N/A N/A $89.45 N/A N/A $152.71 N/A N/A $174.53 N/A N/A $119.99 N/A N/A $152.71 N/A N/A $73.08 N/A N/A N/A N/A N/A $130.90 N/A N/A $76.36 N/A N/A $141.81 N/A N/A N/A N/A N/A $130.90 N/A N/A $152.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $218.16 $218.16 N/A 4400502 Pharmacy methylnaltrexone 12 mg/0.6 mL Sol [BCH] J2212 636 $322.84 $- $83.94 $- $- $258.27 $- N/A $83.94 N/A N/A Not Reimbursed N/A N/A $193.70 N/A N/A $161.42 N/A N/A N/A N/A N/A $219.53 N/A N/A $200.16 N/A N/A $132.36 N/A N/A $225.99 N/A N/A $258.27 N/A N/A $177.56 N/A N/A $225.99 N/A N/A $108.15 N/A N/A N/A N/A N/A $193.70 N/A N/A $112.99 N/A N/A $209.85 N/A N/A N/A N/A N/A $193.70 N/A N/A $225.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $322.84 $322.84 N/A 4409601 Pharmacy nesiritide 1.5 mg IV Inj [BCH] J2325 636 "$2,540.42 " $- $660.51 $- $- "$2,032.34 " $- N/A $660.51 N/A N/A Not Reimbursed N/A N/A "$1,524.25 " N/A N/A "$1,270.21 " N/A N/A N/A N/A N/A "$1,727.49 " N/A N/A "$1,575.06 " N/A N/A "$1,041.57 " N/A N/A "$1,778.29 " N/A N/A "$2,032.34 " N/A N/A "$1,397.23 " N/A N/A "$1,778.29 " N/A N/A $851.04 N/A N/A N/A N/A N/A "$1,524.25 " N/A N/A $889.15 N/A N/A "$1,651.27 " N/A N/A N/A N/A N/A "$1,524.25 " N/A N/A "$1,778.29 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,540.42 " "$2,540.42 " N/A 4400419 Pharmacy citalopram 20 mg Tab [BCH] 250 $5.07 $- $1.32 $- $- $4.05 $- N/A $1.32 N/A N/A $1.92 N/A N/A $3.04 N/A N/A $2.53 N/A N/A N/A N/A N/A $3.45 N/A N/A $3.14 N/A N/A $2.08 N/A N/A $3.55 N/A N/A $4.05 N/A N/A $2.79 N/A N/A $3.55 N/A N/A $1.70 N/A N/A N/A N/A N/A $3.04 N/A N/A $1.77 N/A N/A $3.29 N/A N/A N/A N/A N/A $3.04 N/A N/A $3.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.07 $5.07 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405681 Pharmacy metFORMIN 850 mg Tab [BCH] 250 $2.40 $- $0.62 $- $- $1.92 $- N/A $0.62 N/A N/A $0.91 N/A N/A $1.44 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.63 N/A N/A $1.49 N/A N/A $0.98 N/A N/A $1.68 N/A N/A $1.92 N/A N/A $1.32 N/A N/A $1.68 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.44 N/A N/A $0.84 N/A N/A $1.56 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.40 $2.40 N/A 4409499 Pharmacy amoxicillin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403029 Pharmacy cephalexin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4403045 Pharmacy cephalexin 500 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400751 Pharmacy mirtazapine 15 mg Dis Tab [BCH] 250 $4.71 $- $1.22 $- $- $3.77 $- N/A $1.22 N/A N/A $1.78 N/A N/A $2.83 N/A N/A $2.36 N/A N/A N/A N/A N/A $3.20 N/A N/A $2.92 N/A N/A $1.93 N/A N/A $3.30 N/A N/A $3.77 N/A N/A $2.59 N/A N/A $3.30 N/A N/A $1.58 N/A N/A N/A N/A N/A $2.83 N/A N/A $1.65 N/A N/A $3.06 N/A N/A N/A N/A N/A $2.83 N/A N/A $3.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.71 $4.71 N/A 4403002 Pharmacy cefuroxime 250 mg Tab [BCH] 250 $8.80 $- $2.29 $- $- $7.04 $- N/A $2.29 N/A N/A $3.33 N/A N/A $5.28 N/A N/A $4.40 N/A N/A N/A N/A N/A $5.98 N/A N/A $5.45 N/A N/A $3.61 N/A N/A $6.16 N/A N/A $7.04 N/A N/A $4.84 N/A N/A $6.16 N/A N/A $2.95 N/A N/A N/A N/A N/A $5.28 N/A N/A $3.08 N/A N/A $5.72 N/A N/A N/A N/A N/A $5.28 N/A N/A $6.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.80 $8.80 N/A 4400054 Pharmacy metoprolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403326 Pharmacy metoprolol 50 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400629 Pharmacy metoprolol 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400588 Pharmacy citalopram 10 mg/5 mL Oral Sol [BCH] 250 $235.00 $- $61.10 $- $- $188.00 $- N/A $61.10 N/A N/A $88.83 N/A N/A $141.00 N/A N/A $117.50 N/A N/A N/A N/A N/A $159.80 N/A N/A $145.70 N/A N/A $96.35 N/A N/A $164.50 N/A N/A $188.00 N/A N/A $129.25 N/A N/A $164.50 N/A N/A $78.72 N/A N/A N/A N/A N/A $141.00 N/A N/A $82.25 N/A N/A $152.75 N/A N/A N/A N/A N/A $141.00 N/A N/A $164.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $235.00 $235.00 N/A 4400351 Pharmacy meloxicam 15 mg Tab [BCH] 250 $9.69 $- $2.52 $- $- $7.75 $- N/A $2.52 N/A N/A $3.66 N/A N/A $5.81 N/A N/A $4.84 N/A N/A N/A N/A N/A $6.59 N/A N/A $6.01 N/A N/A $3.97 N/A N/A $6.78 N/A N/A $7.75 N/A N/A $5.33 N/A N/A $6.78 N/A N/A $3.25 N/A N/A N/A N/A N/A $5.81 N/A N/A $3.39 N/A N/A $6.30 N/A N/A N/A N/A N/A $5.81 N/A N/A $6.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.69 $9.69 N/A 4403512 Pharmacy finasteride 5 mg Tab [BCH] S0138 250 $6.25 $- $1.63 $- $- $5.00 $- N/A $1.63 N/A N/A Not Reimbursed N/A N/A $3.75 N/A N/A $3.13 N/A N/A N/A N/A N/A $4.25 N/A N/A $3.88 N/A N/A $2.56 N/A N/A $4.38 N/A N/A $5.00 N/A N/A $3.44 N/A N/A $4.38 N/A N/A $2.09 N/A N/A N/A N/A N/A $3.75 N/A N/A $2.19 N/A N/A $4.06 N/A N/A N/A N/A N/A $3.75 N/A N/A $4.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.25 $6.25 N/A 4407463 Pharmacy clindamycin 150 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $48.40 $- $0.02 $- $- $38.72 $- N/A $12.58 N/A N/A Not Reimbursed N/A N/A $29.04 N/A N/A $24.20 N/A N/A N/A N/A N/A $32.91 N/A N/A $30.01 N/A N/A $19.84 N/A N/A $33.88 N/A N/A $38.72 N/A N/A $26.62 N/A N/A $33.88 N/A N/A $16.21 N/A N/A N/A N/A N/A $29.04 N/A N/A $16.94 N/A N/A $31.46 N/A N/A $0.02 N/A N/A $29.04 N/A N/A $33.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $48.40 $48.40 N/A 4403325 Pharmacy FLUoxetine 20 mg Cap [BCH] 250 $5.34 $- $1.39 $- $- $4.27 $- N/A $1.39 N/A N/A $2.02 N/A N/A $3.20 N/A N/A $2.67 N/A N/A N/A N/A N/A $3.63 N/A N/A $3.31 N/A N/A $2.19 N/A N/A $3.74 N/A N/A $4.27 N/A N/A $2.93 N/A N/A $3.74 N/A N/A $1.79 N/A N/A N/A N/A N/A $3.20 N/A N/A $1.87 N/A N/A $3.47 N/A N/A N/A N/A N/A $3.20 N/A N/A $3.74 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.34 $5.34 N/A 4400794 Pharmacy losartan 25 mg Tab [BCH] 250 $3.37 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.29 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.37 $3.37 N/A 4400066 Pharmacy losartan 50 mg Tab[BCH] 250 $4.53 $- $1.18 $- $- $3.62 $- N/A $1.18 N/A N/A $1.71 N/A N/A $2.72 N/A N/A $2.26 N/A N/A N/A N/A N/A $3.08 N/A N/A $2.81 N/A N/A $1.86 N/A N/A $3.17 N/A N/A $3.62 N/A N/A $2.49 N/A N/A $3.17 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.72 N/A N/A $1.58 N/A N/A $2.94 N/A N/A N/A N/A N/A $2.72 N/A N/A $3.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.53 $4.53 N/A 4400478 Pharmacy losartan 100 mg Tab [BCH] 250 $6.16 $- $1.60 $- $- $4.93 $- N/A $1.60 N/A N/A $2.33 N/A N/A $3.70 N/A N/A $3.08 N/A N/A N/A N/A N/A $4.19 N/A N/A $3.82 N/A N/A $2.53 N/A N/A $4.31 N/A N/A $4.93 N/A N/A $3.39 N/A N/A $4.31 N/A N/A $2.06 N/A N/A N/A N/A N/A $3.70 N/A N/A $2.16 N/A N/A $4.01 N/A N/A N/A N/A N/A $3.70 N/A N/A $4.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.16 $6.16 N/A 4400478 Pharmacy losartan 100 mg Tab [BCH] 250 $6.16 $- $1.60 $- $- $4.93 $- N/A $1.60 N/A N/A $2.33 N/A N/A $3.70 N/A N/A $3.08 N/A N/A N/A N/A N/A $4.19 N/A N/A $3.82 N/A N/A $2.53 N/A N/A $4.31 N/A N/A $4.93 N/A N/A $3.39 N/A N/A $4.31 N/A N/A $2.06 N/A N/A N/A N/A N/A $3.70 N/A N/A $2.16 N/A N/A $4.01 N/A N/A N/A N/A N/A $3.70 N/A N/A $4.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.16 $6.16 N/A 4407265 Pharmacy clopidogrel 75 mg Tab [BCH] 250 $13.90 $- $3.61 $- $- $11.12 $- N/A $3.61 N/A N/A $5.26 N/A N/A $8.34 N/A N/A $6.95 N/A N/A N/A N/A N/A $9.45 N/A N/A $8.62 N/A N/A $5.70 N/A N/A $9.73 N/A N/A $11.12 N/A N/A $7.65 N/A N/A $9.73 N/A N/A $4.66 N/A N/A N/A N/A N/A $8.34 N/A N/A $4.87 N/A N/A $9.04 N/A N/A N/A N/A N/A $8.34 N/A N/A $9.73 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.90 $13.90 N/A 4409738 Pharmacy escitalopram 10 mg Tab [BCH] 250 $9.43 $- $2.45 $- $- $7.54 $- N/A $2.45 N/A N/A $3.56 N/A N/A $5.66 N/A N/A $4.72 N/A N/A N/A N/A N/A $6.41 N/A N/A $5.85 N/A N/A $3.87 N/A N/A $6.60 N/A N/A $7.54 N/A N/A $5.19 N/A N/A $6.60 N/A N/A $3.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $3.30 N/A N/A $6.13 N/A N/A N/A N/A N/A $5.66 N/A N/A $6.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.43 $9.43 N/A 4400307 Pharmacy escitalopram 20 mg Tab [BCH] 250 $9.84 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.89 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.89 N/A N/A $3.30 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.40 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.84 $9.84 N/A 4400719 Pharmacy ondansetron 4 mg Tab Q0162 250 $44.59 $- $0.02 $- $- $35.67 $- N/A $11.59 N/A N/A Not Reimbursed N/A N/A $26.75 N/A N/A $22.29 N/A N/A N/A N/A N/A $30.32 N/A N/A $27.64 N/A N/A $18.28 N/A N/A $31.21 N/A N/A $35.67 N/A N/A $24.52 N/A N/A $31.21 N/A N/A $14.94 N/A N/A N/A N/A N/A $26.75 N/A N/A $15.60 N/A N/A $28.98 N/A N/A $0.02 N/A N/A $26.75 N/A N/A $31.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $44.59 $44.59 N/A 4407806 Pharmacy sulfamethoxazole-trimethoprim 800 mg-160 mg Tab [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409537 Pharmacy galantamine 4 mg Tab [BCH] 250 $6.36 $- $1.65 $- $- $5.09 $- N/A $1.65 N/A N/A $2.41 N/A N/A $3.82 N/A N/A $3.18 N/A N/A N/A N/A N/A $4.33 N/A N/A $3.95 N/A N/A $2.61 N/A N/A $4.46 N/A N/A $5.09 N/A N/A $3.50 N/A N/A $4.46 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.82 N/A N/A $2.23 N/A N/A $4.14 N/A N/A N/A N/A N/A $3.82 N/A N/A $4.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.36 $6.36 N/A 4405673 Pharmacy ramipril 2.5 mg Cap [BCH] 250 $3.61 $- $0.94 $- $- $2.89 $- N/A $0.94 N/A N/A $1.37 N/A N/A $2.17 N/A N/A $1.81 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.24 N/A N/A $1.48 N/A N/A $2.53 N/A N/A $2.89 N/A N/A $1.99 N/A N/A $2.53 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.26 N/A N/A $2.35 N/A N/A N/A N/A N/A $2.17 N/A N/A $2.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.61 $3.61 N/A 4407814 Pharmacy sulfamethoxazole-trimethoprim 200 mg-40 mg/5 mL Oral Susp 473 mL [BCH] 250 $18.22 $- $4.74 $- $- $14.57 $- N/A $4.74 N/A N/A $6.89 N/A N/A $10.93 N/A N/A $9.11 N/A N/A N/A N/A N/A $12.39 N/A N/A $11.29 N/A N/A $7.47 N/A N/A $12.75 N/A N/A $14.57 N/A N/A $10.02 N/A N/A $12.75 N/A N/A $6.10 N/A N/A N/A N/A N/A $10.93 N/A N/A $6.38 N/A N/A $11.84 N/A N/A N/A N/A N/A $10.93 N/A N/A $12.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.22 $18.22 N/A 4400353 Pharmacy amoxicillin-clavulanate 500 mg-125 mg Tab 250 $7.57 $- $1.97 $- $- $6.06 $- N/A $1.97 N/A N/A $2.86 N/A N/A $4.54 N/A N/A $3.78 N/A N/A N/A N/A N/A $5.15 N/A N/A $4.69 N/A N/A $3.10 N/A N/A $5.30 N/A N/A $6.06 N/A N/A $4.16 N/A N/A $5.30 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.54 N/A N/A $2.65 N/A N/A $4.92 N/A N/A N/A N/A N/A $4.54 N/A N/A $5.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.57 $7.57 N/A 4407612 Pharmacy amoxicillin-clavulanate 875 mg-125 mg Tab 250 $10.10 $- $2.63 $- $- $8.08 $- N/A $2.63 N/A N/A $3.82 N/A N/A $6.06 N/A N/A $5.05 N/A N/A N/A N/A N/A $6.87 N/A N/A $6.26 N/A N/A $4.14 N/A N/A $7.07 N/A N/A $8.08 N/A N/A $5.56 N/A N/A $7.07 N/A N/A $3.38 N/A N/A N/A N/A N/A $6.06 N/A N/A $3.54 N/A N/A $6.57 N/A N/A N/A N/A N/A $6.06 N/A N/A $7.07 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.10 $10.10 N/A 4400455 Pharmacy pioglitazone 15 mg Tab[BCH] 250 $14.02 $- $3.64 $- $- $11.21 $- N/A $3.64 N/A N/A $5.30 N/A N/A $8.41 N/A N/A $7.01 N/A N/A N/A N/A N/A $9.53 N/A N/A $8.69 N/A N/A $5.75 N/A N/A $9.81 N/A N/A $11.21 N/A N/A $7.71 N/A N/A $9.81 N/A N/A $4.70 N/A N/A N/A N/A N/A $8.41 N/A N/A $4.91 N/A N/A $9.11 N/A N/A N/A N/A N/A $8.41 N/A N/A $9.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.02 $14.02 N/A 4407872 Pharmacy venlafaxine 37.5 mg Cap 250 $8.33 $- $2.16 $- $- $6.66 $- N/A $2.16 N/A N/A $3.15 N/A N/A $5.00 N/A N/A $4.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $5.16 N/A N/A $3.41 N/A N/A $5.83 N/A N/A $6.66 N/A N/A $4.58 N/A N/A $5.83 N/A N/A $2.79 N/A N/A N/A N/A N/A $5.00 N/A N/A $2.91 N/A N/A $5.41 N/A N/A N/A N/A N/A $5.00 N/A N/A $5.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.33 $8.33 N/A 4409523 Pharmacy venlafaxine 75 mg ERCap [BCH] 250 $9.33 $- $2.43 $- $- $7.46 $- N/A $2.43 N/A N/A $3.53 N/A N/A $5.60 N/A N/A $4.67 N/A N/A N/A N/A N/A $6.35 N/A N/A $5.79 N/A N/A $3.83 N/A N/A $6.53 N/A N/A $7.46 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.13 N/A N/A N/A N/A N/A $5.60 N/A N/A $3.27 N/A N/A $6.07 N/A N/A N/A N/A N/A $5.60 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.33 $9.33 N/A 4409741 Pharmacy levofloxacin 250 mg Tab [BCH] 250 $33.62 $- $8.74 $- $- $26.90 $- N/A $8.74 N/A N/A $12.71 N/A N/A $20.17 N/A N/A $16.81 N/A N/A N/A N/A N/A $22.86 N/A N/A $20.85 N/A N/A $13.79 N/A N/A $23.54 N/A N/A $26.90 N/A N/A $18.49 N/A N/A $23.54 N/A N/A $11.26 N/A N/A N/A N/A N/A $20.17 N/A N/A $11.77 N/A N/A $21.85 N/A N/A N/A N/A N/A $20.17 N/A N/A $23.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.62 $33.62 N/A 4409594 Pharmacy pantoprazole 40 mg Tab [BCH] 250 $10.53 $- $2.74 $- $- $8.43 $- N/A $2.74 N/A N/A $3.98 N/A N/A $6.32 N/A N/A $5.27 N/A N/A N/A N/A N/A $7.16 N/A N/A $6.53 N/A N/A $4.32 N/A N/A $7.37 N/A N/A $8.43 N/A N/A $5.79 N/A N/A $7.37 N/A N/A $3.53 N/A N/A N/A N/A N/A $6.32 N/A N/A $3.69 N/A N/A $6.85 N/A N/A N/A N/A N/A $6.32 N/A N/A $7.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $10.53 $10.53 N/A 4407273 Pharmacy montelukast 10 mg Tab 250 $11.30 $- $2.94 $- $- $9.04 $- N/A $2.94 N/A N/A $4.27 N/A N/A $6.78 N/A N/A $5.65 N/A N/A N/A N/A N/A $7.68 N/A N/A $7.01 N/A N/A $4.63 N/A N/A $7.91 N/A N/A $9.04 N/A N/A $6.22 N/A N/A $7.91 N/A N/A $3.79 N/A N/A N/A N/A N/A $6.78 N/A N/A $3.96 N/A N/A $7.35 N/A N/A N/A N/A N/A $6.78 N/A N/A $7.91 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.30 $11.30 N/A 4400131 Pharmacy divalproex sodium 250 mg Tab 250 $4.91 $- $1.28 $- $- $3.93 $- N/A $1.28 N/A N/A $1.86 N/A N/A $2.95 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.04 N/A N/A $2.01 N/A N/A $3.44 N/A N/A $3.93 N/A N/A $2.70 N/A N/A $3.44 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.95 N/A N/A $1.72 N/A N/A $3.19 N/A N/A N/A N/A N/A $2.95 N/A N/A $3.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.91 $4.91 N/A 4400137 Pharmacy modafinil 100 mg Tab [BCH] 250 $52.81 $- $13.73 $- $- $42.24 $- N/A $13.73 N/A N/A $19.96 N/A N/A $31.68 N/A N/A $26.40 N/A N/A N/A N/A N/A $35.91 N/A N/A $32.74 N/A N/A $21.65 N/A N/A $36.96 N/A N/A $42.24 N/A N/A $29.04 N/A N/A $36.96 N/A N/A $17.69 N/A N/A N/A N/A N/A $31.68 N/A N/A $18.48 N/A N/A $34.32 N/A N/A N/A N/A N/A $31.68 N/A N/A $36.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.81 $52.81 N/A 4400883 Pharmacy aripiprazole 10 mg Tab [BCH] 250 $64.22 $- $16.70 $- $- $51.38 $- N/A $16.70 N/A N/A $24.28 N/A N/A $38.53 N/A N/A $32.11 N/A N/A N/A N/A N/A $43.67 N/A N/A $39.82 N/A N/A $26.33 N/A N/A $44.95 N/A N/A $51.38 N/A N/A $35.32 N/A N/A $44.95 N/A N/A $21.51 N/A N/A N/A N/A N/A $38.53 N/A N/A $22.48 N/A N/A $41.74 N/A N/A N/A N/A N/A $38.53 N/A N/A $44.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.22 $64.22 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $17.93 $- $4.66 $- $- $14.34 $- N/A $4.66 N/A N/A $6.78 N/A N/A $10.76 N/A N/A $8.96 N/A N/A N/A N/A N/A $12.19 N/A N/A $11.11 N/A N/A $7.35 N/A N/A $12.55 N/A N/A $14.34 N/A N/A $9.86 N/A N/A $12.55 N/A N/A $6.01 N/A N/A N/A N/A N/A $10.76 N/A N/A $6.27 N/A N/A $11.65 N/A N/A N/A N/A N/A $10.76 N/A N/A $12.55 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.93 $17.93 N/A 4409240 Pharmacy amoxicillin 250 mg/5 mL Pow[BCH] 250 $7.58 $- $1.97 $- $- $6.07 $- N/A $1.97 N/A N/A $2.87 N/A N/A $4.55 N/A N/A $3.79 N/A N/A N/A N/A N/A $5.16 N/A N/A $4.70 N/A N/A $3.11 N/A N/A $5.31 N/A N/A $6.07 N/A N/A $4.17 N/A N/A $5.31 N/A N/A $2.54 N/A N/A N/A N/A N/A $4.55 N/A N/A $2.65 N/A N/A $4.93 N/A N/A N/A N/A N/A $4.55 N/A N/A $5.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.58 $7.58 N/A 4400723 Pharmacy paricalcitol 1 mcg Cap [BCH] 250 $22.18 $- $5.77 $- $- $17.75 $- N/A $5.77 N/A N/A $8.38 N/A N/A $13.31 N/A N/A $11.09 N/A N/A N/A N/A N/A $15.08 N/A N/A $13.75 N/A N/A $9.09 N/A N/A $15.53 N/A N/A $17.75 N/A N/A $12.20 N/A N/A $15.53 N/A N/A $7.43 N/A N/A N/A N/A N/A $13.31 N/A N/A $7.76 N/A N/A $14.42 N/A N/A N/A N/A N/A $13.31 N/A N/A $15.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.18 $22.18 N/A 4400035 Pharmacy atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg/atropine/hyoscyamine/PB/scopolamine Oral Elix 480 mL 5 mL Eli[BCH] 250 $51.77 $- $13.46 $- $- $41.42 $- N/A $13.46 N/A N/A $19.57 N/A N/A $31.06 N/A N/A $25.89 N/A N/A N/A N/A N/A $35.20 N/A N/A $32.10 N/A N/A $21.23 N/A N/A $36.24 N/A N/A $41.42 N/A N/A $28.47 N/A N/A $36.24 N/A N/A $17.34 N/A N/A N/A N/A N/A $31.06 N/A N/A $18.12 N/A N/A $33.65 N/A N/A N/A N/A N/A $31.06 N/A N/A $36.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $51.77 $51.77 N/A 4400035 Pharmacy atropine/hyoscyamine/PB/scopolamine Oral Elix 480 mL [BCH] 250 $51.77 $- $13.46 $- $- $41.42 $- N/A $13.46 N/A N/A $19.57 N/A N/A $31.06 N/A N/A $25.89 N/A N/A N/A N/A N/A $35.20 N/A N/A $32.10 N/A N/A $21.23 N/A N/A $36.24 N/A N/A $41.42 N/A N/A $28.47 N/A N/A $36.24 N/A N/A $17.34 N/A N/A N/A N/A N/A $31.06 N/A N/A $18.12 N/A N/A $33.65 N/A N/A N/A N/A N/A $31.06 N/A N/A $36.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $51.77 $51.77 N/A 4409796 Pharmacy acetylcysteine 20% IV Sol 30 mL [BCH] J0132 636 $517.47 $- $1.08 $- $- $413.98 $- N/A $134.54 N/A N/A Not Reimbursed N/A N/A $310.48 N/A N/A $258.74 N/A N/A N/A N/A N/A $351.88 N/A N/A $320.83 N/A N/A $212.16 N/A N/A $362.23 N/A N/A $413.98 N/A N/A $284.61 N/A N/A $362.23 N/A N/A $173.35 N/A N/A N/A N/A N/A $310.48 N/A N/A $181.11 N/A N/A $336.36 N/A N/A $1.08 N/A N/A $310.48 N/A N/A $362.23 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $517.47 $517.47 N/A 4408945 Pharmacy aspirin 81 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409710 Pharmacy ezetimibe 10 mg Tab [BCH] 250 $22.85 $- $5.94 $- $- $18.28 $- N/A $5.94 N/A N/A $8.64 N/A N/A $13.71 N/A N/A $11.42 N/A N/A N/A N/A N/A $15.54 N/A N/A $14.17 N/A N/A $9.37 N/A N/A $15.99 N/A N/A $18.28 N/A N/A $12.57 N/A N/A $15.99 N/A N/A $7.65 N/A N/A N/A N/A N/A $13.71 N/A N/A $8.00 N/A N/A $14.85 N/A N/A N/A N/A N/A $13.71 N/A N/A $15.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.85 $22.85 N/A 4409557 Pharmacy sulfanilamide 15% Vag Crm [BCH] 250 $519.48 $- $135.06 $- $- $415.58 $- N/A $135.06 N/A N/A $196.36 N/A N/A $311.69 N/A N/A $259.74 N/A N/A N/A N/A N/A $353.25 N/A N/A $322.08 N/A N/A $212.99 N/A N/A $363.64 N/A N/A $415.58 N/A N/A $285.71 N/A N/A $363.64 N/A N/A $174.03 N/A N/A N/A N/A N/A $311.69 N/A N/A $181.82 N/A N/A $337.66 N/A N/A N/A N/A N/A $311.69 N/A N/A $363.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $519.48 $519.48 N/A 4400354 Pharmacy amoxicillin-clavulanate 200 mg-28.5 mg/5 mL Oral Liq 50 mL [ 250 $36.90 $- $9.59 $- $- $29.52 $- N/A $9.59 N/A N/A $13.95 N/A N/A $22.14 N/A N/A $18.45 N/A N/A N/A N/A N/A $25.09 N/A N/A $22.88 N/A N/A $15.13 N/A N/A $25.83 N/A N/A $29.52 N/A N/A $20.30 N/A N/A $25.83 N/A N/A $12.36 N/A N/A N/A N/A N/A $22.14 N/A N/A $12.92 N/A N/A $23.99 N/A N/A N/A N/A N/A $22.14 N/A N/A $25.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $36.90 $36.90 N/A 4401375 Pharmacy ibuprofen 100 mg/5 mL Oral Susp [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400622 Pharmacy megestrol 40 mg/mL Sus 250 $8.50 $- $2.21 $- $- $6.80 $- N/A $2.21 N/A N/A $3.21 N/A N/A $5.10 N/A N/A $4.25 N/A N/A N/A N/A N/A $5.78 N/A N/A $5.27 N/A N/A $3.49 N/A N/A $5.95 N/A N/A $6.80 N/A N/A $4.68 N/A N/A $5.95 N/A N/A $2.85 N/A N/A N/A N/A N/A $5.10 N/A N/A $2.98 N/A N/A $5.53 N/A N/A N/A N/A N/A $5.10 N/A N/A $5.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.50 $8.50 N/A 4400887 Pharmacy acetaminophen-hydrocodone 325 mg-7.5 mg/15 mL Sol [BCH] 250 $9.72 $- $2.53 $- $- $7.78 $- N/A $2.53 N/A N/A $3.68 N/A N/A $5.83 N/A N/A $4.86 N/A N/A N/A N/A N/A $6.61 N/A N/A $6.03 N/A N/A $3.99 N/A N/A $6.81 N/A N/A $7.78 N/A N/A $5.35 N/A N/A $6.81 N/A N/A $3.26 N/A N/A N/A N/A N/A $5.83 N/A N/A $3.40 N/A N/A $6.32 N/A N/A N/A N/A N/A $5.83 N/A N/A $6.81 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.72 $9.72 N/A 4404084 Pharmacy "nystatin 100,000 units/mL Oral Susp [BCH]" 250 $2.35 $- $0.61 $- $- $1.88 $- N/A $0.61 N/A N/A $0.89 N/A N/A $1.41 N/A N/A $1.18 N/A N/A N/A N/A N/A $1.60 N/A N/A $1.46 N/A N/A $0.96 N/A N/A $1.65 N/A N/A $1.88 N/A N/A $1.29 N/A N/A $1.65 N/A N/A $0.79 N/A N/A N/A N/A N/A $1.41 N/A N/A $0.82 N/A N/A $1.53 N/A N/A N/A N/A N/A $1.41 N/A N/A $1.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.35 $2.35 N/A 4405301 Pharmacy potassium chloride 20 mEq/15 mL Liq 250 $31.20 $- $8.11 $- $- $24.96 $- N/A $8.11 N/A N/A $11.79 N/A N/A $18.72 N/A N/A $15.60 N/A N/A N/A N/A N/A $21.22 N/A N/A $19.34 N/A N/A $12.79 N/A N/A $21.84 N/A N/A $24.96 N/A N/A $17.16 N/A N/A $21.84 N/A N/A $10.45 N/A N/A N/A N/A N/A $18.72 N/A N/A $10.92 N/A N/A $20.28 N/A N/A N/A N/A N/A $18.72 N/A N/A $21.84 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $31.20 $31.20 N/A 4403771 Pharmacy magnesium hydroxide 8% Sus 250 $5.27 $- $1.37 $- $- $4.21 $- N/A $1.37 N/A N/A $1.99 N/A N/A $3.16 N/A N/A $2.63 N/A N/A N/A N/A N/A $3.58 N/A N/A $3.27 N/A N/A $2.16 N/A N/A $3.69 N/A N/A $4.21 N/A N/A $2.90 N/A N/A $3.69 N/A N/A $1.76 N/A N/A N/A N/A N/A $3.16 N/A N/A $1.84 N/A N/A $3.42 N/A N/A N/A N/A N/A $3.16 N/A N/A $3.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.27 $5.27 N/A 4400063 Pharmacy acetaminophen 325 mg/10.15 mL Liq 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405593 Pharmacy charcoal-sorbitol 50 g Oral Susp 240 mL [BCH] 250 $45.00 $- $11.70 $- $- $36.00 $- N/A $11.70 N/A N/A $17.01 N/A N/A $27.00 N/A N/A $22.50 N/A N/A N/A N/A N/A $30.60 N/A N/A $27.90 N/A N/A $18.45 N/A N/A $31.50 N/A N/A $36.00 N/A N/A $24.75 N/A N/A $31.50 N/A N/A $15.08 N/A N/A N/A N/A N/A $27.00 N/A N/A $15.75 N/A N/A $29.25 N/A N/A N/A N/A N/A $27.00 N/A N/A $31.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $45.00 $45.00 N/A 4404530 Pharmacy ePHEDrine 50 mg/mL Inj Sol [BCH] 250 $26.03 $- $6.77 $- $- $20.83 $- N/A $6.77 N/A N/A $9.84 N/A N/A $15.62 N/A N/A $13.02 N/A N/A N/A N/A N/A $17.70 N/A N/A $16.14 N/A N/A $10.67 N/A N/A $18.22 N/A N/A $20.83 N/A N/A $14.32 N/A N/A $18.22 N/A N/A $8.72 N/A N/A N/A N/A N/A $15.62 N/A N/A $9.11 N/A N/A $16.92 N/A N/A N/A N/A N/A $15.62 N/A N/A $18.22 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $26.03 $26.03 N/A 4408503 Pharmacy scopolamine 1.5 mg Fil [BCH] 250 $42.80 $- $11.13 $- $- $34.24 $- N/A $11.13 N/A N/A $16.18 N/A N/A $25.68 N/A N/A $21.40 N/A N/A N/A N/A N/A $29.10 N/A N/A $26.54 N/A N/A $17.55 N/A N/A $29.96 N/A N/A $34.24 N/A N/A $23.54 N/A N/A $29.96 N/A N/A $14.34 N/A N/A N/A N/A N/A $25.68 N/A N/A $14.98 N/A N/A $27.82 N/A N/A N/A N/A N/A $25.68 N/A N/A $29.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $42.80 $42.80 N/A 4401954 Pharmacy levalbuterol 1.25 mg/3 mL Inh Sol [BCH] J7614 636 $13.40 $- $0.06 $- $- $10.72 $- N/A $3.48 N/A N/A Not Reimbursed N/A N/A $8.04 N/A N/A $6.70 N/A N/A N/A N/A N/A $9.11 N/A N/A $8.31 N/A N/A $5.49 N/A N/A $9.38 N/A N/A $10.72 N/A N/A $7.37 N/A N/A $9.38 N/A N/A $4.49 N/A N/A N/A N/A N/A $8.04 N/A N/A $4.69 N/A N/A $8.71 N/A N/A $0.06 N/A N/A $8.04 N/A N/A $9.38 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.40 $13.40 N/A 4409594 Pharmacy pantoprazole 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400974 Pharmacy OLANZapine 10 mg Tab 250 $39.79 $- $10.34 $- $- $31.83 $- N/A $10.34 N/A N/A $15.04 N/A N/A $23.87 N/A N/A $19.89 N/A N/A N/A N/A N/A $27.05 N/A N/A $24.67 N/A N/A $16.31 N/A N/A $27.85 N/A N/A $31.83 N/A N/A $21.88 N/A N/A $27.85 N/A N/A $13.33 N/A N/A N/A N/A N/A $23.87 N/A N/A $13.93 N/A N/A $25.86 N/A N/A N/A N/A N/A $23.87 N/A N/A $27.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $39.79 $39.79 N/A 4404059 Pharmacy ampicillin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400425 Pharmacy ALPRAZolam 0.25 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4404577 Pharmacy ALPRAZolam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400583 Pharmacy fluconazole 100 mg Tab [BCH] 250 $17.51 $- $4.55 $- $- $14.01 $- N/A $4.55 N/A N/A $6.62 N/A N/A $10.50 N/A N/A $8.75 N/A N/A N/A N/A N/A $11.91 N/A N/A $10.85 N/A N/A $7.18 N/A N/A $12.26 N/A N/A $14.01 N/A N/A $9.63 N/A N/A $12.26 N/A N/A $5.87 N/A N/A N/A N/A N/A $10.50 N/A N/A $6.13 N/A N/A $11.38 N/A N/A N/A N/A N/A $10.50 N/A N/A $12.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.51 $17.51 N/A 4401791 Pharmacy hydrOXYzine hydrochloride 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401017 Pharmacy ketamine 50 mg/mL Sol [BCH] 250 $22.00 $- $5.72 $- $- $17.60 $- N/A $5.72 N/A N/A $8.32 N/A N/A $13.20 N/A N/A $11.00 N/A N/A N/A N/A N/A $14.96 N/A N/A $13.64 N/A N/A $9.02 N/A N/A $15.40 N/A N/A $17.60 N/A N/A $12.10 N/A N/A $15.40 N/A N/A $7.37 N/A N/A N/A N/A N/A $13.20 N/A N/A $7.70 N/A N/A $14.30 N/A N/A N/A N/A N/A $13.20 N/A N/A $15.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.00 $22.00 N/A 4409429 Pharmacy amiodarone 50 mg/mL IV Sol [BCH] J0280 636 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $7.31 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404080 Pharmacy esmolol 10 mg/mL IV Sol [BCH] 250 $17.50 $- $4.55 $- $- $14.00 $- N/A $4.55 N/A N/A $6.62 N/A N/A $10.50 N/A N/A $8.75 N/A N/A N/A N/A N/A $11.90 N/A N/A $10.85 N/A N/A $7.18 N/A N/A $12.25 N/A N/A $14.00 N/A N/A $9.63 N/A N/A $12.25 N/A N/A $5.86 N/A N/A N/A N/A N/A $10.50 N/A N/A $6.13 N/A N/A $11.38 N/A N/A N/A N/A N/A $10.50 N/A N/A $12.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.50 $17.50 N/A 4408580 Pharmacy atropine-edrophonium IV Sol 5 mL [BCH] 250 $52.80 $- $13.73 $- $- $42.24 $- N/A $13.73 N/A N/A $19.96 N/A N/A $31.68 N/A N/A $26.40 N/A N/A N/A N/A N/A $35.90 N/A N/A $32.74 N/A N/A $21.65 N/A N/A $36.96 N/A N/A $42.24 N/A N/A $29.04 N/A N/A $36.96 N/A N/A $17.69 N/A N/A N/A N/A N/A $31.68 N/A N/A $18.48 N/A N/A $34.32 N/A N/A N/A N/A N/A $31.68 N/A N/A $36.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $52.80 $52.80 N/A 4406733 Pharmacy thiamine 100 mg/mL Inj Sol [BCH] J3411 636 $21.64 $- $2.76 $- $- $17.31 $- N/A $5.63 N/A N/A Not Reimbursed N/A N/A $12.99 N/A N/A $10.82 N/A N/A N/A N/A N/A $14.72 N/A N/A $13.42 N/A N/A $8.87 N/A N/A $15.15 N/A N/A $17.31 N/A N/A $11.90 N/A N/A $15.15 N/A N/A $7.25 N/A N/A N/A N/A N/A $12.99 N/A N/A $7.58 N/A N/A $14.07 N/A N/A $2.76 N/A N/A $12.99 N/A N/A $15.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.64 $21.64 N/A 4400195 Pharmacy fomepizole 1 g/mL IV Sol [BCH] J1451 636 "$2,265.00 " $- $588.90 $- $- "$1,812.00 " $- N/A $588.90 N/A N/A Not Reimbursed N/A N/A "$1,359.00 " N/A N/A "$1,132.50 " N/A N/A N/A N/A N/A "$1,540.20 " N/A N/A "$1,404.30 " N/A N/A $928.65 N/A N/A "$1,585.50 " N/A N/A "$1,812.00 " N/A N/A "$1,245.75 " N/A N/A "$1,585.50 " N/A N/A $758.78 N/A N/A N/A N/A N/A "$1,359.00 " N/A N/A $792.75 N/A N/A "$1,472.25 " N/A N/A N/A N/A N/A "$1,359.00 " N/A N/A "$1,585.50 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$2,265.00 " "$2,265.00 " N/A 4407673 Pharmacy methocarbamol 100 mg/mL Inj Sol [BCH] J2800 636 $142.56 $- $6.28 $- $- $114.05 $- N/A $37.07 N/A N/A Not Reimbursed N/A N/A $85.54 N/A N/A $71.28 N/A N/A N/A N/A N/A $96.94 N/A N/A $88.39 N/A N/A $58.45 N/A N/A $99.79 N/A N/A $114.05 N/A N/A $78.41 N/A N/A $99.79 N/A N/A $47.76 N/A N/A N/A N/A N/A $85.54 N/A N/A $49.90 N/A N/A $92.66 N/A N/A $6.28 N/A N/A $85.54 N/A N/A $99.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $142.56 $142.56 N/A 4402285 Pharmacy naloxone 0.4 mg/mL Sol [BCH] J2310 636 $47.45 $- $12.34 $- $- $37.96 $- N/A $12.34 N/A N/A Not Reimbursed N/A N/A $28.47 N/A N/A $23.72 N/A N/A N/A N/A N/A $32.26 N/A N/A $29.42 N/A N/A $19.45 N/A N/A $33.21 N/A N/A $37.96 N/A N/A $26.10 N/A N/A $33.21 N/A N/A $15.89 N/A N/A N/A N/A N/A $28.47 N/A N/A $16.61 N/A N/A $30.84 N/A N/A $14.22 N/A N/A $28.47 N/A N/A $33.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.45 $47.45 N/A 4408610 Pharmacy vancomycin 500 mg Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405346 Pharmacy vancomycin 1 g IV Inj [BCH] J3370 636 $38.50 $- $2.77 $- $- $30.80 $- N/A $10.01 N/A N/A Not Reimbursed N/A N/A $23.10 N/A N/A $19.25 N/A N/A N/A N/A N/A $26.18 N/A N/A $23.87 N/A N/A $15.78 N/A N/A $26.95 N/A N/A $30.80 N/A N/A $21.17 N/A N/A $26.95 N/A N/A $12.90 N/A N/A N/A N/A N/A $23.10 N/A N/A $13.47 N/A N/A $25.02 N/A N/A $2.77 N/A N/A $23.10 N/A N/A $26.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $38.50 $38.50 N/A 4409224 Pharmacy ampicillin 1 g Pow [BCH] J0290 636 $28.00 $- $0.93 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $0.93 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4405016 Pharmacy heparin 5000 units/mL Sol [ J1644 636 $12.00 $- $0.25 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.25 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4409121 Pharmacy dexamethasone 4 mg/mL Sol [BCH] J1100 636 $12.00 $- $0.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.12 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400820 Pharmacy dexamethasone 10 mg/mL Sol [BCH] J1100 636 $95.96 $- $0.12 $- $- $76.77 $- N/A $24.95 N/A N/A Not Reimbursed N/A N/A $57.58 N/A N/A $47.98 N/A N/A N/A N/A N/A $65.25 N/A N/A $59.50 N/A N/A $39.34 N/A N/A $67.17 N/A N/A $76.77 N/A N/A $52.78 N/A N/A $67.17 N/A N/A $32.15 N/A N/A N/A N/A N/A $57.58 N/A N/A $33.59 N/A N/A $62.37 N/A N/A $0.12 N/A N/A $57.58 N/A N/A $67.17 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $95.96 $95.96 N/A 4409121 Pharmacy dexamethasone 4 mg/mL Sol [BCH] J1100 636 $12.00 $- $0.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.12 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404944 Pharmacy haloperidol 5 mg/mL Sol [BCH] J1630 636 $12.00 $- $0.99 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.99 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4407992 Pharmacy doxycycline 100 mg Pow 636 $40.01 $- $10.40 $- $- $32.01 $- N/A $10.40 N/A N/A $15.12 N/A N/A $24.01 N/A N/A $20.01 N/A N/A N/A N/A N/A $27.21 N/A N/A $24.81 N/A N/A $16.41 N/A N/A $28.01 N/A N/A $32.01 N/A N/A $22.01 N/A N/A $28.01 N/A N/A $13.40 N/A N/A N/A N/A N/A $24.01 N/A N/A $14.00 N/A N/A $26.01 N/A N/A N/A N/A N/A $24.01 N/A N/A $28.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.01 $40.01 N/A 4409680 Pharmacy vecuronium 10 mg IV Inj [BCH] 250 $12.00 $- $3.12 $- $- $9.60 $- N/A $3.12 N/A N/A $4.54 N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A N/A N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4404593 Pharmacy flumazenil 0.1 mg/mL IV Sol [BCH] 250 $16.32 $- $4.24 $- $- $13.06 $- N/A $4.24 N/A N/A $6.17 N/A N/A $9.79 N/A N/A $8.16 N/A N/A N/A N/A N/A $11.10 N/A N/A $10.12 N/A N/A $6.69 N/A N/A $11.42 N/A N/A $13.06 N/A N/A $8.98 N/A N/A $11.42 N/A N/A $5.47 N/A N/A N/A N/A N/A $9.79 N/A N/A $5.71 N/A N/A $10.61 N/A N/A N/A N/A N/A $9.79 N/A N/A $11.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.32 $16.32 N/A 4409000 Pharmacy tobramycin 40 mg/mL Sol [BCH] J3260 636 $28.00 $- $3.45 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.45 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400820 Pharmacy dexamethasone 10 mg/mL Sol[BCH] J1100 250 $12.00 $- $0.12 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.12 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400624 Pharmacy fosphenytoin 500 mgPE/10 mL Sol [BCH] Q2009 636 $115.20 $- $29.95 $- $- $92.16 $- N/A $29.95 N/A N/A Not Reimbursed N/A N/A $69.12 N/A N/A $57.60 N/A N/A N/A N/A N/A $78.34 N/A N/A $71.42 N/A N/A $47.23 N/A N/A $80.64 N/A N/A $92.16 N/A N/A $63.36 N/A N/A $80.64 N/A N/A $38.59 N/A N/A N/A N/A N/A $69.12 N/A N/A $40.32 N/A N/A $74.88 N/A N/A N/A N/A N/A $69.12 N/A N/A $80.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $115.20 $115.20 N/A 4401921 Pharmacy piperacillin-tazobactam 3 g-0.375 g Pow [BCH] J2543 636 $33.29 $- $1.68 $- $- $26.63 $- N/A $8.65 N/A N/A Not Reimbursed N/A N/A $19.97 N/A N/A $16.64 N/A N/A N/A N/A N/A $22.64 N/A N/A $20.64 N/A N/A $13.65 N/A N/A $23.30 N/A N/A $26.63 N/A N/A $18.31 N/A N/A $23.30 N/A N/A $11.15 N/A N/A N/A N/A N/A $19.97 N/A N/A $11.65 N/A N/A $21.64 N/A N/A $1.68 N/A N/A $19.97 N/A N/A $23.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $33.29 $33.29 N/A 4400387 Pharmacy vancomycin 750 mg Pow[BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4409821 Pharmacy DAPTOmycin 500 mg Pow [BCH] J0878 636 $372.00 $- $0.14 $- $- $297.60 $- N/A $96.72 N/A N/A Not Reimbursed N/A N/A $223.20 N/A N/A $186.00 N/A N/A N/A N/A N/A $252.96 N/A N/A $230.64 N/A N/A $152.52 N/A N/A $260.40 N/A N/A $297.60 N/A N/A $204.60 N/A N/A $260.40 N/A N/A $124.62 N/A N/A N/A N/A N/A $223.20 N/A N/A $130.20 N/A N/A $241.80 N/A N/A $0.14 N/A N/A $223.20 N/A N/A $260.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $372.00 $372.00 N/A 4401005 Pharmacy clindamycin 150 mg/mL IV Sol [BCH] 636 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4402394 Pharmacy adenosine 3 mg/mL Sol [BCH] J0150 636 $15.00 $- $3.90 $- $- $12.00 $- N/A $3.90 N/A N/A Not Reimbursed N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A N/A N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $5.01 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4400904 Pharmacy methadone 10 mg Tab [BCH] S0109 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4407624 Pharmacy temazepam 15 mg Cap [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $49.48 $- $0.02 $- $- $39.59 $- N/A $12.87 N/A N/A Not Reimbursed N/A N/A $29.69 N/A N/A $24.74 N/A N/A N/A N/A N/A $33.65 N/A N/A $30.68 N/A N/A $20.29 N/A N/A $34.64 N/A N/A $39.59 N/A N/A $27.22 N/A N/A $34.64 N/A N/A $16.58 N/A N/A N/A N/A N/A $29.69 N/A N/A $17.32 N/A N/A $32.16 N/A N/A $0.02 N/A N/A $29.69 N/A N/A $34.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.48 $49.48 N/A 4400364 Pharmacy amLODIPine 5 mg Tab [BCH] 250 $3.58 $- $0.93 $- $- $2.86 $- N/A $0.93 N/A N/A $1.35 N/A N/A $2.15 N/A N/A $1.79 N/A N/A N/A N/A N/A $2.43 N/A N/A $2.22 N/A N/A $1.47 N/A N/A $2.50 N/A N/A $2.86 N/A N/A $1.97 N/A N/A $2.50 N/A N/A $1.20 N/A N/A N/A N/A N/A $2.15 N/A N/A $1.25 N/A N/A $2.33 N/A N/A N/A N/A N/A $2.15 N/A N/A $2.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.58 $3.58 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.77 $- $1.24 $- $- $3.81 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.86 N/A N/A $2.38 N/A N/A N/A N/A N/A $3.24 N/A N/A $2.96 N/A N/A $1.95 N/A N/A $3.34 N/A N/A $3.81 N/A N/A $2.62 N/A N/A $3.34 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.86 N/A N/A $1.67 N/A N/A $3.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $3.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.77 $4.77 N/A 4403029 Pharmacy cephalexin 250 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400186 Pharmacy gabapentin 300 mg Cap [BCH] 250 $2.68 $- $0.70 $- $- $2.14 $- N/A $0.70 N/A N/A $1.01 N/A N/A $1.61 N/A N/A $1.34 N/A N/A N/A N/A N/A $1.82 N/A N/A $1.66 N/A N/A $1.10 N/A N/A $1.87 N/A N/A $2.14 N/A N/A $1.47 N/A N/A $1.87 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.61 N/A N/A $0.94 N/A N/A $1.74 N/A N/A N/A N/A N/A $1.61 N/A N/A $1.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.68 $2.68 N/A 4405693 Pharmacy ibuprofen 600 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409755 Pharmacy linezolid 600 mg Tab [BCH] 250 $367.33 $- $95.50 $- $- $293.86 $- N/A $95.50 N/A N/A $138.85 N/A N/A $220.40 N/A N/A $183.66 N/A N/A N/A N/A N/A $249.78 N/A N/A $227.74 N/A N/A $150.60 N/A N/A $257.13 N/A N/A $293.86 N/A N/A $202.03 N/A N/A $257.13 N/A N/A $123.05 N/A N/A N/A N/A N/A $220.40 N/A N/A $128.56 N/A N/A $238.76 N/A N/A N/A N/A N/A $220.40 N/A N/A $257.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $367.33 $367.33 N/A 4409755 Pharmacy linezolid 600 mg Tab [BCH] 250 $367.32 $- $95.50 $- $- $293.86 $- N/A $95.50 N/A N/A $138.85 N/A N/A $220.39 N/A N/A $183.66 N/A N/A N/A N/A N/A $249.78 N/A N/A $227.74 N/A N/A $150.60 N/A N/A $257.13 N/A N/A $293.86 N/A N/A $202.03 N/A N/A $257.13 N/A N/A $123.05 N/A N/A N/A N/A N/A $220.39 N/A N/A $128.56 N/A N/A $238.76 N/A N/A N/A N/A N/A $220.39 N/A N/A $257.13 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $367.32 $367.32 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $4.54 $- $1.18 $- $- $3.63 $- N/A $1.18 N/A N/A $1.72 N/A N/A $2.72 N/A N/A $2.27 N/A N/A N/A N/A N/A $3.09 N/A N/A $2.81 N/A N/A $1.86 N/A N/A $3.18 N/A N/A $3.63 N/A N/A $2.50 N/A N/A $3.18 N/A N/A $1.52 N/A N/A N/A N/A N/A $2.72 N/A N/A $1.59 N/A N/A $2.95 N/A N/A N/A N/A N/A $2.72 N/A N/A $3.18 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.54 $4.54 N/A 4409821 Pharmacy DAPTOmycin 500 mg IV Inj [BCH] J0878 636 "$1,069.18 " $- $0.14 $- $- $855.34 $- N/A $277.99 N/A N/A Not Reimbursed N/A N/A $641.51 N/A N/A $534.59 N/A N/A N/A N/A N/A $727.04 N/A N/A $662.89 N/A N/A $438.36 N/A N/A $748.43 N/A N/A $855.34 N/A N/A $588.05 N/A N/A $748.43 N/A N/A $358.18 N/A N/A N/A N/A N/A $641.51 N/A N/A $374.21 N/A N/A $694.97 N/A N/A $0.14 N/A N/A $641.51 N/A N/A $748.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,069.18 " "$1,069.18 " N/A 4400519 Pharmacy atorvastatin 20 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400678 Pharmacy atorvastatin 40 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $16.93 $- $4.40 $- $- $13.54 $- N/A $4.40 N/A N/A $6.40 N/A N/A $10.16 N/A N/A $8.47 N/A N/A N/A N/A N/A $11.51 N/A N/A $10.50 N/A N/A $6.94 N/A N/A $11.85 N/A N/A $13.54 N/A N/A $9.31 N/A N/A $11.85 N/A N/A $5.67 N/A N/A N/A N/A N/A $10.16 N/A N/A $5.93 N/A N/A $11.01 N/A N/A N/A N/A N/A $10.16 N/A N/A $11.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.93 $16.93 N/A 4400163 Pharmacy ziprasidone 40 mg Cap [BCH] 250 $16.93 $- $4.40 $- $- $13.54 $- N/A $4.40 N/A N/A $6.40 N/A N/A $10.16 N/A N/A $8.47 N/A N/A N/A N/A N/A $11.51 N/A N/A $10.50 N/A N/A $6.94 N/A N/A $11.85 N/A N/A $13.54 N/A N/A $9.31 N/A N/A $11.85 N/A N/A $5.67 N/A N/A N/A N/A N/A $10.16 N/A N/A $5.93 N/A N/A $11.01 N/A N/A N/A N/A N/A $10.16 N/A N/A $11.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $16.93 $16.93 N/A 4409587 Pharmacy mirtazapine 30 mg Tab [BCH] 250 $2.58 $- $0.67 $- $- $2.06 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.55 N/A N/A $1.29 N/A N/A N/A N/A N/A $1.75 N/A N/A $1.60 N/A N/A $1.06 N/A N/A $1.80 N/A N/A $2.06 N/A N/A $1.42 N/A N/A $1.80 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.55 N/A N/A $0.90 N/A N/A $1.67 N/A N/A N/A N/A N/A $1.55 N/A N/A $1.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.58 $2.58 N/A 4401909 Pharmacy traZODone 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401987 Pharmacy sertraline 50 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400610 Pharmacy oxyCODONE 15 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4406576 Pharmacy benzonatate 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400015 Pharmacy valACYclovir 500 mg Tab [BCH] 250 $7.42 $- $1.93 $- $- $5.93 $- N/A $1.93 N/A N/A $2.80 N/A N/A $4.45 N/A N/A $3.71 N/A N/A N/A N/A N/A $5.04 N/A N/A $4.60 N/A N/A $3.04 N/A N/A $5.19 N/A N/A $5.93 N/A N/A $4.08 N/A N/A $5.19 N/A N/A $2.48 N/A N/A N/A N/A N/A $4.45 N/A N/A $2.60 N/A N/A $4.82 N/A N/A N/A N/A N/A $4.45 N/A N/A $5.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.42 $7.42 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $47.89 $- $0.02 $- $- $38.31 $- N/A $12.45 N/A N/A Not Reimbursed N/A N/A $28.73 N/A N/A $23.94 N/A N/A N/A N/A N/A $32.56 N/A N/A $29.69 N/A N/A $19.63 N/A N/A $33.52 N/A N/A $38.31 N/A N/A $26.34 N/A N/A $33.52 N/A N/A $16.04 N/A N/A N/A N/A N/A $28.73 N/A N/A $16.76 N/A N/A $31.13 N/A N/A $0.02 N/A N/A $28.73 N/A N/A $33.52 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.89 $47.89 N/A 4407463 Pharmacy clindamycin 150 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4400065 Pharmacy carbidopa-levodopa 25 mg-100 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400679 Pharmacy glipiZIDE 2.5 mg Tab [BCH] 250 $2.72 $- $0.71 $- $- $2.18 $- N/A $0.71 N/A N/A $1.03 N/A N/A $1.63 N/A N/A $1.36 N/A N/A N/A N/A N/A $1.85 N/A N/A $1.69 N/A N/A $1.12 N/A N/A $1.90 N/A N/A $2.18 N/A N/A $1.50 N/A N/A $1.90 N/A N/A $0.91 N/A N/A N/A N/A N/A $1.63 N/A N/A $0.95 N/A N/A $1.77 N/A N/A N/A N/A N/A $1.63 N/A N/A $1.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.72 $2.72 N/A 4400131 Pharmacy divalproex sodium 250 mg Tab [BCH] 250 $4.89 $- $1.27 $- $- $3.92 $- N/A $1.27 N/A N/A $1.85 N/A N/A $2.94 N/A N/A $2.45 N/A N/A N/A N/A N/A $3.33 N/A N/A $3.03 N/A N/A $2.01 N/A N/A $3.43 N/A N/A $3.92 N/A N/A $2.69 N/A N/A $3.43 N/A N/A $1.64 N/A N/A N/A N/A N/A $2.94 N/A N/A $1.71 N/A N/A $3.18 N/A N/A N/A N/A N/A $2.94 N/A N/A $3.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.89 $4.89 N/A 4406515 Pharmacy divalproex sodium 125 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400505 Pharmacy lamoTRIgine 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401902 Pharmacy lamoTRIgine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409551 Pharmacy topiramate 25 mg Tab [BCH] 250 $4.20 $- $1.09 $- $- $3.36 $- N/A $1.09 N/A N/A $1.59 N/A N/A $2.52 N/A N/A $2.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $2.60 N/A N/A $1.72 N/A N/A $2.94 N/A N/A $3.36 N/A N/A $2.31 N/A N/A $2.94 N/A N/A $1.41 N/A N/A N/A N/A N/A $2.52 N/A N/A $1.47 N/A N/A $2.73 N/A N/A N/A N/A N/A $2.52 N/A N/A $2.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.20 $4.20 N/A 4400717 Pharmacy topiramate 100 mg Tab[BCH] 250 $12.40 $- $3.22 $- $- $9.92 $- N/A $3.22 N/A N/A $4.69 N/A N/A $7.44 N/A N/A $6.20 N/A N/A N/A N/A N/A $8.43 N/A N/A $7.69 N/A N/A $5.08 N/A N/A $8.68 N/A N/A $9.92 N/A N/A $6.82 N/A N/A $8.68 N/A N/A $4.15 N/A N/A N/A N/A N/A $7.44 N/A N/A $4.34 N/A N/A $8.06 N/A N/A N/A N/A N/A $7.44 N/A N/A $8.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.40 $12.40 N/A 4400291 Pharmacy potassium chloride 20 mEq Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409664 Pharmacy digoxin 125 mcg (0.125 mg) Tab 250 $5.12 $- $1.33 $- $- $4.10 $- N/A $1.33 N/A N/A $1.94 N/A N/A $3.07 N/A N/A $2.56 N/A N/A N/A N/A N/A $3.48 N/A N/A $3.17 N/A N/A $2.10 N/A N/A $3.58 N/A N/A $4.10 N/A N/A $2.82 N/A N/A $3.58 N/A N/A $1.72 N/A N/A N/A N/A N/A $3.07 N/A N/A $1.79 N/A N/A $3.33 N/A N/A N/A N/A N/A $3.07 N/A N/A $3.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.12 $5.12 N/A 4405965 Pharmacy phenytoin 100 mg Cap[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403595 Pharmacy oxybutynin 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400854 Pharmacy divalproex sodium 500 mg Tab[BCH] 258 $7.66 $- $1.99 $- $- $6.13 $- N/A $1.99 N/A N/A $2.90 N/A N/A $4.60 N/A N/A $3.83 N/A N/A N/A N/A N/A $5.21 N/A N/A $4.75 N/A N/A $3.14 N/A N/A $5.36 N/A N/A $6.13 N/A N/A $4.22 N/A N/A $5.36 N/A N/A $2.57 N/A N/A N/A N/A N/A $4.60 N/A N/A $2.68 N/A N/A $4.98 N/A N/A N/A N/A N/A $4.60 N/A N/A $5.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.66 $7.66 N/A 4400058 Pharmacy polyethylene glycol 3350 Oral Pwdr for Recon [BCH] 250 $5.57 $- $1.45 $- $- $4.45 $- N/A $1.45 N/A N/A $2.10 N/A N/A $3.34 N/A N/A $2.78 N/A N/A N/A N/A N/A $3.78 N/A N/A $3.45 N/A N/A $2.28 N/A N/A $3.90 N/A N/A $4.45 N/A N/A $3.06 N/A N/A $3.90 N/A N/A $1.86 N/A N/A N/A N/A N/A $3.34 N/A N/A $1.95 N/A N/A $3.62 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.57 $5.57 N/A 4401847 Pharmacy nitrofurantoin macrocrystals-monohydrate 100 mg Cap [BCH] 250 $7.06 $- $1.84 $- $- $5.65 $- N/A $1.84 N/A N/A $2.67 N/A N/A $4.24 N/A N/A $3.53 N/A N/A N/A N/A N/A $4.80 N/A N/A $4.38 N/A N/A $2.89 N/A N/A $4.94 N/A N/A $5.65 N/A N/A $3.88 N/A N/A $4.94 N/A N/A $2.36 N/A N/A N/A N/A N/A $4.24 N/A N/A $2.47 N/A N/A $4.59 N/A N/A N/A N/A N/A $4.24 N/A N/A $4.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.06 $7.06 N/A 4400705 Pharmacy calcium acetate 667 mg Cap 250 $3.36 $- $0.87 $- $- $2.69 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.02 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.08 N/A N/A $1.38 N/A N/A $2.35 N/A N/A $2.69 N/A N/A $1.85 N/A N/A $2.35 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.02 N/A N/A $1.18 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.02 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.36 $3.36 N/A 4409457 Pharmacy isosorbide mononitrate 30 mg Tab [BCH] 250 $3.35 $- $0.87 $- $- $2.68 $- N/A $0.87 N/A N/A $1.27 N/A N/A $2.01 N/A N/A $1.68 N/A N/A N/A N/A N/A $2.28 N/A N/A $2.08 N/A N/A $1.37 N/A N/A $2.35 N/A N/A $2.68 N/A N/A $1.84 N/A N/A $2.35 N/A N/A $1.12 N/A N/A N/A N/A N/A $2.01 N/A N/A $1.17 N/A N/A $2.18 N/A N/A N/A N/A N/A $2.01 N/A N/A $2.35 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.35 $3.35 N/A 4400307 Pharmacy escitalopram 20 mg Tab [BCH] 250 $9.02 $- $2.34 $- $- $7.21 $- N/A $2.34 N/A N/A $3.41 N/A N/A $5.41 N/A N/A $4.51 N/A N/A N/A N/A N/A $6.13 N/A N/A $5.59 N/A N/A $3.70 N/A N/A $6.31 N/A N/A $7.21 N/A N/A $4.96 N/A N/A $6.31 N/A N/A $3.02 N/A N/A N/A N/A N/A $5.41 N/A N/A $3.16 N/A N/A $5.86 N/A N/A N/A N/A N/A $5.41 N/A N/A $6.31 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.02 $9.02 N/A 4400627 Pharmacy sildenafil 20 mg oral tablet [BCH] 250 $40.45 $- $10.52 $- $- $32.36 $- N/A $10.52 N/A N/A $15.29 N/A N/A $24.27 N/A N/A $20.23 N/A N/A N/A N/A N/A $27.51 N/A N/A $25.08 N/A N/A $16.59 N/A N/A $28.32 N/A N/A $32.36 N/A N/A $22.25 N/A N/A $28.32 N/A N/A $13.55 N/A N/A N/A N/A N/A $24.27 N/A N/A $14.16 N/A N/A $26.30 N/A N/A N/A N/A N/A $24.27 N/A N/A $28.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.45 $40.45 N/A 4400170 Pharmacy sotalol 80 mg Tab [BCH] 250 $4.64 $- $1.21 $- $- $3.71 $- N/A $1.21 N/A N/A $1.75 N/A N/A $2.78 N/A N/A $2.32 N/A N/A N/A N/A N/A $3.16 N/A N/A $2.88 N/A N/A $1.90 N/A N/A $3.25 N/A N/A $3.71 N/A N/A $2.55 N/A N/A $3.25 N/A N/A $1.55 N/A N/A N/A N/A N/A $2.78 N/A N/A $1.62 N/A N/A $3.02 N/A N/A N/A N/A N/A $2.78 N/A N/A $3.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.64 $4.64 N/A 4401941 Pharmacy metoclopramide 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409329 Pharmacy buPROPion 150 mg/12 hours Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409754 Pharmacy tiZANidine 2 mg Tab [BCH] 250 $3.50 $- $0.91 $- $- $2.80 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.10 N/A N/A $1.75 N/A N/A N/A N/A N/A $2.38 N/A N/A $2.17 N/A N/A $1.43 N/A N/A $2.45 N/A N/A $2.80 N/A N/A $1.92 N/A N/A $2.45 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.10 N/A N/A $1.22 N/A N/A $2.27 N/A N/A N/A N/A N/A $2.10 N/A N/A $2.45 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.50 $3.50 N/A 4403713 Pharmacy divalproex sodium 250 mg Tab [BCH] 250 $3.52 $- $0.92 $- $- $2.82 $- N/A $0.92 N/A N/A $1.33 N/A N/A $2.11 N/A N/A $1.76 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.18 N/A N/A $1.44 N/A N/A $2.47 N/A N/A $2.82 N/A N/A $1.94 N/A N/A $2.47 N/A N/A $1.18 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.23 N/A N/A $2.29 N/A N/A N/A N/A N/A $2.11 N/A N/A $2.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.52 $3.52 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405707 Pharmacy traMADol 50 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400607 Pharmacy hydrOXYzine pamoate 25 mg Cap [BCH] Q0177 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A Not Reimbursed N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400627 Pharmacy sildenafil 20 mg Tab [BCH] 250 $40.45 $- $10.52 $- $- $32.36 $- N/A $10.52 N/A N/A $15.29 N/A N/A $24.27 N/A N/A $20.23 N/A N/A N/A N/A N/A $27.51 N/A N/A $25.08 N/A N/A $16.59 N/A N/A $28.32 N/A N/A $32.36 N/A N/A $22.25 N/A N/A $28.32 N/A N/A $13.55 N/A N/A N/A N/A N/A $24.27 N/A N/A $14.16 N/A N/A $26.30 N/A N/A N/A N/A N/A $24.27 N/A N/A $28.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $40.45 $40.45 N/A 4400370 Pharmacy niMODipine 30 mg Cap [BCH] 250 $37.41 $- $9.73 $- $- $29.93 $- N/A $9.73 N/A N/A $14.14 N/A N/A $22.45 N/A N/A $18.71 N/A N/A N/A N/A N/A $25.44 N/A N/A $23.19 N/A N/A $15.34 N/A N/A $26.19 N/A N/A $29.93 N/A N/A $20.58 N/A N/A $26.19 N/A N/A $12.53 N/A N/A N/A N/A N/A $22.45 N/A N/A $13.09 N/A N/A $24.32 N/A N/A N/A N/A N/A $22.45 N/A N/A $26.19 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $37.41 $37.41 N/A 4400540 Pharmacy PROPYLTHIOURACIL 50 mg Tab [BCH] 250 $3.48 $- $0.91 $- $- $2.79 $- N/A $0.91 N/A N/A $1.32 N/A N/A $2.09 N/A N/A $1.74 N/A N/A N/A N/A N/A $2.37 N/A N/A $2.16 N/A N/A $1.43 N/A N/A $2.44 N/A N/A $2.79 N/A N/A $1.92 N/A N/A $2.44 N/A N/A $1.17 N/A N/A N/A N/A N/A $2.09 N/A N/A $1.22 N/A N/A $2.26 N/A N/A N/A N/A N/A $2.09 N/A N/A $2.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.48 $3.48 N/A 4403797 Pharmacy prazosin 1 mg Cap [BCH] 250 $3.57 $- $0.93 $- $- $2.86 $- N/A $0.93 N/A N/A $1.35 N/A N/A $2.14 N/A N/A $1.79 N/A N/A N/A N/A N/A $2.43 N/A N/A $2.21 N/A N/A $1.46 N/A N/A $2.50 N/A N/A $2.86 N/A N/A $1.96 N/A N/A $2.50 N/A N/A $1.20 N/A N/A N/A N/A N/A $2.14 N/A N/A $1.25 N/A N/A $2.32 N/A N/A N/A N/A N/A $2.14 N/A N/A $2.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.57 $3.57 N/A 7000001 Pharmacy levetiracetam 250 mg Tab [BCH] 250 $119.76 $- $31.14 $- $- $95.81 $- N/A $31.14 N/A N/A $45.27 N/A N/A $71.86 N/A N/A $59.88 N/A N/A N/A N/A N/A $81.44 N/A N/A $74.25 N/A N/A $49.10 N/A N/A $83.83 N/A N/A $95.81 N/A N/A $65.87 N/A N/A $83.83 N/A N/A $40.12 N/A N/A N/A N/A N/A $71.86 N/A N/A $41.92 N/A N/A $77.84 N/A N/A N/A N/A N/A $71.86 N/A N/A $83.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $119.76 $119.76 N/A 4400705 Pharmacy calcium acetate 667 mg Cap [BCH] 250 $2.16 $- $0.56 $- $- $1.73 $- N/A $0.56 N/A N/A $0.82 N/A N/A $1.30 N/A N/A $1.08 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.34 N/A N/A $0.89 N/A N/A $1.51 N/A N/A $1.73 N/A N/A $1.19 N/A N/A $1.51 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.30 N/A N/A $0.76 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.30 N/A N/A $1.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.16 $2.16 N/A 4407566 Pharmacy phentolamine 5 mg Pow [BCH] J2760 636 "$1,007.52 " $- $261.96 $- $- $806.02 $- N/A $261.96 N/A N/A Not Reimbursed N/A N/A $604.51 N/A N/A $503.76 N/A N/A N/A N/A N/A $685.11 N/A N/A $624.66 N/A N/A $413.08 N/A N/A $705.26 N/A N/A $806.02 N/A N/A $554.14 N/A N/A $705.26 N/A N/A $337.52 N/A N/A N/A N/A N/A $604.51 N/A N/A $352.63 N/A N/A $654.89 N/A N/A $374.74 N/A N/A $604.51 N/A N/A $705.26 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,007.52 " "$1,007.52 " N/A 4409495 Pharmacy valproic acid 250 mg/5 mL Syr 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400622 Pharmacy megestrol 40 mg/mL Oral Susp [BCH] 250 $8.45 $- $2.20 $- $- $6.76 $- N/A $2.20 N/A N/A $3.20 N/A N/A $5.07 N/A N/A $4.23 N/A N/A N/A N/A N/A $5.75 N/A N/A $5.24 N/A N/A $3.47 N/A N/A $5.92 N/A N/A $6.76 N/A N/A $4.65 N/A N/A $5.92 N/A N/A $2.83 N/A N/A N/A N/A N/A $5.07 N/A N/A $2.96 N/A N/A $5.49 N/A N/A N/A N/A N/A $5.07 N/A N/A $5.92 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.45 $8.45 N/A 4401375 Pharmacy ibuprofen 100 mg/5 mL Sus [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400622 Pharmacy megestrol 40 mg/mL Oral Susp [BCH] 250 $8.40 $- $2.18 $- $- $6.72 $- N/A $2.18 N/A N/A $3.18 N/A N/A $5.04 N/A N/A $4.20 N/A N/A N/A N/A N/A $5.71 N/A N/A $5.21 N/A N/A $3.44 N/A N/A $5.88 N/A N/A $6.72 N/A N/A $4.62 N/A N/A $5.88 N/A N/A $2.81 N/A N/A N/A N/A N/A $5.04 N/A N/A $2.94 N/A N/A $5.46 N/A N/A N/A N/A N/A $5.04 N/A N/A $5.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.40 $8.40 N/A 4404084 Pharmacy "nystatin 100,000 units/mL Oral Susp [BCH]" 250 $3.39 $- $0.88 $- $- $2.71 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.70 N/A N/A N/A N/A N/A $2.31 N/A N/A $2.10 N/A N/A $1.39 N/A N/A $2.37 N/A N/A $2.71 N/A N/A $1.87 N/A N/A $2.37 N/A N/A $1.14 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.19 N/A N/A $2.20 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.39 $3.39 N/A 4400887 Pharmacy acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Sol [BCH] 250 $6.59 $- $1.71 $- $- $5.28 $- N/A $1.71 N/A N/A $2.49 N/A N/A $3.96 N/A N/A $3.30 N/A N/A N/A N/A N/A $4.48 N/A N/A $4.09 N/A N/A $2.70 N/A N/A $4.62 N/A N/A $5.28 N/A N/A $3.63 N/A N/A $4.62 N/A N/A $2.21 N/A N/A N/A N/A N/A $3.96 N/A N/A $2.31 N/A N/A $4.29 N/A N/A N/A N/A N/A $3.96 N/A N/A $4.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.59 $6.59 N/A 4403045 Pharmacy cephalexin 500 mg Cap 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409738 Pharmacy escitalopram 10 mg Tab [BCH] 250 $9.43 $- $2.45 $- $- $7.54 $- N/A $2.45 N/A N/A $3.56 N/A N/A $5.66 N/A N/A $4.72 N/A N/A N/A N/A N/A $6.41 N/A N/A $5.85 N/A N/A $3.87 N/A N/A $6.60 N/A N/A $7.54 N/A N/A $5.19 N/A N/A $6.60 N/A N/A $3.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $3.30 N/A N/A $6.13 N/A N/A N/A N/A N/A $5.66 N/A N/A $6.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.43 $9.43 N/A 4400621 Pharmacy ziprasidone 20 mg Cap [BCH] 250 $17.98 $- $4.67 $- $- $14.38 $- N/A $4.67 N/A N/A $6.80 N/A N/A $10.79 N/A N/A $8.99 N/A N/A N/A N/A N/A $12.22 N/A N/A $11.15 N/A N/A $7.37 N/A N/A $12.58 N/A N/A $14.38 N/A N/A $9.89 N/A N/A $12.58 N/A N/A $6.02 N/A N/A N/A N/A N/A $10.79 N/A N/A $6.29 N/A N/A $11.68 N/A N/A N/A N/A N/A $10.79 N/A N/A $12.58 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.98 $17.98 N/A 4400557 Pharmacy sertraline 25 mg Tab [BCH] 250 $5.70 $- $1.48 $- $- $4.56 $- N/A $1.48 N/A N/A $2.16 N/A N/A $3.42 N/A N/A $2.85 N/A N/A N/A N/A N/A $3.88 N/A N/A $3.54 N/A N/A $2.34 N/A N/A $3.99 N/A N/A $4.56 N/A N/A $3.14 N/A N/A $3.99 N/A N/A $1.91 N/A N/A N/A N/A N/A $3.42 N/A N/A $2.00 N/A N/A $3.71 N/A N/A N/A N/A N/A $3.42 N/A N/A $3.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.70 $5.70 N/A 4403991 Pharmacy cephalexin 250 mg/5 mL Pow [BCH] 250 $115.00 $- $29.90 $- $- $92.00 $- N/A $29.90 N/A N/A $43.47 N/A N/A $69.00 N/A N/A $57.50 N/A N/A N/A N/A N/A $78.20 N/A N/A $71.30 N/A N/A $47.15 N/A N/A $80.50 N/A N/A $92.00 N/A N/A $63.25 N/A N/A $80.50 N/A N/A $38.53 N/A N/A N/A N/A N/A $69.00 N/A N/A $40.25 N/A N/A $74.75 N/A N/A N/A N/A N/A $69.00 N/A N/A $80.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $115.00 $115.00 N/A 4403991 Pharmacy cephalexin 250 mg/5 mL Pow [BCH] 250 $102.50 $- $26.65 $- $- $82.00 $- N/A $26.65 N/A N/A $38.75 N/A N/A $61.50 N/A N/A $51.25 N/A N/A N/A N/A N/A $69.70 N/A N/A $63.55 N/A N/A $42.03 N/A N/A $71.75 N/A N/A $82.00 N/A N/A $56.38 N/A N/A $71.75 N/A N/A $34.34 N/A N/A N/A N/A N/A $61.50 N/A N/A $35.88 N/A N/A $66.63 N/A N/A N/A N/A N/A $61.50 N/A N/A $71.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $102.50 $102.50 N/A 4405673 Pharmacy ramipril 2.5 mg Cap [BCH] 250 $3.61 $- $0.94 $- $- $2.89 $- N/A $0.94 N/A N/A $1.37 N/A N/A $2.17 N/A N/A $1.81 N/A N/A N/A N/A N/A $2.46 N/A N/A $2.24 N/A N/A $1.48 N/A N/A $2.53 N/A N/A $2.89 N/A N/A $1.99 N/A N/A $2.53 N/A N/A $1.21 N/A N/A N/A N/A N/A $2.17 N/A N/A $1.26 N/A N/A $2.35 N/A N/A N/A N/A N/A $2.17 N/A N/A $2.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.61 $3.61 N/A 4400350 Pharmacy levothyroxine 112 mcg (0.112 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409561 Pharmacy levothyroxine 137 mcg (0.137 mg) Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4408123 Pharmacy lisinopril 10 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400619 Pharmacy pramoxine topical 1% Foa[BCH] 250 $99.76 $- $25.94 $- $- $79.81 $- N/A $25.94 N/A N/A $37.71 N/A N/A $59.86 N/A N/A $49.88 N/A N/A N/A N/A N/A $67.84 N/A N/A $61.85 N/A N/A $40.90 N/A N/A $69.83 N/A N/A $79.81 N/A N/A $54.87 N/A N/A $69.83 N/A N/A $33.42 N/A N/A N/A N/A N/A $59.86 N/A N/A $34.92 N/A N/A $64.84 N/A N/A N/A N/A N/A $59.86 N/A N/A $69.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $99.76 $99.76 N/A 4409776 Pharmacy acetaminophen-oxyCODONE 325 mg-7.5 mg Tab [BCH] 250 $5.43 $- $1.41 $- $- $4.34 $- N/A $1.41 N/A N/A $2.05 N/A N/A $3.26 N/A N/A $2.72 N/A N/A N/A N/A N/A $3.69 N/A N/A $3.37 N/A N/A $2.23 N/A N/A $3.80 N/A N/A $4.34 N/A N/A $2.99 N/A N/A $3.80 N/A N/A $1.82 N/A N/A N/A N/A N/A $3.26 N/A N/A $1.90 N/A N/A $3.53 N/A N/A N/A N/A N/A $3.26 N/A N/A $3.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.43 $5.43 N/A 4400069 Pharmacy atenolol 25 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403713 Pharmacy divalproex sodium 250 mg DR Oral EC Tab [BCH] 250 $3.52 $- $0.92 $- $- $2.82 $- N/A $0.92 N/A N/A $1.33 N/A N/A $2.11 N/A N/A $1.76 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.19 N/A N/A $1.45 N/A N/A $2.47 N/A N/A $2.82 N/A N/A $1.94 N/A N/A $2.47 N/A N/A $1.18 N/A N/A N/A N/A N/A $2.11 N/A N/A $1.23 N/A N/A $2.29 N/A N/A N/A N/A N/A $2.11 N/A N/A $2.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.52 $3.52 N/A 4407872 Pharmacy venlafaxine 37.5 mg Cap[BCH] 250 $8.33 $- $2.16 $- $- $6.66 $- N/A $2.16 N/A N/A $3.15 N/A N/A $5.00 N/A N/A $4.16 N/A N/A N/A N/A N/A $5.66 N/A N/A $5.16 N/A N/A $3.41 N/A N/A $5.83 N/A N/A $6.66 N/A N/A $4.58 N/A N/A $5.83 N/A N/A $2.79 N/A N/A N/A N/A N/A $5.00 N/A N/A $2.91 N/A N/A $5.41 N/A N/A N/A N/A N/A $5.00 N/A N/A $5.83 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.33 $8.33 N/A 4409523 Pharmacy venlafaxine 75 mg Cap [BCH] 250 $9.33 $- $2.43 $- $- $7.46 $- N/A $2.43 N/A N/A $3.53 N/A N/A $5.60 N/A N/A $4.67 N/A N/A N/A N/A N/A $6.35 N/A N/A $5.79 N/A N/A $3.83 N/A N/A $6.53 N/A N/A $7.46 N/A N/A $5.13 N/A N/A $6.53 N/A N/A $3.13 N/A N/A N/A N/A N/A $5.60 N/A N/A $3.27 N/A N/A $6.07 N/A N/A N/A N/A N/A $5.60 N/A N/A $6.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.33 $9.33 N/A 4402414 Pharmacy warfarin 3 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404936 Pharmacy haloperidol 5 mg Tab [BCH] 250 $2.05 $- $0.53 $- $- $1.64 $- N/A $0.53 N/A N/A $0.77 N/A N/A $1.23 N/A N/A $1.02 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.27 N/A N/A $0.84 N/A N/A $1.43 N/A N/A $1.64 N/A N/A $1.13 N/A N/A $1.43 N/A N/A $0.69 N/A N/A N/A N/A N/A $1.23 N/A N/A $0.72 N/A N/A $1.33 N/A N/A N/A N/A N/A $1.23 N/A N/A $1.43 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.05 $2.05 N/A 4400971 Pharmacy haloperidol 20 mg Tab [BCH] 250 $2.69 $- $0.70 $- $- $2.15 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.61 N/A N/A $1.34 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.10 N/A N/A $1.88 N/A N/A $2.15 N/A N/A $1.48 N/A N/A $1.88 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.61 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.61 N/A N/A $1.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.69 $2.69 N/A 4408792 Pharmacy carvedilol 3.125 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.42 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.56 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.42 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4408784 Pharmacy carvedilol 12.5 mg Tab [BCH] 250 $4.27 $- $1.11 $- $- $3.42 $- N/A $1.11 N/A N/A $1.62 N/A N/A $2.56 N/A N/A $2.14 N/A N/A N/A N/A N/A $2.91 N/A N/A $2.65 N/A N/A $1.75 N/A N/A $2.99 N/A N/A $3.42 N/A N/A $2.35 N/A N/A $2.99 N/A N/A $1.43 N/A N/A N/A N/A N/A $2.56 N/A N/A $1.50 N/A N/A $2.78 N/A N/A N/A N/A N/A $2.56 N/A N/A $2.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.27 $4.27 N/A 4400293 Pharmacy risperiDONE 0.5 mg Tab [BCH] 250 $8.56 $- $2.23 $- $- $6.85 $- N/A $2.23 N/A N/A $3.24 N/A N/A $5.14 N/A N/A $4.28 N/A N/A N/A N/A N/A $5.82 N/A N/A $5.31 N/A N/A $3.51 N/A N/A $5.99 N/A N/A $6.85 N/A N/A $4.71 N/A N/A $5.99 N/A N/A $2.87 N/A N/A N/A N/A N/A $5.14 N/A N/A $3.00 N/A N/A $5.57 N/A N/A N/A N/A N/A $5.14 N/A N/A $5.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.56 $8.56 N/A 4405798 Pharmacy risperiDONE 1 mg Tab [BCH] 250 $9.10 $- $2.37 $- $- $7.28 $- N/A $2.37 N/A N/A $3.44 N/A N/A $5.46 N/A N/A $4.55 N/A N/A N/A N/A N/A $6.19 N/A N/A $5.64 N/A N/A $3.73 N/A N/A $6.37 N/A N/A $7.28 N/A N/A $5.01 N/A N/A $6.37 N/A N/A $3.05 N/A N/A N/A N/A N/A $5.46 N/A N/A $3.19 N/A N/A $5.92 N/A N/A N/A N/A N/A $5.46 N/A N/A $6.37 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.10 $9.10 N/A 4400364 Pharmacy amLODIPine 5 mg Tab [BCH] 250 $3.46 $- $0.90 $- $- $2.77 $- N/A $0.90 N/A N/A $1.31 N/A N/A $2.08 N/A N/A $1.73 N/A N/A N/A N/A N/A $2.36 N/A N/A $2.15 N/A N/A $1.42 N/A N/A $2.42 N/A N/A $2.77 N/A N/A $1.91 N/A N/A $2.42 N/A N/A $1.16 N/A N/A N/A N/A N/A $2.08 N/A N/A $1.21 N/A N/A $2.25 N/A N/A N/A N/A N/A $2.08 N/A N/A $2.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.46 $3.46 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.75 $- $1.24 $- $- $3.80 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.85 N/A N/A $2.38 N/A N/A N/A N/A N/A $3.23 N/A N/A $2.95 N/A N/A $1.95 N/A N/A $3.33 N/A N/A $3.80 N/A N/A $2.61 N/A N/A $3.33 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.85 N/A N/A $1.66 N/A N/A $3.09 N/A N/A N/A N/A N/A $2.85 N/A N/A $3.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.75 $4.75 N/A 4400749 Pharmacy risperiDONE 0.5 mg Dis Tab [BCH] 250 $9.83 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.88 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.88 N/A N/A $3.29 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.39 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.83 $9.83 N/A 4400748 Pharmacy risperiDONE 1 mg Tab[BCH] 250 $11.48 $- $2.98 $- $- $9.18 $- N/A $2.98 N/A N/A $4.34 N/A N/A $6.89 N/A N/A $5.74 N/A N/A N/A N/A N/A $7.81 N/A N/A $7.12 N/A N/A $4.71 N/A N/A $8.03 N/A N/A $9.18 N/A N/A $6.31 N/A N/A $8.03 N/A N/A $3.85 N/A N/A N/A N/A N/A $6.89 N/A N/A $4.02 N/A N/A $7.46 N/A N/A N/A N/A N/A $6.89 N/A N/A $8.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.48 $11.48 N/A 4400750 Pharmacy risperiDONE 2 mg Dis Tab [BCH] 250 $18.66 $- $4.85 $- $- $14.93 $- N/A $4.85 N/A N/A $7.05 N/A N/A $11.19 N/A N/A $9.33 N/A N/A N/A N/A N/A $12.69 N/A N/A $11.57 N/A N/A $7.65 N/A N/A $13.06 N/A N/A $14.93 N/A N/A $10.26 N/A N/A $13.06 N/A N/A $6.25 N/A N/A N/A N/A N/A $11.19 N/A N/A $6.53 N/A N/A $12.13 N/A N/A N/A N/A N/A $11.19 N/A N/A $13.06 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.66 $18.66 N/A 4404480 Pharmacy amiodarone 200 mg Tab [BCH] 250 $6.64 $- $1.73 $- $- $5.32 $- N/A $1.73 N/A N/A $2.51 N/A N/A $3.99 N/A N/A $3.32 N/A N/A N/A N/A N/A $4.52 N/A N/A $4.12 N/A N/A $2.72 N/A N/A $4.65 N/A N/A $5.32 N/A N/A $3.65 N/A N/A $4.65 N/A N/A $2.23 N/A N/A N/A N/A N/A $3.99 N/A N/A $2.33 N/A N/A $4.32 N/A N/A N/A N/A N/A $3.99 N/A N/A $4.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.64 $6.64 N/A 4401950 Pharmacy oxybutynin 5 mg/24 hours Tab [BCH] 250 $6.58 $- $1.71 $- $- $5.26 $- N/A $1.71 N/A N/A $2.49 N/A N/A $3.95 N/A N/A $3.29 N/A N/A N/A N/A N/A $4.47 N/A N/A $4.08 N/A N/A $2.70 N/A N/A $4.60 N/A N/A $5.26 N/A N/A $3.62 N/A N/A $4.60 N/A N/A $2.20 N/A N/A N/A N/A N/A $3.95 N/A N/A $2.30 N/A N/A $4.27 N/A N/A N/A N/A N/A $3.95 N/A N/A $4.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.58 $6.58 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours Tab [BCH] 250 $9.55 $- $2.48 $- $- $7.64 $- N/A $2.48 N/A N/A $3.61 N/A N/A $5.73 N/A N/A $4.77 N/A N/A N/A N/A N/A $6.49 N/A N/A $5.92 N/A N/A $3.91 N/A N/A $6.68 N/A N/A $7.64 N/A N/A $5.25 N/A N/A $6.68 N/A N/A $3.20 N/A N/A N/A N/A N/A $5.73 N/A N/A $3.34 N/A N/A $6.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $6.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.55 $9.55 N/A 4400745 Pharmacy ranitidine 25 mg/mL Inj Sol [BCH] J2780 636 $17.62 $- $3.91 $- $- $14.09 $- N/A $4.58 N/A N/A Not Reimbursed N/A N/A $10.57 N/A N/A $8.81 N/A N/A N/A N/A N/A $11.98 N/A N/A $10.92 N/A N/A $7.22 N/A N/A $12.33 N/A N/A $14.09 N/A N/A $9.69 N/A N/A $12.33 N/A N/A $5.90 N/A N/A N/A N/A N/A $10.57 N/A N/A $6.17 N/A N/A $11.45 N/A N/A $3.91 N/A N/A $10.57 N/A N/A $12.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.62 $17.62 N/A 4400792 Pharmacy ritonavir 100 mg Tab 250 $18.52 $- $4.81 $- $- $14.81 $- N/A $4.81 N/A N/A $7.00 N/A N/A $11.11 N/A N/A $9.26 N/A N/A N/A N/A N/A $12.59 N/A N/A $11.48 N/A N/A $7.59 N/A N/A $12.96 N/A N/A $14.81 N/A N/A $10.18 N/A N/A $12.96 N/A N/A $6.20 N/A N/A N/A N/A N/A $11.11 N/A N/A $6.48 N/A N/A $12.04 N/A N/A N/A N/A N/A $11.11 N/A N/A $12.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.52 $18.52 N/A 4406069 Pharmacy metFORMIN 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409710 Pharmacy ezetimibe 10 mg Tab [BCH] 250 $22.59 $- $5.87 $- $- $18.07 $- N/A $5.87 N/A N/A $8.54 N/A N/A $13.56 N/A N/A $11.30 N/A N/A N/A N/A N/A $15.36 N/A N/A $14.01 N/A N/A $9.26 N/A N/A $15.82 N/A N/A $18.07 N/A N/A $12.43 N/A N/A $15.82 N/A N/A $7.57 N/A N/A N/A N/A N/A $13.56 N/A N/A $7.91 N/A N/A $14.69 N/A N/A N/A N/A N/A $13.56 N/A N/A $15.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.59 $22.59 N/A 4406913 Pharmacy doxazosin 2 mg Tab 250 $2.70 $- $0.70 $- $- $2.16 $- N/A $0.70 N/A N/A $1.02 N/A N/A $1.62 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.83 N/A N/A $1.67 N/A N/A $1.11 N/A N/A $1.89 N/A N/A $2.16 N/A N/A $1.48 N/A N/A $1.89 N/A N/A $0.90 N/A N/A N/A N/A N/A $1.62 N/A N/A $0.94 N/A N/A $1.75 N/A N/A N/A N/A N/A $1.62 N/A N/A $1.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.70 $2.70 N/A 4400654 Pharmacy traZODone 50 mg Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.40 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4401909 Pharmacy traZODone 100 mg Tab [BCH] 250 $2.78 $- $0.72 $- $- $2.23 $- N/A $0.72 N/A N/A $1.05 N/A N/A $1.67 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.89 N/A N/A $1.73 N/A N/A $1.14 N/A N/A $1.95 N/A N/A $2.23 N/A N/A $1.53 N/A N/A $1.95 N/A N/A $0.93 N/A N/A N/A N/A N/A $1.67 N/A N/A $0.97 N/A N/A $1.81 N/A N/A N/A N/A N/A $1.67 N/A N/A $1.95 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.78 $2.78 N/A 4401136 Pharmacy benztropine 1 mg/mL Sol J0515 636 $117.50 $- $15.52 $- $- $94.00 $- N/A $30.55 N/A N/A Not Reimbursed N/A N/A $70.50 N/A N/A $58.75 N/A N/A N/A N/A N/A $79.90 N/A N/A $72.85 N/A N/A $48.18 N/A N/A $82.25 N/A N/A $94.00 N/A N/A $64.63 N/A N/A $82.25 N/A N/A $39.36 N/A N/A N/A N/A N/A $70.50 N/A N/A $41.13 N/A N/A $76.38 N/A N/A $15.52 N/A N/A $70.50 N/A N/A $82.25 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $117.50 $117.50 N/A 4407992 Pharmacy doxycycline 100 mg Pow [BCH] 636 $60.40 $- $15.70 $- $- $48.32 $- N/A $15.70 N/A N/A $22.83 N/A N/A $36.24 N/A N/A $30.20 N/A N/A N/A N/A N/A $41.07 N/A N/A $37.45 N/A N/A $24.76 N/A N/A $42.28 N/A N/A $48.32 N/A N/A $33.22 N/A N/A $42.28 N/A N/A $20.23 N/A N/A N/A N/A N/A $36.24 N/A N/A $21.14 N/A N/A $39.26 N/A N/A N/A N/A N/A $36.24 N/A N/A $42.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $60.40 $60.40 N/A 4400583 Pharmacy fluconazole 100 mg Tab [BCH] 250 $17.61 $- $4.58 $- $- $14.08 $- N/A $4.58 N/A N/A $6.66 N/A N/A $10.56 N/A N/A $8.80 N/A N/A N/A N/A N/A $11.97 N/A N/A $10.92 N/A N/A $7.22 N/A N/A $12.32 N/A N/A $14.08 N/A N/A $9.68 N/A N/A $12.32 N/A N/A $5.90 N/A N/A N/A N/A N/A $10.56 N/A N/A $6.16 N/A N/A $11.44 N/A N/A N/A N/A N/A $10.56 N/A N/A $12.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $17.61 $17.61 N/A 4400161 Pharmacy ondansetron 4 mg Tab [BCH] Q0162 250 $49.00 $- $0.02 $- $- $39.20 $- N/A $12.74 N/A N/A Not Reimbursed N/A N/A $29.40 N/A N/A $24.50 N/A N/A N/A N/A N/A $33.32 N/A N/A $30.38 N/A N/A $20.09 N/A N/A $34.30 N/A N/A $39.20 N/A N/A $26.95 N/A N/A $34.30 N/A N/A $16.42 N/A N/A N/A N/A N/A $29.40 N/A N/A $17.15 N/A N/A $31.85 N/A N/A $0.02 N/A N/A $29.40 N/A N/A $34.30 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $49.00 $49.00 N/A 4402404 Pharmacy mupirocin topical 2% Oin [BCH] 250 $85.50 $- $22.23 $- $- $68.40 $- N/A $22.23 N/A N/A $32.32 N/A N/A $51.30 N/A N/A $42.75 N/A N/A N/A N/A N/A $58.14 N/A N/A $53.01 N/A N/A $35.05 N/A N/A $59.85 N/A N/A $68.40 N/A N/A $47.02 N/A N/A $59.85 N/A N/A $28.64 N/A N/A N/A N/A N/A $51.30 N/A N/A $29.92 N/A N/A $55.57 N/A N/A N/A N/A N/A $51.30 N/A N/A $59.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $85.50 $85.50 N/A 4400744 Pharmacy lithium 300 mg ER Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400826 Pharmacy mometasone Top 0.1% Oint [BCH] 250 $95.00 $- $24.70 $- $- $76.00 $- N/A $24.70 N/A N/A $35.91 N/A N/A $57.00 N/A N/A $47.50 N/A N/A N/A N/A N/A $64.60 N/A N/A $58.90 N/A N/A $38.95 N/A N/A $66.50 N/A N/A $76.00 N/A N/A $52.25 N/A N/A $66.50 N/A N/A $31.83 N/A N/A N/A N/A N/A $57.00 N/A N/A $33.25 N/A N/A $61.75 N/A N/A N/A N/A N/A $57.00 N/A N/A $66.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $95.00 $95.00 N/A 4409147 Pharmacy ropinirole 0.25 mg Tab [BCH] 250 $5.01 $- $1.30 $- $- $4.01 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.05 N/A N/A $3.51 N/A N/A $4.01 N/A N/A $2.76 N/A N/A $3.51 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.75 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4409668 Pharmacy rOPINIRole 1 mg Tab [BCH] 250 $5.01 $- $1.30 $- $- $4.01 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.01 N/A N/A $2.51 N/A N/A N/A N/A N/A $3.41 N/A N/A $3.11 N/A N/A $2.05 N/A N/A $3.51 N/A N/A $4.01 N/A N/A $2.76 N/A N/A $3.51 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.01 N/A N/A $1.75 N/A N/A $3.26 N/A N/A N/A N/A N/A $3.01 N/A N/A $3.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.01 $5.01 N/A 4409755 Pharmacy LINEZOLID 600MG 600 mg Tab [BCH] 250 $367.34 $- $95.51 $- $- $293.87 $- N/A $95.51 N/A N/A $138.85 N/A N/A $220.40 N/A N/A $183.67 N/A N/A N/A N/A N/A $249.79 N/A N/A $227.75 N/A N/A $150.61 N/A N/A $257.14 N/A N/A $293.87 N/A N/A $202.04 N/A N/A $257.14 N/A N/A $123.06 N/A N/A N/A N/A N/A $220.40 N/A N/A $128.57 N/A N/A $238.77 N/A N/A N/A N/A N/A $220.40 N/A N/A $257.14 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $367.34 $367.34 N/A 4405338 Pharmacy verapamil 120 mg ER Tab [BCH] 250 $2.15 $- $0.56 $- $- $1.72 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.29 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.46 N/A N/A $1.33 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.72 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.29 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.29 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.15 $2.15 N/A 4400827 Pharmacy nystatin-triamcinolone topical 100000 units/g-0.1% Cre[BCH] 250 $223.88 $- $58.21 $- $- $179.10 $- N/A $58.21 N/A N/A $84.63 N/A N/A $134.33 N/A N/A $111.94 N/A N/A N/A N/A N/A $152.24 N/A N/A $138.81 N/A N/A $91.79 N/A N/A $156.72 N/A N/A $179.10 N/A N/A $123.13 N/A N/A $156.72 N/A N/A $75.00 N/A N/A N/A N/A N/A $134.33 N/A N/A $78.36 N/A N/A $145.52 N/A N/A N/A N/A N/A $134.33 N/A N/A $156.72 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $223.88 $223.88 N/A 4400413 Pharmacy pramipexole 0.5 mg Tab [BCH] 250 $6.68 $- $1.74 $- $- $5.35 $- N/A $1.74 N/A N/A $2.53 N/A N/A $4.01 N/A N/A $3.34 N/A N/A N/A N/A N/A $4.55 N/A N/A $4.14 N/A N/A $2.74 N/A N/A $4.68 N/A N/A $5.35 N/A N/A $3.68 N/A N/A $4.68 N/A N/A $2.24 N/A N/A N/A N/A N/A $4.01 N/A N/A $2.34 N/A N/A $4.35 N/A N/A N/A N/A N/A $4.01 N/A N/A $4.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.68 $6.68 N/A 4405248 Pharmacy indomethacin 25 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409411 Pharmacy mupirocin Top 2% Crm [BCH] 250 $601.34 $- $156.35 $- $- $481.07 $- N/A $156.35 N/A N/A $227.31 N/A N/A $360.80 N/A N/A $300.67 N/A N/A N/A N/A N/A $408.91 N/A N/A $372.83 N/A N/A $246.55 N/A N/A $420.94 N/A N/A $481.07 N/A N/A $330.74 N/A N/A $420.94 N/A N/A $201.45 N/A N/A N/A N/A N/A $360.80 N/A N/A $210.47 N/A N/A $390.87 N/A N/A N/A N/A N/A $360.80 N/A N/A $420.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $601.34 $601.34 N/A 4403728 Pharmacy nitroglycerin 0.4 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4403728 Pharmacy nitroglycerin 0.4 mg Tab 250 $2.08 $- $0.54 $- $- $1.67 $- N/A $0.54 N/A N/A $0.79 N/A N/A $1.25 N/A N/A $1.04 N/A N/A N/A N/A N/A $1.42 N/A N/A $1.29 N/A N/A $0.85 N/A N/A $1.46 N/A N/A $1.67 N/A N/A $1.15 N/A N/A $1.46 N/A N/A $0.70 N/A N/A N/A N/A N/A $1.25 N/A N/A $0.73 N/A N/A $1.35 N/A N/A N/A N/A N/A $1.25 N/A N/A $1.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.08 $2.08 N/A 4400899 Pharmacy theophylline 300 mg Tab [BCH] 250 $8.59 $- $2.23 $- $- $6.87 $- N/A $2.23 N/A N/A $3.25 N/A N/A $5.15 N/A N/A $4.30 N/A N/A N/A N/A N/A $5.84 N/A N/A $5.33 N/A N/A $3.52 N/A N/A $6.01 N/A N/A $6.87 N/A N/A $4.73 N/A N/A $6.01 N/A N/A $2.88 N/A N/A N/A N/A N/A $5.15 N/A N/A $3.01 N/A N/A $5.58 N/A N/A N/A N/A N/A $5.15 N/A N/A $6.01 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.59 $8.59 N/A 4400375 Pharmacy albumin human 25% IV Sol 50 mL [BCH] P9047 636 $180.00 $- $46.80 $- $- $144.00 $- N/A $46.80 N/A N/A Not Reimbursed N/A N/A $108.00 N/A N/A $90.00 N/A N/A N/A N/A N/A $122.40 N/A N/A $111.60 N/A N/A $73.80 N/A N/A $126.00 N/A N/A $144.00 N/A N/A $99.00 N/A N/A $126.00 N/A N/A $60.30 N/A N/A N/A N/A N/A $108.00 N/A N/A $63.00 N/A N/A $117.00 N/A N/A $52.45 N/A N/A $108.00 N/A N/A $126.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $180.00 $180.00 N/A 4400375 Pharmacy albumin human 25% Sol [BCH] P9047 636 $180.00 $- $46.80 $- $- $144.00 $- N/A $46.80 N/A N/A Not Reimbursed N/A N/A $108.00 N/A N/A $90.00 N/A N/A N/A N/A N/A $122.40 N/A N/A $111.60 N/A N/A $73.80 N/A N/A $126.00 N/A N/A $144.00 N/A N/A $99.00 N/A N/A $126.00 N/A N/A $60.30 N/A N/A N/A N/A N/A $108.00 N/A N/A $63.00 N/A N/A $117.00 N/A N/A $52.45 N/A N/A $108.00 N/A N/A $126.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $180.00 $180.00 N/A 4401451 Pharmacy zinc sulfate 220 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404957 Pharmacy phytonadione 5 mg Tab [BCH] 250 $133.97 $- $34.83 $- $- $107.18 $- N/A $34.83 N/A N/A $50.64 N/A N/A $80.38 N/A N/A $66.99 N/A N/A N/A N/A N/A $91.10 N/A N/A $83.06 N/A N/A $54.93 N/A N/A $93.78 N/A N/A $107.18 N/A N/A $73.68 N/A N/A $93.78 N/A N/A $44.88 N/A N/A N/A N/A N/A $80.38 N/A N/A $46.89 N/A N/A $87.08 N/A N/A N/A N/A N/A $80.38 N/A N/A $93.78 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $133.97 $133.97 N/A 4409635 Pharmacy pyridostigmine 60 mg Tab [BCH] 250 $2.45 $- $0.64 $- $- $1.96 $- N/A $0.64 N/A N/A $0.93 N/A N/A $1.47 N/A N/A $1.22 N/A N/A N/A N/A N/A $1.66 N/A N/A $1.52 N/A N/A $1.00 N/A N/A $1.71 N/A N/A $1.96 N/A N/A $1.35 N/A N/A $1.71 N/A N/A $0.82 N/A N/A N/A N/A N/A $1.47 N/A N/A $0.86 N/A N/A $1.59 N/A N/A N/A N/A N/A $1.47 N/A N/A $1.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.45 $2.45 N/A 4403520 Pharmacy diltiazem 120 mg/24 hours ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401714 Pharmacy diltiazem 180 mg/24 hours ERCap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400653 Pharmacy diltiazem 360 mg/24 hours ERCap [BCH] 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4400053 Pharmacy metroNIDAZOLE 0.75% Vag Gel w/Appl [BCH] 250 $293.41 $- $76.29 $- $- $234.73 $- N/A $76.29 N/A N/A $110.91 N/A N/A $176.05 N/A N/A $146.71 N/A N/A N/A N/A N/A $199.52 N/A N/A $181.92 N/A N/A $120.30 N/A N/A $205.39 N/A N/A $234.73 N/A N/A $161.38 N/A N/A $205.39 N/A N/A $98.29 N/A N/A N/A N/A N/A $176.05 N/A N/A $102.69 N/A N/A $190.72 N/A N/A N/A N/A N/A $176.05 N/A N/A $205.39 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $293.41 $293.41 N/A 4400766 Pharmacy acyclovir topical 5% Oint 30 gm [BCH] 250 "$1,536.00 " $- $399.36 $- $- "$1,228.80 " $- N/A $399.36 N/A N/A $580.61 N/A N/A $921.60 N/A N/A $768.00 N/A N/A N/A N/A N/A "$1,044.48 " N/A N/A $952.32 N/A N/A $629.76 N/A N/A "$1,075.20 " N/A N/A "$1,228.80 " N/A N/A $844.80 N/A N/A "$1,075.20 " N/A N/A $514.56 N/A N/A N/A N/A N/A $921.60 N/A N/A $537.60 N/A N/A $998.40 N/A N/A N/A N/A N/A $921.60 N/A N/A "$1,075.20 " N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A "$1,536.00 " "$1,536.00 " N/A 4403761 Pharmacy acyclovir 200 mg Cap [BCH] 250 $4.00 $- $1.04 $- $- $3.20 $- N/A $1.04 N/A N/A $1.51 N/A N/A $2.40 N/A N/A $2.00 N/A N/A N/A N/A N/A $2.72 N/A N/A $2.48 N/A N/A $1.64 N/A N/A $2.80 N/A N/A $3.20 N/A N/A $2.20 N/A N/A $2.80 N/A N/A $1.34 N/A N/A N/A N/A N/A $2.40 N/A N/A $1.40 N/A N/A $2.60 N/A N/A N/A N/A N/A $2.40 N/A N/A $2.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.00 $4.00 N/A 4409551 Pharmacy topiramate 25 mg Tab [BCH] 250 $5.05 $- $1.31 $- $- $4.04 $- N/A $1.31 N/A N/A $1.91 N/A N/A $3.03 N/A N/A $2.53 N/A N/A N/A N/A N/A $3.44 N/A N/A $3.13 N/A N/A $2.07 N/A N/A $3.54 N/A N/A $4.04 N/A N/A $2.78 N/A N/A $3.54 N/A N/A $1.69 N/A N/A N/A N/A N/A $3.03 N/A N/A $1.77 N/A N/A $3.28 N/A N/A N/A N/A N/A $3.03 N/A N/A $3.54 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.05 $5.05 N/A 4400717 Pharmacy topiramate 100 mg Tab [BCH] 250 $13.77 $- $3.58 $- $- $11.02 $- N/A $3.58 N/A N/A $5.21 N/A N/A $8.26 N/A N/A $6.89 N/A N/A N/A N/A N/A $9.36 N/A N/A $8.54 N/A N/A $5.65 N/A N/A $9.64 N/A N/A $11.02 N/A N/A $7.57 N/A N/A $9.64 N/A N/A $4.61 N/A N/A N/A N/A N/A $8.26 N/A N/A $4.82 N/A N/A $8.95 N/A N/A N/A N/A N/A $8.26 N/A N/A $9.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.77 $13.77 N/A 4400364 Pharmacy amLODIPine 5 mg Tab 250 $3.46 $- $0.90 $- $- $2.77 $- N/A $0.90 N/A N/A $1.31 N/A N/A $2.08 N/A N/A $1.73 N/A N/A N/A N/A N/A $2.35 N/A N/A $2.15 N/A N/A $1.42 N/A N/A $2.42 N/A N/A $2.77 N/A N/A $1.90 N/A N/A $2.42 N/A N/A $1.16 N/A N/A N/A N/A N/A $2.08 N/A N/A $1.21 N/A N/A $2.25 N/A N/A N/A N/A N/A $2.08 N/A N/A $2.42 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.46 $3.46 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.75 $- $1.23 $- $- $3.80 $- N/A $1.23 N/A N/A $1.79 N/A N/A $2.85 N/A N/A $2.37 N/A N/A N/A N/A N/A $3.23 N/A N/A $2.94 N/A N/A $1.95 N/A N/A $3.32 N/A N/A $3.80 N/A N/A $2.61 N/A N/A $3.32 N/A N/A $1.59 N/A N/A N/A N/A N/A $2.85 N/A N/A $1.66 N/A N/A $3.09 N/A N/A N/A N/A N/A $2.85 N/A N/A $3.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.75 $4.75 N/A 4401902 Pharmacy lamoTRIgine 100 mg Tab [BCH] 250 $9.50 $- $2.47 $- $- $7.60 $- N/A $2.47 N/A N/A $3.59 N/A N/A $5.70 N/A N/A $4.75 N/A N/A N/A N/A N/A $6.46 N/A N/A $5.89 N/A N/A $3.90 N/A N/A $6.65 N/A N/A $7.60 N/A N/A $5.23 N/A N/A $6.65 N/A N/A $3.18 N/A N/A N/A N/A N/A $5.70 N/A N/A $3.33 N/A N/A $6.18 N/A N/A N/A N/A N/A $5.70 N/A N/A $6.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.50 $9.50 N/A 4400102 Pharmacy DULoxetine 30 mg Cap [BCH] 250 $15.70 $- $4.08 $- $- $12.56 $- N/A $4.08 N/A N/A $5.94 N/A N/A $9.42 N/A N/A $7.85 N/A N/A N/A N/A N/A $10.68 N/A N/A $9.74 N/A N/A $6.44 N/A N/A $10.99 N/A N/A $12.56 N/A N/A $8.64 N/A N/A $10.99 N/A N/A $5.26 N/A N/A N/A N/A N/A $9.42 N/A N/A $5.50 N/A N/A $10.21 N/A N/A N/A N/A N/A $9.42 N/A N/A $10.99 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.70 $15.70 N/A 4409459 Pharmacy budesonide 0.25 mg/2 mL Sus [BCH] J7626 636 $18.97 $- $1.78 $- $- $15.18 $- N/A $4.93 N/A N/A Not Reimbursed N/A N/A $11.38 N/A N/A $9.49 N/A N/A N/A N/A N/A $12.90 N/A N/A $11.76 N/A N/A $7.78 N/A N/A $13.28 N/A N/A $15.18 N/A N/A $10.44 N/A N/A $13.28 N/A N/A $6.36 N/A N/A N/A N/A N/A $11.38 N/A N/A $6.64 N/A N/A $12.33 N/A N/A $1.78 N/A N/A $11.38 N/A N/A $13.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.97 $18.97 N/A 4409460 Pharmacy budesonide 0.5 mg/2 mL Sus [BCH] J7626 636 $22.33 $- $1.78 $- $- $17.87 $- N/A $5.81 N/A N/A Not Reimbursed N/A N/A $13.40 N/A N/A $11.17 N/A N/A N/A N/A N/A $15.19 N/A N/A $13.85 N/A N/A $9.16 N/A N/A $15.63 N/A N/A $17.87 N/A N/A $12.28 N/A N/A $15.63 N/A N/A $7.48 N/A N/A N/A N/A N/A $13.40 N/A N/A $7.82 N/A N/A $14.52 N/A N/A $1.78 N/A N/A $13.40 N/A N/A $15.63 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $22.33 $22.33 N/A 4400938 Pharmacy ABACAVIR AND LAMIVUDINE 600-300 Tab [BCH] 250 $93.00 $- $24.18 $- $- $74.40 $- N/A $24.18 N/A N/A $35.16 N/A N/A $55.80 N/A N/A $46.50 N/A N/A N/A N/A N/A $63.24 N/A N/A $57.66 N/A N/A $38.13 N/A N/A $65.10 N/A N/A $74.40 N/A N/A $51.15 N/A N/A $65.10 N/A N/A $31.16 N/A N/A N/A N/A N/A $55.80 N/A N/A $32.55 N/A N/A $60.45 N/A N/A N/A N/A N/A $55.80 N/A N/A $65.10 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $93.00 $93.00 N/A 4400261 Pharmacy diclofenac topical 1% Gel 250 $105.24 $- $27.36 $- $- $84.19 $- N/A $27.36 N/A N/A $39.78 N/A N/A $63.14 N/A N/A $52.62 N/A N/A N/A N/A N/A $71.56 N/A N/A $65.25 N/A N/A $43.15 N/A N/A $73.67 N/A N/A $84.19 N/A N/A $57.88 N/A N/A $73.67 N/A N/A $35.26 N/A N/A N/A N/A N/A $63.14 N/A N/A $36.83 N/A N/A $68.41 N/A N/A N/A N/A N/A $63.14 N/A N/A $73.67 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $105.24 $105.24 N/A 4406366 Pharmacy gabapentin 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404753 Pharmacy cyclobenzaprine 10 mg Tab [BCH] 250 $2.32 $- $0.60 $- $- $1.85 $- N/A $0.60 N/A N/A $0.88 N/A N/A $1.39 N/A N/A $1.16 N/A N/A N/A N/A N/A $1.57 N/A N/A $1.44 N/A N/A $0.95 N/A N/A $1.62 N/A N/A $1.85 N/A N/A $1.27 N/A N/A $1.62 N/A N/A $0.78 N/A N/A N/A N/A N/A $1.39 N/A N/A $0.81 N/A N/A $1.50 N/A N/A N/A N/A N/A $1.39 N/A N/A $1.62 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.32 $2.32 N/A 4408655 Pharmacy chlorproMAZINE 25 mg Tab [BCH] 250 $15.28 $- $3.97 $- $- $12.23 $- N/A $3.97 N/A N/A $5.78 N/A N/A $9.17 N/A N/A $7.64 N/A N/A N/A N/A N/A $10.39 N/A N/A $9.47 N/A N/A $6.27 N/A N/A $10.70 N/A N/A $12.23 N/A N/A $8.40 N/A N/A $10.70 N/A N/A $5.12 N/A N/A N/A N/A N/A $9.17 N/A N/A $5.35 N/A N/A $9.93 N/A N/A N/A N/A N/A $9.17 N/A N/A $10.70 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.28 $15.28 N/A 4400291 Pharmacy potassium chloride 20 mEq Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400462 Pharmacy ursodiol 300 mg Cap [BCH] 250 $14.70 $- $3.82 $- $- $11.76 $- N/A $3.82 N/A N/A $5.56 N/A N/A $8.82 N/A N/A $7.35 N/A N/A N/A N/A N/A $10.00 N/A N/A $9.12 N/A N/A $6.03 N/A N/A $10.29 N/A N/A $11.76 N/A N/A $8.09 N/A N/A $10.29 N/A N/A $4.93 N/A N/A N/A N/A N/A $8.82 N/A N/A $5.15 N/A N/A $9.56 N/A N/A N/A N/A N/A $8.82 N/A N/A $10.29 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.70 $14.70 N/A 4400691 Pharmacy fluPHENAZine 5 mg Tab [BCH] 250 $18.40 $- $4.78 $- $- $14.72 $- N/A $4.78 N/A N/A $6.96 N/A N/A $11.04 N/A N/A $9.20 N/A N/A N/A N/A N/A $12.51 N/A N/A $11.41 N/A N/A $7.54 N/A N/A $12.88 N/A N/A $14.72 N/A N/A $10.12 N/A N/A $12.88 N/A N/A $6.16 N/A N/A N/A N/A N/A $11.04 N/A N/A $6.44 N/A N/A $11.96 N/A N/A N/A N/A N/A $11.04 N/A N/A $12.88 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.40 $18.40 N/A 4407384 Pharmacy NIFEdipine 10 mg Cap 250 $2.14 $- $0.56 $- $- $1.71 $- N/A $0.56 N/A N/A $0.81 N/A N/A $1.28 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.88 N/A N/A $1.50 N/A N/A $1.71 N/A N/A $1.18 N/A N/A $1.50 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.14 $2.14 N/A 4409818 Pharmacy hydrocortisone topical 2.5% Cre 250 $180.00 $- $46.80 $- $- $144.00 $- N/A $46.80 N/A N/A $68.04 N/A N/A $108.00 N/A N/A $90.00 N/A N/A N/A N/A N/A $122.40 N/A N/A $111.60 N/A N/A $73.80 N/A N/A $126.00 N/A N/A $144.00 N/A N/A $99.00 N/A N/A $126.00 N/A N/A $60.30 N/A N/A N/A N/A N/A $108.00 N/A N/A $63.00 N/A N/A $117.00 N/A N/A N/A N/A N/A $108.00 N/A N/A $126.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $180.00 $180.00 N/A 4405013 Pharmacy LORazepam 0.5 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400311 Pharmacy LORazepam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400311 Pharmacy LORazepam 1 mg Tab [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400847 Pharmacy LORazepam 2 mg Tab 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401030 Pharmacy acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab [BCH] 250 $3.38 $- $0.88 $- $- $2.70 $- N/A $0.88 N/A N/A $1.28 N/A N/A $2.03 N/A N/A $1.69 N/A N/A N/A N/A N/A $2.30 N/A N/A $2.09 N/A N/A $1.38 N/A N/A $2.36 N/A N/A $2.70 N/A N/A $1.86 N/A N/A $2.36 N/A N/A $1.13 N/A N/A N/A N/A N/A $2.03 N/A N/A $1.18 N/A N/A $2.19 N/A N/A N/A N/A N/A $2.03 N/A N/A $2.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.38 $3.38 N/A 4400335 Pharmacy sodium chloride 1 g Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400723 Pharmacy Paricalcitol 1 mcg Cap 250 $665.46 $- $173.02 $- $- $532.37 $- N/A $173.02 N/A N/A $251.54 N/A N/A $399.28 N/A N/A $332.73 N/A N/A N/A N/A N/A $452.51 N/A N/A $412.59 N/A N/A $272.84 N/A N/A $465.82 N/A N/A $532.37 N/A N/A $366.00 N/A N/A $465.82 N/A N/A $222.93 N/A N/A N/A N/A N/A $399.28 N/A N/A $232.91 N/A N/A $432.55 N/A N/A N/A N/A N/A $399.28 N/A N/A $465.82 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $665.46 $665.46 N/A 4407273 Pharmacy montelukast 10 mg Tab [BCH] 250 $9.55 $- $2.48 $- $- $7.64 $- N/A $2.48 N/A N/A $3.61 N/A N/A $5.73 N/A N/A $4.78 N/A N/A N/A N/A N/A $6.50 N/A N/A $5.92 N/A N/A $3.92 N/A N/A $6.69 N/A N/A $7.64 N/A N/A $5.25 N/A N/A $6.69 N/A N/A $3.20 N/A N/A N/A N/A N/A $5.73 N/A N/A $3.34 N/A N/A $6.21 N/A N/A N/A N/A N/A $5.73 N/A N/A $6.69 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.55 $9.55 N/A 4400391 Pharmacy "ergocalciferol 50,000 intl units Cap [BCH]" 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400623 Pharmacy calcitriol 0.25 mcg Cap [BCH] 250 $2.56 $- $0.67 $- $- $2.05 $- N/A $0.67 N/A N/A $0.97 N/A N/A $1.54 N/A N/A $1.28 N/A N/A N/A N/A N/A $1.74 N/A N/A $1.59 N/A N/A $1.05 N/A N/A $1.79 N/A N/A $2.05 N/A N/A $1.41 N/A N/A $1.79 N/A N/A $0.86 N/A N/A N/A N/A N/A $1.54 N/A N/A $0.90 N/A N/A $1.66 N/A N/A N/A N/A N/A $1.54 N/A N/A $1.79 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.56 $2.56 N/A 4400363 Pharmacy phenylephrine nasal 0.25% Sol 15 mL [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4400160 Pharmacy phenylephrine Nasal 0.5% Spry [BCH] 250 $7.60 $- $1.98 $- $- $6.08 $- N/A $1.98 N/A N/A $2.87 N/A N/A $4.56 N/A N/A $3.80 N/A N/A N/A N/A N/A $5.17 N/A N/A $4.71 N/A N/A $3.12 N/A N/A $5.32 N/A N/A $6.08 N/A N/A $4.18 N/A N/A $5.32 N/A N/A $2.55 N/A N/A N/A N/A N/A $4.56 N/A N/A $2.66 N/A N/A $4.94 N/A N/A N/A N/A N/A $4.56 N/A N/A $5.32 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $7.60 $7.60 N/A 4407778 Pharmacy OLANZapine 2.5 mg Tab [BCH] 250 $20.21 $- $5.26 $- $- $16.17 $- N/A $5.26 N/A N/A $7.64 N/A N/A $12.13 N/A N/A $10.11 N/A N/A N/A N/A N/A $13.74 N/A N/A $12.53 N/A N/A $8.29 N/A N/A $14.15 N/A N/A $16.17 N/A N/A $11.12 N/A N/A $14.15 N/A N/A $6.77 N/A N/A N/A N/A N/A $12.13 N/A N/A $7.07 N/A N/A $13.14 N/A N/A N/A N/A N/A $12.13 N/A N/A $14.15 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.21 $20.21 N/A 4400974 Pharmacy OLANZapine 10 mg Tab [BCH] 250 $35.94 $- $9.34 $- $- $28.75 $- N/A $9.34 N/A N/A $13.58 N/A N/A $21.56 N/A N/A $17.97 N/A N/A N/A N/A N/A $24.44 N/A N/A $22.28 N/A N/A $14.73 N/A N/A $25.16 N/A N/A $28.75 N/A N/A $19.77 N/A N/A $25.16 N/A N/A $12.04 N/A N/A N/A N/A N/A $21.56 N/A N/A $12.58 N/A N/A $23.36 N/A N/A N/A N/A N/A $21.56 N/A N/A $25.16 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $35.94 $35.94 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406062 Pharmacy fluconazole 200 mg/100 mL-0.9% Sol [BCH] J1450 636 $75.00 $- $16.11 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $16.11 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4400058 Pharmacy polyethylene glycol 3350 - Pow [BCH] 250 $5.57 $- $1.45 $- $- $4.45 $- N/A $1.45 N/A N/A $2.10 N/A N/A $3.34 N/A N/A $2.78 N/A N/A N/A N/A N/A $3.78 N/A N/A $3.45 N/A N/A $2.28 N/A N/A $3.90 N/A N/A $4.45 N/A N/A $3.06 N/A N/A $3.90 N/A N/A $1.86 N/A N/A N/A N/A N/A $3.34 N/A N/A $1.95 N/A N/A $3.62 N/A N/A N/A N/A N/A $3.34 N/A N/A $3.90 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.57 $5.57 N/A 4400845 Pharmacy desmopressin 4 mcg/mL Sol [BCH] J2597 636 $76.20 $- $11.06 $- $- $60.96 $- N/A $19.81 N/A N/A Not Reimbursed N/A N/A $45.72 N/A N/A $38.10 N/A N/A N/A N/A N/A $51.81 N/A N/A $47.24 N/A N/A $31.24 N/A N/A $53.34 N/A N/A $60.96 N/A N/A $41.91 N/A N/A $53.34 N/A N/A $25.53 N/A N/A N/A N/A N/A $45.72 N/A N/A $26.67 N/A N/A $49.53 N/A N/A $11.06 N/A N/A $45.72 N/A N/A $53.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $76.20 $76.20 N/A 4406069 Pharmacy metFORMIN 500 mg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4405681 Pharmacy metFORMIN 850 mg Tab [BCH] 250 $2.39 $- $0.62 $- $- $1.92 $- N/A $0.62 N/A N/A $0.90 N/A N/A $1.44 N/A N/A $1.20 N/A N/A N/A N/A N/A $1.63 N/A N/A $1.48 N/A N/A $0.98 N/A N/A $1.68 N/A N/A $1.92 N/A N/A $1.32 N/A N/A $1.68 N/A N/A $0.80 N/A N/A N/A N/A N/A $1.44 N/A N/A $0.84 N/A N/A $1.56 N/A N/A N/A N/A N/A $1.44 N/A N/A $1.68 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.39 $2.39 N/A 4400986 Pharmacy Metformin ER 500 mg Tab-ER [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400870 Pharmacy dexamethasone 10 mg/mL preservative-free Sol J1100 636 $12.58 $- $0.12 $- $- $10.06 $- N/A $3.27 N/A N/A Not Reimbursed N/A N/A $7.55 N/A N/A $6.29 N/A N/A N/A N/A N/A $8.55 N/A N/A $7.80 N/A N/A $5.16 N/A N/A $8.80 N/A N/A $10.06 N/A N/A $6.92 N/A N/A $8.80 N/A N/A $4.21 N/A N/A N/A N/A N/A $7.55 N/A N/A $4.40 N/A N/A $8.17 N/A N/A $0.12 N/A N/A $7.55 N/A N/A $8.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.58 $12.58 N/A 4407673 Pharmacy methocarbamol 100 mg/mL Sol [BCH] J2800 636 $69.25 $- $6.28 $- $- $55.40 $- N/A $18.01 N/A N/A Not Reimbursed N/A N/A $41.55 N/A N/A $34.63 N/A N/A N/A N/A N/A $47.09 N/A N/A $42.94 N/A N/A $28.39 N/A N/A $48.48 N/A N/A $55.40 N/A N/A $38.09 N/A N/A $48.48 N/A N/A $23.20 N/A N/A N/A N/A N/A $41.55 N/A N/A $24.24 N/A N/A $45.01 N/A N/A $6.28 N/A N/A $41.55 N/A N/A $48.48 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $69.25 $69.25 N/A 4403804 Pharmacy tobramycin ophthalmic 0.3% Sol [BCH] 250 $12.50 $- $3.25 $- $- $10.00 $- N/A $3.25 N/A N/A $4.73 N/A N/A $7.50 N/A N/A $6.25 N/A N/A N/A N/A N/A $8.50 N/A N/A $7.75 N/A N/A $5.13 N/A N/A $8.75 N/A N/A $10.00 N/A N/A $6.88 N/A N/A $8.75 N/A N/A $4.19 N/A N/A N/A N/A N/A $7.50 N/A N/A $4.38 N/A N/A $8.13 N/A N/A N/A N/A N/A $7.50 N/A N/A $8.75 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.50 $12.50 N/A 4409501 Pharmacy brimonidine ophthalmic 0.2% Sol[BCH] 250 $25.00 $- $6.50 $- $- $20.00 $- N/A $6.50 N/A N/A $9.45 N/A N/A $15.00 N/A N/A $12.50 N/A N/A N/A N/A N/A $17.00 N/A N/A $15.50 N/A N/A $10.25 N/A N/A $17.50 N/A N/A $20.00 N/A N/A $13.75 N/A N/A $17.50 N/A N/A $8.38 N/A N/A N/A N/A N/A $15.00 N/A N/A $8.75 N/A N/A $16.25 N/A N/A N/A N/A N/A $15.00 N/A N/A $17.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.00 $25.00 N/A 4401913 Pharmacy eptifibatide 2 mg/mL Sol J1327 636 $240.00 $- $62.40 $- $- $192.00 $- N/A $62.40 N/A N/A Not Reimbursed N/A N/A $144.00 N/A N/A $120.00 N/A N/A N/A N/A N/A $163.20 N/A N/A $148.80 N/A N/A $98.40 N/A N/A $168.00 N/A N/A $192.00 N/A N/A $132.00 N/A N/A $168.00 N/A N/A $80.40 N/A N/A N/A N/A N/A $144.00 N/A N/A $84.00 N/A N/A $156.00 N/A N/A N/A N/A N/A $144.00 N/A N/A $168.00 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $240.00 $240.00 N/A 4409537 Pharmacy galantamine 4 mg Tab [BCH] 250 $6.37 $- $1.66 $- $- $5.09 $- N/A $1.66 N/A N/A $2.41 N/A N/A $3.82 N/A N/A $3.18 N/A N/A N/A N/A N/A $4.33 N/A N/A $3.95 N/A N/A $2.61 N/A N/A $4.46 N/A N/A $5.09 N/A N/A $3.50 N/A N/A $4.46 N/A N/A $2.13 N/A N/A N/A N/A N/A $3.82 N/A N/A $2.23 N/A N/A $4.14 N/A N/A N/A N/A N/A $3.82 N/A N/A $4.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $6.37 $6.37 N/A 4400709 Pharmacy buPROPion 150 mg/24 hours Tab [BCH] 250 $8.62 $- $2.24 $- $- $6.89 $- N/A $2.24 N/A N/A $3.26 N/A N/A $5.17 N/A N/A $4.31 N/A N/A N/A N/A N/A $5.86 N/A N/A $5.34 N/A N/A $3.53 N/A N/A $6.03 N/A N/A $6.89 N/A N/A $4.74 N/A N/A $6.03 N/A N/A $2.89 N/A N/A N/A N/A N/A $5.17 N/A N/A $3.02 N/A N/A $5.60 N/A N/A N/A N/A N/A $5.17 N/A N/A $6.03 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.62 $8.62 N/A 4400967 Pharmacy "influenza virus vaccine, inactivated mdck cell derived quadrivalent Sus [LTC]" 90756 636 $- $- $- $- $- $- $- N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A 4405438 Pharmacy bacitracin 50000 units Pow [BCH] 636 $28.00 $- $7.28 $- $- $22.40 $- N/A $7.28 N/A N/A $10.58 N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A N/A N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4406062 Pharmacy fluconazole 200 mg/100 mL-0.9% Sol [BCH] J1450 636 $75.00 $- $16.11 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $16.11 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4406062 Pharmacy fluconazole 200 mg/100 mL-0.9% Sol [BCH} J1450 636 $75.00 $- $16.11 $- $- $60.00 $- N/A $19.50 N/A N/A Not Reimbursed N/A N/A $45.00 N/A N/A $37.50 N/A N/A N/A N/A N/A $51.00 N/A N/A $46.50 N/A N/A $30.75 N/A N/A $52.50 N/A N/A $60.00 N/A N/A $41.25 N/A N/A $52.50 N/A N/A $25.13 N/A N/A N/A N/A N/A $45.00 N/A N/A $26.25 N/A N/A $48.75 N/A N/A $16.11 N/A N/A $45.00 N/A N/A $52.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $75.00 $75.00 N/A 4408305 Pharmacy nicotine 21 mg/24 hr Fil 250 $3.78 $- $0.98 $- $- $3.03 $- N/A $0.98 N/A N/A $1.43 N/A N/A $2.27 N/A N/A $1.89 N/A N/A N/A N/A N/A $2.57 N/A N/A $2.35 N/A N/A $1.55 N/A N/A $2.65 N/A N/A $3.03 N/A N/A $2.08 N/A N/A $2.65 N/A N/A $1.27 N/A N/A N/A N/A N/A $2.27 N/A N/A $1.32 N/A N/A $2.46 N/A N/A N/A N/A N/A $2.27 N/A N/A $2.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.78 $3.78 N/A 4402534 Pharmacy docusate sodium 100 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407083 Pharmacy senna 8.6 mg tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400929 Pharmacy loperamide 2 mg Cap 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407927 Pharmacy cyproheptadine 4 mg Tab [BCH] 250 $2.13 $- $0.55 $- $- $1.71 $- N/A $0.55 N/A N/A $0.81 N/A N/A $1.28 N/A N/A $1.07 N/A N/A N/A N/A N/A $1.45 N/A N/A $1.32 N/A N/A $0.88 N/A N/A $1.49 N/A N/A $1.71 N/A N/A $1.17 N/A N/A $1.49 N/A N/A $0.72 N/A N/A N/A N/A N/A $1.28 N/A N/A $0.75 N/A N/A $1.39 N/A N/A N/A N/A N/A $1.28 N/A N/A $1.49 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.13 $2.13 N/A 4408234 Pharmacy doxycycline monohydrate 100 mg Tab [BCH] 250 $9.84 $- $2.56 $- $- $7.87 $- N/A $2.56 N/A N/A $3.72 N/A N/A $5.90 N/A N/A $4.92 N/A N/A N/A N/A N/A $6.69 N/A N/A $6.10 N/A N/A $4.03 N/A N/A $6.89 N/A N/A $7.87 N/A N/A $5.41 N/A N/A $6.89 N/A N/A $3.30 N/A N/A N/A N/A N/A $5.90 N/A N/A $3.44 N/A N/A $6.40 N/A N/A N/A N/A N/A $5.90 N/A N/A $6.89 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $9.84 $9.84 N/A 4409392 Pharmacy succinylcholine 20 mg/mL Sol J0330 636 $47.95 $- $12.47 $- $- $38.36 $- N/A $12.47 N/A N/A Not Reimbursed N/A N/A $28.77 N/A N/A $23.98 N/A N/A N/A N/A N/A $32.61 N/A N/A $29.73 N/A N/A $19.66 N/A N/A $33.57 N/A N/A $38.36 N/A N/A $26.37 N/A N/A $33.57 N/A N/A $16.06 N/A N/A N/A N/A N/A $28.77 N/A N/A $16.78 N/A N/A $31.17 N/A N/A N/A N/A N/A $28.77 N/A N/A $33.57 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $47.95 $47.95 N/A 4401515 Pharmacy azithromycin 500 mg Pow J0456 636 $28.00 $- $3.42 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.42 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4401515 Pharmacy azithromycin 500 mg Pow [BCH] J0456 636 $28.00 $- $3.42 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $3.42 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4401276 Pharmacy levothyroxine 100 mcg (0.1 mg) Pow 636 $226.80 $- $58.97 $- $- $181.44 $- N/A $58.97 N/A N/A $85.73 N/A N/A $136.08 N/A N/A $113.40 N/A N/A N/A N/A N/A $154.22 N/A N/A $140.62 N/A N/A $92.99 N/A N/A $158.76 N/A N/A $181.44 N/A N/A $124.74 N/A N/A $158.76 N/A N/A $75.98 N/A N/A N/A N/A N/A $136.08 N/A N/A $79.38 N/A N/A $147.42 N/A N/A N/A N/A N/A $136.08 N/A N/A $158.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $226.80 $226.80 N/A 4403797 Pharmacy prazosin 1 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400953 Pharmacy trihexyphenidyl 5 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409748 Pharmacy trihexyphenidyl 2 mg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4409139 Pharmacy enoxaparin 40 mg/0.4 mL Sol J1650 636 $18.48 $- $0.69 $- $- $14.78 $- N/A $4.80 N/A N/A Not Reimbursed N/A N/A $11.09 N/A N/A $9.24 N/A N/A N/A N/A N/A $12.57 N/A N/A $11.46 N/A N/A $7.58 N/A N/A $12.94 N/A N/A $14.78 N/A N/A $10.16 N/A N/A $12.94 N/A N/A $6.19 N/A N/A N/A N/A N/A $11.09 N/A N/A $6.47 N/A N/A $12.01 N/A N/A $0.69 N/A N/A $11.09 N/A N/A $12.94 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $18.48 $18.48 N/A 4400579 Pharmacy lactobacillus acidophilus and bulgaricus 1 MM CELL Tab-Chew [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401001 Pharmacy oseltamivir 30 mg Cap[BCH] 250 $28.36 $- $7.37 $- $- $22.69 $- N/A $7.37 N/A N/A $10.72 N/A N/A $17.02 N/A N/A $14.18 N/A N/A N/A N/A N/A $19.28 N/A N/A $17.58 N/A N/A $11.63 N/A N/A $19.85 N/A N/A $22.69 N/A N/A $15.60 N/A N/A $19.85 N/A N/A $9.50 N/A N/A N/A N/A N/A $17.02 N/A N/A $9.93 N/A N/A $18.43 N/A N/A N/A N/A N/A $17.02 N/A N/A $19.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.36 $28.36 N/A 4409479 Pharmacy oseltamivir 75 mg Cap[BCH] 250 $30.91 $- $8.04 $- $- $24.73 $- N/A $8.04 N/A N/A $11.69 N/A N/A $18.55 N/A N/A $15.46 N/A N/A N/A N/A N/A $21.02 N/A N/A $19.17 N/A N/A $12.67 N/A N/A $21.64 N/A N/A $24.73 N/A N/A $17.00 N/A N/A $21.64 N/A N/A $10.36 N/A N/A N/A N/A N/A $18.55 N/A N/A $10.82 N/A N/A $20.09 N/A N/A N/A N/A N/A $18.55 N/A N/A $21.64 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $30.91 $30.91 N/A 4402013 Pharmacy dicyclomine 10 mg/mL Sol [BCH] J0500 636 $59.04 $- $15.35 $- $- $47.23 $- N/A $15.35 N/A N/A Not Reimbursed N/A N/A $35.42 N/A N/A $29.52 N/A N/A N/A N/A N/A $40.15 N/A N/A $36.60 N/A N/A $24.21 N/A N/A $41.33 N/A N/A $47.23 N/A N/A $32.47 N/A N/A $41.33 N/A N/A $19.78 N/A N/A N/A N/A N/A $35.42 N/A N/A $20.66 N/A N/A $38.38 N/A N/A $40.65 N/A N/A $35.42 N/A N/A $41.33 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $59.04 $59.04 N/A 4403804 Pharmacy tobramycin ophthalmic 0.3% Sol [BCH] 250 $32.06 $- $8.34 $- $- $25.65 $- N/A $8.34 N/A N/A $12.12 N/A N/A $19.24 N/A N/A $16.03 N/A N/A N/A N/A N/A $21.80 N/A N/A $19.88 N/A N/A $13.14 N/A N/A $22.44 N/A N/A $25.65 N/A N/A $17.63 N/A N/A $22.44 N/A N/A $10.74 N/A N/A N/A N/A N/A $19.24 N/A N/A $11.22 N/A N/A $20.84 N/A N/A N/A N/A N/A $19.24 N/A N/A $22.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $32.06 $32.06 N/A 4400165 Pharmacy diphenhydrAMINE 50 mg/mL Sol J1200 636 $20.34 $- $0.72 $- $- $16.27 $- N/A $5.29 N/A N/A Not Reimbursed N/A N/A $12.20 N/A N/A $10.17 N/A N/A N/A N/A N/A $13.83 N/A N/A $12.61 N/A N/A $8.34 N/A N/A $14.24 N/A N/A $16.27 N/A N/A $11.19 N/A N/A $14.24 N/A N/A $6.81 N/A N/A N/A N/A N/A $12.20 N/A N/A $7.12 N/A N/A $13.22 N/A N/A $0.72 N/A N/A $12.20 N/A N/A $14.24 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.34 $20.34 N/A 4405874 Pharmacy ketorolac 30 mg/mL Sol [BCH] J1885 636 $12.00 $- $0.58 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.58 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408610 Pharmacy vancomycin 500 mg Pow [BCH] J3370 636 $28.00 $- $2.77 $- $- $22.40 $- N/A $7.28 N/A N/A Not Reimbursed N/A N/A $16.80 N/A N/A $14.00 N/A N/A N/A N/A N/A $19.04 N/A N/A $17.36 N/A N/A $11.48 N/A N/A $19.60 N/A N/A $22.40 N/A N/A $15.40 N/A N/A $19.60 N/A N/A $9.38 N/A N/A N/A N/A N/A $16.80 N/A N/A $9.80 N/A N/A $18.20 N/A N/A $2.77 N/A N/A $16.80 N/A N/A $19.60 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $28.00 $28.00 N/A 4400496 Pharmacy permethrin topical 0.5% Spr [BCH] 250 $11.83 $- $3.08 $- $- $9.47 $- N/A $3.08 N/A N/A $4.47 N/A N/A $7.10 N/A N/A $5.92 N/A N/A N/A N/A N/A $8.05 N/A N/A $7.34 N/A N/A $4.85 N/A N/A $8.28 N/A N/A $9.47 N/A N/A $6.51 N/A N/A $8.28 N/A N/A $3.96 N/A N/A N/A N/A N/A $7.10 N/A N/A $4.14 N/A N/A $7.69 N/A N/A N/A N/A N/A $7.10 N/A N/A $8.28 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $11.83 $11.83 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4402365 Pharmacy ascorbic acid 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407525 Pharmacy phenazopyridine 100 mg Tab [BCH] 250 $4.80 $- $1.25 $- $- $3.84 $- N/A $1.25 N/A N/A $1.81 N/A N/A $2.88 N/A N/A $2.40 N/A N/A N/A N/A N/A $3.26 N/A N/A $2.98 N/A N/A $1.97 N/A N/A $3.36 N/A N/A $3.84 N/A N/A $2.64 N/A N/A $3.36 N/A N/A $1.61 N/A N/A N/A N/A N/A $2.88 N/A N/A $1.68 N/A N/A $3.12 N/A N/A N/A N/A N/A $2.88 N/A N/A $3.36 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.80 $4.80 N/A 4400035 Pharmacy atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg/5 mL Eli [BCH] 250 $65.09 $- $16.92 $- $- $52.07 $- N/A $16.92 N/A N/A $24.61 N/A N/A $39.06 N/A N/A $32.55 N/A N/A N/A N/A N/A $44.26 N/A N/A $40.36 N/A N/A $26.69 N/A N/A $45.56 N/A N/A $52.07 N/A N/A $35.80 N/A N/A $45.56 N/A N/A $21.81 N/A N/A N/A N/A N/A $39.06 N/A N/A $22.78 N/A N/A $42.31 N/A N/A N/A N/A N/A $39.06 N/A N/A $45.56 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $65.09 $65.09 N/A 4400035 Pharmacy atropine/hyoscyamine/PB/scopolamine 0.0194 mg-0.1037 mg-16.2 mg-0.0065 mg/5 mL Eli [BCH] 250 $64.95 $- $16.89 $- $- $51.96 $- N/A $16.89 N/A N/A $24.55 N/A N/A $38.97 N/A N/A $32.48 N/A N/A N/A N/A N/A $44.17 N/A N/A $40.27 N/A N/A $26.63 N/A N/A $45.47 N/A N/A $51.96 N/A N/A $35.73 N/A N/A $45.47 N/A N/A $21.76 N/A N/A N/A N/A N/A $38.97 N/A N/A $22.73 N/A N/A $42.22 N/A N/A N/A N/A N/A $38.97 N/A N/A $45.47 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $64.95 $64.95 N/A 4402084 Pharmacy verapamil 180 mg/12 hours Tab [BCH] 250 $2.88 $- $0.75 $- $- $2.30 $- N/A $0.75 N/A N/A $1.09 N/A N/A $1.73 N/A N/A $1.44 N/A N/A N/A N/A N/A $1.96 N/A N/A $1.79 N/A N/A $1.18 N/A N/A $2.02 N/A N/A $2.30 N/A N/A $1.58 N/A N/A $2.02 N/A N/A $0.96 N/A N/A N/A N/A N/A $1.73 N/A N/A $1.01 N/A N/A $1.87 N/A N/A N/A N/A N/A $1.73 N/A N/A $2.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.88 $2.88 N/A 4400682 Pharmacy zinc oxide topical 20% Oin [BCH] 250 $27.72 $- $7.21 $- $- $22.18 $- N/A $7.21 N/A N/A $10.48 N/A N/A $16.63 N/A N/A $13.86 N/A N/A N/A N/A N/A $18.85 N/A N/A $17.19 N/A N/A $11.36 N/A N/A $19.40 N/A N/A $22.18 N/A N/A $15.25 N/A N/A $19.40 N/A N/A $9.29 N/A N/A N/A N/A N/A $16.63 N/A N/A $9.70 N/A N/A $18.02 N/A N/A N/A N/A N/A $16.63 N/A N/A $19.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $27.72 $27.72 N/A 4404530 Pharmacy ePHEDrine 50 mg/mL Sol [BCH] 636 $95.50 $- $24.83 $- $- $76.40 $- N/A $24.83 N/A N/A $36.10 N/A N/A $57.30 N/A N/A $47.75 N/A N/A N/A N/A N/A $64.94 N/A N/A $59.21 N/A N/A $39.15 N/A N/A $66.85 N/A N/A $76.40 N/A N/A $52.52 N/A N/A $66.85 N/A N/A $31.99 N/A N/A N/A N/A N/A $57.30 N/A N/A $33.42 N/A N/A $62.07 N/A N/A N/A N/A N/A $57.30 N/A N/A $66.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $95.50 $95.50 N/A 4407467 Pharmacy neostigmine 1 mg/mL Soln [BCH] J2710 636 $34.11 $- $8.87 $- $- $27.28 $- N/A $8.87 N/A N/A Not Reimbursed N/A N/A $20.46 N/A N/A $17.05 N/A N/A N/A N/A N/A $23.19 N/A N/A $21.15 N/A N/A $13.98 N/A N/A $23.87 N/A N/A $27.28 N/A N/A $18.76 N/A N/A $23.87 N/A N/A $11.43 N/A N/A N/A N/A N/A $20.46 N/A N/A $11.94 N/A N/A $22.17 N/A N/A N/A N/A N/A $20.46 N/A N/A $23.87 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $34.11 $34.11 N/A 4400165 Pharmacy diphenhydrAMINE 50 mg/mL Sol [BCH] J1200 636 $12.00 $- $0.72 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.72 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4400870 Pharmacy dexamethasone 10 mg/mL preservative-free Sol [BCH] J1100 636 $13.87 $- $0.12 $- $- $11.10 $- N/A $3.61 N/A N/A Not Reimbursed N/A N/A $8.32 N/A N/A $6.94 N/A N/A N/A N/A N/A $9.43 N/A N/A $8.60 N/A N/A $5.69 N/A N/A $9.71 N/A N/A $11.10 N/A N/A $7.63 N/A N/A $9.71 N/A N/A $4.65 N/A N/A N/A N/A N/A $8.32 N/A N/A $4.86 N/A N/A $9.02 N/A N/A $0.12 N/A N/A $8.32 N/A N/A $9.71 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $13.87 $13.87 N/A 4404944 Pharmacy haloperidol 5 mg/mL Sol [BCH] J1630 636 $12.00 $- $0.99 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.99 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4408743 Pharmacy albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol [BCH] J7620 250 $5.00 $- $0.13 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.13 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4408743 Pharmacy albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Sol[BCH] J7620 250 $5.00 $- $0.13 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.13 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4409873 Pharmacy levalbuterol 0.63 mg/3 mL Sol [BCH] J7614 636 $5.00 $- $0.06 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.06 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4401954 Pharmacy levalbuterol 1.25 mg/3 mL Sol [BCH] J7614 636 $5.00 $- $0.06 $- $- $4.00 $- N/A $1.30 N/A N/A Not Reimbursed N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A $0.06 N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400557 Pharmacy sertraline 25 mg Tab 250 $5.50 $- $1.43 $- $- $4.40 $- N/A $1.43 N/A N/A $2.08 N/A N/A $3.30 N/A N/A $2.75 N/A N/A N/A N/A N/A $3.74 N/A N/A $3.41 N/A N/A $2.26 N/A N/A $3.85 N/A N/A $4.40 N/A N/A $3.03 N/A N/A $3.85 N/A N/A $1.84 N/A N/A N/A N/A N/A $3.30 N/A N/A $1.93 N/A N/A $3.58 N/A N/A N/A N/A N/A $3.30 N/A N/A $3.85 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.50 $5.50 N/A 4401144 Pharmacy amLODIPine 10 mg Tab [BCH] 250 $4.77 $- $1.24 $- $- $3.82 $- N/A $1.24 N/A N/A $1.80 N/A N/A $2.86 N/A N/A $2.39 N/A N/A N/A N/A N/A $3.25 N/A N/A $2.96 N/A N/A $1.96 N/A N/A $3.34 N/A N/A $3.82 N/A N/A $2.62 N/A N/A $3.34 N/A N/A $1.60 N/A N/A N/A N/A N/A $2.86 N/A N/A $1.67 N/A N/A $3.10 N/A N/A N/A N/A N/A $2.86 N/A N/A $3.34 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $4.77 $4.77 N/A 4409738 Pharmacy escitalopram 10 mg Tab 250 $8.60 $- $2.24 $- $- $6.88 $- N/A $2.24 N/A N/A $3.25 N/A N/A $5.16 N/A N/A $4.30 N/A N/A N/A N/A N/A $5.85 N/A N/A $5.33 N/A N/A $3.53 N/A N/A $6.02 N/A N/A $6.88 N/A N/A $4.73 N/A N/A $6.02 N/A N/A $2.88 N/A N/A N/A N/A N/A $5.16 N/A N/A $3.01 N/A N/A $5.59 N/A N/A N/A N/A N/A $5.16 N/A N/A $6.02 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $8.60 $8.60 N/A 4400434 Pharmacy lidocaine Top 2% Gel w/Appl [BCH] 250 $15.38 $- $4.00 $- $- $12.31 $- N/A $4.00 N/A N/A $5.82 N/A N/A $9.23 N/A N/A $7.69 N/A N/A N/A N/A N/A $10.46 N/A N/A $9.54 N/A N/A $6.31 N/A N/A $10.77 N/A N/A $12.31 N/A N/A $8.46 N/A N/A $10.77 N/A N/A $5.15 N/A N/A N/A N/A N/A $9.23 N/A N/A $5.38 N/A N/A $10.00 N/A N/A N/A N/A N/A $9.23 N/A N/A $10.77 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.38 $15.38 N/A 4400199 Pharmacy calcium chloride 100 mg/mL Inj Sol [BCH] 250 $21.60 $- $5.62 $- $- $17.28 $- N/A $5.62 N/A N/A $8.16 N/A N/A $12.96 N/A N/A $10.80 N/A N/A N/A N/A N/A $14.69 N/A N/A $13.39 N/A N/A $8.86 N/A N/A $15.12 N/A N/A $17.28 N/A N/A $11.88 N/A N/A $15.12 N/A N/A $7.24 N/A N/A N/A N/A N/A $12.96 N/A N/A $7.56 N/A N/A $14.04 N/A N/A N/A N/A N/A $12.96 N/A N/A $15.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.60 $21.60 N/A 4400511 Pharmacy EPINEPHrine 0.1 mg/mL Inj Sol [BCH] J0171 636 $14.40 $- $0.91 $- $- $11.52 $- N/A $3.74 N/A N/A Not Reimbursed N/A N/A $8.64 N/A N/A $7.20 N/A N/A N/A N/A N/A $9.79 N/A N/A $8.93 N/A N/A $5.90 N/A N/A $10.08 N/A N/A $11.52 N/A N/A $7.92 N/A N/A $10.08 N/A N/A $4.82 N/A N/A N/A N/A N/A $8.64 N/A N/A $5.04 N/A N/A $9.36 N/A N/A $0.91 N/A N/A $8.64 N/A N/A $10.08 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $14.40 $14.40 N/A 4401858 Pharmacy atropine 0.1 mg/mL Inj Sol [BCH] J0461 636 $21.60 $- $0.06 $- $- $17.28 $- N/A $5.62 N/A N/A Not Reimbursed N/A N/A $12.96 N/A N/A $10.80 N/A N/A N/A N/A N/A $14.69 N/A N/A $13.39 N/A N/A $8.86 N/A N/A $15.12 N/A N/A $17.28 N/A N/A $11.88 N/A N/A $15.12 N/A N/A $7.24 N/A N/A N/A N/A N/A $12.96 N/A N/A $7.56 N/A N/A $14.04 N/A N/A $0.06 N/A N/A $12.96 N/A N/A $15.12 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $21.60 $21.60 N/A 4401858 Pharmacy atropine 0.1 mg/mL Sol [BCH] J0461 636 $25.01 $- $0.06 $- $- $20.01 $- N/A $6.50 N/A N/A Not Reimbursed N/A N/A $15.00 N/A N/A $12.50 N/A N/A N/A N/A N/A $17.01 N/A N/A $15.50 N/A N/A $10.25 N/A N/A $17.51 N/A N/A $20.01 N/A N/A $13.75 N/A N/A $17.51 N/A N/A $8.38 N/A N/A N/A N/A N/A $15.00 N/A N/A $8.75 N/A N/A $16.26 N/A N/A $0.06 N/A N/A $15.00 N/A N/A $17.51 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $25.01 $25.01 N/A 4404932 Pharmacy sodium bicarbonate 8.4% IV Sol 50 mL [BCH] 258 $24.00 $- $6.24 $- $- $19.20 $- N/A $6.24 N/A N/A $9.07 N/A N/A $14.40 N/A N/A $12.00 N/A N/A N/A N/A N/A $16.32 N/A N/A $14.88 N/A N/A $9.84 N/A N/A $16.80 N/A N/A $19.20 N/A N/A $13.20 N/A N/A $16.80 N/A N/A $8.04 N/A N/A N/A N/A N/A $14.40 N/A N/A $8.40 N/A N/A $15.60 N/A N/A N/A N/A N/A $14.40 N/A N/A $16.80 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.00 $24.00 N/A 4405973 Pharmacy naloxone 1 mg/mL Inj Sol [BCH] J2310 636 $79.20 $- $14.22 $- $- $63.36 $- N/A $20.59 N/A N/A Not Reimbursed N/A N/A $47.52 N/A N/A $39.60 N/A N/A N/A N/A N/A $53.86 N/A N/A $49.10 N/A N/A $32.47 N/A N/A $55.44 N/A N/A $63.36 N/A N/A $43.56 N/A N/A $55.44 N/A N/A $26.53 N/A N/A N/A N/A N/A $47.52 N/A N/A $27.72 N/A N/A $51.48 N/A N/A $14.22 N/A N/A $47.52 N/A N/A $55.44 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $79.20 $79.20 N/A 4403227 Pharmacy lidocaine 2% preservative-free Sol [BCH] J2001 636 $15.00 $- $0.02 $- $- $12.00 $- N/A $3.90 N/A N/A Not Reimbursed N/A N/A $9.00 N/A N/A $7.50 N/A N/A N/A N/A N/A $10.20 N/A N/A $9.30 N/A N/A $6.15 N/A N/A $10.50 N/A N/A $12.00 N/A N/A $8.25 N/A N/A $10.50 N/A N/A $5.03 N/A N/A N/A N/A N/A $9.00 N/A N/A $5.25 N/A N/A $9.75 N/A N/A $0.02 N/A N/A $9.00 N/A N/A $10.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $15.00 $15.00 N/A 4407141 Pharmacy EPINEPHrine 1 mg/mL Inj Sol [BCH] J0171 636 $12.00 $- $0.91 $- $- $9.60 $- N/A $3.12 N/A N/A Not Reimbursed N/A N/A $7.20 N/A N/A $6.00 N/A N/A N/A N/A N/A $8.16 N/A N/A $7.44 N/A N/A $4.92 N/A N/A $8.40 N/A N/A $9.60 N/A N/A $6.60 N/A N/A $8.40 N/A N/A $4.02 N/A N/A N/A N/A N/A $7.20 N/A N/A $4.20 N/A N/A $7.80 N/A N/A $0.91 N/A N/A $7.20 N/A N/A $8.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $12.00 $12.00 N/A 4402518 Pharmacy benztropine 1 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4407681 Pharmacy methocarbamol 500 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406614 Pharmacy hyoscyamine 0.125 mg sublingual Tab [BCH] 250 $2.19 $- $0.57 $- $- $1.75 $- N/A $0.57 N/A N/A $0.83 N/A N/A $1.32 N/A N/A $1.10 N/A N/A N/A N/A N/A $1.49 N/A N/A $1.36 N/A N/A $0.90 N/A N/A $1.53 N/A N/A $1.75 N/A N/A $1.21 N/A N/A $1.53 N/A N/A $0.73 N/A N/A N/A N/A N/A $1.32 N/A N/A $0.77 N/A N/A $1.43 N/A N/A N/A N/A N/A $1.32 N/A N/A $1.53 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.19 $2.19 N/A 4400731 Pharmacy calcium-vitamin D 600 mg-10 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4406725 Pharmacy thiamine 100 mg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400105 Pharmacy cyanocobalamin 1000 mcg Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400208 Pharmacy cholecalciferol 10 mcg Tab[BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4404172 Pharmacy carbamide peroxide otic 6.5% Sol [BCH] 250 $5.00 $- $1.30 $- $- $4.00 $- N/A $1.30 N/A N/A $1.89 N/A N/A $3.00 N/A N/A $2.50 N/A N/A N/A N/A N/A $3.40 N/A N/A $3.10 N/A N/A $2.05 N/A N/A $3.50 N/A N/A $4.00 N/A N/A $2.75 N/A N/A $3.50 N/A N/A $1.68 N/A N/A N/A N/A N/A $3.00 N/A N/A $1.75 N/A N/A $3.25 N/A N/A N/A N/A N/A $3.00 N/A N/A $3.50 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $5.00 $5.00 N/A 4400677 Pharmacy cholecalciferol 1000 intl units Tab 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400043 Pharmacy multivitamin Multiple Vitamins Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4401451 Pharmacy zinc sulfate 220 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400731 Pharmacy calcium-vitamin D 600 mg-400 intl units Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400414 Pharmacy multivitamin with minerals Therapeutic Multiple Vitamins with Minerals Tab [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 7000006 Pharmacy vitamin E 90 mg Cap [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A 4400677 Pharmacy cholecalciferol 1000 intl units Tab 250 $3.94 $- $1.02 $- $- $3.15 $- N/A $1.02 N/A N/A $1.49 N/A N/A $2.36 N/A N/A $1.97 N/A N/A N/A N/A N/A $2.68 N/A N/A $2.44 N/A N/A $1.62 N/A N/A $2.76 N/A N/A $3.15 N/A N/A $2.17 N/A N/A $2.76 N/A N/A $1.32 N/A N/A N/A N/A N/A $2.36 N/A N/A $1.38 N/A N/A $2.56 N/A N/A N/A N/A N/A $2.36 N/A N/A $2.76 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $3.94 $3.94 N/A 4400013 Pharmacy niacin 500 MG ER Tab-ER [BCH] 250 $24.18 $- $6.29 $- $- $19.34 $- N/A $6.29 N/A N/A $9.14 N/A N/A $14.51 N/A N/A $12.09 N/A N/A N/A N/A N/A $16.44 N/A N/A $14.99 N/A N/A $9.91 N/A N/A $16.93 N/A N/A $19.34 N/A N/A $13.30 N/A N/A $16.93 N/A N/A $8.10 N/A N/A N/A N/A N/A $14.51 N/A N/A $8.46 N/A N/A $15.72 N/A N/A N/A N/A N/A $14.51 N/A N/A $16.93 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.18 $24.18 N/A 4400856 Pharmacy GI Cocktail 30 mL Liquid [BCH] 250 $24.23 $- $6.30 $- $- $19.38 $- N/A $6.30 N/A N/A $9.16 N/A N/A $14.54 N/A N/A $12.11 N/A N/A N/A N/A N/A $16.48 N/A N/A $15.02 N/A N/A $9.93 N/A N/A $16.96 N/A N/A $19.38 N/A N/A $13.33 N/A N/A $16.96 N/A N/A $8.12 N/A N/A N/A N/A N/A $14.54 N/A N/A $8.48 N/A N/A $15.75 N/A N/A N/A N/A N/A $14.54 N/A N/A $16.96 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $24.23 $24.23 N/A 4400153 Pharmacy Magic Mouthwash [BCH] 250 $20.66 $- $5.37 $- $- $16.53 $- N/A $5.37 N/A N/A $7.81 N/A N/A $12.40 N/A N/A $10.33 N/A N/A N/A N/A N/A $14.05 N/A N/A $12.81 N/A N/A $8.47 N/A N/A $14.46 N/A N/A $16.53 N/A N/A $11.37 N/A N/A $14.46 N/A N/A $6.92 N/A N/A N/A N/A N/A $12.40 N/A N/A $7.23 N/A N/A $13.43 N/A N/A N/A N/A N/A $12.40 N/A N/A $14.46 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $20.66 $20.66 N/A 4400024 Pharmacy non formulary med [BCH] 250 $2.00 $- $0.52 $- $- $1.60 $- N/A $0.52 N/A N/A $0.76 N/A N/A $1.20 N/A N/A $1.00 N/A N/A N/A N/A N/A $1.36 N/A N/A $1.24 N/A N/A $0.82 N/A N/A $1.40 N/A N/A $1.60 N/A N/A $1.10 N/A N/A $1.40 N/A N/A $0.67 N/A N/A N/A N/A N/A $1.20 N/A N/A $0.70 N/A N/A $1.30 N/A N/A N/A N/A N/A $1.20 N/A N/A $1.40 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $2.00 $2.00 N/A PREMIX Pharmacy PM amiodarone [BCH] 250 $- $- $- $- $- $- $- N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A $- N/A N/A $- N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A $- $- N/A