ABCDEF
1
 Charge # Description Rev Code CPT/HCPCS Charge Amt Effective
2
11000001MED/SURG GENERAL PVT 110J3475 22416.7402/21/22
3
11000002GENERAL PVT 11016482.901/01/19
4
11900001
OPEN TX TRIMALLEOLAR ANKLE FX WITH OR WITHOUT INTERNAL FIXATION
3602782246481.9308/05/20
5
11900002MICU ROOM 11918057.908/05/20
6
12000002MED/SURG GENERAL SEMI PVT 12017948.708/05/20
7
25000004AZITHROMYCIN 200MG/5ML 15ML OS 251G9498 65.9208/05/20
8
25000005BUMETANIDE 1MG 2508.5108/05/20
9
25000007IOPAMIDOL (ISOVUE M300) 61% 300MG 100ML 255Q9967 170.1608/05/20
10
25000009GENTAMICIN (GARAMYCIN) PEDI 20MG 2ML SDVIAL 636J1580 81.1108/05/20
11
25000010SYNVISC HYLAN G-F 20 2ML SYRINGE 63660.208/05/20
12
25000011ACETADOTE 20% INJECTION 25029.408/05/20
13
25000012GENTAMICIN 80MG 50ML IV 636J1580 60.208/05/20
14
25000013GENTAMICIN 80MG/ SOD.CHL. 0.9% 100ML PREMIX 251G9498 81.1108/05/20
15
25000014OMNIPAQUE-240MGI/ML 20ML BTL 251Q9966 279.308/05/20
16
25000015OMNIPAQUE-240MGI/ML 10ML BTL 251Q9966 279.308/05/20
17
25000016OMNIPAQUE-300MGI/ML 10ML BTL 251Q9967 279.308/05/20
18
25000017OMNIPAQUE-300MGI/ML 50ML BTL 251Q9967 287.708/05/20
19
25000018CHLORPROMAZINE 25MG/1ML AMPULE 251J3230 74.508/05/20
20
25000019CLEOCIN 900MG 50ML IV 25034.1808/05/20
21
25000020CLEOCIN 900MG 6ML SDVIAL 25011.0308/05/20
22
25000021CLEOCIN ADDV 900MG 6ML SDVIAL 25011.0308/05/20
23
25000023CLINDAMYCIN 300MG/2ML SDVIAL 251G9498 29.9308/05/20
24
25000024CLINDAMYCIN 600MG/4ML SDVIAL 251G9498 20.1608/05/20
25
25000025CLINDAMYCIN 900MG/6ML SDVIAL 251G9498 34.1808/05/20
26
25000026FAMOTIDINE 20MG/50ML IV 25014.4908/05/20
27
25000027SOLUMEDROL 1GM (8-125MG DOSES) MDVIAL 250128.6802/02/21
28
25000028SOLUMEDROL 500MG (4-125MG DOSES) MDVIAL 25064.3408/05/20
29
25000029ACETAMINOPHEN 1000MG/100ML VIAL 251J0131 61.9508/05/20
30
25000030DOPAMINE 200MG/5ML VIAL 251J1265 47.2508/05/20
31
25000031HYPERTONIC SALINE 3% 500ML IV FL 258J7131 14.4708/05/20
32
25000032ALBUTEROL 0.5% 2.5MG/0.5ML INH VIAL 251J7611 34.1308/05/20
33
25000033DEXAMETHASONE 1MG/1ML 30ML OS 251J8540 44.1808/05/20
34
25000034HYDROXYZINE 10MG/5ML ORAL SYRUP 250J8499 89.8408/05/20
35
25000035PHARMACY GENERAL 250008/05/20
36
25000036FOLIC ACID 5MG/ML-10ML INJECTION MDV 250J3490 155.6108/05/20
37
25000037ASPIRIN 325MG TABLET 2572001/01/19
38
25000038LABETALOL 20MG 4ML CPJT SYG 250J3490 8211/29/20
39
25000039VEKLURY 100MG SDVIAL 252J8499 2003/20/20
40
25000040LATUDA (LURASIDONE)60 MG TABLET 250225.3502/03/21
41
25000041SACUBITRIL + VALSARTAN(ENTRESTO)24/26 MG 25048.602/03/21
42
25000042CLARITIN (LORATADINE) 10 MG 2501.3402/04/21
43
25000044DRONABINOL 2.5 MG (MARINOL) 250Q0167 15.5502/18/21
44
25000045MELATONIN 3MG TABLET 257A9150 7.4805/01/21
45
25000046DILTIAZEM 50MG/10ML SDVIAL 251J3490 422.106/01/21
46
25000047BICILLIN C-R 1,200,000 UNIT/2ML SYRINGE 251J0558 348.2601/01/21
47
25000048RANOLAZINE 500MG 250J3490 210501/01/20
48
25000050FUROSEMIDE 40MG TABLET 251J8499 15.6201/01/20
49
25000051ELIQUIS 2.5MG TAB 25019.2601/01/20
50
25000052ELIQUIS 5MG TABLET 252J8499 19.2601/01/20
51
25000053AMINOPHYLLINE 250MG/10ML VIAL 251J0280 53.2101/01/20
52
25000055ATROPINE 0.4MG/1ML SDVIAL 251J0461 73.508/05/20
53
25000056GENTAMICIN 80MG/2ML SD VIAL 250J1580 3.8201/01/20
54
25000057HEPARIN IN NS 2000UN/1000ML IV FL 258J1644 19.3201/01/20
55
25000058MIDODRINE HCL 5MG TABLET 251J8499 31.3901/01/20
56
25000062GABAPENTIN 800MG TABLET 251J8499 114.9801/01/20
57
25000066COREG 6.25MG/CARVEDILOL 25022.6801/01/20
58
25000068ACTIDOSE W/SORBITOL 120ML 25048.4601/01/20
59
25000070ADENOSINE 12MG/4ML VIAL 250203.5801/01/20
60
25000071ADENOSINE 6MG/2ML VIAL 25056.5201/01/20
61
25000072ADMELOG 3ML VIAL 250142.8801/01/20
62
25000073ALBUTEROL SULFATE 0.083% 2.5MG/3ML VIAL 250J7613 17.0301/01/20
63
25000075ALLOPURINOL 100MG 25059.7601/01/20
64
25000077JARDIANCE 25MG TABLET 252J8499 1612.9101/01/20
65
25000079ISOPROTERENOL 1MG/5ML VIAL 251J7658 2038.8201/01/20
66
25000080BACITRACIN OINTMENT 28.4G 250A6250 6.3701/01/20
67
25000081LEVOTHYROXINE 100MCG TABLET 251J8499 145.6901/01/20
68
25000082METHIMAZOLE 10MG TAB 251J8499 187.6301/01/20
69
25000083HYDROXYCHLOROQUINE 200MG TAB 251J8499 339.5501/01/20
70
25000084IVERMECTIN 3MG TABLET 251J3490 225.1801/01/20
71
25000085MINOXIDIL 2.5MG TAB 251J3490 39.6701/01/20
72
25000086QUERCETIN 500MG CAPSULE 257A9150 32.7201/01/20
73
25000087CLOPIDOGREL 300MG TABLET 251J8499 398.201/01/20
74
25000088HEPARIN 10,000UNITS/10ML VIAL 251J3490 218.5201/01/20
75
25000089VISIPAQUE 320 MGI/ML 50ML 255Q9967 1194.6201/01/20
76
25000090ATORVASTATIN 40MG TABLET 25068.1501/01/20
77
25000091PAROXETINE 10MG TABLET 251J8499 62.7501/01/20
78
25000092MINOXIDIL 2.5MG TAB 250J3490 162.501/01/20
79
25000093MINOXIDIL 10MG TAB 250S0139 200.1201/01/20
80
25000094FLEET LAXATIVE 2503.3501/01/20
81
25000095LEVOTHYROXINE 137MCG TAB 251J8499 182.0801/01/20
82
25000096EMTRICITABINE/TENOFOVIR 200MG/300MG TABLET 250J3490 180.7201/01/20
83
25000097ACTIDOSE W/SORBITOL 50GRAMS/96GRAMS 240ML 250J3490 68.7201/01/20
84
25000098ZIPRASIDONE 80MG CAPSULE 251J3490 49.901/01/20
85
25000100GOLYTELY (PEG-3350) 4L ORAL SOLUTION 250J8499 46.4401/01/20
86
25000101ACETYLCYSTEINE 20% 200MG/ML 10ML INH. VIAL 250J7608 68.1801/01/20
87
25000102PAXLOVID TABLET 250008/01/22
88
25000103ACETAZOLAMIDE 250MG TAB 251J8499 868.9701/01/20
89
25000104AMPICILLIN 1GRAM VIAL 25047.8401/01/20
90
25000105ATENOLOL 25MG TABLET 251J8499 68.2901/01/20
91
25000106BACLOFEN 20MG TAB 250189.3901/01/20
92
25000107BARIUM SULFATE ORAL SUSPENSION 450ML BTL 250145.801/01/20
93
25000108BUPIVACAINE 0.25% 50ML MDVIAL 250J3490 151.0201/01/20
94
25000109CHOLECALCIFEROL 1000IU (250MCG)TAB 25012.4901/01/20
95
25000112EMTRICITABINE/TENOFOVIR 200MG/300MG TABLET 251J8499 180.7201/01/20
96
25000113ENTRESTO 24MG/26MG TABLET 252J8499 1964.0501/01/20
97
25000114FOLIC ACID 50MG/10ML MDVIAL 251J3490 70.0901/01/20
98
25000115LAMOTRIGINE 100MG TABLET 251J8499 32.401/01/20
99
25000116MAGNESIUM SULFATE 50% 1G/2ML SDVIAL 251J3490 104.6801/01/20
100
25000117MUPIROCIN 2% 1GRAM TUBE 25054.310/22/23