STANDARD HOSPITAL CHARGES - encompasshealth.com · assay of thyroid (t3 $ 55.26 assay of total...

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STANDARD HOSPITAL CHARGES Encompass Health Rehabilitation Hospital of Sunrise 4399 Nob Hill Road Sunrise, FL 33351 954.749.0300 encompasshealth.com/sunriserehab The following charges reflect the most common services offered by our Hospital. Patients may have additional charges, depending on services performed. Room and Care - Per Day Charges Rehab Room and Care $ 1,067.00 Rehab Room and Care Priv Medically Justified $ 1,113.00 Inpatient Physical Therapy Physical Therapy – Evaluation, 15 min $ 76.50 Physical Therapy – Individual Tx, 15 min $ 69.00 Physical Therapy – Group Tx, 15 min $ 49.50 Physical Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50 Inpatient Occupational Therapy Occupational Therapy – Evaluation, 15 min $ 72.00 Occupational Therapy – Individual Tx, 15 min $ 69.00 Occupational Therapy – Group Tx, 15 min $ 49.50 Occupational Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50 Inpatient Speech Therapy Speech Therapy – Evaluation, 15 min $ 76.50 Speech Therapy – Individual Tx, 15 min $ 64.50 Speech Therapy – Group Tx, 15 min $ 49.50 Speech Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50 X-Ray and Radiological ABD CMP INC DEC/ERCT $ 225.00 ABDMN SNGL AP VIEW $ 200.00 Abdominal Series $ 225.00 ANKLE 2 VIEWS $ 225.00 ANKLE 3 OR MORE VIEW $ 250.00 CHEST 1 VIEW $ 200.00 CHEST 2 VIEWS $ 225.00 Chest special, Lat a $ 250.00 CLAVICLE $ 225.00 CRVCL SPN MIN 2 VWS $ 225.00 CRVCL SPN MIN 4 VWS $ 350.00 ELBOW 2 VIEWS $ 225.00 ELBOW 3 OR MORE VIEW $ 250.00 Femur (2 views) $ 225.00 FINGER(S) $ 250.00 FOOT 2 VIEWS $ 225.00

Transcript of STANDARD HOSPITAL CHARGES - encompasshealth.com · assay of thyroid (t3 $ 55.26 assay of total...

STANDARD HOSPITAL CHARGES

Encompass Health Rehabilitation Hospital of Sunrise4399 Nob Hill RoadSunrise, FL 33351954.749.0300encompasshealth.com/sunriserehab

The following charges reflect the most common services offered by our Hospital. Patients may have additional charges, depending on services performed. Room and Care - Per Day ChargesRehab Room and Care $ 1,067.00 Rehab Room and Care Priv Medically Justified $ 1,113.00

Inpatient Physical TherapyPhysical Therapy – Evaluation, 15 min $ 76.50 Physical Therapy – Individual Tx, 15 min $ 69.00 Physical Therapy – Group Tx, 15 min $ 49.50 Physical Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50

Inpatient Occupational TherapyOccupational Therapy – Evaluation, 15 min $ 72.00 Occupational Therapy – Individual Tx, 15 min $ 69.00 Occupational Therapy – Group Tx, 15 min $ 49.50 Occupational Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50

Inpatient Speech TherapySpeech Therapy – Evaluation, 15 min $ 76.50 Speech Therapy – Individual Tx, 15 min $ 64.50 Speech Therapy – Group Tx, 15 min $ 49.50 Speech Therapy – Concurrent/CoTreat Tx, 15 min $ 64.50

X-Ray and RadiologicalABD CMP INC DEC/ERCT $ 225.00 ABDMN SNGL AP VIEW $ 200.00 Abdominal Series $ 225.00 ANKLE 2 VIEWS $ 225.00 ANKLE 3 OR MORE VIEW $ 250.00 CHEST 1 VIEW $ 200.00 CHEST 2 VIEWS $ 225.00 Chest special, Lat a $ 250.00 CLAVICLE $ 225.00 CRVCL SPN MIN 2 VWS $ 225.00 CRVCL SPN MIN 4 VWS $ 350.00 ELBOW 2 VIEWS $ 225.00 ELBOW 3 OR MORE VIEW $ 250.00 Femur (2 views) $ 225.00 FINGER(S) $ 250.00 FOOT 2 VIEWS $ 225.00

STANDARD HOSPITAL CHARGES

FOOT 3 OR MORE VIEWS $ 250.00 FOREARM 2 VIEWS $ 225.00 HAND 2 VIEWS $ 225.00 HAND 3 OR MORE VIEWS $ 250.00 HEEL 2 OR MORE VIEWS $ 225.00 Hip Bilateral $ 225.00 Hip Unilateral, min $ 225.00 HUMERUS 2 OR MORE VW $ 225.00 KNEE 1 OR 2 VIEWS $ 225.00 KNEE 3 VIEWS $ 250.00 LMBSCRL SPN 2-3 VWS $ 250.00 MANDIBLE, 4 VWS $ 275.00 PELVIS 1 OR 2 VIEWS $ 200.00 Ribs Bilateral, 3 VW $ 300.00 Ribs Unilateral (2 v $ 250.00 Sacro-iliac Jnts 3 o $ 250.00 SHLDR 2 OR MORE VWS $ 250.00 SINUSES 3 OR MORE VW $ 250.00 SKULL < 4 VIEWS $ 250.00 SWLLW FNCT W/RECORDI $ 650.00 TAILBONE 2 OR MORE V $ 250.00 THORAC SPN MIN 2 VWS $ 225.00 Thoraco-Lumbar Spine $ 250.00 TIBIA AND FIBULA 2 V $ 225.00 TOES 2 OR MORE VIEWS $ 250.00 WRIST 2 VIEWS $ 225.00 WRIST 3 OR MORE VWS $ 250.00

Other Ancillary24 HR HOLTER MONITOR $ 350.00 ABD LTD (LVR,GB,PNC,SPLN) $ 188.61 ABD/RETRO PRTNL DOPPLR $ 350.00 ABDOMINAL COMPLETE $ 238.95 ABO BLOOD TYPING $ 120.00 ANTIBODY SCREEN $ 120.00 ANTIGEN TEST - EACH ANTIGEN $ 130.00 ART DUP LWR EXT UNILAT $ 251.75 ART DUP UPPR EXT UNILAT $ 350.00 BLOOD TRANSFUSION 1 UNIT $ 1,758.51 BLOOD TRANSFUSION 2 UNITS $ 3,517.02 BLOOD TRANSFUSION 3 UNITS $ 5,275.53 BREAST SONOGRAM $ 350.00 CAROTID $ 350.00 CAROTID DOPPLER $ 160.00 CATH SHUNT FOR DIALYSIS $ 800.00 CHANGE G OR J TUBE $ 600.00 COLLECTION OF VENOUS BLOOD $ 15.00

STANDARD HOSPITAL CHARGES

DIALYSIS PROC W/SGL PHYS EV $ 650.00 DIRECT ANTIGLOBULIN TEST $ 99.00 DPLX EXTRM VEINS BILAT $ 358.92 DPPLR ART PRSSR MLTILVL $ 225.00 DPPLR LWR EXT ARTERIES $ 449.16 DPPLR UPPR EXT ARTERIES $ 350.00 DUPLEX AORTA LIMITED $ 251.17 ECHO COMPLETE $ 386.61 ECHO LIMITED $ 350.00 EEG INCLUDING AWAKE & ASLEEP $ 369.00 EMERGENCY ROOM CHARGE $ 1,367.04 GI ENDOSCOPY $ 1,250.00 IVC FILTER INSERTION $ 5,200.00 IVC/AORTA/ILIAC DOPPLER $ 350.00 LEUKOCYTE POOR BLOOD-EACH UNIT $ 60.00 LUMBAR FACET $ 1,650.00 MIDLINE INSERTION $ 750.00 NON-VAS EST COMPLETE $ 350.00 NON-VAS EST LIMITED $ 350.00 PARACENTESIS $ 600.00 PEG REMOVAL $ 1,200.00 PEG TUBE INSERTION $ 927.72 PERIPHERAL IV $ 312.50 PICC LINE INSERTION $ 750.00 PICC LINE REMOVAL $ 212.50 PLATELETS CONCENTRATE EACH UNI $ 124.00 PLVC SNGRM (TRANSVAGNL) $ 350.00 RBC ANTIBODY IDENTIFICATION $ 215.50 RBC EACH UNIT-TYPE A NEGATIVE $ 299.40 RBC EACH UNIT-TYPE A POSITIVE $ 299.40 RBC EACH UNIT-TYPE AB NEGATIVE $ 255.75 RBC EACH UNIT-TYPE AB POSITIVE $ 255.75 RBC EACH UNIT-TYPE B NEGATIVE $ 302.50 RBC EACH UNIT-TYPE B POSITIVE $ 302.50 RBC EACH UNIT-TYPE O NEGATIVE $ 311.85 RBC EACH UNIT-TYPE O POSITIVE $ 305.65 REPLACE J TUBE $ 500.00 RETROPERI ABD LTD SNGRM $ 87.09 RETROPERITIONEAL SONOGRAM $ 350.00 RF CERVICAL MBNB $ 2,000.00 RF CERVICL MBNB ADD LVL $ 250.00 SCREENING CROSSMATCH $ 30.00 SINGLE LEVEL ABI $ 350.00 TESTICULAR SONOGRAM $ 350.00 THYRD/PARATHYRD SNGRM $ 350.00 TRANSABDOMINAL SONOGRAM $ 350.00 TRANSFUSION BLOOD OR COMPONENT $ 187.50

STANDARD HOSPITAL CHARGES

TRANSFUSION REACTION WORK UP $ 258.75 TRIPLE LUMEN $ 937.50 TROUBLESHOOT $ 275.00 TYPE & SCREEN RH (D) $ 124.00 Ultrasound Chest $ 161.92 UNILAT VENOUS DOPPLER $ 350.00 UNILAT VENOUS DOPPLER $ 215.46 UNSUCCESSFUL LINE PLACEMENT $ 500.00 VENOUS DOPPLER STUDY $ 150.00 WOUND CARE SET - VAC DRESSING $ 120.00 WOUND CLINIC VISIT $ 160.75 WOUND VAC PER DAY $ 142.00

LaboratoryACUTE HEPATITIS PANE $ 169.68 ALANINE AMINO (ALT) $ 76.65 ALPHA-FETOPROTEIN SE $ 57.99 ANGIOTENSIN I ENZYME $ 105.33 ANTINUCLEAR ANTIBODI $ 54.00 ASSAY ALKALINE PHOSP $ 42.54 ASSAY CARBAMAZEPINE $ 78.69 ASSAY DIPROPYLACETIC $ 73.44 ASSAY OF ALDOLASE $ 47.22 ASSAY OF AMIKACIN $ 36.42 ASSAY OF AMMONIA $ 72.03 ASSAY OF AMYLASE $ 31.11 ASSAY OF BLOOD OSMOL $ 70.35 ASSAY OF BLOOD/URIC $ 22.44 ASSAY OF CALCIUM $ 43.40 ASSAY OF CALCIUM $ 112.62 ASSAY OF CK (CPK) $ 76.89 ASSAY OF COPPER $ 65.04 ASSAY OF CPK IN BLOO $ 76.89 ASSAY OF CREATINE $ 71.40 ASSAY OF CREATININE $ 50.25 ASSAY OF CRYOFIBRINO $ 24.18 ASSAY OF CYCLOSPORIN $ 62.61 ASSAY OF DIGOXIN $ 78.69 ASSAY OF FERRITIN $ 48.54 ASSAY OF FOLIC ACID $ 52.38 ASSAY OF GENTAMICIN $ 69.90 ASSAY OF GGT $ 34.65 ASSAY OF GLYCATED PR $ 31.20 ASSAY OF HAPTOGLOBIN $ 71.70 ASSAY OF HOMOCYSTINE $ 72.03 ASSAY OF IRON $ 23.07 ASSAY OF LIPASE $ 71.34

STANDARD HOSPITAL CHARGES

ASSAY OF LITHIUM $ 63.12 ASSAY OF MAGNESIUM $ 23.88 ASSAY OF MYOGLOBIN $ 27.00 ASSAY OF NATRIURETIC $ 120.96 ASSAY OF PARATHORMON $ 27.69 ASSAY OF PHENYTOIN F $ 49.86 ASSAY OF PHENYTOIN T $ 57.27 ASSAY OF PHOSPHORUS $ 33.84 ASSAY OF PREALBUMIN $ 51.96 ASSAY OF PROLACTIN $ 88.38 ASSAY OF PROTEIN SER $ 78.27 ASSAY OF PSA TOTAL $ 105.15 ASSAY OF SERUM POTAS $ 37.75 ASSAY OF SERUM SODIU $ 57.99 ASSAY OF TACROLIMUS $ 59.19 ASSAY OF THYROID (T3 $ 55.26 ASSAY OF TOTAL TESTO $ 95.01 ASSAY OF TOTAL THYRO $ 107.40 ASSAY OF TRANSFERRIN $ 24.18 ASSAY OF TROPONIN QU $ 72.33 ASSAY OF TROPONIN QU $ 34.11 ASSAY OF URINE CREAT $ 51.57 ASSAY OF URINE OSMOL $ 82.62 ASSAY OF URINE SODIU $ 35.12 ASSAY OF URINE/URIC $ 30.03 ASSAY OF VANCOMYCIN $ 68.97 ASSAY OF VITAMIN B-1 $ 107.22 ASSAY THYROID STIM H $ 59.85 ASSAY TRIIODOTHYRONI $ 53.52 AUTOMATED LEUKOCYTE $ 19.35 AUTOMATED PLATELET C $ 25.83 AUTOMATED RETICULOCY $ 15.33 BETA-2 GLYCOPROTEIN $ 24.18 BILIRUBIN DIRECT $ 39.26 BILIRUBIN TOTAL $ 73.11 BL SMEAR W/O DIFF WB $ 29.49 BLOOD CULTURE FOR BA $ 36.78 CARCINOEMBRYONIC ANT $ 70.59 CARDIOLIPIN ANTIBODY $ 55.98 CCP ANTIBODY $ 49.14 CHORIONIC GONADOTROP $ 49.59 CHROMOTOGRAPHY QUANT $ 78.69 CLOSTRIDIUM TOXIN A $ 42.75 CLOT FACTOR X STUART $ 96.90 COLUMN CHROMOTOGRAPH $ 51.78 COMPLEMENT ANTIGEN $ 45.78 COMPLEMENT TOTAL (CH $ 52.14

STANDARD HOSPITAL CHARGES

COMPLETE CBC W/AUTO $ 27.69 COMPREHEN METABOLIC $ 37.65 COOMBS TEST DIRECT $ 22.14 C-REACTIVE PROTEIN $ 32.88 CREATINE MB FRACTION $ 36.15 CREATININE CLEARANCE $ 23.97 CULTURE OTHR SPECIMN $ 41.64 DRUG SCREEN LAMOTRIG $ 62.61 DRUG SCREEN MULTI DR $ 52.14 DRUG SCRN LEVETIRACE $ 57.27 ELECTROLYTE PANEL $ 37.62 EXAM SYNOVIAL FLUID $ 25.53 FIBRIN DEGRADJ D-DIM $ 32.19 GLYCOSYLATED HEMOGLO $ 34.59 HEMATOCRIT $ 17.25 HEMOGLOBIN $ 12.69 HEMOGLOBIN ELECTROPH $ 80.07 HEP B SURFACE ANTIBO $ 52.32 HEPATIC FUNCTION PAN $ 38.55 HEPATITIS B SURFACE $ 61.86 HEPATITIS BE AG EIA $ 45.30 HEPATITIS C RNA DIR $ 146.61 HIV-1 QUANT&REVRSE T $ 85.08 IMMUNOASSAY TUMOR CA $ 83.31 IMMUNOASSAY TUMOR CA $ 85.38 IMMUNOFIX E-PHORESIS $ 52.05 IMMUNOGLOBULIN ASSAY $ 64.62 INFLUENZA VIRUS ANTI $ 53.70 IRON BINDING TEST $ 68.10 JAK2 GENE $ 378.00 LACTATE (LD) (LDH) E $ 110.64 LIPID PANEL $ 59.16 METABOLIC PANEL TOTA $ 30.18 MICROALBUMIN QUANTIT $ 23.25 MICROSOMAL ANTIBODY $ 112.59 MYCOBACTERIA CULTURE $ 38.73 NUCLEAR ANTIGEN ANTI $ 59.22 OCCULT BLOOD FECES $ 21.63 ORGANIC ACID SINGLE $ 70.35 OVA AND PARASITES SM $ 34.71 PLATELET ANTIBODIES $ 68.43 PROCALCITONIN (PCT) $ 96.39 PROTEIN E-PHORESIS S $ 24.18 PROTHROMBIN TIME $ 14.01 RBC SED RATE AUTOMAT $ 43.29 REAGENT STRIP/BLOOD $ 9.00 RENAL FUNCTION PANEL $ 46.23

STANDARD HOSPITAL CHARGES

RHEUMATOID FACTOR QU $ 46.53 RIA NONANTIBODY $ 40.98 STOOL CULTR AEROBIC $ 45.27 T CELLS TOTAL COUNT $ 112.59 THROMBOPLASTIN TIME $ 56.42 THYROGLOBULIN ANTIBO $ 55.74 TOTAL CORTISOL $ 95.16 TRANSFERASE (AST) (S $ 61.02 TREPONEMA PALLIDUM $ 61.92 URINALYSIS $ 13.47 URINALYSIS AUTO W/SC $ 11.31 URINE BACTERIA CULTU $ 28.77 URINE PREGNANCY TEST $ 15.45 VIT D 1 25-DIHYDROXY $ 137.13 VITAMIN B-12 $ 53.70 VITAMIN D 25 HYDROXY $ 108.12 WBC ANTIBODY IDENTIF $ 110.25

DialysisHemodialysis $ 750.00 Peritoneal Dialysis $ 750.00

Pulmonary/Respiratory Services and SuppliesSX CANIS / LINE $ 23.00 SUCTION CATH/GLOVE KIT $ 6.00 SUCTION TUBE REPLAC $ 9.00 SUCTION YANKAUER $ 11.00 TRACH MASK OR COLLAR $ 27.00 TRACH CR KT FOR NW TRCH $ 15.00 PULS-OX SPOT CK-CLIN MON-UNTIM $ 13.00 PULS-OX OXIMETER/HR-CLIN MONIT $ 28.00 ETCO2 MONITOR/HR-CLIN MONITOR $ 87.00 APNEA MONITOR-CLINICAL MONITOR $ 48.00 CPR-CLINICAL ER RESUSCITATION $ 439.00 VAPOTHERM THERAPY PER HR $ 54.00 VENT/HR-THERA WO MEDICATION $ 48.00 INC SPIROMETRY TX-THERA WO MED $ 66.00 CPT-CHEST PHYSIO/POST DRAIN WO $ 69.00 FLUTTER VALVE TX-THERAP WO MED $ 100.00 BIPAP/HR-THERAP WO MEDICATION $ 27.00 CPAP/HR-THERAP WO MEDICATION $ 12.00 VEST TX/THPY/CHEST VIB VEST TH $ 100.00 PEP THERAPY-THERA WO MEDICATIO $ 100.00 EZPAP-THERA W/ PRESCRIBED MED $ 71.00 RESPIRATORY ASSESS (INIT) 1/4H $ 64.00 AEROSOL TX-THERAP/1 PRESCR MED $ 64.00 AEROSOL TX-THERA/MULT PRES MED $ 128.00

STANDARD HOSPITAL CHARGES

SUCTION-THERAPEUTIC $ 64.00 TRACH CARE-THERA AIRWAY MAINT $ 69.00 MDI-THERAP W/ PRESCR MED $ 56.00 DPI-THERAPEUTIC W/ PRESCR MED $ 42.00 DISKUS INHALER-THERA/PRESC MED $ 42.00 ASSISTED COUGH-THERAP/NON-MED $ 37.00 EDUCATION-PATIENT/FAMILY 1/4HR $ 47.00 SPIROMETER BASIC-DIAG PULM FUN $ 66.00 SPIROMETER PRE&POST BRONCHIODI $ 66.00 ARTERIAL BLOOD GAS (ABG)-DIAGN $ 106.00 PH-PLEURAL FLUID-DIAGNOSTIC $ 59.00 HOLTER MONITOR -DIAGNOSTIC $ 55.00 EKG W/ RHYTHM STRIP -DIAGNOSTI $ 73.00 SPUTUM COLLECTION -DIAGNOSTIC $ 64.00 BEDSIDE PULM MECH-DIAG W/O MED $ 25.00 RT TIME 1/4HR MISCELLANEOUS $ 59.00 HUMIDIFIED AIR PER HOUR $ 46.00 METANEB THERAPY W/PRESCRIPTION $ 42.00 EZPAP-THERAPY W/MULT PRESCRIBD $ 42.00 NOCTURNAL PULSE-OX STUDY $ 47.00 O2 HOURLY $ 10.00 O2 DAILY $ 248.00 ABG KIT $ 3.50 HEAT MOISTURE EXCHANGER $ 7.00 TRACH TUBE $ 150.00 DISPOSABLE INNER CANNULA (DIC) $ 10.00 VENTILATOR CIRCUIT $ 10.00 INCENTIVE SPIROMETER $ 8.00 HIGH O2 FLOW NASAL CANNULA $ 10.00 CPAP/BIPAP CIRCUIT CHARGE $ 20.00 NEBULIZER UPDRAFT  DEVICE $ 3.50 DISP. RESUSCITATOR BAG $ 23.00 VAPOTHERM CARTRIDGE $ 215.00 FLUTTER VALVE $ 158.00 EZPAP CIRCUIT $ 6.60 CPAP/BIPAP NASAL MASK $ 48.00 CPAP/BIPAP FACE MASK $ 48.00 CPAP/BIPAP FULL FACE MASK $ 73.00 CPAP/BIPAP TOTAL FACE MASK $ 306.00 VEST THERAPY SET-UP   $ 69.00 AEROCHAMBER FOR MDI $ 16.00

Orthotics and ProstheticsABDUCT RESTRAINER CANVAS&WEB $ 273.80 ACROMIO/CLAVICULAR CANVAS&WE $ 311.80 AFO ANKLE GAUNTLET PRE-FAB $ 219.50 AFO DOUB SOLID STIRRUP CALF $ 1,272.60

STANDARD HOSPITAL CHARGES

AFO MOLDED PLAS RIG ANT TIB $ 2,615.50 AFO MOLDED TO PATIENT PLASTI $ 1,396.40 AFO PLASTIC MOLDED W/ANKLE J $ 1,962.50 AFO PLASTIC PRE-FAB $ 659.00 AFO POS SOLID ANK PLASTIC MO $ 1,561.40 AFO RIG ANT TIB PREFAB TCF/= $ 2,326.90 AFO SING UPRIGHT W/ ADJUST S $ 973.80 AFO SPIRAL PREFABRICATED $ 2,189.90 AFO SUPRAMALLEOLAR CUSTOM $ 1,467.30 AFO TIB FX SEMI-RIGID $ 1,635.40 AFO W/ANKLE JOINT, PREFAB $ 1,222.30 AFO, WALKING BOOT, CUSTOM $ 4,107.90 AFO-STATIC OR DYNAMIC PRE-FAB $ 436.60 AK FLEX INNER SICKET EXT FRA $ 3,521.90 AK PELVIC CONTROL BELT LIGHT $ 390.70 AK/KNEE DISARTIC ACRYLIC SOC $ 1,290.70 ANKLE CONTROL ORTHOSIS PREFAB $ 248.70 ANTERIOR THORACIC EXTENSION $ 626.10 BELOW KNEE SUS/SEAL SLEEVE $ 334.70 BELOW KNEE TOTAL CONTACT $ 906.80 BELT STRAP SLEEVE GARMENT $ 120.00 BK FORK STRAP $ 142.00 BK WAIST BELT WEBBING $ 182.50 CANVAS VEST SO $ 418.10 CERV COL FOAM 2 PIECE W THOR $ 749.20 CERV COL SUPP ADJ BAR & THOR $ 1,448.40 CERV COL THERM FOAM 2 PI PREFB $ 348.60 CERV FLEX NON-ADJUST PRE-FAB $ 74.70 CUSTOM MOLDED MULTI-DENSITY IN $ 135.00 DIABETIC SHOE OTS DEPTH-INLA $ 222.00 DIABETIC SHOE W/ROLLER OR ROCK $ 111.00 DORSI & PLANTAR FLEX ASS/RES $ 228.00 DORSIFLEXION ASSIST EACH JOINT $ 185.70 DROP LOCK RETAINER EACH $ 88.60 ENDO AK ULTRA-LIGHT MATERIAL $ 2,243.10 EO W/O JOINTS CF $ 685.30 EO WITHJOINT, PREFABRICATED $ 1,191.20 EWHO RIGID W/O JNTS CF $ 1,739.60 EWHO W/JOINT(S) CF $ 1,985.60 EXTENDED STEEL SHANK $ 144.30 EXTENSION PER EXTENSION PER $ 170.10 FLEX GLOVE W/ELASTIC FINGER $ 259.10 FO NONTORSION JOINT CF $ 524.30 FO PIP/DIP W/O JOINT/SPRING $ 83.10 FO PIP/DIP WITH JOINT/SPRING $ 133.30 FO W/O JOINTS CF $ 506.40 FOOT DROP SPLINT RECUMBENT $ 201.10

STANDARD HOSPITAL CHARGES

FOOT INSERT PLASTAZOTE OR EQ $ 421.20 FOOT LONGITUD/METATARSAL SUP $ 517.40 FOOT PLATE MOLDED STIRRUP AT $ 982.60 FOOT PRESSURE SUPPORT DEVICE $ 795.00 FT INSERT UCB BERKELEY SHELL $ 819.10 GARMENT BELT SLEEVE OR OTHER $ 120.00 GRADIANT COMP STOCKING BK 18 $ 159.00 GRADIENT COMP STOCKING THIGH $ 237.00 HALO REPL LINER/INTERFACE $ 562.10 HELMET HARD PREFAB $ 474.00 HELMET SOFT PRE FAB $ 474.00 HFO W/JOINTS(S) CF $ 762.30 HFO W/O JOINTS CF $ 642.80 HFO W/O JOINTS PF $ 220.60 HIP ADJ FLEX EXT ABDUCT CONT $ 934.90 HO POST-OP HIP ABDUCTION PREFB $ 2,570.30 HO W/O JOINTS CF $ 642.80 ISCH CONTAINMT/NARROW M-I SO $ 5,558.10 KAFO DBL SOLID STIRRUP BAND/ $ 3,257.10 KAFO PLAS DOUB FREE KNEE MOL $ 5,177.50 KNEE CONTROL CONDYLAR PAD $ 220.20 KNEE CONTROL FULL KNEECAP $ 233.10 KNEE JNT RATCHET LOCK EA JNT $ 373.80 KNEE JOINT CAM LOCK EACH JOI $ 316.80 KNEE JOINT DROP LOCK EA JNT $ 227.40 KNEE ORTH POS LOCKING JOINT $ 767.50 KO ADJ JNT POS R SUP PRE OTS $ 1,772.60 KO ADJ JNT POS RIGID PRE-FAB $ 1,772.60 KO ELAS W/COND PAD&JO PRE-FAB $ 356.30 KO ELASTIC WITH JOINTS PRE-FAB $ 273.20 KO IMMOB CANVAS LONGIT PRE-FAB $ 246.10 KO SINGLE UPRIGHT CUSTOM FIT $ 2,339.70 KO SWEDISH TYPE $ 801.40 KO W/ADJ FLEX/EXT ROTAT CUS $ 2,232.00 LIMITED ANKLE MOTION EA JNT $ 137.40 LO FLEX W/O RIGID STAYS PREFAB $ 218.90 LO FLEXIBL L1-BELOW L5 PRE-FAB $ 143.70 LO SAG RI AN/POS PNL PRE OTS $ 1,072.10 LO SAG STAYS/PANELS PRE-FAB $ 203.30 LO SAGITT RIGID PANEL PREFAB $ 1,072.10 LONG TONGUE STIRRUP $ 339.30 LSO S/C SHELL/PANEL CUSTOM $ 2,728.50 LSO SAG R AN/POS PNL PRE OTS $ 2,677.50 LSO SAG-CORO RIGID FRAME PREFB $ 2,677.50 LSO SAG-CORONAL PANEL PREFAB $ 3,097.90 LSO SC R ANT/POS PNL PRE OTS $ 3,097.90 MAN'S SHOE OXFORD BRACE $ 193.50

STANDARD HOSPITAL CHARGES

MISC ADDITION TO SPINAL ORTHOS $ 111.00 MISC SPINAL ORTHOSIS $ 276.00 MOLDED INNER BOOT $ 1,238.90 MULTI-DENSITY INSERT DIRECT F $ 90.00 NON CORROSIVE FINISH $ 183.80 NON-PNEUM WALK BOOT PRE OTS $ 413.50 NON-PNEUM WALK BOOT PREFAB $ 413.50 O&P SUPPLY ACCESSORY OR SERVI $ 360.00 OFFSET KNEE JOINT EACH $ 301.00 ORTH SHOE DEPTH INLAY LADIES $ 270.00 ORTH SHOE DEPTH INLAY MENS $ 279.00 ORTH SHOE MODIFICATION NOS $ 294.00 ORTHO SHOE OXFORD MENS $ 291.00 ORTHO SHOE ADD FULL SOLE $ 132.70 ORTHOPEDIC SHOE ADD RUB INSL $ 76.30 ORTHOTIC REPAIR OR REPLACE MI $ 120.00 ORTHOTIC DEVICE REPAIR PER 15 $ 60.00 PELVIC CONTROL HIP HEAVY DUTY $ 759.10 PLASTAZOTE SANDAL $ 192.00 PLASTIC MOD LOW EXT PAD/LINE $ 346.10 PLATING CHROME/NICKEL PR BAR $ 221.70 PNEUMA/VAC WALK BOOT PRE OTS $ 753.40 PNEUMATI WALKING BOOT PREFAB $ 753.40 POSTOP APP NON-WGT BEAR DSG $ 1,164.80 POSTOP APP NON-WGT BEAR DSG $ 1,542.80 PRE-TIBIAL SHELL MOLDED TO P $ 1,253.80 PROS SHEATH/SOCK W GEL CUSHN $ 196.80 PROS SOCK SINGLE PLY AK $ 26.70 PROS SOCK SINGLE PLY BK $ 18.90 PROSTHETIC LABOR PER 15/MIN $ 60.00 PROSTHETIC REPAIR OR REPLACE $ 120.00 PROSTHETIC SOCK MULTI PLY AK $ 65.50 PROSTHETIC SOCK MULTI PLY BK $ 58.20 REPLACE PAD SET FOR ASPEN COLL $ 111.00 REPLACE PAD SET FOR MIAMI J CO $ 111.00 REPLACE SOCKET ABOVE KNEE $ 9,824.90 SHEATH ABOVE KNEE $ 61.80 SHEATH BELOW KNEE $ 47.40 SHLDR FIG 8 ABD RESTRAIN PREFB $ 163.70 SHO INSERT W ARCH TOE FILLER $ 1,450.40 SHO LIFT TAPER TO METATARSAL $ 136.00 SHOE HEEL WEDGE $ 59.70 SHOE LIFT ELEV HEEL/SOLE NEO $ 212.30 SHOE LIFTS TAPERED TO ONE-HA $ 192.40 SHRINKER ABOVE KNEE $ 198.20 SHRINKER BELOW KNEE $ 124.90 SIOO FLEX PELVISACRAL PREFAB $ 256.90

STANDARD HOSPITAL CHARGES

SLING $ 24.00 SOCKET INSERT W LOCK MECH $ 1,947.00 SOCKET INSERT W/O LOCK LOWER $ 299.90 SOCKET INSERT W/O LOCK MECH $ 1,622.40 SOFT INTERFACE ABOVE KNEE SE $ 276.40 SOFT INTERFACE BELOW KNEE SE $ 258.80 STRAIGHT KNEE JOINT HEAVY DU $ 374.00 SURGICAL BOOT/SHOE $ 231.00 SUSPENSION SLEEVE LOWER EXT $ 306.70 TEST SOCKET ABOVE KNEE $ 1,073.70 TH/WGHT BEAR QUAD-LAT BRIM M $ 2,036.00 TIBIAL LENGTH SOCK FX OR EQU $ 120.30 TLSO 2MOD SYMPHIS-XIPHO PRE $ 2,325.50 TLSO 2MOD SYMPHSIS-STERN PRE $ 2,617.50 TLSO 4MOD SACRO-SCAP PRE $ 3,875.90 TLSO FLEX PREFAB $ 2,593.40 TLSO FLEX PREFAB THORACIC $ 487.20 TLSO FLEX TRNK SJ-SS PRE OTS $ 2,593.40 TLSO RIGID FRAME HYPEREX PRE $ 1,145.20 TLSO RIGID LINED CUST FAB TWO $ 5,144.00 TLSO RIGID PLASTIC CUST FAB $ 4,834.70 TOT CONTACT AK/KNEE DISART S $ 1,454.20 TRUS SINGLE W/STANDARD PAD $ 256.40 TRUSS ADD TO STD PAD SCROTAL $ 149.50 UPP EXT FX ORTHOSIS HUMERAL $ 892.60 VARUS/VALGUS STRAP PADDED/LI $ 153.80 WHFO W/JOIONT(S) CUSTOM FAB $ 1,078.00 WHFO W/O JOINTS PRE OTS $ 595.60 WHFO, NO JOINT, PREFABRICATED $ 595.60 WHFO, RIGID W/O JOINTS $ 892.50 WHO W NONTOR JNT(S) PREFAB $ 1,261.50 WHO W/NONTORSION JNT(S) CF $ 2,353.40 WHO W/O JOINTS CF $ 1,054.80 WRIST COCK-UP NON-MOLDED $ 166.60

Pharmacyabacavir 300 mg Tab $ 35.16 abacavir/dolutegravir/lamivudine 600 mg-50 mg-300 mg Tab $ 357.02 abacavir-lamiVUDine 600 mg-300 mg Tab $ 162.76 abiraterone 500 mg Tab $ 716.25 acamprosate 333 mg Oral EC Tab $ 5.11 acarbose 100 mg Tab $ 4.06 acarbose 25 mg Tab $ 3.50 acarbose 50 mg Tab $ 3.50 acebutolol 200 mg Cap $ 3.53 acebutolol 400 mg Cap $ 4.69 acetaminophen 10 mg/mL Inj Sol 100 mL $ 3.50

STANDARD HOSPITAL CHARGES

acetaminophen 120 mg Sup $ 3.50 acetaminophen 160 mg/5 mL Oral Liquid (5mL UD) $ 3.50 acetaminophen 160 mg/5 mL Oral Suspension (5mL UD) $ 3.50 acetaminophen 325 mg Sup $ 3.50 acetaminophen 325 mg Tab $ 3.50 acetaminophen 325mg/10.15mL Oral Liquid (10.15mL UD) $ 3.50 acetaminophen 325mg/10.15mL Oral Susp (10.15mL UD) $ 3.50 acetaminophen 500 mg Tab $ 3.50 acetaminophen 650 mg Sup $ 3.50 acetaminophen 650 mg Tab ER $ 3.50 acetaminophen 650mg/20.3mL Oral Liquid (20.3mL UD Liq) $ 3.50 acetaminophen 650mg/20.3mL Oral Susp (20.3mL UD Liq) $ 3.50 acetaminophen/aspirin/caffeine 250 mg-250 mg-65 mg Tab $ 3.50 acetaminophen/butalbital/caffeine 300 mg-50 mg-40 mg Cap $ 10.28 acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Cap $ 16.85 acetaminophen/butalbital/caffeine 325 mg-50 mg-40 mg Tab $ 5.91 acetaminophen/butalbital/caffeine/codeine 300 mg-50 mg-40 mg-30 mg Cap $ 21.54 acetaminophen/butalbital/caffeine/codeine 325 mg-50 mg-40 mg-30 mg Cap $ 5.25 acetaminophen/caffeine/pyrilamine 500 mg-60 mg-15 mg Tab $ 3.50 acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liquid (12.5mL UD) $ 3.50 acetaminophen-codeine 120 mg-12 mg/5 mL Oral Liquid (5mL UD) $ 3.50 acetaminophen-codeine 300 mg-30 mg Tab $ 3.50 acetaminophen-codeine 300 mg-60 mg Tab $ 3.50 acetaminophen-dexbrompheniramine 500 mg-1 mg Tab $ 3.50 acetaminophen-diphenhydrAMINE 500 mg-25 mg Tab $ 3.50 acetaminophen-HYDROcodone 108 mg-2.5 mg/5 mL Oral Solution (5 mL UD) $ 4.96 acetaminophen-HYDROcodone 167 mg-2.5 mg/5 mL Oral Elixir (5mL UD) $ 11.40 acetaminophen-HYDROcodone 217 mg-5 mg/10 mL Oral Solution (10mL UD) $ 3.50 acetaminophen-HYDROcodone 325 mg-10 mg Tab $ 4.24 acetaminophen-HYDROcodone 325 mg-10 mg/15 mL Oral Sol (15mL UD) $ 3.50 acetaminophen-HYDROcodone 325 mg-5 mg Tab $ 3.50 acetaminophen-HYDROcodone 325 mg-7.5 mg Tab $ 3.50 acetaminophen-HYDROcodone 325 mg-7.5 mg/15 mL Oral Soln(15mL UD) $ 3.50 acetaminophen-HYDROcodone 333 mg-5 mg/10 mL Oral Elixir (10mL UD Liq) $ 3.50 acetaminophen-oxyCODONE 325 mg-10 mg Tab $ 12.43 acetaminophen-oxycodone 325 mg-2.5 mg Tab $ 19.50 acetaminophen-oxyCODONE 325 mg-5 mg Tab $ 4.79 acetaminophen-oxyCODONE 325 mg-7.5 mg Tab $ 9.50 acetaminophen-oxyCODONE 325-5mg/5mL Oral Soln (5mL UD Liq) $ 3.50 acetaminophen-pentazocine 650 mg-25 mg Tab $ 5.34 acetaminophen-traMADol 325 mg-37.5 mg Tab $ 3.59 acetaZOLAMIDE 125 mg Tab $ 7.63 acetaZOLAMIDE 250 mg Tab $ 10.09 acetaZOLAMIDE 500 mg ERCap $ 15.03 acetaZOLAMIDE 500 mg Pow $ 168.00 acetic acid 0.25% Topical Soln (1,000mL Bulk) $ 3.50 acetic acid 0.25% Topical Soln (250mL Bulk) $ 3.50

STANDARD HOSPITAL CHARGES

acetic acid 0.25% Topical Soln (500mL Bulk) $ 3.50 acetic acid otic 2% Otic Soln (15mL Bulk) $ 9.33 acetic acid-aluminum acetate 2%-0.79% Otic Soln (60mL Bulk) $ 4.20 acetic acid-hydrocortisone 2%-1% Otic Soln (10mL Bulk) $ 79.02 acetohydroxamic acid 250 mg Tab $ 65.63 acetylcysteine 10% Inh Sol (10mL MDV per mL) $ 5.10 acetylcysteine 10% Inh Sol (30mL MDV per mL) $ 3.50 acetylcysteine 10% Inh Sol (4mL MDV per mL) $ 8.72 acetylcysteine 20% Inh Sol (30mL UD) $ 3.50 acetylcysteine 20% Inh Soln (10mL MDV per mL) $ 5.10 acetylcysteine 20% Inh Soln (4mL MDV per mL) $ 13.09 acetylcysteine 20% Inj Sol (30mL UD) $ 40.83 acetylcysteine 600 mg Cap $ 3.50 aclidinium 400 mcg/inh Powder {30 count} (1EA Bulk) $ 651.95 acyclovir 200 mg Cap $ 3.50 acyclovir 200 mg/5 mL Oral Susp (5mL UD Liq) $ 3.50 acyclovir 400 mg Tab $ 13.11 acyclovir 5% Ointment (15gm Bulk) $ 93.05 acyclovir 5% Ointment (30gm Bulk) $ 93.05 acyclovir 5% Ointment (5gm Bulk) $ 98.26 acyclovir 5% Topical Cream (5gm Bulk) $ 669.06 acyclovir 50 mg/mL IV Sol 10 mL $ 5.60 acyclovir 50 mg/mL IV Sol 20 mL $ 5.25 acyclovir 500 mg IV Powd. Inj. $ 18.90 acyclovir 800 mg Tab $ 12.83 adalimumab 40 mg/0.8 mL Kit (1EA Bulk) $10,231.26 adenosine 3mg/mL Solution IV (20mL MDV) $ 23.00 Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-20 mg Tab $ 3.50 Al hydroxide/Mg hydroxide/simethicone 200 mg-200 mg-25 mg Tab Chew $ 3.50 albendazole 200 mg Tab $ 927.40 albumin human 25% IV Sol 50 mL $ 3.89 albumin human 25% Solution IV (100mL IVPB) $ 3.88 albumin human 5% Solution IV (500mL IVPB) $ 3.50 albuterol 0.042% Inh Sol $ 3.50 albuterol 0.083% Inh Sol $ 3.50 albuterol 0.5% Inh Sol (20mL Bulk) $ 7.00 albuterol 0.5% Inh Sol 0.5ml $ 3.50 albuterol 2 mg Tab $ 24.68 albuterol 2 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 albuterol 4 mg ER Tab $ 8.15 albuterol 4 mg Tab $ 23.22 albuterol 90 mcg/inh Powder (RespiClick) $ 214.58 albuterol CFC free 90 mcg/inh Aer w/Adapt (18gm Bulk) $ 12.54 albuterol CFC free 90 mcg/inh Inh Aer w/Adapt (6.7gm Bulk) $ 49.98 albuterol CFC free 90 mcg/inh Inh Aer w/Adapt (8gm Bulk) $ 10.23 albuterol-ipratropium 100 mcg-20 mcg/inh Aerosol (4gm Bulk) $ 391.14 albuterol-ipratropium 103 mcg-18 mcg/inh Inh Aer w/Adapt (14.7gm Bulk) $ 57.23

STANDARD HOSPITAL CHARGES

albuterol-ipratropium 2.5 mg-0.5 mg/3 mL Inh Soln (3mL UD) $ 3.50 alclometasone Top 0.05% Cream (45gm Bulk) $ 7.58 aldioxa-chloroxylenol 0.22%-0.5% Topical Powder (70.9gm Bulk) $ 3.50 alendronate 10 mg Tab $ 10.24 alendronate 35 mg Tab $ 71.68 alendronate 40 mg Tab $ 23.10 alendronate 5 mg Tab $ 10.24 alendronate 70 mg Tab $ 71.71 alfentanil 0.5 mg/mL IV Sol $ 18.41 alfuzosin 10 mg ER Tab $ 14.76 aliskiren 150 mg oral tablet $ 25.19 aliskiren 300 mg oral tablet $ 24.12 allantoin/camphor/phenol topical Ointment (10.5gm Bulk) $ 3.50 allantoin/camphor/phenol topical Ointment (4.25gm Bulk) $ 3.50 allantoin/camphor/phenol topical Ointment (7gm Bulk) $ 3.50 allopurinol 100 mg Tab $ 3.50 allopurinol 300 mg Tab $ 3.50 aloe vera topical - Gel (240gm Bulk) $ 3.50 aloe/collagen/lidocai/Na hyaluronate topical - Gel (85gm Bulk) $ 3.50 alogliptin 12.5 mg Tab $ 27.30 alogliptin 25 mg Tab $ 27.30 alogliptin 6.25 mg Tab $ 27.30 AlOH/diphenhyd/lidocaine/MgOH/simeth 3.15 g-0.2 g-1.6 g-3.15 g-0.315 g/237 mL Susp (5mL UD Liq RXD2) $ 3.50 alosetron 0.5 mg Tab $ 91.08 alpha lipoic acid 300mg cap $ 3.50 alpha-lipoic acid 100 mg Cap $ 3.50 alpha-lipoic acid 200 mg Cap $ 3.50 alpha-lipoic acid 600 mg Cap $ 3.50 ALPRAZolam 0.25 mg Tab $ 3.50 ALPRAZolam 0.25 mg Tab ODT $ 5.31 ALPRAZolam 0.5 mg Tab $ 3.50 ALPRAZolam 0.5 mg Tab-ER $ 3.50 ALPRAZolam 1 mg Tab $ 3.50 ALPRAZolam 1 mg Tab ER $ 3.50 ALPRAZolam 1 mg Tab ODT $ 8.83 ALPRAZolam 2 mg Tab $ 3.50 alteplase 2 mg IV Inj $ 606.28 aluminum chloride hexahydrate 20% top Soln (60mL BUlk) $ 3.50 aluminum hydroxide320mg/5mL Oral Susp (Extemp) $ 3.50 aluminum hydroxide-magnesium carbonate 160 mg-105 mg Tab $ 3.50

aluminum hydroxide-magnesium carbonate 95 mg-358 mg/15 mL Oral Susp (15mL UD Liq) $ 3.50 aluminum sulfate-calcium acetate Topical Powder (1EA UD) $ 3.97 alum-mag hydroxide 1200-1200mg/30mL Oral Susp (30mL UD) $ 3.50 alum-mag hydroxide-simethicone 1200-1200-120mg/30mL Oral Susp (30mL UD Liq) $ 3.50 alum-mag hydroxide-simethicone 2400-2400-240mg/30mL Oral Susp (30mL UD) $ 3.50

STANDARD HOSPITAL CHARGES

amantadine 100 mg Cap $ 6.78 amantadine 100 mg Tab $ 6.24 amantadine 100 mg/10 mL Oral Syrup (10mL UD Liq) $ 3.50 ambrisentan 10 mg Tab $ 876.60 amikacin 250 mg/mL IV Sol (2mL Vial) $ 23.61 amikacin 250 mg/mL IV Sol (4mL Vial) $ 25.74 aMILoride 5 mg Tab $ 3.50 aMILoride-hydrochlorothiazide 5 mg-50 mg Tab $ 4.06 Amino Acids 2.36%, 6.8% Dextrose, 3.5% Lipids, and Electrolytes (Perikabiven) IV emulsion (1,440 mL Bulk) $ 3.50 Amino Acids 2.36%, 6.8% Dextrose, 3.5% Lipids, and Electrolytes (Perikabiven) IV emulsion (1,920 mL Bulk) $ 3.50 Amino Acids 2.75% with 5% Dextrose and Electrolytes Sol 1000 mL $ 3.50 Amino Acids 2.75% with 5% Dextrose and Electrolytes Sol 2000 mL $ 3.50 Amino Acids 3% and Glycerin 3% with Electrolytes Sol $ 3.50 Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) IV emulsion ( 2,053mL) $ 3.50 Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) IV emulsion ( 2,566mL) $ 3.50 Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) IV emulsion (1,026 mL Bulk) $ 3.50 Amino Acids 3.31% with 9.8% Dextrose, 3.9% Lipids, and Electrolytes (Kabiven) IV emulsion (1,540 mL Bulk) $ 3.50 Amino Acids 4.25% with 10% Dextrose and Electrolytes $ 3.50 Amino Acids 4.25% with 10% Dextrose and Electrolytes (2,000mL) $ 3.50 Amino Acids 4.25% with 10% Dextrose IV Sol (1,000 mL) $ 3.50 Amino Acids 4.25% with 10% Dextrose IV Sol (2,000 mL) $ 3.50 Amino Acids 4.25% with 25% Dextrose and Electrolytes Sol 1000 mL $ 3.50 Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) IV Solution 1000mL $ 3.50 Amino Acids 4.25% with 5% Dextrose (Clinimix Sulfite-Free) IV Solution 2000mL $ 3.50 Amino Acids 4.25% with 5% Dextrose and Electrolytes Sol 1000 mL $ 3.50 Amino Acids 4.25% with 5% Dextrose and Electrolytes Sol 2000 mL $ 3.50 Amino Acids 5% with 15% Dextrose and Electrolytes Sol 1000 ml $ 3.50 Amino Acids 5% with 15% Dextrose and Electrolytes Sol 2000ml $ 3.50 Amino Acids 5% with 15% Dextrose IV Sol (1000mL) $ 3.50 Amino Acids 5% with 15% Dextrose IV Sol (2000mL) $ 3.50 Amino Acids 5% with 20% Dextrose and Electrolytes Sol 1000mL $ 3.50 Amino Acids 5% with 20% Dextrose and Electrolytes Sol 2000mL $ 3.50 Amino Acids 5% with 20% Dextrose IV Sol (1000mL) $ 3.50 Amino Acids 5% with 20% Dextrose IV Sol (2000mL) $ 3.50 Amino Acids 5% with 25% Dextrose and Electrolytes IV Sol 1,000 mL $ 3.50 Amino Acids 5% with 25% Dextrose and Electrolytes IV Sol 2,000 mL $ 3.50 amino acids 8.5% Parenteral Nutrition Solution (500mL Bulk) $ 3.50 aminocaproic acid 500 mg Tab $ 86.53 amiodarone 100 mg Tab $ 26.00 amiodarone 150 mg/100 mL-D5% IV Sol $ 3.50 amiodarone 200 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

amiodarone 50 mg/mL Solution IV (3mL Vial) $ 5.08 amitriptyline 10 mg Tab $ 3.50 amitriptyline 100 mg Tab $ 8.89 amitriptyline 25 mg Tab $ 3.50 amitriptyline 50 mg Tab $ 4.08 amitriptyline 75 mg Tab $ 6.68 amLODIPine 10 mg Tab $ 8.31 amLODIPine 2.5 mg Tab $ 6.05 amLODIPine 5 mg Tab $ 5.75 amLODIPine-valsartan 10 mg-160 mg Tab $ 21.68 ammonium lactate 12% Topical Cream (140gm Bulk) $ 3.50 ammonium lactate 12% Topical Lotion (225gm Bulk) $ 3.50 ammonium lactate 12% Topical Lotion (400gm Bulk) $ 3.50 ammonium lactate 5% Topical Lotion (240gm Bulk) $ 3.50 amoxapine 100 mg Tab $ 5.84 amoxapine 25 mg Tab $ 3.50 amoxapine 50 mg Tab $ 3.50 amoxicillin 200 mg/5 mL Oral Liquid (Extemp) $ 3.50 amoxicillin 250 mg Cap $ 3.50 amoxicillin 250 mg Tab Chew $ 3.50 amoxicillin 250mg/5mL Oral Liquid (Extemp) $ 3.50 amoxicillin 400mg/5mL Oral Liquid (Extemp) $ 3.50 amoxicillin 500 mg Cap $ 3.50 amoxicillin 500 mg Tab $ 3.50 amoxicillin 875 mg Tab $ 3.50 amoxicillin-clavulanate 1000 mg-62.5 mg ER Tab $ 24.43 amoxicillin-clavulanate 200 mg-28.5 mg/5 mL Oral Liquid (Extemp) $ 3.50 amoxicillin-clavulanate 250 mg-125 mg Tab $ 20.71 amoxicillin-clavulanate 250 mg-62.5 mg/5 mL Oral Liquid (Extemp) $ 5.07 amoxicillin-clavulanate 400 mg-57 mg/5 mL Oral Liquid (Extemp) $ 3.50 amoxicillin-clavulanate 500 mg-125 mg Tab $ 13.25 amoxicillin-clavulanate 600 mg-42.9 mg/5 mL Oral Liquid (Extemp) $ 3.50 amoxicillin-clavulanate 875 mg-125 mg Tab $ 17.68 amphetamine-dextroamphetamine 10 mg Cap ER $ 21.46 amphetamine-dextroamphetamine 10 mg Tab $ 6.00 amphetamine-dextroamphetamine 15 mg Cap ER $ 21.46 amphetamine-dextroamphetamine 15 mg Tab $ 6.00 amphetamine-dextroamphetamine 20 mg Cap ER $ 24.67 amphetamine-dextroamphetamine 20 mg Tab $ 6.00 amphetamine-dextroamphetamine 25 mg Cap ER $ 21.46 amphetamine-dextroamphetamine 30 mg Cap ER $ 24.67 amphetamine-dextroamphetamine 30 mg Tab $ 6.00 amphetamine-dextroamphetamine 5 mg Cap ER $ 24.67 amphetamine-dextroamphetamine 5 mg Tab $ 6.00 amphotericin B 50 mg Powder Injection (Vial) $ 159.60 amphotericin B lipid complex 5 mg/mL Injectable Susp $ 21.00 amphotericin B liposomal 50 mg IV Inj $ 1,038.00

STANDARD HOSPITAL CHARGES

ampicillin 0.5 gm Pow inj $ 10.33 ampicillin 1 gm Pow inj $ 30.24 ampicillin 1 gm Pow inj ADD-Vantage $ 62.70 ampicillin 2 gm pow Inj $ 58.64 ampicillin 2 gm Pow Inj ADD-Vantage $ 121.62 ampicillin 250 mg Cap $ 3.50 ampicillin 250 mg/5 mL Oral Liquid (Extemp) $ 3.50 ampicillin 500 mg Cap $ 3.50 ampicillin-sulbactam 1 gm-0.5 gm Pow ADDVantage $ 22.26 ampicillin-sulbactam 1 gm-0.5 gm Powder Injection (Vial) $ 16.35 ampicillin-sulbactam 2 gm-1 gm Pow inj $ 51.10 ampicillin-sulbactam 2 gm-1 gm Pow inj ADDV $ 38.22 anagrelide 0.5 mg Cap $ 39.07 anagrelide 1 mg Cap $ 84.24 anakinra 100mg/0.67mL Solution Injection $ 876.34 anastrozole 1 mg Tab $ 46.56 anidulafungin 100 mg Powder injection (vial) $ 756.00 anidulafungin 50mg Powder Injection (Vial) $ 378.00 anticoagulant citrate dextrose solution (50mL Bulk) $ 3.50 Antioxidant Multiple Vitamins and Minerals Cap (Ocuvite Lutein) $ 3.50 antipyrine-benzocaine 54 mg-14 mg/mL Otic Sol (15mL Bulk) $ 3.50 antipyrine-benzocaine 54 mg-14 mg/mL Otic Soln (10mL Bulk) $ 4.18 APAP/dichloralphenazone/isometheptene 325 mg-100 mg-65 mg Cap $ 16.12 apixaban 2.5 mg tab $ 29.33 apixaban 5 mg Tab $ 29.33 apraclonidine 0.5% Ophthalmic Solution (5mL Bulk) $ 60.74 arformoterol 15 mcg/2 mL Inh Sol $ 33.98 argatroban 100 mg/mL IV Sol 2.5 mL $ 714.00 arginine 500 mg Cap $ 3.50 arginine 500 mg Tab $ 3.50 ARIPiprazole 1 mg/mL Oral Soln (Extemp) $ 33.31 ARIPiprazole 10 mg Tab $ 112.26 ARIPiprazole 15 mg Tab $ 112.26 ARIPiprazole 2 mg tablet $ 112.26 ARIPiprazole 20 mg Tab $ 158.75 ARIPiprazole 30 mg Tab $ 158.75 ARIPiprazole 5 mg Tab $ 112.26 armodafinil 150 mg Tab $ 77.62 armodafinil 200 mg Tab $ 76.61 armodafinil 250 mg Tab $ 77.62 armodafinil 50 mg Tab $ 25.79 arnica topical ointment (30gm Bulk) $ 3.50 ascorbic acid 250 mg Tab $ 3.50 ascorbic acid 500 mg Tab $ 3.50 ascorbic acid 500 mg Tab-Chew $ 3.50 ascorbic acid 500 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 ascorbic acid 500 mg/mL Inj Sol (50mL UD Inj) $ 7.60

STANDARD HOSPITAL CHARGES

ascorbic acid-carbonyl iron (as elemental iron) 125 mg-65 mg Tab $ 3.50 ascorbic acid-carbonyl iron 250 mg-100 mg Tab $ 3.50 ascorbic acid-iron polysaccharide 50 mg-150 mg oral capsule $ 4.45 asenapine 10 mg Tab-SL $ 84.06 asenapine 5 mg Tab-SL $ 84.06 aspirin 300 mg Supp $ 5.10 aspirin 325 mg EC Tab $ 3.50 aspirin 600 mg Supp $ 5.28 aspirin 81 mg Chew Tab $ 3.50 aspirin 81 mg EC Tab $ 3.50 aspirin buffered 325 mg Tab $ 3.50 aspirin/butalbital/caffeine 325 mg-50 mg-40 mg Cap $ 5.95 aspirin/butalbital/caffeine 325 mg-50 mg-40 mg Tab $ 3.50 aspirin/butalbital/caffeine/codeine 325 mg-50 mg-40 mg-30 mg Cap $ 9.59 aspirin-caffeine 400 mg-32 mg Tab $ 3.50 aspirin-dipyridamole 25 mg-200 mg ERCap $ 29.24 aspirin-oxyCODONE 325 mg-4.8355 mg Tab $ 4.14 atazanavir 150 mg Cap $ 97.31 atazanavir 200 mg Cap $ 97.31 atazanavir 300 mg Cap $ 192.77 atenolol 100 mg Tab $ 5.22 atenolol 25 mg Tab $ 3.50 atenolol 50 mg Tab $ 3.50 atenolol-chlorthalidone 50 mg-25 mg Tab $ 5.27 atomoxetine 10 mg Cap $ 50.53 atomoxetine 100 mg Cap $ 59.24 atomoxetine 25 mg Cap $ 50.53 atomoxetine 40 mg Cap $ 54.90 atomoxetine 60 mg Cap $ 54.90 atomoxetine 80 mg Cap $ 59.24 atorvastatin 10 mg Tab $ 3.50 atorvastatin 20 mg Tab $ 3.50 atorvastatin 40 mg Tab $ 3.50 atorvastatin 80 mg Tab $ 20.21 atovaquone 750 mg/5 mL Oral Susp (5mL UD) $ 22.97 atropine 0.1 mg/mL Inj Sol (10mL Vial) $ 3.78 atropine 0.1 mg/mL Inj Sol (5mL Vial) $ 6.97 atropine 0.4 mg/mL Inj Sol (1mL Vial) $ 30.63 atropine 1 mg/mL Inj Sol (1mL Vial) $ 48.13 atropine 1% Opht Ointment (3.5gm Bulk) $ 19.27 atropine 1% Opht Soln (15mL Bulk) $ 22.23 atropine 1% Opht Soln (2mL Bulk) $ 53.81 atropine 1% Opht Soln (5mL Bulk) $ 40.87 atropine/hyoscyamine/PB/scopolamine 16.2 mg Tab $ 32.66 atropine/hyoscyamine/PB/scopolamine 16.2 mg/5mL Oral Elixer (Extemp) $ 9.47 atropine-diphenoxylate 0.025 mg-2.5 mg Tab $ 3.50 atropine-diphenoxylate 0.025-2.5mg/5mL Oral Liquid (5mL UD Liq) $ 4.90

STANDARD HOSPITAL CHARGES

avibactam-cefTAZidime 0.5 g-2 g Powder Inj (vial) $ 1,191.56 azaTHIOprine 50 mg Tab $ 7.39 azelastine 0.05% Opht Soln (6mL Bulk) $ 60.71 azelastine 205.5 mcg/inh Nasal Spray (30mL Bulk) $ 16.24 azelastine Nasal 137 mcg/inh Nasal Spray (30mL Bulk) $ 12.27 azilsartan-chlorthalidone 40 mg-12.5 mg Tab $ 25.36 azithromycin 1% Opht Soln (2.5mL Bulk) $ 298.77 azithromycin 100mg/5mL Oral Liquid (Extemp) $ 8.14 azithromycin 200mg/5mL Oral Liquid (Extemp) $ 4.07 azithromycin 250 mg Tab $ 5.91 azithromycin 500 mg Pow (addv) $ 41.41 azithromycin 500 mg Powder Injection (Vial) $ 25.20 azithromycin 500 mg Tab $ 54.49 azithromycin 600 mg Tab $ 15.89 aztreonam 1 gm/50 mL IV Sol $ 3.50 aztreonam 2 gm/50 mL IV Sol $ 5.60 bacITRACIN {ZINC} 500 units/g Topical Oin (15gm Bulk) $ 3.50 bacITRACIN {ZINC} 500units/gm Topical Ointment (1gm UD) $ 3.50 bacITRACIN {ZINC} 500units/gm Topical Ointment (454gm Bulk) $ 3.50 bacITRACIN 50,000 units IM Inj $ 37.80 bacITRACIN 500units/gm Ophthalmic Ointment (3.5gm Bulk) $ 118.44 bacITRACIN 500units/gm Topical Ointment (14gm Bulk) $ 3.50 bacITRACIN 500units/gm Topical Ointment (1gm UD) $ 3.50 bacitracin/HC/neomycin/polymyxin B ophthalmic 400 units-10 mg-3.5 mg-10000 units/g Oin $ 65.05 bacITRACIN/neomycin/polymyxin B 400 units-3.5 mg-10000 units/g Ophthalmic Oint (3.5gm Bulk) $ 56.95 bacITRACIN/neomycin/polymyxin B 400 units-3.5 mg-5000 units/g Top Oin (15gm Bulk) $ 3.50 bacITRACIN/neomycin/polymyxin B 400 units-3.5 mg-5000 units/g Topical Oint (1gm UD) $ 3.50 bacITRACIN/neomycin/polymyxin B 400 units-3.5 mg-5000 units/g Topical Ointment (30gm Bulk) $ 3.50 bacITRACIN-polymyxin B 500 units-10000 units/g Topical Oint (15gm Oint) $ 3.50 bacITRACIN-polymyxin B 500 units-10000 units/g Topical Oint (1EA UD) $ 3.50 bacITRACIN-polymyxin B 500 units-10000 units/g Topical Oint (30gm Bulk) $ 39.38 bacITRACIN-polymyxin B Ophthalmic Oint 500 units-10000 units/g (3.5gm Bulk) $ 26.12 baclofen 0.05 mg/mL Sol Injection $ 336.00 baclofen 0.5 mg/mL Sol Injection (20mL Amp) $ 49.62 baclofen 1 mg/mL Sol $ 90.30 baclofen 10 mg Tab $ 3.50 baclofen 20 mg Tab $ 3.50 Balanced Salt Ophthalmic Solution (15mL Bulk) $ 3.50 balsalazide 750 mg Cap $ 3.50 balsam Peru/castor oil/trypsin Topical Ointment (30gm Bulk) $ 3.50 balsam Peru/castor oil/trypsin Topical Spray (120mL Bulk) $ 3.50 balsam Peru/castor oil/trypsin Topical Spray (56.7gm Bulk) $ 3.50 balsam peru/zinc oxide Top Cream (60gm Bulk) $ 23.54 balsam Peru-castor oil Topical Ointment (30gm Bulk) $ 3.50

STANDARD HOSPITAL CHARGES

balsam Peru-castor oil Topical Ointment (5gm UD) $ 6.58 balsam Peru-castor oil Topical Ointment (60gm Bulk) $ 3.50 balsam Peru-castor oil Topical Spray (113.4gm Bulk) $ 3.50 barium sulfate 2% Suspension (450mL Bulk) $ 3.50 barium sulfate 96% Oral Powder (176gm Bulk) $ 3.50 bazedoxifene-conjugated estrogens 20 mg-0.45 mg Tab $ 21.43 beclomethasone 0.5mg/ml Oral Susp (Extemp) $ 3.50 beclomethasone 40 mcg/inh Inh Aer w/Adapt (10.6 gm Bulk) $ 60.98 beclomethasone 40 mcg/inh Inh Aer w/Adapt (8.7gm Bulk) $ 74.29 beclomethasone 80 mcg/inh Inh Aer w/Adapt (8.7gm Bulk) $ 99.47 beclomethasone Nasal 0.042 mg/inh Spry $ 49.28 belladonna-opium 16.2 mg-30 mg Supp (1EA UD) $ 96.31 belladonna-opium 16.2 mg-60 mg Supp (1EA UD) $ 117.08 benazepril 10 mg Tab $ 3.50 benazepril 20 mg Tab $ 3.50 benazepril 40 mg Tab $ 3.68 benazepril 5 mg Tab $ 3.68 benzocaine 10% mucous membrane gel (5.3gm Bulk) $ 3.50 benzocaine 10% mucous membrane gel (7gm Bulk) $ 3.50 benzocaine 10% Topical Liquid (12.3mL Bulk) $ 3.50 benzocaine 20% mucous membrane gel (5.3gm Bulk) $ 3.50 benzocaine 20% mucous membrane gel (11.9gm Bulk) $ 3.50 benzocaine 20% mucous membrane Gel (15gm Bulk) $ 3.50 benzocaine 20% mucous membrane gel (30gm Bulk) $ 3.50 benzocaine 20% mucous membrane gel (9.9gm Bulk) $ 3.50 benzocaine 20% Topical Liquid (12.3mL Bulk) $ 3.50 benzocaine 20% Topical Oint (28gm Bulk) $ 3.50 benzocaine 20% Topical Paste (12gm Bulk) $ 3.50 benzocaine 20% Topical Rectal Ointment (30gm Bulk) $ 3.50 benzocaine 20% Topical Spray (57gm bulk) $ 3.50 benzocaine 7.5% mucous membrane gel (10gm Bulk) $ 3.50 benzocaine topical 20% Spray (1EA UD) $ 44.75 benzocaine topical 20% Swab (1EA UD) $ 3.50 benzocaine/butamben/tetracaine 14%-2%-2% Topical Aerosol (20gm Bulk) $ 12.67 benzocaine/butamben/tetracaine 14%-2%-2% Topical Aerosol (56m Bulk) $ 4.94 benzocaine/butamben/tetracaine 14%-2%-2% Topical Aerosol (5gm Bulk) $ 44.11 benzocaine-docusate 20 mg-283 mg Enema (1EA UD) $ 3.50 benzocaine-menthol 20%-0.5% topical Spray (56gm Bulk) $ 3.50 benzocaine-menthol topical 15 mg-2.3 mg Loz $ 3.50 benzocaine-menthol topical 15 mg-2.6 mg Loz $ 3.50 benzocaine-menthol topical 15 mg-3.6 mg Loz $ 3.50 benzocaine-menthol topical 15 mg-3.6 mg SF Loz $ 3.50 benzocaine-menthol topical 15 mg-4 mg Loz $ 3.50 benzocaine-menthol topical 6 mg-10 mg Loz $ 3.50 benzocaine-resorcinol topical 5%-2% Vaginal Cream $ 3.50 benzoin topical - Spray (120 mL Bulk) $ 3.50 benzonatate 100 mg Cap $ 8.76

STANDARD HOSPITAL CHARGES

benzonatate 200 mg Cap $ 16.69 benzoyl peroxide 2.5% Topical Cream (21gm Bulk) $ 3.50 benzoyl peroxide-clindamycin topical 5%-1% Gel (25gm Bulk) $ 28.59 benzoyl peroxide-clindamycin topical 5%-1% Gel (50gm Bulk) $ 29.77 benzoyl peroxide-clindamycin topical 5%-1.2% Gel (45gm Bulk) $ 15.81 benzphetamine 50 mg Tab $ 4.69 benztropine 0.5 mg Tab $ 3.50 benztropine 1 mg Tab $ 3.50 benztropine 2 mg Tab $ 3.50 benztropine 2mg/2mL Inj Sol 2 mL $ 102.81 besifloxacin 0.6% Ophthalmic Suspension (5mL Bulk) $ 122.01 beta-carotene 25000 units Cap $ 3.50 betamethasone acetate-betamethasone sodium phosphate 3 mg-3 mg Inj Susp 5 mL $ 43.26 betamethasone dipropionate 0.05% Topical Cre (45gm Bulk) $ 6.47 betamethasone dipropionate 0.05% Topical Cream (15gm Bulk) $ 12.33 betamethasone dipropionate 0.05% Topical Lotion (60mL Bulk) $ 3.50 betamethasone dipropionate 0.05% Topical Ointment (15gm Bulk) $ 14.35 betamethasone dipropionate 0.05% Topical Ointment (45gm Bulk) $ 9.56 betamethasone dipropionate, augmented 0.05% Topical Gel (15gm Bulk) $ 14.35 betamethasone dipropionate, augmented 0.05% Topical Ointment (15gm Bulk) $ 14.80 betamethasone topical dipropionate, augmented 0.05% Cre $ 3.50 betamethasone topical dipropionate, augmented 0.05% Lot (30 mL Bulk) $ 8.75 betamethasone topical dipropionate, augmented 0.05% Lot (60 mL Bulk) $ 8.63 betamethasone topical valerate 0.1% Lot (60mL Bulk) $ 4.21 betamethasone valerate 0.1% Topical Cream (15gm Bulk) $ 6.53 betamethasone valerate 0.1% Topical Cream (45gm Bulk) $ 4.44 betamethasone valerate 0.1% Topical Ointment (15gm Bulk) $ 4.75 betamethasone-calcipotriene 0.064%-0.005% Topical Ointment (60gm Bulk) $ 48.07 betamethasone-clotrimazole 0.05%-1% Topical Cream (15gm Bulk) $ 7.17 betamethasone-clotrimazole 0.05%-1% Topical Cream (45gm Bulk) $ 3.50 betamethasone-clotrimazole 0.05%-1% Topical Lotion (30mL Bulk) $ 19.55 betaxolol 0.25% Opht Susp (10mL Bulk) $ 130.42 betaxolol 0.5% Opht Soln (5mL Bulk) $ 44.39 betaxolol 10 mg Tab $ 4.35 bethanechol 10 mg Tab $ 7.00 bethanechol 25 mg Tab $ 9.34 bethanechol 5 mg Tab $ 3.50 bethanechol 50 mg Tab $ 14.95 betrixaban 40 mg Cap $ 63.00 betrixaban 80 mg Cap $ 63.00 bicalutamide 50 mg Tab $ 3.50 bifidobacterium infantis 4 mg Cap $ 3.50 bifidobacterium/lactobacillus/streptococcus - Cap $ 3.50 bifidobacterium-lactobacillus - Cap $ 3.50 bimatoprost 0.01% Opht Soln (2.5mL Bulk) $ 302.20 bimatoprost 0.01% Opht Soln (5mL Bulk) $ 302.08 bimatoprost 0.03% Opht Soln (2.5mL Bulk) $ 188.48

STANDARD HOSPITAL CHARGES

bimatoprost 0.03% Opht Soln (3mL Bulk) $ 163.80 biotene moisturizing mouth spray Oral Spray (45mL Bulk) $ 3.50 biotene mouthwash Oral Soln (240 mL Bulk) $ 3.50 biotene mouthwash Oral Soln (474mL Bulk) $ 18.80 biotene mouthwash Oral Soln (59 mL Bulk) $ 5.40 biotene oral balance Oral Gel (42gm Bulk) $ 3.50 biotene oral balance Oral Soln (45mL Bulk) $ 3.50 biotin 1000 mcg Tab $ 3.50 biotin 300 mcg Tab $ 3.50 biotin 5 mg Cap $ 3.50 bisacodyl 10 mg Enema $ 3.50 bisacodyl 10 mg Supp $ 3.50 bisacodyl 5 mg Oral EC Tab $ 3.50 bismuth subsalicylate 262 mg Tab $ 3.50 bismuth subsalicylate 262 mg Tab-Chew $ 3.50 bismuth subsalicylate 524mg/30mL Oral Susp (30mL UD Liq) $ 3.50 bismuth subsalicylate 525 mg/15 mL OralSusp (15mL UD Liq) $ 3.50 bisoprolol 10 mg Tab $ 4.27 bisoprolol 5 mg Tab $ 4.27 bisoprolol-hydrochlorothiazide 10 mg-6.25 mg Tab $ 4.00 bisoprolol-hydrochlorothiazide 2.5 mg-6.25 mg Tab $ 3.95 bisoprolol-hydrochlorothiazide 5 mg-6.25 mg Tab $ 3.99 bosentan 125 mg Tab $ 173.25 brewer's yeast - Tab $ 3.50 brexpiprazole 2 mg Tab $ 155.32 brimonidine 0.1% Opht Soln (5mL Bulk) $ 122.71 brimonidine 0.15% Opht Soln (10mL Bulk) $ 52.96 brimonidine 0.15% Opht Soln (5mL Bulk) $ 91.21 brimonidine 0.2% Opht Soln (10mL Bulk) $ 11.95 brimonidine 0.2% Opht Soln (15mL Bulk) $ 12.80 brimonidine 0.2% Opht Soln (5mL Bulk) $ 22.86 brimonidine-brinzolamide 0.2%-1% Ophthalmic Suspension (8mL Bulk) $ 71.91 brimonidine-timolol 0.2%-0.5% Opht Soln (10ml Bulk) $ 135.27 brimonidine-timolol 0.2%-0.5% Opht Soln (5ml Bulk) $ 135.27 brinzolamide 1% Opht Susp (10mL Bulk) $ 119.93 brivaracetam 10 mg/mL Oral Liquid (10 ml UD) $ 14.00 brivaracetam 100 mg Tab $ 74.91 brivaracetam 50 mg Tab $ 74.91 brivaracetam 75 mg Tab $ 74.91 bromfenac 0.075% ophthalmic Sol (5mL Bulk) $ 226.80 bromfenac 0.09% ophthalmic Solution (1.7mL Bulk) $ 416.95 bromocriptine 0.8 mg Tab $ 15.11 bromocriptine 2.5 mg Tab $ 13.14 bromocriptine 5 mg Cap $ 32.59 brompheniramine/dextromethorphan/PSE 2 mg-10 mg-30 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 budesonide 0.032 mg/inh Nasal Spray (8.6gm Bulk) $ 72.59

STANDARD HOSPITAL CHARGES

budesonide 0.25 mg/2 mL Inh Susp $ 16.47 budesonide 0.5 mg/2 mL Inh Susp $ 19.39 budesonide 1 mg/2 mL Inh Susp $ 40.39 budesonide 180 mcg/inh Inh Pwdr $ 876.28 budesonide 3 mg ERCap $ 87.00 budesonide 9 mg Tab-ER $ 238.45 budesonide 90 mcg/inh Inh Pwdr $ 654.37 budesonide-formoterol 160 mcg-4.5 mcg/inh Inh Aerosol (6gm Bulk) $ 141.49 budesonide-formoterol 80 mcg-4.5 mcg/inh Inh Aerosol (6.9gm Bulk) $ 117.65 bumetanide 0.25 mg/mL Sol $ 3.50 bumetanide 0.5 mg Tab $ 8.50 bumetanide 1 mg Tab $ 3.82 bumetanide 1mg/4mL Inj Sol 4 mL $ 3.50 bumetanide 2 mg Tab $ 10.38 bupivacaine 0.25% Inj Soln (50mL UD Inj) $ 3.50 bupivacaine 0.25% PF Inj Soln (10mL UD Inj) $ 3.50 bupivacaine 0.25% PF Inj Soln (30mL UD Inj) $ 3.50 bupivacaine 0.5% Inj Soln (50mL UD Inj) $ 3.50 bupivacaine 0.5% PF Inj Soln (10mL UD Inj) $ 3.50 bupivacaine 0.5% PF Inj Soln (30mL UD Inj) $ 3.50 bupivacaine 0.5%-EPINEPHrine 1:200,000 Inj Soln (10mL UD Inj) $ 3.50 bupivacaine 0.75% PF Inj Soln (10mL UD Inj) $ 3.50 bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Soln (10mL UD Inj) $ 3.50 bupivacaine-EPINEPHrine 0.25%-1:200,000 PF Inj Soln (30mL UD Inj) $ 3.50 buprenorphine 10 mcg/hr Film $ 422.81 buprenorphine 15 mcg/hr Film $ 609.90 buprenorphine 150 mcg buccal Film $ 19.32 buprenorphine 2 mg Tab-SL $ 14.49 buprenorphine 20 mcg/hr Film $ 748.52 buprenorphine 5 mcg/hr Film $ 281.87 buprenorphine 7.5 mcg/hr Film $ 394.62 buprenorphine 75 mcg buccal Film $ 19.32 buprenorphine 8 mg Tab-SL $ 10.15 buprenorphine-naloxone 2 mg-0.5 mg Film $ 17.37 buprenorphine-naloxone 2 mg-0.5 mg Tab SL $ 15.90 buprenorphine-naloxone 4 mg-1 mg Film $ 31.11 buprenorphine-naloxone 5.7 mg-1.4 mg Tab SL $ 34.88 buprenorphine-naloxone 8 mg-2 mg Film $ 31.11 buprenorphine-naloxone 8 mg-2 mg Tab SL $ 28.42 buPROPion 100 mg SR twice daily Tab $ 5.91 buPROPion 100 mg Tab $ 6.87 buPROPion 150 mg SR twice daily Tab $ 6.34 buPROPion 150 mg XL once daily Tab $ 16.71 buPROPion 300 mg XL once daily Tab $ 16.69 buPROPion 75 mg Tab $ 5.41 busPIRone 10 mg Tab $ 4.71 busPIRone 15 mg Tab $ 7.07

STANDARD HOSPITAL CHARGES

busPIRone 30 mg Tab $ 12.72 busPIRone 5 mg Tab $ 3.50 busPIRone 7.5 mg Tab $ 5.53 butorphanol 10 mg/mL Spr $ 134.85 cabergoline 0.5 mg Tab $ 128.31 cadexomer iodine 0.9% Topical Gel (10gm Bulk) $ 8.28 cadexomer iodine 0.9% Topical Gel (40gm Bulk) $ 11.99 caffeine 200 mg Tab $ 3.50 calamine 8% Topical Lotion (120mL Bulk) $ 3.50 calamine-pramoxine 8%-1% Topical Lotion (180mL Bulk) $ 3.50 calazime topical paste $ 55.72 calcipotriene 0.005% Topical Cream (60gm Bulk) $ 25.85 calcitonin 200 intl units/inh Nasal Spray (3.7mL Bulk) $ 84.99 calcitonin 200 intl units/mL Inj Sol 2mL $ 5,676.44 calcitriol 0.25 mcg Oral Cap $ 4.29 calcitriol 0.5 mcg Oral Cap $ 6.77 calcitriol 1 mcg/mL Inj Sol $ 21.00 calcitriol 1 mcg/mL Oral Liquid (Extemp) $ 41.88 calcium acetate 667 mg Cap $ 3.59 calcium acetate 667 mg tab $ 3.50 calcium acetate 667 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 calcium carbonate 1250 mg Tab (500mg elemental calcium) $ 3.50 calcium carbonate 1250 mg/5 mL Oral Susp (5mL UD) $ 3.50 calcium carbonate 500 mg Chew Tab $ 3.50 calcium carbonate 600 mg Tab $ 3.50 calcium carbonate 750 mg ChewTab $ 3.50 calcium carbonate-magnesium chloride 112 mg-64 mg Tab $ 3.50 calcium chloride 100mg/mL Solution IV (10mL Vial) $ 3.78 calcium citrate 950 mg (200mg elemental Calcium)Tab $ 3.50 calcium citrate-vitamin D 200 mg-250 intl units Tab $ 3.50 calcium gluconate 100 mg/mL Inj Sol 10 mL $ 3.84 calcium gluconate 500 mg Tab $ 3.50 calcium-vita D-Phosphorus 500mg-500intlunits-100mg/15 ml Oral Liq (15mL UD Liq) $ 3.50 calcium-vitamin D 250 mg-125 intl units Tab $ 3.50 calcium-vitamin D 315 mg-250 intl units Tab $ 3.50 calcium-vitamin D 500 mg-200 intl units Tab $ 3.50 calcium-vitamin D 500 mg-400 intl units Tab-Chew $ 3.50 calcium-vitamin D 600 mg-200 intl units Tab $ 3.50 calcium-vitamin D 600 mg-400 intl units Tab $ 3.50 camphor/menthol/methyl salicylate 3.1%-6%-10% Topical Film $ 3.50 camphor-menthol 0.5%-0.5% Topical Lotion (225mL Bulk) $ 3.50 camphor-menthol 0.5%-0.5% Topical Lotion (59mL Bulk) $ 3.50 camphor-menthol 4.8%-2.6% Topical Oint (50gm Bulk) $ 3.50 camphor-menthol topical 0.2%-3.5% Top Gel (89gm Bulk) $ 3.50 canagliflozin 100 mg Tab $ 59.13 canagliflozin 300 mg Tab $ 59.13 canagliflozin-metFORMIN 150 mg-1000 mg Tab $ 29.56

STANDARD HOSPITAL CHARGES

canagliflozin-metFORMIN 50 mg-500 mg Tab $ 29.56 candesartan 16 mg Tab $ 11.57 candesartan 32 mg Tab $ 15.03 candesartan 4 mg Tab $ 11.11 candesartan 8 mg Tab $ 11.11 capecitabine 500 mg Tab $ 138.87 capsaicin 0.025% Topical Cream (60gm Bulk) $ 3.50 capsaicin 0.025% Topical Film $ 4.43 capsaicin 0.075% Topical Crem (57gm Bulk) $ 3.50 capsaicin 0.1% Topical Cream (42.5gm Bulk) $ 3.50 capsaicin 0.1% Topical Cream (60gm Bulk) $ 3.50 captoPRIL 12.5 mg Tab $ 6.01 captoPRIL 25 mg Tab $ 5.84 captoPRIL 50 mg Tab $ 10.15 carBAMazepine 100 mg Cap ER $ 6.26 carBAMazepine 100 mg Chew Tab $ 3.50 carBAMazepine 100 mg ER Tab $ 4.01 carBAMazepine 100 mg/5 mL Oral Susp (5mL UD Liq) $ 3.50 carBAMazepine 200 mg Cap ER $ 6.26 carBAMazepine 200 mg Tab $ 5.60 carBAMazepine 200 mg Tab-ER $ 7.27 carBAMazepine 200mg/10mL Oral Susp (10mL UD Liq) $ 3.50 carBAMazepine 300 mg ERCap $ 6.26 carBAMazepine 400 mg Tab-ER $ 14.54 carbamide peroxide 10% Oral Topical Solution (15mL Bulk) $ 3.50 carbamide peroxide 6.5% Otic Soln (15mL Bulk) $ 3.50 carbidopa 25 mg Tab $ 76.47 carbidopa/entacapone/levodopa 12.5 mg-200 mg-50 mg Tab $ 13.11 carbidopa/entacapone/levodopa 18.75 mg-200 mg-75 mg Tab $ 13.11 carbidopa/entacapone/levodopa 25 mg-200 mg-100 mg Tab $ 12.98 carbidopa/entacapone/levodopa 31.25 mg-200 mg-125 mg Tab $ 13.11 carbidopa/entacapone/levodopa 37.5 mg-200 mg-150 mg Tab $ 12.98 carbidopa/entacapone/levodopa 50 mg-200 mg-200 mg oral tablet $ 13.11 carbidopa-levodopa 10 mg-100 mg $ 4.01 carbidopa-levodopa 10 mg-100 mg ODT Tab $ 4.25 carbidopa-levodopa 23.75 mg-95 mg Cap $ 12.25 carbidopa-levodopa 25 mg-100 mg $ 3.50 carbidopa-levodopa 25 mg-100 mg ER Tab $ 3.50 carbidopa-levodopa 25 mg-100 mg ODT Tab $ 4.80 carbidopa-levodopa 25 mg-250 mg $ 5.65 carbidopa-levodopa 25 mg-250 mg ODT Tab $ 6.12 carbidopa-levodopa 36.25 mg-145 mg Cap $ 12.25 carbidopa-levodopa 48.75 mg-195 mg Cap $ 12.25 carbidopa-levodopa 50 mg-200 mg ER Tab $ 6.10 carbidopa-levodopa 61.25 mg-245 mg Cap $ 15.39 cariprazine 1.5 mg Cap $ 152.83 carisoprodol 250 mg Tab $ 11.57

STANDARD HOSPITAL CHARGES

carisoprodol 350 mg Tab $ 3.50 carteolol 1% Opht Soln (5mL Bulk) $ 14.90 carveDILOL 10 mg Cap ER $ 36.13 carveDILOL 12.5 mg Tab $ 7.47 carveDILOL 20 mg Cap ER $ 36.13 carveDILOL 25 mg Tab $ 3.50 carveDILOL 3.125 mg Tab $ 7.47 carveDILOL 40 mg Cap ER $ 36.13 carveDILOL 6.25 mg Tab $ 7.47 carveDILOL 80 mg Cap ER $ 36.13 caspofungin 50 mg IV Inj $ 942.90 caspofungin 70 mg IV Inj $ 1,343.83 cefaclor 250 mg Cap $ 6.96 cefaclor 500 mg Cap $ 13.63 cefadroxil 250 mg/5 mL Oral Liquid (Extemp) $ 3.50 cefadroxil 500 mg Cap $ 12.60 cefadroxil 500 mg/5 mL (5mL UD LIq) $ 3.50 ceFAZolin 1 gm Pow inj (vial) $ 4.62 ceFAZolin 1 gm Powder Injection (addv) $ 10.33 ceFAZolin 1 gm/50 mL- D5% Solution IV (duplex) $ 25.70 ceFAZolin 1 gm/50 mL Sol (frozen) $ 3.50 ceFAZolin 10 g Pow inj (vial) $ 91.70 ceFAZolin 2 g/100 mL-D5% Solution IV (frozen) $ 3.50 ceFAZolin 2 gm/50mL - D5% Solution IV (duplex) $ 38.56 ceFAZolin 500 mg Pow inj (vial) $ 34.07 cefdinir 125 mg/5 mL Powder-Recon (Extemp) $ 3.50 cefdinir 300 mg Cap $ 3.50 cefepime 1 gm Pow inj $ 71.16 cefepime 1 gm Pow inj (addv) $ 23.72 cefepime 1 gm/50 mL - D5% Solution IV (Duplex) $ 49.22 cefepime 2 g/100 mL Solution IV (frozen) $ 3.50 cefepime 2 gm Pow inj $ 141.25 cefepime 2 gm Pow inj (addv) $ 39.02 cefepime 2 gm/50 mL - D5% Solution IV (Duplex) $ 74.24 cefixime 100 mg/5 mL Oral Liquid (Extemp) $ 15.59 cefixime 400 mg Cap UD $ 96.87 cefotaxime 1 gm Pow Inj (vial) $ 22.75 cefotaxime 2 gm Powder Injection (Vial) $ 92.35 cefOXitin 1 gm Pow inj (Vial) $ 26.81 cefOXitin 1 gm/50 mL Solution IV (duplex) $ 45.89 cefOXitin 2 gm Pow inj (vial) $ 53.55 cefOXitin 2 gm/50 mL Solution IV (duplex) $ 84.24 cefpodoxime 100 mg Tab $ 23.58 cefpodoxime 200 mg Tab $ 29.60 cefprozil 125 mg/5 mL (5mL UD Liq) $ 3.50 cefprozil 250 mg Tab $ 15.33 cefprozil 500 mg Tab $ 31.65

STANDARD HOSPITAL CHARGES

ceftaroline 400 mg Pow inj $ 669.91 ceftaroline 600 mg Pow inj $ 669.91 cefTAZidime 1 g/50 mL Solution IV (Duplex) $ 43.85 cefTAZidime 1 gm Pow inj (Addv) $ 22.51 cefTAZidime 1 gm Pow inj (vial) $ 18.90 cefTAZidime 1 gm/50 mL Sol (frozen) $ 3.50 cefTAZidime 2 g/50 mL Solution IV (Duplex) $ 63.39 cefTAZidime 2 gm Pow inj (addv) $ 45.74 cefTAZidime 2 gm Pow inj (vial) $ 42.00 cefTAZidime 500 mg Pow inj (vial) $ 27.72 ceftolozane-tazobactam 1 g-0.5 g Pow inj $ 402.59 cefTRIAXone 1 gm Pow inj (addv) $ 13.18 cefTRIAXone 1 gm/50 mL Sol (frozen) $ 3.50 cefTRIAXone 1 gm/50 mL Solution IV (Duplex) $ 48.72 cefTRIAXone 2 gm Pow inj (addv) $ 30.16 cefTRIAXone 2 gm Pow inj (vial) $ 11.97 cefTRIAXone 2 gm/50 mL Sol (frozen) $ 5.80 cefTRIAXone 2 gm/50 mL Solution IV (Duplex) $ 77.88 cefTRIAXone 500 mg Pow Inj (vial) $ 26.25 cefuroxime 1.5 gm Powder Injection (Vial) $ 47.04 cefuroxime 250 mg Tab $ 15.39 cefuroxime 500 mg Tab $ 28.05 cefuroxime 750 mg Powder Injection (Vial) $ 12.85 celecoxib 100 mg Cap $ 15.28 celecoxib 200 mg Cap $ 26.53 celecoxib 50 mg Cap $ 7.55 cellulose 100% Powder (240gm Bulk) $ 3.50 cephalexin 250 mg Cap $ 3.50 cephalexin 250 mg/5 mL Oral Liquid (Extemp) $ 3.50 cephalexin 500 mg Cap $ 3.50 cetirizine 1 mg/mL Oral Syrup (Extemp) $ 3.50 cetirizine 10 mg Tab $ 7.87 cetirizine 5 mg Tab $ 8.73 cetirizine-pseudoephedrine 5 mg-120 mg ER Tab 12 hr $ 3.50 cevimeline 30 mg Cap $ 12.20 charcoal 25 g Oral Suspension (120mL Bulk) $ 3.50 charcoal 50 g Oral Suspension (240mL Bulk) $ 3.50 charcoal-sorbitol 25 g Oral Susp (120mL UD Liq) $ 3.50 charcoal-sorbitol 50 g Oral Suspension (240mL Bulk) $ 3.50 chloral hydrate 500 mg Cap $ 5.67 chloral hydrate 500 mg/5 mL Oral Syrup (5mL UD) $ 3.50 chlorambucil 2 mg Tab $ 102.18 chlordiazePOXIDE 10 mg Cap $ 3.50 chlordiazePOXIDE 25 mg Cap $ 3.50 chlordiazePOXIDE 5 mg Cap $ 3.50 chlordiazePOXIDE-clidinium 5 mg-2.5 mg Cap $ 18.00 chlorhexidine 0.12% Oral Topical Liquid (118mL Bulk) $ 3.50

STANDARD HOSPITAL CHARGES

chlorhexidine 0.12% Oral Topical Liquid (480mL Bulk) $ 3.50 chlorhexidine 0.12% Oral Topical Soln (15mL UD) $ 3.50 chlorhexidine 4% Topical Soap (120mL Bulk) $ 3.50 chlorhexidine 4% Topical Soap (15mL Bulk) $ 3.50 chlorhexidine 4% Topical Soap (237mL Bulk) $ 3.50 chlorhexidine 4% Topical Soap (473mL Bulk) $ 3.50 chlorophyllin 3 mg Tab $ 3.50 chloroquine 250 mg Tab $ 16.26 chlorothiazide 0.5 g Inj $ 436.63 chlorothiazide 250 mg Tab $ 3.50 chlorothiazide 500 mg Tab $ 4.34 chlorpheniramine 4 mg Tab $ 3.50 chlorpheniramine-dextromethorphan 2 mg-15 mg/5 mL Syrup $ 3.50 chlorpheniramine-HYDROcodone 8 mg-10 mg Cap $ 132.42 chlorpheniramine-HYDROcodone 8mg-10mg/5mL Oral Susp-ER (5mL UD Liq) $ 3.50 chlorproMAZINE 10 mg Tab $ 23.20 chlorproMAZINE 100 mg Tab $ 52.10 chlorproMAZINE 200 mg Tab $ 79.95 chlorproMAZINE 25 mg Tab $ 33.46 chlorproMAZINE 25 mg/mL Inj Sol $ 93.97 chlorproMAZINE 25 mg/mL Inj Sol (2mL) $ 53.84 chlorproMAZINE 50 mg Tab $ 48.42 chlorproPAMIDE 100 mg Tab $ 4.21 chlorproPAMIDE 250 mg Tab $ 8.89 chlorthalidone 25 mg Tab $ 8.03 chlorthalidone 50 mg Tab $ 5.21 chlorzoxazone 500 mg Tab $ 3.50 cholecalciferol 1000 intl units Tab $ 3.50 cholecalciferol 1000 intl units/10 mL Oral Liquid (10mL UD Liq) $ 3.50 cholecalciferol 10000 intl units Cap $ 6.42 cholecalciferol 2000 intl units Cap $ 3.50 cholecalciferol 2000 intl units Tab $ 3.50 cholecalciferol 400 intl units Cap $ 3.50 cholecalciferol 400 intl units Tab $ 3.50 cholecalciferol 400 intl units/mL Oral Liquid (Extemp) $ 3.50 cholecalciferol 50,000 intl units Cap $ 3.50 cholecalciferol 5000 intl units Cap $ 3.50 cholecalciferol 5000 intl units Oral Liquid (1mL UD Liq) $ 3.50 cholestyramine 4 g/5 g Oral Powder (1EA UD) $ 11.73 cholestyramine 4 g/5.5g Oral Powder (1EA UD) $ 17.88 cholestyramine 4 g/9 g Oral Powder (1EA UD) $ 11.79 choline-magnesium salicylate 500 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 chondroitin-glucosamine 200 mg-250 mg Cap $ 3.50 chondroitin-glucosamine 400 mg-500 mg oral capsule $ 3.50 chondroitin-glucosamine 400 mg-500 mg Tab $ 3.50 chromium picolinate 200 mcg Cap $ 3.50 chromium picolinate 200 mcg Tab $ 3.50

STANDARD HOSPITAL CHARGES

ciclopirox 0.77% Topical Cream (15gm Bulk) $ 7.37 ciclopirox 8% Topical Solution (6.6mL Bulk) $ 89.39 cilostazol 100 mg Tab $ 6.39 cilostazol 50 mg Tab $ 6.39 cimetidine 400 mg Tab $ 9.14 cinacalcet 30 mg Tab $ 112.94 cinacalcet 60 mg Tab $ 225.88 cinacalcet 90 mg Tab $ 338.81 cinnamon 500mg cap $ 3.50 ciprofloxacin 0.3% Opht Oint (3.5gm Bulk) $ 257.23 ciprofloxacin 0.3% Opht Soln (10mL Bulk) $ 33.05 ciprofloxacin 0.3% Opht Soln (2.5mL Bulk) $ 35.04 ciprofloxacin 0.3% Opht Soln (5mL Bulk) $ 33.12 ciprofloxacin 200 mg/100 mL IV Sol $ 3.50 ciprofloxacin 250 mg Tab $ 19.11 ciprofloxacin 400mg/200mL IV Sol $ 3.50 ciprofloxacin 500 mg Tab $ 3.50 ciprofloxacin 500 mg/5 mL Oral Powder $ 6.09 ciprofloxacin 750 mg Tab $ 26.81 ciprofloxacin otic 0.2% Otic Sol (1 EA) $ 29.79 ciprofloxacin-dexamethasone 0.3%-0.1% Otic Susp (7.5mL Bulk) $ 122.42 ciprofloxacin-hydrocortisone 0.2%-1% Otic Susp (10mL Bulk) $ 125.16 citalopram 10 mg Tab $ 8.49 citalopram 10 mg/5 mL Oral Solution ( 5mL UD Liq) $ 3.50 citalopram 20 mg Tab $ 9.43 citalopram 40 mg Tab $ 12.22 citicoline 1000 mg Tab $ 9.33 citric acid/gluconodelta-lactone/Mg carbonate - Solution IRR (30mL) $ 3.50 citric acid/Mg oxide/Na picosulfate 12 g-3.5 g-10 mg Pow $ 270.62 citric acid-potassium bicarbonate 10 mEq Tab-eff $ 3.50 citric acid-potassium bicarbonate 20 mEq Tab-eff $ 3.50 citric acid-potassium citrate 30 mEq/1packet Oral Powder (1EA UD) $ 5.80 citric acid-potassium citrate 334 mg-1100 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 citric acid-sodium citrate 1002mg-1500mg/15mL Oral Soln (15mL UD) $ 3.50 citric acid-sodium citrate 2004mg-3000mg/30mL Oral Soln (30mL UD Liq) $ 7.60 citric acid-sodium citrate 3840mg-2940mg/30mL Oral Sol (30mL UD Liq) $ 3.50 clarithromycin 250 mg Tab $ 21.05 clarithromycin 250 mg/5 mL Oral Liquid (Extemp) $ 6.32 clarithromycin 500 mg Tab $ 21.05 clemastine 2.68 mg Tab $ 8.30 clindamycin 2% Vaginal Cream (40gm Bulk) $ 11.40 clindamycin 1% Topical Soln (30mL Bulk) $ 3.50 clindamycin 150 mg Cap $ 3.50 clindamycin 150 mg/mL Sol IV (2 mL vial) $ 6.24 clindamycin 150 mg/mL Sol IV (4 mL addv) $ 6.09 clindamycin 150 mg/mL Sol IV (4 mL vial) $ 3.69 clindamycin 150 mg/mL Sol IV (6 mL addv) $ 3.50

STANDARD HOSPITAL CHARGES

clindamycin 150 mg/mL Sol IV (6 mL SDV) $ 3.50 clindamycin 300 mg Cap $ 4.54 clindamycin 300 mg/50 mL-D5W IV Sol (premix) $ 3.50 clindamycin 600 mg/50 mL 0.9% NS IV Sol (premix) $ 3.50 clindamycin 600 mg/50 mL-D5W IV Sol (premix) $ 3.50 clindamycin 75 mg/5 mL Powder-Recon (Extemp) $ 3.50 clindamycin 900 mg/50 mL-D5W IV Sol (premix) $ 3.50 clindamycin topical 1% Gel (30gm Bulk) $ 10.08 clobazam 10 mg Tab $ 76.88 clobazam 2.5 mg/mL Oral Suspension (1mL UD Liq) $ 33.66 clobazam 20 mg Tab $ 153.76 clobetasol 0.05% Topical Cream (15gm Bulk) $ 29.92 clobetasol 0.05% Topical Cream (30gm Bulk) $ 29.92 clobetasol 0.05% Topical Cream (45gm Bulk) $ 29.92 clobetasol 0.05% Topical Cream (60gm Bulk) $ 26.77 clobetasol 0.05% Topical Gel (15gm Bulk) $ 38.81 clobetasol 0.05% Topical Oint (15gm Bulk) $ 36.27 clobetasol 0.05% Topical Oint (30gm Bulk) $ 30.30 clobetasol 0.05% Topical Oint (45gm Bulk) $ 32.29 clobetasol 0.05% Topical Shampoo (118mL Bulk) $ 11.92 clobetasol 0.05% Topical Soln (25mL Bulk) $ 14.44 clobetasol 0.05% Topical Soln (50mL Bulk) $ 14.44 clobetasol/emoll 0.05% Topical Cream (60gm Bulk) $ 15.90 clomiPRAMINE 25 mg Cap $ 39.35 clomiPRAMINE 50 mg Cap $ 39.35 clomiPRAMINE 75 mg Cap $ 39.35 clonazePAM 0.125 mg DisTab $ 4.55 clonazePAM 0.25 mg Dis Tab $ 4.55 clonazePAM 0.5 mg Tab $ 3.50 clonazePAM 0.5 mg Tab-Dis $ 4.54 clonazePAM 1 mg Tab $ 3.50 clonazePAM 1 mg Tab-Dis $ 5.19 clonazePAM 2 mg $ 4.15 cloNIDine 0.1 mg Tab $ 3.50 cloNIDine 0.1 mg/24 hr Transderm ER Film $ 115.93 cloNIDine 0.2 mg Tab $ 3.50 cloNIDine 0.2 mg/24 hr Transderm ER Film $ 195.18 cloNIDine 0.3 mg Tab $ 3.50 cloNIDine 0.3 mg/24 hr Transderm ER Film $ 270.76 clopidogrel 75 mg Tab $ 15.27 clorazepate 15 mg Tab $ 16.36 clorazepate 3.75 mg Tab $ 7.11 clorazepate 7.5 mg Tab $ 17.56 clotrimazole 2% Topical Vaginal Cream (21gm Bulk) $ 3.50 clotrimazole 1% Topical Cream (15gm Bulk) $ 3.50 clotrimazole 1% Topical Cream (30gm Bulk) $ 3.50 clotrimazole 1% Topical Cream (45gm Bulk) $ 3.81

STANDARD HOSPITAL CHARGES

clotrimazole 1% Topical Soln (10mL Bulk) $ 15.80 clotrimazole 1% Topical Soln (30mL Bulk) $ 8.72 clotrimazole 1% Topical Vaginal Cream (45gm Bulk) $ 3.50 clotrimazole 10 mg Loz $ 12.02 cloZAPine 100 mg Tab $ 12.00 cloZAPine 100 mg Tab-Dis $ 28.61 cloZAPine 25 mg Tab $ 4.62 cloZAPine 25 mg Tab-Dis $ 10.49 cloZAPine 50 mg Tab $ 5.85 coal tar 2% Topical Shampoo (120mL Bulk) $ 3.50 coal tar 0.5% Topical Shampoo (235mL Bulk) $ 3.50 cobicistat/elvitegravir/emtricitabine/tenofov 150 mg-150 mg-200 mg-10 mg Tab $ 412.39 cobicistat-darunavir 150 mg-800 mg Tab $ 229.93 cocaine 4% Topical Soln (4mL Bulk) $ 195.23 codeine sulfate 15 mg Tab $ 3.50 codeine sulfate 30 mg Tab $ 3.50 codeine-guaiFENesin 10 mg-100 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 codeine-guaiFENesin 20 mg-200 mg/10 mL Oral Syrup (10mL UD) $ 3.50 codeine-promethazine 10 mg-6.25 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 colchicine 0.6 mg Cap $ 22.87 colchicine 0.6 mg Tab $ 23.58 colchicine-probenecid 0.5 mg-500 mg $ 3.50 colesevelam 3.75gm/1packet Oral Powder (1EA UD) $ 78.61 colesevelam 625 mg Tab $ 13.10 colestipol 1 g Tab $ 4.42 colestipol 5 g packet $ 13.76 colistimethate 150 mg Inj $ 117.56 collagenase 250 units/g Topical Ointment (30gm Bulk) $ 31.61 collagenase 250 units/g Topical Ointment (90gm Bulk) $ 30.03 conj. estrog.-medroxyPROG. 0.3 mg-1.5 mg Tab $ 27.59 conj. estrog.-medroxyPROG. 0.45 mg-1.5 mg Tab $ 27.59 conj. estrog.-medroxyPROG. 0.625 mg-2.5 mg Tab $ 27.59 conjugated estrogens 0.3 mg Tab $ 22.49 conjugated estrogens 0.45 mg Tab $ 22.49 conjugated estrogens 0.625 mg Tab $ 22.49 conjugated estrogens 0.625 mg/g Vaginal Cream w/Appl (30gm Bulk) $ 49.81 conjugated estrogens 0.9 mg Tab $ 22.49 cortisone 25 mg Tab $ 10.94 cosyntropin 0.25 mg Inj $ 336.84 cranberry 200 mg Cap $ 3.50 cranberry 250 mg tab $ 3.50 cranberry 475mg Cap $ 3.50 cranberry 500mg Cap $ 3.50 cranberry extract 400mg $ 3.50 cromolyn 100mg/5mLOral Soln (5mL UD) $ 4.40 cromolyn 4% ophthalmic Solution (10mL Bulk) $ 13.02 cromolyn 5.2 mg/inh Nasal Spray (26mL Bulk) $ 3.50

STANDARD HOSPITAL CHARGES

cyanocobalamin 100 mcg Tab $ 3.50 cyanocobalamin 1000 mcg Loz $ 3.50 cyanocobalamin 1000 mcg SL Tab $ 3.50 cyanocobalamin 1000 mcg Tab $ 3.50 cyanocobalamin 1000 mcg/mL Inj Sol $ 30.59 cyanocobalamin 250 mcg Tab $ 3.50 cyanocobalamin 2500 mcg SL Tab $ 3.50 cyanocobalamin 500 mcg Tab $ 3.50 cyanocobalamin-methylcobalamin 600 mcg-600 mcg Tab-SL $ 3.50 cyclobenzaprine 10 mg Tab $ 3.50 cyclobenzaprine 30 mg Cap-ER $ 152.47 cyclobenzaprine 5 mg Tab $ 5.74 cyclopentolate 1% ophthalmic Solution (15mL Bulk) $ 8.16 cyclopentolate 1% ophthalmic Solution (2mL Bulk) $ 25.87 cyclophosphamide 25 mg Cap $ 32.77 cyclophosphamide 25 mg Tab $ 9.75 cyclophosphamide 50 mg Cap $ 60.13 cyclophosphamide 50 mg Tab $ 17.90 cycloSPORINE 0.05% Opht Emulsion (1EA UD) $ 32.41 cycloSPORINE 100 mg/mL Oral Soln (Extemp) $ 54.67 cycloSPORINE 25 mg Cap $ 11.64 cycloSPORINE modified 100 mg Cap (Gengraf) $ 26.71 cycloSPORINE modified 100 mg Cap (Neoral) $ 32.82 cycloSPORINE modified 100 mg/mL Oral Liquid (Extemp) $ 20.69 cycloSPORINE modified 25 mg Cap (Gengraf) $ 4.83 cycloSPORINE modified 25 mg Cap (Neoral) $ 4.81 cycloSPORINE modified 50 mg Cap (Gengraf) $ 9.58 cyproheptadine 2 mg/5 mL Syrup (10mL UD) $ 3.50 cyproheptadine 4 mg Tab $ 3.74 dabigatran 110 mg Cap $ 25.49 dabigatran 150 mg Cap $ 27.53 dabigatran 75 mg Cap $ 27.53 dalfampridine 10 mg Tab $ 68.38 dalfopristin-quinupristin 350 mg-150 mg IV Inj $ 1,688.38 dalteparin 10,000 intl units/mL Sol $ 344.72 dalteparin 12,500 intl units/0.5 mL Inj Sol $ 861.85 dalteparin 15,000 intl units/0.6 mL Sol $ 861.80 dalteparin 18,000 intl units/0.72 mL Sol $ 861.79 dalteparin 2500 intl units/0.2 mL Injection Solution $ 531.20 dalteparin 5000 intl units/0.2 mL Injection Solution $ 854.65 danazol 100 mg Cap $ 10.03 danazol 200 mg Cap $ 36.01 danazol 50 mg Cap $ 12.70 dantrolene 100 mg Cap $ 7.59 dantrolene 25 mg Cap $ 3.74 dantrolene 50 mg Cap $ 6.05 dapagliflozin 10 mg Tab $ 65.04

STANDARD HOSPITAL CHARGES

dapagliflozin 5 mg Tab $ 65.04 dapsone 100 mg Tab $ 10.58 dapsone 25 mg Tab $ 7.70 DAPTOmycin 350 mg Powder Injection (vial) $ 1,229.19 DAPTOmycin 500 mg Powder Injection (Vial) $ 1,871.03 darbepoetin alfa 100 mcg/0.5 mL Inj Sol $ 6,501.60 darbepoetin alfa 100 mcg/mL Inj Sol $ 3,250.80 darbepoetin alfa 150 mcg/0.3 mL Inj Sol $16,254.00 darbepoetin alfa 150 mcg/0.75 mL Inj Sol $ 5,673.36 darbepoetin alfa 200 mcg/0.4 mL Inj Sol $16,254.00 darbepoetin alfa 200 mcg/mL Inj Sol $ 6,501.60 darbepoetin alfa 25 mcg/0.42 mL Sol $ 1,935.00 darbepoetin alfa 25 mcg/mL Inj Sol $ 812.70 darbepoetin alfa 300 mcg/0.6 mL Sol $16,254.00 darbepoetin alfa 300 mcg/mL Inj Sol $ 9,752.40 darbepoetin alfa 40 mcg/0.4 mL Sol $ 3,250.80 darbepoetin alfa 40 mcg/mL Inj Sol $ 1,300.32 darbepoetin alfa 500 mcg/mL Inj Sol $16,254.00 darbepoetin alfa 60 mcg/0.3 mL Sol $ 6,501.60 darbepoetin alfa 60 mcg/mL Inj Sol $ 1,950.48 darifenacin 15 mg ER Tab $ 38.70 darifenacin 7.5 mg ER Tab $ 38.70 darunavir 150 mg Tab $ 25.15 darunavir 400 mg Tab $ 80.06 darunavir 600 mg Tab $ 100.59 darunavir 800 mg Tab $ 201.17 deferasirox 500 mg Tab-Dis $ 656.86 deferoxamine 500mg Powder Injection (Vial) $ 36.61 delavirdine 200 mg Tab $ 10.38 demeclocycline 150 mg Tab $ 22.54 demeclocycline 300 mg Tab $ 59.74 desipramine 10 mg Tab $ 4.14 desipramine 150 mg Tab $ 32.01 desipramine 25 mg Tab $ 7.02 desipramine 50 mg Tab $ 9.37 desmopressin 0.1 mg Tab $ 4.41 desmopressin 0.2 mg Tab $ 4.95 desmopressin 10mcg/spray Nasal Solution (2.5mL Bulk) $ 444.01 desmopressin 10mcg/spray Nasal Spray (5mL Bulk) $ 165.48 desmopressin 4 mcg/mL IV Sol (1 mL) $ 43.47 desmopressin 4 mcg/mL IV Sol (10 mL) $ 249.98 desonide 0.05% Topical Cream (15gm Bulk) $ 18.73 desonide 0.05% Topical Cream (60gm Bulk) $ 18.73 desonide 0.05% topical Lotion (59mL Bulk) $ 17.57 desonide 0.05% Topical Ointment (15gm Bulk) $ 14.02 desoximetasone 0.25% Topical Cream (15gm Bulk) $ 13.60 desoximetasone 0.25% Topical Cream (60gm Bulk) $ 11.62

STANDARD HOSPITAL CHARGES

desoximetasone 0.25% Topical Ointment (15gm Bulk) $ 15.68 desvenlafaxine 100 mg Tab ER $ 20.56 desvenlafaxine 25 mg Tab ER $ 40.16 desvenlafaxine 50 mg Tab ER $ 41.83 dexameth/neomycin/polymyxin B 1 mg-3.5 mg-10000 units/g Opht Oint (3.5gm Bulk) $ 44.00 dexameth/neomycin/polymyxin B 1 mg-3.5 mg-10000 units/mL Opht Susp (5mL Bulk) $ 13.90 dexamethasone 0.1% Opht Sol (5mL Bulk) $ 47.17 dexamethasone 0.1% Opht Susp (5mL Bulk) $ 63.34 dexamethasone 0.5 mg Tab $ 3.50 dexamethasone 0.5 mg/5 mL Liq Oral Liquid (Extemp) $ 3.50 dexamethasone 0.75 mg Tab $ 3.50 dexamethasone 1 mg Tab $ 3.50 dexamethasone 1.5 mg Tab $ 3.50 dexamethasone 10 mg/mL Inj Sol (10mL Bulk) $ 4.55 dexamethasone 10 mg/mL preservative-free Sol $ 22.05 dexamethasone 10 mg/mL Sol $ 5.46 dexamethasone 2 mg Tab $ 3.50 dexamethasone 4 mg Tab $ 4.22 dexamethasone 4 mg/mL Inj Sol $ 9.24 dexamethasone 4 mg/mL Inj Sol 30 mL $ 3.98 dexamethasone 4 mg/mL Inj Sol 5ml $ 3.50 dexamethasone-tobramycin 0.1%-0.3% Opht Susp (2.5mL Bulk) $ 83.99 dexamethasone-tobramycin 0.1%-0.3% Opht Susp (5mL Bulk) $ 85.18 dexamethasone-tobramycin 0.1%-0.3% Opth Oint (3.5gm Bulk) $ 250.78 dexlansoprazole 30 mg DR Cap $ 38.39 dexlansoprazole 60 mg DR Cap $ 38.39 dexmethylphenidate 10 mg Cap ER $ 33.17 dexmethylphenidate 5 mg Tab $ 3.50 dextroamphetamine 10 mg Cap ER $ 17.71 dextroamphetamine 10 mg tab $ 7.14 dextroamphetamine 15 mg Cap ER $ 22.58 dextroamphetamine 15 mg Tab $ 25.95 dextroamphetamine 5 mg Cap ER $ 14.18 dextroamphetamine 5 mg Tab $ 6.30 dextromethorphan 15 mg Cap $ 3.50 dextromethorphan 30 mg/5 mL Oral Susp (5mL UD Liq) $ 3.50 dextromethorphan-guaiFENesin 10 mg-100 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 dextromethorphan-guaiFENesin 20 mg-200 mg/10 mL Oral Liq (10mL UD) $ 3.50 dextromethorphan-guaiFENesin 20 mg-200 mg/10 mL Oral Soln (10mL UD) $ 3.50 dextromethorphan-guaiFENesin 20 mg-400 mg Tab $ 3.50 dextromethorphan-guaiFENesin 30 mg-600 mg Tab $ 3.50 dextromethorphan-guaiFENesin 60 mg-1200 mg Tab ER $ 3.50 dextromethorphan-promethazine 15 mg-6.25 mg/5 mL Syr $ 3.50 dextromethorphan-quiNIDine 20 mg-10 mg Cap $ 76.86 Dextrose 1.5% with Electrolytes (Dianeal PD-2) intraperitoneal solution (2,000 mL) $ 3.50 dextrose 10% in water IV Soln 1000 mL $ 3.50 dextrose 10% in water IV Soln 250 mL $ 3.50

STANDARD HOSPITAL CHARGES

dextrose 10% in water IV Soln 500 mL $ 3.50 dextrose 5 % in water IV Sol LVP 1000 ml CONT $ 3.50 Dextrose 5% in Lactated Ringers IV Sol LVP 1000 mL $ 3.50 dextrose 5% in water IV Sol 100 mL ADDV $ 3.50 dextrose 5% in water IV Soln 100 mL $ 3.50 dextrose 5% in water IV Soln 150 mL $ 3.50 dextrose 5% in water IV Soln 250 mL $ 3.50 dextrose 5% in water IV Soln 50 mL $ 3.50 dextrose 5% in water IV Soln 500 mL $ 3.50 Dextrose 5% in Water with KCl 20 mEq/L $ 3.50 dextrose 5% with 0.2% NaCl IV Soln 1000 mL $ 3.50 dextrose 5% with 0.2% NaCl IV Soln 500 mL $ 3.50 dextrose 5% with 0.225% NaCl IV Soln 500 mL $ 3.50 dextrose 5% with 0.33% NaCl IV Soln 1000 mL $ 3.50 dextrose 5% with 0.45% NaCl and KCl 10 mEq/L IV Soln 1000mL $ 3.50 dextrose 5% with 0.45% NaCl and KCl 20 mEq/L IV Soln 1000mL $ 3.50 dextrose 5% with 0.45% NaCl and KCl 30 mEq/L IV Soln 1000mL $ 3.50 dextrose 5% with 0.45% NaCl and KCl 40 mEq/L IV Soln 1000mL $ 3.50 dextrose 5% with 0.45% NaCl IV Soln 1000 mL $ 3.50 dextrose 5% with 0.45% NaCl IV Soln 500 mL $ 3.50 dextrose 5% with 0.9% NaCL and KCL 20 mEq/L $ 3.50 dextrose 5% with 0.9% NaCL and KCL 40 mEq/L $ 3.50 dextrose 5% with NS IV Soln 1000 mL $ 3.50 Dextrose 50% IV Sol 50 mL $ 3.50 diatrizoate 66%-10% Oral Soln (120mL Bulk) $ 3.50 diatrizoate 66%-10% Oral Soln (30mL Bulk) $ 3.50 diazepam 0.01mg/1mL Oral Solution (Extemp) $ 3.50 diazepam 10 mg rectal kit $ 1,274.21 diazepam 10 mg Tab $ 3.50 diazepam 2 mg Tab $ 3.50 diazepam 2.5 mg rectal Kit $ 1,085.12 diazepam 20 mg rectal Kit $ 1,287.21 diazepam 5 mg Tab $ 3.50 diazePAM 5 mg/5 mL Oral Solution (5mL UD) $ 3.50 diazepam 5 mg/mL Inj Sol (10mL Vial) $ 15.09 diazepam 5 mg/mL Inj Sol 2 mL $ 55.03 diazoxide 50 mg/mL Oral Susp (30mL Bulk) $ 37.32 dibucaine 1% Topical Ointment (30gm Bulk) $ 3.50 dibucaine 1% Topical Ointment (56.7gm Bulk) $ 3.50 diclofenac 0.1% Opht Soln (2.5mL Bulk) $ 62.68 diclofenac 0.1% Opht Soln (5mL Bulk) $ 51.12 diclofenac 1% Topical Gel (100gm Bulk) $ 3.50 diclofenac 1.3% Topical Film (1EA UD) $ 52.22 diclofenac 1.5% Topical Soln (150mL Bulk) $ 6.08 Diclofenac 1.5% Topical Solution (2mL UD) $ 27.09 diclofenac 3% Topical Gel (100gm Bulk) $ 39.63 diclofenac potassium 50 mg Tab $ 9.66

STANDARD HOSPITAL CHARGES

diclofenac sodium 100 mg Tab ER $ 9.84 diclofenac sodium 25 mg DR Tab $ 4.98 diclofenac sodium 50 mg Tab EC $ 5.15 diclofenac sodium 75 mg Tab EC $ 4.01 diclofenac-misoprostol 50 mg-200 mcg Tab $ 11.73 diclofenac-misoprostol 75 mg-200 mcg Tab $ 11.73 dicloxacillin 250 mg Cap $ 4.39 dicloxacillin 500 mg Cap $ 7.98 dicyclomine 10 mg Cap $ 3.50 dicyclomine 10 mg/mL Inj Sol 2 mL $ 85.31 dicyclomine 20 mg Tab $ 3.50 diflunisal 500 mg Tab $ 5.94 difluprednate 0.05% ophthalmic Emulsion (5 mL Bulk) $ 131.89 digoxin 125 mcg (0.125 mg) Tab $ 8.05 digoxin 250 mcg (0.25 mg) Tab $ 8.05 digoxin 250 mcg/mL (0.25 mg/mL) Inj Sol 2 mL $ 11.55 digoxin 50 mcg/mL (0.05 mg/mL) Elixer (2.5mL UD) $ 5.71 digoxin 50 mcg/mL (0.05 mg/mL) Oral Elixir (Extemp) $ 9.80 dihydroergotamine 1 mg/mL Inj Sol $ 524.09 diltiazem 100 mg vial (ADDV) $ 48.67 diltiazem 120 mg SR Cap 12hr $ 22.82 dilTIAZem 120 mg Tab (non-ER) $ 10.10 diltiazem 120 mg/24 hours ER Tab $ 15.98 diltiazem 120 mg/24 hours ERCap $ 4.19 diltiazem 180 mg/24 hours ERCap $ 3.50 diltiazem 240 mg/24 hours ERCap $ 7.18 diltiazem 30 mg Tab (non-ER) $ 3.50 diltiazem 300 mg/24 hours ERCap $ 5.80 dilTIAZem 360 mg/24 hours ER Cap $ 34.39 diltiazem 420 mg/24 hours ER Cap $ 6.19 diltiazem 5mg/mL Solution IV (10mL Vial) $ 3.50 diltiazem 5mg/mL Solution IV (25mL Vial) $ 3.50 diltiazem 5mg/mL Solution IV (5mL Vial) $ 3.50 diltiazem 60 mg SRCap 12hr $ 13.91 diltiazem 60 mg Tab (non-ER) $ 3.50 diltiazem 90 mg SRCap 12hr $ 16.35 diltiazem 90 mg Tab (non-ER) $ 3.50 dimenhyDRINATE 50 mg Tab $ 3.50 dimethyl fumarate 240 mg Cap DR $ 266.88 diphenhydrAMINE 12.5 mg Tab-Chew $ 3.50 diphenhydrAMINE 12.5 mg/5 mL Oral Liq (5mL UD) $ 3.50 diphenhydrAMINE 25 mg Cap $ 3.50 diphenhydrAMINE 25 mg Tab $ 3.50 diphenhydrAMINE 25mg/10mL Oral Liquid (10mL UD Liq) $ 3.50 diphenhydrAMINE 50 mg Cap $ 3.50 diphenhydrAMINE 50 mg/mL Inj Sol $ 11.55

STANDARD HOSPITAL CHARGES

diphenhydrAMINE/HC/nystatin topical 0.525 g-0.06 g-0.6 g/237 mL Oral Susp (237mL Bulk) $ 3.50 diphenhydrAMINE/HC/nystatin/TCN topical 0.45 g-0.06 g-1.2 g-1.5 g/237 mL Oral Susp (237mL Bulk) $ 3.50 diphenhydrAMINE/lidocaine/nystatin topical 0.2 g-1.6 g-1.6 g/237 mL Oral Susp (237mL Bulk) $ 3.50 diphenhydramine-ibuprofen 38 mg-200 mg Tab $ 3.50 diphenhydrAMINE-zinc acetate 1%-0.1% Topical Cream (30gm Bulk) $ 3.50 diphenhydrAMINE-zinc acetate 2%-0.1% Topical Cream (28gm Bulk) $ 3.50 dipyridamole 25 mg Tab $ 3.71 dipyridamole 50 mg Tab $ 5.98 dipyridamole 75 mg Tab $ 3.50 disopyramide 100 mg Cap $ 4.86 disopyramide 150 mg Cap $ 5.74 disulfiram 250 mg Tab $ 14.14 divalproex sodium 125 mg Cap-DR Sprinkle $ 3.50 divalproex sodium 125 mg DR Tab-EC $ 3.86 divalproex sodium 250 mg DR Tab-EC $ 6.10 divalproex sodium 250 mg ER Tab $ 5.43 divalproex sodium 500 mg DR Tab-EC $ 4.98 divalproex sodium 500 mg ER Tab $ 14.26 DOBUTamine 1mg/mL-D5% Solution IV (250mL IVPB) $ 3.50 DOBUTamine 2mg/mL-D5% Solution IV (250mL IVPB) $ 3.50 DOBUTamine 4mg/mL-D5% Solution IV (250mL IVPB) $ 3.50 docosanol 10% Topical Cream (2gm Bulk) $ 32.46 docusate 10 mg/mL Oral Liquid (10mL UD Liq) $ 3.50 docusate 283 mg Rectal Enema $ 3.50 docusate calcium 240 mg Cap $ 3.50 docusate sodium 100 mg Cap $ 3.50 docusate sodium 100 mg Tab $ 3.50 docusate sodium 250 mg Cap $ 3.50 docusate sodium 60 mg/15 mL Oral Syrup (Extemp) $ 3.50 docusate-senna 50 mg-8.6 mg Tab $ 3.50 dofetilide 125 mcg Cap $ 29.94 dofetilide 250 mcg Cap $ 43.65 dofetilide 500 mcg Cap $ 29.94 dolutegravir 25 mg Tab $ 105.49 dolutegravir 50 mg Tab $ 210.97 donepezil 10 mg Tab $ 3.50 donepezil 10 mg Tab ODT $ 27.26 donepezil 23 mg Tab $ 7.62 donepezil 5 mg Tab $ 3.50 donepezil 5 mg Tab ODT $ 27.26 donepezil-memantine 10 mg-14 mg Cap-ER $ 53.78 donepezil-memantine 10 mg-28 mg Cap-ER $ 53.78 DOPamine 1.6 mg/mL-D5% Solution IV $ 3.50 DOPamine 3.2 mg/mL-D5% Solution IV $ 3.50

STANDARD HOSPITAL CHARGES

doripenem 250 mg Pow inj $ 86.45 doripenem 500 mg Pow inj $ 157.78 dornase alfa 2.5 mg/2.5 mL Inh Sol $ 193.06 dorzolamide 2% Opht Soln (10mL Bulk) $ 23.36 dorzolamide-timolol 2%-0.5% PF Ophthalmic Solution (1EA UD) $ 10.99 dorzolamide-timolol 2.23%-0.68% Opht Soln (10mL Bulk) $ 23.62 doxazosin 1 mg Tab $ 3.55 doxazosin 2 mg Tab $ 3.55 doxazosin 4 mg Tab $ 3.62 doxazosin 8 mg Tab $ 5.20 doxepin 10 mg Cap $ 3.50 doxepin 10 mg/mL Oral Concentrate $ 3.50 doxepin 100 mg Cap $ 6.99 doxepin 150 mg Cap $ 3.50 doxepin 25 mg Cap $ 3.50 doxepin 3 mg Tab $ 47.18 doxepin 5% Topical Cream (45gm Bulk) $ 51.03 doxepin 50 mg Cap $ 4.09 doxepin 6 mg Tab $ 46.79 doxercalciferol 0.5 mcg Oral Cap $ 59.79 doxercalciferol 2 mcg/mL Inj Sol (1mL Vial) $ 26.25 doxercalciferol 2 mcg/mL Inj Sol (2 mL Vial) $ 26.25 doxercalciferol 2.5 mcg Cap $ 58.38 doxycycline 100 mg Powder Injection (Vial) $ 101.47 doxycycline 25 mg/5 mL Oral Liquid (20 ml UD liq) $ 3.50 doxycycline hyclate 100 mg Cap $ 11.49 doxycycline hyclate 100 mg Tab $ 11.49 doxycycline hyclate 20 mg Tab $ 4.16 doxycycline hyclate 50 mg Cap $ 6.30 doxycycline monohydrate 100 mg Cap $ 8.29 doxycycline monohydrate 100 mg Tab $ 8.40 doxycycline monohydrate 50 mg Cap $ 5.08 doxycycline monohydrate 50 mg Tab $ 11.75 doxylamine 25 mg Tab $ 3.50 dronabinol 2.5 mg Cap $ 20.62 dronabinol 5 mg Cap $ 42.92 dronedarone 400 mg Tab $ 42.14 droxidopa 100 mg Cap $ 54.79 droxidopa 200 mg Cap $ 109.59 dulaglutide 0.75 mg/0.5 mL Sol Inj $ 1,533.42 dulaglutide 1.5 mg/0.5 mL Sol Inj $ 1,533.42 DULoxetine 20 mg Cap $ 24.49 DULoxetine 30 mg Cap $ 20.74 DULoxetine 60 mg Cap-DR $ 27.48 dutasteride 0.5 mg Cap $ 21.18 econazole Top 1% Cream (15gm Bulk) $ 7.01 econazole Top 1% Cream (30gm Bulk) $ 7.01

STANDARD HOSPITAL CHARGES

edoxaban 15 mg Tab $ 47.12 edoxaban 30 mg Tab $ 47.12 edoxaban 60 mg Tab $ 47.12 efavirenz 200 mg Cap $ 41.77 efavirenz 600 mg Tab $ 130.42 efavirenz/emtricitabine/tenofovir 600 mg-200 mg-300 mg Tab $ 257.83 eletriptan 20 mg Tab $ 214.87 eluxadoline 100 mg Tab $ 80.21 emollients, topical - Cream (114gm Bulk) $ 3.50 emollients, topical - Cream (106gm Bulk) $ 3.50 emollients, topical - Cream (120gm Bulk) $ 3.50 emollients, topical - Cream (240gm Bulk) $ 3.50 emollients, topical - Cream (454gm Bulk) $ 3.50 emollients, topical - Cream (79gm Bulk) $ 3.50 emollients, topical - Cream (Nivea) (60gm Bulk) $ 3.50 emollients, topical - Emulsion (45gm Bulk) $ 3.50 emollients, topical - Emulsion (90gm Bulk) $ 3.50 emollients, topical - Gel Nasal (14gm Bulk) $ 3.50 emollients, topical - Liquid (120mL Bulk) $ 3.50 emollients, topical - Liquid (236mL Bulk) $ 3.50 emollients, topical - Lotion (180mL Bulk) $ 3.50 emollients, topical - Lotion (241gm Bulk) $ 3.50 emollients, topical - Ointment (100gm Bulk) $ 3.50 emollients, topical - Ointment (10gm Bulk) $ 3.50 emollients, topical - Ointment (113gm Bulk) $ 3.50 emollients, topical - Ointment (120gm Bulk) $ 3.50 emollients, topical - Ointment (226.8gm Bulk) $ 12.63 emollients, topical - Ointment (396gm Bulk) $ 3.50 emollients, topical - Ointment (454gm Bulk) $ 3.50 emollients, topical - Ointment (50gm Bulk) $ 3.50 emollients, topical - Ointment (7.5gm Bulk) $ 3.50 emollients, topical - Ointment (70gm Bulk) $ 3.50 emollients, topical - Ointment (90gm Bulk) $ 3.50 emollients, topical - Stick (2.8gm Bulk) $ 4.33 emollients, topical - Stick (4.5gm Bulk) $ 3.50 emollients, topical -(Resta Lite) Lotion (480mL Bulk) $ 3.50 empagliflozin 10 mg Tab $ 65.09 empagliflozin 25 mg Tab $ 65.09 emtricitabine 200 mg Cap $ 63.88 emtricitabine/rilpivirine/tenofovir 200 mg-25 mg-25 mg Tab $ 375.31 emtricitabine/rilpivirine/tenofovir 200 mg-25 mg-300 mg Tab $ 287.39 emtricitabine-tenofovir 200 mg-25 mg Tab $ 186.64 emtricitabine-tenofovir 200 mg-300 mg Tab $ 154.82 enalapril 1.25 mg/mL IV Sol $ 12.92 enalapril 1.25 mg/mL IV Sol (2mL Vial) $ 5.90 enalapril 10 mg Tab $ 3.50 enalapril 2.5 mg Tab $ 5.10

STANDARD HOSPITAL CHARGES

enalapril 20 mg Tab $ 8.03 enalapril 5 mg Tab $ 5.41 enoxaparin 100 mg/1mL SubQ Soln $ 83.50 enoxaparin 120 mg/0.8 mL SubQ Soln $ 125.21 enoxaparin 150 mg/1mL SubQ Soln $ 125.20 enoxaparin 30 mg/0.3 mL SubQ Soln $ 83.58 enoxaparin 300 mg/3 mL SubQ Soln $ 98.58 enoxaparin 40 mg/0.4 mL SubQ Soln $ 83.37 enoxaparin 60 mg/0.6 mL SubQ Soln $ 83.51 enoxaparin 80 mg/0.8 mL SubQ Soln $ 83.48 entacapone 200 mg Tab $ 23.84 entecavir 0.5 mg Tab $ 155.51 entecavir 1 mg Tab $ 155.52 ePHEDrine 50 mg/mL Sol $ 45.56 epinastine 0.05% Opht Soln (5mL Bulk) $ 74.89 EPINEPHrine 0.1 mg/mL Inj Sol 10 mL $ 3.50 EPINEPHrine 0.15 mg Inj Kit $ 1,278.08 EPINEPHrine 0.3 mg Inj kit $ 656.25 EPINEPHrine 1 mg/mL Inj Sol $ 61.25 EPINEPHrine 1 mg/mL Inj Sol (30mL Bulk) $ 8.26 EPINEPHrine-lidocaine 1:100000-1% Inj Sol $ 3.50 EPINEPHrine-lidocaine 1:100000-1% Sol 30 mL $ 3.50 EPINEPHrine-lidocaine 1:100000-1% Sol 50 mL $ 3.50 EPINEPHrine-lidocaine 1:100000-2% Inj $ 3.50 EPINEPHrine-lidocaine 1:200,000-1.5% Inj Soln PF ( 30mL Bulk) $ 3.50 EPINEPHrine-lidocaine 1:200,000-1.5% Inj Soln PF ( 5mL Bulk) $ 4.08 EPINEPHrine-lidocaine 1:200,000-2% PF Inj Soln $ 3.50 eplerenone 25 mg Tab $ 14.34 eplerenone 50 mg Tab $ 14.58 epoetin alfa 10000 units/mL Injection Sol (1 mL Vial) $ 1,080.32 epoetin alfa 2000 units/mL Sol $ 139.27 epoetin alfa 20000 units/mL Injection Sol (MDV by unit) $ 1,392.72 epoetin alfa 3000 units/mL Sol $ 208.91 epoetin alfa 4000 units/mL Sol $ 278.54 epoetin alfa 40000 units/mL Sol $ 4,321.21 ergocalciferol 2000 intl units Cap $ 3.50 ergocalciferol 50,000 intl units Cap (D2) $ 5.34 ergocalciferol 8000 intl units/mL Oral Soln (Extemp) $ 5.90 ertapenem 1 gm Pow inj $ 491.69 erythromycin 0.5% Opht Oint (1gm Bulk) $ 43.44 erythromycin 0.5% Opht Oint (3.5gm Bulk) $ 19.00 erythromycin 250 mg EC Tab $ 30.90 erythromycin 250 mg Cap-DR $ 21.12 erythromycin 250 mg Tab $ 48.74 erythromycin 333 mg Tab EC $ 38.91 erythromycin 500 mg Tab CP $ 48.59 erythromycin ethylsuccinate 200 mg/5 mL Oral Liquid (Extemp) $ 15.80

STANDARD HOSPITAL CHARGES

erythromycin ethylsuccinate 400 mg Tab $ 51.13 erythromycin ethylsuccinate 400 mg/5 mL Oral Liquid (Extemp) $ 27.79 erythromycin lactobionate 500 mg Pow inj $ 306.43 erythromycin stearate 250 mg Tab $ 45.94 erythromycin topical 2% Gel (30gm Bulk) $ 19.20 escitalopram 10 mg Tab $ 15.12 escitalopram 10 mg/10 mL Oral Solution (10mL UD Liq) $ 3.50 escitalopram 20 mg Tab $ 16.00 escitalopram 5 mg Tab $ 14.48 eslicarbazepine 200 mg Tab $ 128.48 eslicarbazepine 400 mg Tab $ 128.48 eslicarbazepine 600 mg Tab $ 128.48 esmolol 10 mg/mL IV Sol PF(10mL Vial) $ 6.04 esomeprazole 20 mg Oral Granules(1EA UD) $ 37.94 esomeprazole 20 mg Cap $ 3.50 esomeprazole 40 mg Oral Powder (1 EA UD) $ 37.94 esomeprazole 40 mg Cap $ 20.52 esomeprazole 40 mg Pow $ 210.00 esomeprazole 49.3 mg Cap $ 25.13 estazolam 1 mg Tab $ 3.50 esterified estrogens 0.3 mg Tab $ 7.38 esterified estrogens 0.625 mg Tab $ 10.48 esterified estrogens-methylTESTOSTERone 0.625 mg-1.25 mg Tab $ 16.80 esterified estrogens-methylTESTOSTERone 1.25 mg-2.5 mg Tab $ 12.60 estradiol 0.025 mg/24 hours twice weekly Transderm Film $ 47.56 estradiol 0.025 mg/24 hours weekly Transderm ER Film $ 77.35 estradiol 0.0375 mg/24 hours twice weekly Transderm Film $ 47.55 estradiol 0.05 mg/24 hours twice weekly Transdermal Film $ 47.58 estradiol 0.05 mg/24 hours weekly Transderm ER Film $ 81.23 estradiol 0.075 mg/24 hours weekly Transderm ER Film $ 77.35 estradiol 0.1 mg/24 hours twice weekly Transderm ER Film $ 47.65 estradiol 0.1 mg/24 hours weekly Transderm ER Film $ 77.35 estradiol 0.1 mg/g Vaginal Cream (42.5gm Bulk) $ 31.12 estradiol 0.5 mg Tab $ 3.50 estradiol 0.5 mg/0.5 g (0.1%) Topical Gel (0.5gm UD) $ 17.31 estradiol 1 mg Tab $ 3.50 estradiol 10 mcg Tab-Vag $ 84.87 estradiol 2 mg Tab $ 3.50 estropipate 0.75 mg Tab $ 3.50 eszopiclone 1 mg Tab $ 42.56 eszopiclone 2 mg Tab $ 3.50 eszopiclone 3 mg Tab $ 3.50 etanercept 50 mg/mL Sol $ 5,220.00 ethacrynic acid 25 mg Tab $ 102.66 ethambutol 100 mg Tab $ 3.50 ethambutol 400 mg Tab $ 5.69 ethosuximide 250 mg Cap $ 7.81

STANDARD HOSPITAL CHARGES

ethyl chloride 100% Topical Spray (103.5mL Bulk) $ 3.50 etidronate 200 mg Tab $ 15.12 etidronate 400 mg Tab $ 30.24 etodolac 200 mg Cap $ 5.03 etodolac 300 mg Cap $ 5.66 etodolac 400 mg Tab $ 5.14 etodolac 400 mg Tab ER $ 10.36 etodolac 500 mg Tab $ 5.25 etravirine 100 mg Tab $ 40.38 everolimus 0.5 mg Tab $ 61.52 everolimus 0.75 mg Tab $ 92.29 everolimus 5 mg Tab $ 2,181.49 evolocumab 140 mg/mL Inj Sol $ 2,346.05 exemestane 25 mg Tab $ 45.61 exenatide 10 mcg/0.04 mL Injection (2.4mL Bulk) $ 1,239.67 exenatide 2 mg Pen $ 693.17 exenatide 2 mg Pow Vial $ 693.17 exenatide 2 mg/0.85 mL injection $ 741.35 exenatide 5 mcg/0.02 mL Injection (1.2mL Bulk) $ 2,479.33 ezetimibe 10 mg Tab $ 9.18 ezetimibe-simvastatin 10 mg-20 mg Tab $ 39.41 ezogabine 50 mg Tab $ 23.03 famciclovir 125 mg Tab $ 20.35 famciclovir 250 mg Tab $ 24.31 famciclovir 500 mg Tab $ 44.43 famotidine 10 mg Tab $ 3.50 famotidine 10 mg/mL IV Sol 2 mL $ 3.50 famotidine 10 mg/mL IV Sol 4 mL $ 3.50 famotidine 20 mg Tab $ 5.31 famotidine 20 mg/50 mL IV Solution $ 3.50 famotidine 20mg/2.5 ml Oral Liquid (2.5mL UD Liq) $ 12.39 famotidine 40 mg Tab $ 16.39 fat emulsion, with fish, medium chain, olive, and soy oil 20% IV 100 mL $ 3.50 fat emulsion, with fish, medium chain, olive, and soy oil 20% IV 250 mL $ 3.50 febuxostat 40 mg Tab $ 40.78 febuxostat 80 mg Tab $ 40.78 felbamate 400 mg Tab $ 18.27 felbamate 600 mg Tab $ 21.00 felodipine 10 mg Tab ER $ 9.50 felodipine 2.5 mg Tab ER $ 5.29 felodipine 5 mg Tab ER $ 5.29 fenofibrate 134 mg Cap $ 6.86 fenofibrate 145 mg Tab $ 18.03 fenofibrate 160 mg Tab $ 8.32 fenofibrate 200 mg Cap $ 11.03 fenofibrate 40 mg Tab $ 36.57 fenofibrate 48 mg Tab $ 6.68

STANDARD HOSPITAL CHARGES

fenofibrate 54 mg Tab $ 3.50 fenofibrate 67 mg Cap $ 3.70 fenofibric acid 135 mg Cap DR $ 20.98 fenofibric acid 45 mg Cap $ 6.99 fentaNYL 100 mcg/hr Transderm ER Film $ 275.49 fentaNYL 12 mcg/hr Transderm ER Film $ 71.06 fentaNYL 200 mcg Lozenge $ 65.81 fentaNYL 25 mcg/hr Transderm ER Film $ 74.43 fentaNYL 37.5 mcg/hr Transderm ER Film $ 228.60 fentaNYL 50 mcg/hr Transderm ER Film $ 136.09 fentaNYL 50mcg/mL Solution IV (2mL) $ 3.50 fentaNYL 50mcg/mL Solution IV (5mL Vial) $ 3.50 fentaNYL 75 mcg/hr Transderm ER Film $ 207.57 ferric citrate 210 mg Tab $ 22.47 ferrous fumarate 65 mg Tab-ER $ 3.50 ferrous fumarate 324 mg Tab $ 3.50 ferrous gluconate 324 mg Tab $ 3.50 ferrous sulfate (as elemental iron) 45 mg Tab ER $ 3.50 ferrous sulfate 160 mg Tab-ER $ 3.50 ferrous sulfate 220 mg/5 mL Oral Elixer (5mL UD Liq) $ 3.50 ferrous sulfate 300 mg/5 mL Oral Liquid (5mL UD) $ 3.50 ferrous sulfate 324 mg Tab DR $ 3.50 ferrous sulfate 325 mg Tab $ 3.50 ferrous sulfate 325 mg Tab EC $ 3.50 fesoterodine 4 mg Tab ER $ 41.71 fesoterodine 8 mg Tab ER $ 41.71 fexofenadine 180 mg Tab $ 8.49 fexofenadine 60 mg Tab $ 5.30 fexofenadine-pseudoephedrine 60 mg-120 mg Tab ER 12 hr $ 3.50 fidaxomicin 200 mg Tab $ 702.85 filgrastim 300 mcg/0.5 mLInj Sol $ 1,994.58 filgrastim 300 mcg/mL Inj Sol $ 1,322.30 filgrastim 480 mcg/0.8 mL Inj Sol $ 2,789.99 filgrastim 480 mcg/1.6 mL Inj Sol SDV $ 1,315.99 filgrastim-sndz 300 mcg/0.5 mL Inj Sol $ 2,315.53 filgrastim-sndz 480 mcg/0.8 mL Inj Sol $ 2,304.66 finasteride 1 mg Tab $ 13.65 finasteride 5 mg Tab $ 10.94 fingolimod 0.5 mg Cap $ 816.37 flavoxATE 100 mg Tab $ 4.48 flax seed oil - Cap $ 3.50 flecainide 100 mg Tab $ 14.05 flecainide 50 mg Tab $ 6.09 fluconazole 100 mg Tab $ 30.81 fluconazole 100 mg/50 mL-NS IV Sol $ 3.50 fluconazole 150 mg Tab $ 49.04 fluconazole 200 mg Tab $ 47.63

STANDARD HOSPITAL CHARGES

fluconazole 200 mg/100 mL-Dex 5% Sol $ 3.50 fluconazole 200 mg/100 mL-NS IV Sol $ 3.50 fluconazole 40 mg/mL Oral Liquid (Extemp) $ 12.55 fluconazole 400 mg/200 mL-NS IV Sol $ 3.50 fluconazole 50 mg Tab $ 19.50 flucytosine 250 mg Cap $ 291.35 flucytosine 500 mg Cap $ 658.01 fludrocortisone 0.1 mg Tab $ 3.50 flumazenil 0.1 mg/mL IV Sol (10 mL Vial) $ 26.21 flumazenil 0.1 mg/mL IV Sol 5 mL $ 5.69 flunisolide 25 mcg/inh Nasal Spray (25mL Bulk) $ 10.07 fluocinolone 0.01% Topical Cream (15gm Bulk) $ 10.47 fluocinolone 0.025% Topical Cream (15gm Bulk) $ 8.19 fluocinolone 0.025% Topical Cream (60gm Bulk) $ 5.93 fluocinolone 0.025% Topical Ointment (15gm Bulk) $ 7.92 fluocinonide 0.05% Topical Cream (15gm Bulk) $ 10.63 fluocinonide 0.05% Topical Cream (30gm Bulk) $ 11.24 fluocinonide 0.05% Topical Ointment (15gm Bulk) $ 16.51 fluocinonide 0.05% Topical Ointment (30gm Bulk) $ 16.51 fluocinonide 0.05% Topical Ointment (60gm Bulk) $ 16.51 fluocinonide 0.05% Topical Solution (20mL Bulk) $ 10.07 fluocinonide 0.05% Topical Solution (60mL Bulk) $ 6.76 fluorometholone 0.1% Ophthalmic Oint (3.5gm Bulk) $ 174.74 fluorometholone 0.1% Ophthalmic Suspension (5mL Bulk) $ 59.68 fluorometholone acetate 0.1% ophthalmic Suspension (5mL Bulk) $ 58.81 fluorouracil 5% Topical Cream (40gm Bulk) $ 24.86 FLUoxetine 10 mg Cap $ 8.47 FLUoxetine 10 mg Tab $ 10.04 FLUoxetine 20 mg Cap $ 8.80 FLUoxetine 20 mg/5 mL Oral Soln (5mL UD) $ 4.79 FLUoxetine 20 mg/5 mL Oral Soln (Extemp) $ 3.50 FLUoxetine 40 mg Cap $ 12.69 fluoxymesterone 10 mg Tab $ 20.22 fluPHENAZine 1 mg Tab $ 3.50 fluPHENAZine 10 mg Tab $ 3.50 fluPHENAZine 2.5 mg Tab $ 3.50 fluPHENAZine 5 mg Tab $ 3.50 fluPHENAZine decanoate 25 mg/mL Inj Sol 5 mL $ 130.17 flurazepam 15 mg Cap $ 3.50 flurazepam 30 mg Cap $ 3.50 flurbiprofen 0.03% Ophthalmic Solution (2.5mL Bulk) $ 12.22 flurbiprofen 100 mg Tab $ 6.63 flurbiprofen 50 mg Tab $ 3.50 flutamide 125 mg Cap $ 7.32 fluticasone 0.05% Topical Cream (15gm Bulk) $ 5.19 fluticasone 0.05% Topical Cream (60gm Bulk) $ 3.50 fluticasone 100 mcg Pow (28 count) $ 15.21

STANDARD HOSPITAL CHARGES

fluticasone 100 mcg Pow (60 count) $ 12.72 fluticasone 250 mcg Pow (28 count) $ 20.37 fluticasone 250 mcg Pow (60 count) $ 17.03 fluticasone 50 mcg Pow (60 count) $ 12.06 fluticasone 50mcg/inh Nasal Spray (16gm Bulk) $ 18.65 fluticasone 50mcg/inh Nasal Spray (9.9mL Bulk) $ 6.18 fluticasone CFC free 110 mcg/inh Inh Aer w/adapter (12gm Bulk) $ 81.63 fluticasone CFC free 220 mcg/inh Inh Aer w/adapter (12gm Bulk) $ 126.79 fluticasone CFC free 44 mcg/inh Aerosol (10.6gm Bulk) $ 69.03 fluticasone furoate 100 mcg Inh Pow (14 count) $ 21.44 fluticasone furoate 100 mcg Inh Pow (30 count) $ 21.45 fluticasone furoate 200 mcg Inh Pow (14 count) $ 28.71 fluticasone/umeclidinium/vilanterol 100 mcg-62.5 mcg-25 mcg Inh Powder (28 EA) $ 37.05 fluticasone-salmeterol 100 mcg-50 mcg Inh Powder (60 Count) $ 21.39 fluticasone-salmeterol 100 mcg-50 mcg Inh Pwdr (14 count) $ 43.86 fluticasone-salmeterol 250 mcg-50 mcg Inh Powder (60 Count) $ 26.57 fluticasone-salmeterol 250 mcg-50 mcg Inh Pwdr (14 count) $ 43.86 fluticasone-salmeterol 500 mcg-50 mcg Inh Powder (60 count) $ 34.95 fluticasone-salmeterol 500 mcg-50 mcg Inh Pwdr (14 count) $ 71.49 fluticasone-salmeterol CFC free 115 mcg-21 mcg/inh Aer (12gm Bulk) $ 132.86 fluticasone-salmeterol CFC free 115 mcg-21 mcg/inh Aer (8gm Bulk) $ 107.49 fluticasone-salmeterol CFC free 230 mcg-21 mcg/inh Aer (8gm Bulk) $ 159.41 fluticasone-salmeterol CFC free 45 mcg-21 mcg/inh Aer (8gm Bulk) $ 107.49 fluticasone-vilanterol 100 mcg-25 mcg Inh Pwdr (14 day) $ 17.91 fluticasone-vilanterol 100 mcg-25 mcg InhPowder (30 day) $ 21.70 fluticasone-vilanterol 200 mcg-25 mcg/inh Pow (14 day) $ 17.91 fluticasone-vilanterol 200 mcg-25 mcg/inh Pow (30 day) $ 21.70 fluvastatin 20 mg Cap $ 17.52 fluvastatin 40 mg Cap $ 17.52 fluvastatin 80 mg Tab XL $ 45.22 fluvoxaMINE 100 mg Cap-ER $ 35.64 fluvoxaMINE 100 mg Tab $ 9.21 fluvoxaMINE 150 mg Cap-ER $ 38.25 fluvoxaMINE 25 mg Tab $ 8.05 fluvoxaMINE 50 mg Tab $ 9.01 folic acid 0.4 mg Tab $ 3.50 folic acid 0.8 mg Tab $ 3.50 folic acid 1 mg Tab $ 3.50 folic acid 5 mg/mL Inj Sol 10 mL $ 18.95 fondaparinux 10 mg/0.8 mL SubQ Soln $ 562.67 fondaparinux 2.5 mg/0.5 mL SubQ Soln $ 382.56 fondaparinux 5 mg/0.4 mL SubQ Soln $ 1,188.25 fondaparinux 7.5 mg/0.6 mL SubQ Soln $ 750.23 formoterol 12 mcg Inh Cap $ 21.01 formoterol 20 mcg/2 mL Inh Sol $ 34.03 formoterol-mometasone 5 mcg-100 mcg/inh Aer (13gm Bulk) $ 100.59 formoterol-mometasone 5 mcg-100 mcg/inh Aer (8.8gm Bulk) $ 100.59

STANDARD HOSPITAL CHARGES

formoterol-mometasone 5 mcg-200 mcg/inh Aer (13gm Bulk) $ 100.59 formoterol-mometasone 5 mcg-200 mcg/inh Aer (8.8gm Bulk) $ 100.59 fosfomycin 3gm/1packet Oral Powder (1EA UD) $ 303.08 fosinopril 10 mg Tab $ 4.16 fosinopril 20 mg Tab $ 4.16 fosphenytoin 100 mg PE/2 mL Sol $ 10.08 fosphenytoin 500 mgPE/10 mL Sol $ 41.80 furosemide 10 mg/mL Inj Sol 10 mL $ 3.50 furosemide 10 mg/mL Inj Sol 2mL $ 7.18 furosemide 10 mg/mL Inj Sol 4 mL $ 3.50 furosemide 10 mg/mL Oral Liquid (Extemp) $ 3.50 furosemide 20 mg Tab $ 3.50 furosemide 40 mg Tab $ 3.50 furosemide 40 mg/4 mL Oral Liq (4mL UD) $ 3.50 furosemide 40 mg/5 mL Oral Soln (5mL UD) $ 3.50 furosemide 80 mg Tab $ 3.50 gabapentin 100 mg Cap $ 3.50 gabapentin 250 mg/5 mL Oral Sol (5mL UD) $ 3.50 gabapentin 250 mg/5 mL Oral Sol (6ml UD) $ 3.50 gabapentin 250 mg/5 mL Oral Soln (Extemp) $ 3.50 gabapentin 300 mg Cap $ 3.50 gabapentin 300 mg/24 hours Tab ER $ 30.03 gabapentin 400 mg Cap $ 4.27 gabapentin 600 mg Tab $ 8.48 gabapentin 800 mg Tab $ 10.17 gadopentetate dimeglumine 46.9% Solution IV (5mL Vial) $ 19.40 galantamine 12 mg Tab $ 10.68 galantamine 16 mg Cap ER $ 22.28 galantamine 24 mg oral Cap, ER $ 22.28 galantamine 4 mg Tab $ 9.51 galantamine 8 mg oral Cap, ER $ 22.28 galantamine 8 mg Tab $ 14.78 ganciclovir 250 mg Cap $ 16.52 ganciclovir 500 mg Powder Injection (Vial) $ 408.53 gatifloxacin 0.5% Sol Opth (2.5mL Bulk) $ 165.42 gemfibrozil 600 mg Tab $ 4.07 gentamicin 0.1% Topical Cream (15gm Bulk) $ 11.52 gentamicin 0.1% Topical Cream (30gm Bulk) $ 11.06 gentamicin 0.1% Topical Oint (30gm Bulk) $ 11.52 gentamicin 0.1% Topical Ointment (15gm Bulk) $ 11.52 gentamicin 0.3% Ophthalmic Ointment (3.5gm Bulk) $ 35.44 gentamicin 0.3% Ophthalmic Solution (5mL Bulk) $ 13.43 gentamicin 10 mg/mL Inj Sol (2 mL) $ 8.27 gentamicin 100 mg/100 mL-0.9% Sol $ 3.50 gentamicin 100 mg/50 mL-NS IV Sol $ 3.50 gentamicin 120 mg/100 mL-NS IV Sol $ 3.50 gentamicin 40 mg/mL Inj Sol (2 mL) $ 6.78

STANDARD HOSPITAL CHARGES

gentamicin 40 mg/mL Inj Sol (20mL MDV) $ 4.25 gentamicin 60 mg/50 mL-NS IV Sol $ 3.50 gentamicin 80 mg/100 mL-0.9% Sol $ 3.50 gentamicin 80 mg/50 mL-NS IV Sol $ 3.50 gentamicin-prednisolone 0.3%-1% Ophthalmic Suspension (5mL Bulk) $ 106.39 gentian violet 1% Topical Solution (59mL Bulk) $ 3.50 glatiramer 20 mg/mL Solution Injection $ 949.44 glatiramer 40 mg/mL Sol Inj $ 644.84 glecaprevir-pibrentasvir 100 mg-40 mg Tab $ 660.00 glimepiride 1 mg Tab $ 3.50 glimepiride 2 mg Tab $ 3.50 glimepiride 4 mg Tab $ 4.27 glipiZIDE 10 mg ER Tab $ 3.50 glipiZIDE 10 mg Tab $ 3.50 glipiZIDE 2.5 mg ER Tab $ 3.50 glipiZIDE 5 mg ER Tab $ 3.50 glipiZIDE 5 mg Tab $ 3.50 glucagon 1 mg Powder Injection Kit $ 1,167.79 glucagon recombinant 1 mg Inj $ 680.40 glucosamine 500 mg Cap $ 3.50 glucosamine 500 mg Tab $ 3.50 glucose 4 g Tab $ 3.50 glucose Oral Gel {1Tube=15gm glucose delivered from tube} (37.5gm Bulk) $ 3.50 glyBURIDE 1.25 mg Tab $ 3.50 glyBURIDE 2.5 mg Tab $ 3.50 glyBURIDE 5 mg Tab $ 3.50 glyBURIDE micronized 1.5 mg Tab $ 3.50 glyBURIDE micronized 3 mg Tab $ 3.50 glycerin - Liquid (177mL Bulk) $ 3.50 glycerin adult Sup $ 3.50 glycerin pediatric Sup $ 3.50 glycerin-phenol Topical Oral Solution (180mL Bulk) $ 3.50 glycopyrrolate 0.2 mg/mL Sol $ 56.88 glycopyrrolate 1 mg Tab $ 3.72 glycopyrrolate 2 mg Tab $ 6.21 gramicidin/neomycin/polymyxin B 0.025-1.75mg-10000units/mL Ophthalmic Soln (10mL Bulk) $ 19.89 granisetron 1 mg Tab $ 23.52 granisetron 1 mg/mL IV Solution $ 82.53 granisetron 3.1 mg/24 hr Film $ 2,240.91 griseofulvin microcrystalline 500 mg Tab $ 29.78 guaiFENesin 100 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 guaiFENesin 1200 mg Tab ER $ 3.50 guaiFENesin 200 mg Tab $ 3.50 guaiFENesin 200mg/10mL Oral Liq (10mL UD Liq) $ 3.50 guaiFENesin 300mg/15mL Oral Liquid (15mL UD) $ 3.50 guaiFENesin 400 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

guaiFENesin 600 mg ER Tab $ 3.50 guaiFENesin-pseudoephedrine 600 mg-60 mg Tab ER $ 3.50 guanFACINE 1 mg Tab $ 3.50 guanFACINE 1 mg Tab ER $ 24.06 guanFACINE 2 mg Tab $ 4.12 guanFACINE 2 mg Tab ER $ 36.72 guar gum Oral Powder (4gm UD) $ 3.50 halobetasol 0.05% Topical Cream (15gm Bulk) $ 18.57 halobetasol 0.05% Topical Ointment (15gm Bulk) $ 18.57 haloperidol 0.5 mg Tab $ 3.50 haloperidol 1 mg Tab $ 3.50 haloperidol 2 mg Tab $ 3.50 haloperidol 2 mg/mL Oral Concentrate $ 6.22 haloperidol 5 mg Tab $ 3.82 haloperidol 5 mg/mL Inj Sol $ 3.70 haloperidol decanoate 50 mg/mL Inj Sol $ 108.74 heme iron polypeptide 12 mg Tab $ 3.50 heparin 1000 units/mL Inj Sol (1mL UD Inj) $ 10.08 heparin 1000 units/mL Inj Sol (2mL UD Inj) $ 21.84 heparin 10000 units/mL Inj Sol $ 30.63 heparin 20000 units/mL Inj Sol $ 73.33 heparin 25,000 units/250 mL-D5% IV Sol $ 3.50 heparin 25,000 units/250 mL-NaCl 0.45% IV Sol 250 mL $ 3.50 heparin 25,000 units/500 mL-D5% IV Sol $ 3.50 heparin 25,000 units/500 mL-NS 0.45% IV Sol $ 3.50 heparin 5000 units/0.5 mL Inj Sol $ 24.11 heparin 5000 units/mL Inj Sol $ 10.92 heparin 5000 units/mL Inj Sol (10 mL Bulk) $ 3.53 heparin 7,500 units/0.75 mL Inj Sol (Extemp) $ 12.12 heparin FLUSH 10 units/mL Inj Sol (3mL) $ 3.50 heparin FLUSH 10 units/mL Inj Sol (5mL) $ 3.50 heparin FLUSH 100 units/mL Inj Sol (10mL) $ 3.50 heparin FLUSH 100 units/mL Inj Sol (1mL) $ 11.80 heparin FLUSH 100 units/mL Inj Sol (3mL) $ 3.61 hepatitis A adult vaccine 1440 units/mL PF IM Susp $ 277.23 hepatitis B pediatric vaccine 10 mcg/0.5 mL IM Susp $ 170.09 hepatitis B pediatric vaccine 5 mcg/0.5 mL IM Susp $ 182.89 hepatitis B vaccine adult 10 mcg/mL IM Sol $ 253.85 hepatitis B vaccine adult 20 mcg/mL IM Sol $ 215.23 hexachlorophene 3% Topical Liquid (148mL Bulk) $ 3.50 homatropine 5% Ophthalmic Solution (5mL Bulk) $ 12.14 homatropine-HYDROcodone 1.5 mg-5 mg Tab $ 3.50 homatropine-HYDROcodone 1.5 mg-5 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 hyaluronidase 200 units/mL Inj Sol $ 328.21 hydrALAZINE 10 mg Tab $ 3.50 hydrALAZINE 100 mg Tab $ 3.55 hydrALAZINE 20 mg/mL Inj Sol $ 50.40

STANDARD HOSPITAL CHARGES

hydrALAZINE 25 mg Tab $ 3.50 hydrALAZINE 50 mg Tab $ 3.50 hydrALAZINE-isosorbide dinitrate 37.5 mg-20 mg Tab $ 13.60 hydrochlorothiazide 12.5 mg Cap $ 3.50 hydrochlorothiazide 12.5 mg Tab $ 3.50 hydrochlorothiazide 25 mg Tab $ 3.50 hydrochlorothiazide 50 mg Tab $ 3.50 hydrochlorothiazide-lisinopril 12.5 mg-10 mg Tab $ 3.92 hydrochlorothiazide-losartan 12.5 mg-100 mg Tab $ 11.12 hydrochlorothiazide-losartan 12.5 mg-50 mg Tab $ 8.76 hydrochlorothiazide-methyldopa 25 mg-250 mg Tab $ 7.55 hydrochlorothiazide-spironolactone 25 mg-25 mg Tab $ 5.38 hydrochlorothiazide-telmisartan 25 mg-80 mg Tab $ 18.53 hydrochlorothiazide-triamterene 25 mg-37.5 mg Cap $ 3.50 hydrochlorothiazide-triamterene 25 mg-37.5 mg Tab $ 3.50 hydrochlorothiazide-triamterene 50 mg-75 mg Tab $ 3.50 hydrochlorothiazide-valsartan 12.5 mg-160 mg Tab $ 14.96 hydrochlorothiazide-valsartan 25 mg-160 mg Tab $ 16.98 HYDROcodone 10 mg Cap ER $ 35.99 HYDROcodone 20 mg Cap-ER $ 39.69 HYDROcodone 20 mg Tab ER $ 36.23 HYDROcodone 40 mg Tab-ER $ 71.24 HYDROcodone-ibuprofen 7.5 mg-200 mg Tab $ 4.01 hydrocortisone 1% Topical Cream (0.9gm UD) $ 3.50 hydrocortisone 1% Topical Cream (1.5gm UD) $ 3.50 hydrocortisone 1% Topical Cream (30 gm Bulk) $ 3.50 hydrocortisone 1% Topical Cream (454 gm Bulk) $ 3.50 hydrocortisone 1% Topical Lotion (118mL Bulk) $ 3.50 hydrocortisone 1% Topical Ointment (30gm Bulk) $ 3.50 hydrocortisone 1% Topical Rectal Cream (27gm Bulk) $ 3.50 hydrocortisone 10 mg Tab $ 3.50 hydrocortisone 100 mg preservative-free Pow $ 56.40 hydrocortisone 100 mg/60 mL Enema $ 3.50 hydrocortisone 2.5% Rectal Crm w/Appl (28gm Bulk) $ 10.19 hydrocortisone 2.5% Topical Lotion (59mL Bulk) $ 3.50 hydrocortisone 2.5% Topical Ointment (20gm Bulk) $ 3.50 hydrocortisone 20 mg Tab $ 3.80 hydrocortisone 250 mg preservative-free Pow $ 104.34 hydrocortisone 5 mg Tab $ 3.50 hydrocortisone 500 mg preservative-free Pow $ 208.70 hydrocortisone butyrate 0.1% topical Cream (15gm Bulk) $ 14.63 hydrocortisone Top 0.5% Cream (30gm Bulk) $ 3.50 hydrocortisone Top 0.5% Ointment (30gm Bulk) $ 3.50 hydrocortisone topical 2.5% Cream (20gm Bulk) $ 3.50 hydrocortisone topical 2.5% Cream (28gm Bulk) $ 3.50 hydrocortisone topical 25 mg Sup $ 201.70 hydrocortisone valerate 0.2% Topical Cream (15gm Bulk) $ 20.89

STANDARD HOSPITAL CHARGES

hydrocortisone/neomycin/polymyxin B Ophthalmic Suspension (7.5mL Bulk) $ 66.02 hydrocortisone/neomycin/polymyxin B Otic Solution (10mL Bulk) $ 10.78 hydrocortisone/neomycin/polymyxin B Otic Susp (10mL Bulk) $ 10.78 hydrocortisone-iodoquinol 1%-1% Topical Cream (28.4gm Bulk) $ 13.21 hydrocortisone-lidocaine 0.5%-3% Topical Cream (7gm Bulk) $ 4.20 hydrocortisone-pramoxine 1%-1% Topical Rectal Cream (30gm Bulk) $ 16.98 hydrocortisone-pramoxine 1%-1% Rectal Foam (10gm Bulk) $ 54.40 hydrocortisone-pramoxine 1%-1% Topical Cream (30gm Bulk) $ 9.73 hydrocortisone-pramoxine 2.5%-1% Rectal Cream w/Appl (4gm Bulk) $ 16.01 hydrocortisone-pramoxine 2.5%-1% Topical Cream (30gm Bulk) $ 17.50 hydrocortisone-pramoxine 2.5%-1% Topical Cream w/Appl (30gm Bulk) $ 18.34 hydrogen peroxide 1.5% Oral Solution (236mL Bulk) $ 3.50 hydrogen peroxide 3% Topical Sol (237mL Bulk) $ 3.50 HYDROmorphone 0.5mg/0.5mL Inj Sol $ 20.57 HYDROmorphone 1 mg/mL Inj Sol $ 6.76 HYDROmorphone 10 mg/mL Inj Sol $ 14.66 HYDROmorphone 2 mg Tab $ 3.50 HYDROmorphone 2 mg/mL Inj Sol $ 6.30 HYDROmorphone 4 mg Tab $ 3.50 HYDROmorphone 4 mg/mL Inj Sol $ 10.75 HYDROmorphone 4mg/4mL Oral Soln (4mL UD Liq) $ 3.50 HYDROmorphone 8 mg Tab $ 4.84 HYDROmorphone 8 mg Tab-ER $ 47.39 hydroxychloroquine 200 mg Tab $ 14.31 hydroxypropyl methylcellulose 0.5% Ophthalmic Solution (15mL Bulk) $ 6.45 hydroxypropyl methylcellulose 2.5% Ophthalmic Solution (15mL Bulk) $ 3.50 hydroxyurea 400 mg Cap $ 3.50 hydroxyurea 500 mg Cap $ 4.47 hydrOXYzine hydrochloride 10 mg Tab $ 3.50 hydrOXYzine hydrochloride 25 mg Tab $ 3.50 hydrOXYzine hydrochloride 25 mg/mL Sol $ 84.70 hydrOXYzine hydrochloride 50 mg/mL Sol $ 93.45 hydrOXYzine hydrochloride Oral Syrup 10 mg/5 mL (5mL UD) $ 3.50 hydrOXYzine pamoate 25 mg Cap $ 3.50 hyoscyamine 0.125 mg Tab $ 3.55 hyoscyamine 0.125 mg Tab ODT $ 3.97 hyoscyamine 0.125 mg Tab SL $ 3.50 hyoscyamine 0.375 mg ER Tab $ 3.50 hyoscyamine/methena/mblue/phenylsal/sodbiphos 0.12 mg-118 mg-10 mg-36 mg-40.8 mg Cap $ 9.05 hyoscyamine/methenam/m-blue/phenyl salicyl 0.03 mg-40.8 mg-5.4 mg-18.1 mg Tab $ 3.50 hyoscyamine/methenam/m-blue/phenyl salicyl 0.12 mg-118 mg-10 mg-36 mg Cap $ 12.08 hyoscyamine/methenam/m-blue/sodium biphosphat 0.12 mg-120 mg-10 mg-40.8 mg Cap $ 13.02

hyoscyamine/methenam/m-blue/sodium biphosphat 0.12 mg-81.6 mg-10.8 mg-40.8 mg Tab $ 10.58 ibandronate 150 mg Tab $ 486.03 ibrutinib 140 mg Cap $ 347.59

STANDARD HOSPITAL CHARGES

ibuprofen 100 mg/5 mL Oral Susp (5mL UD Liq) $ 3.50 ibuprofen 200 mg Tab - Advil $ 3.50 ibuprofen 200 mg Tab - Motrin $ 3.50 ibuprofen 200 mg/10 mL Oral Susp (10mL UD) $ 3.50 ibuprofen 400 mg Tab $ 3.50 ibuprofen 600 mg Tab $ 3.50 ibuprofen 800 mg Tab $ 3.50 iloperidone 2 mg Tab $ 76.29 iloperidone 4 mg Tab $ 76.23 iloperidone 6 mg Tab $ 93.87 imatinib 100 mg Tab $ 15.91 imatinib 400 mg Tab $ 1,381.31 imipenem-cilastatin 250 mg-250 mg Pow inj $ 20.96 imipenem-cilastatin 250 mg-250 mg Powder Injection (addv) $ 41.16 imipenem-cilastatin 500 mg-500 mg Powder Injection (addv) $ 40.78 imipramine 10 mg Tab $ 3.50 imipramine 25 mg Tab $ 3.50 imipramine 50 mg Tab $ 4.26 imiquimod topical 5% Cream (UD) $ 64.39 immune globulin 10% IV Solution (50mL SDV) $ 33.32 indapamide 1.25 mg Tab $ 4.97 indapamide 2.5 mg Tab $ 5.42 indomethacin 25 mg Cap $ 3.50 indomethacin 50 mg Cap $ 3.50 indomethacin 75 mg ERCap $ 10.62 influenza vaccine, inactivated (HIGH-DOSE) 0.5mL PF IM $ 393.27 influenza vaccine, inactivated 0.5mL IM $ 71.75 influenza vaccine, inactivated 0.5mL PF IM $ 126.90 influenza virus vaccine, inactivated 0.5mL PF quadrivalent Susp $ 141.29 influenza virus vaccine, inactivated 0.5mL quadrivalent Susp $ 138.57 influenza virus vaccine, inactivated adjuvanted PF trivalent 0.5mL IM $ 309.23 influenza virus vaccine, inactivated mdck cell derived quadrivalent 0.5mL (5mL Vial) $ 167.95 influenza virus vaccine, inactivated mdck cell derived quadrivalent 0.5mL Syringe $ 177.19 influenza virus vaccine, inactivated mdck cell derived trivalent 0.5mL PF Syringe $ 152.25 influenza virus vaccine, live quadrivalent Spray $ 95.34 insulin aspart 100 units/mL (NovoLOG 10mL MDV){Bulk} $ 110.48 insulin aspart 100 units/mL (NovoLOG 3mL FlexPen){Bulk} $ 142.25 insulin aspart-insulin aspart protamine 30 units-70 units/mL (NovoLOG 70/30 10mL MDV){Bulk} $ 114.59 insulin aspart-insulin aspart protamine 30 units-70 units/mL (NovoLOG 70/30 3mL FlexPen){Bulk} $ 142.25 insulin degludec 100 units/mL (Tresiba Flex Touch 3mL Pen) (Bulk) $ 135.71 insulin degludec 200 units/mL (Tresiba Flex Touch 3mL Pen) (Bulk) $ 271.42 insulin detemir 100 units/mL (Levemir 10mL MDV Bulk) $ 112.16 insulin detemir 100 units/mL (Levemir 3mL FlexPen or FlexTouch){Bulk} $ 112.16 insulin glargine 100 units/mL (Lantus 10mL MDV){Bulk} $ 113.21 insulin glargine 100 units/mL (Lantus Solostar 3mL Pen){Bulk} $ 113.20

STANDARD HOSPITAL CHARGES

insulin glargine 300 units/mL (Toujeo SoloStar 1.5mL Pen) {Bulk} $ 315.92 insulin glulisine 100 units/mL (Apidra 10mL MDV){Bulk} $ 103.91 insulin glulisine 100 units/mL (Apidra Solostar 3mL Pen){Bulk} $ 133.83 insulin isophane 100 units/mL (NPH 10mL MDV){Bulk} $ 52.57 insulin isophane-insulin regular human 70 units-30 units/mL (HumuLIN 70/30 10mL MDV){Bulk} $ 56.49 insulin isophane-insulin regular human 70 units-30 units/mL (HumuLIN 70/30 3mL KwikPen){Bulk} $ 119.97 insulin isophane-insulin regular human 70 units-30 units/mL (NovoLIN 70/30 10mL MDV){Bulk} $ 52.57 insulin lispro 100 units/mL (HumaLOG 10mL MDV){Bulk} $ 105.94 insulin lispro-insulin lispro protamine 25 units-75 units/mL (HumaLOG 75/25 10mL MDV){Bulk} $ 108.77 insulin lispro-insulin lispro protamine 25 units-75 units/mL (HumaLOG 75/25 3mL FlexPen){Bulk} $ 136.32 insulin lispro-insulin lispro protamine 50 units-50 units/mL (HumaLOG 50/50 10mL MDV) {Bulk} $ 108.77 insulin regular 100 units/mL (HumuLIN R 10mL MDV){Bulk} $ 56.50 insulin regular 100 units/mL (NovoLIN R 10mL MDV){Bulk} $ 52.57 insulin regular 500 units/mL *HIGH CONCENTRATION* (20mL MDV){Bulk} $ 312.27 insulin regular 500 units/mL *HIGH CONCENTRATION* (3mL Kwik Pen){Bulk} $ 401.94 interferon beta-1a 30 mcg/0.5 mL (1 Kit) $28,517.79 interferon beta-1a 44 mcg/0.5 mL Sol $ 5,096.03 interferon beta-1b 0.3 mg Powder-inj $ 1,938.13 iohexol 240mg/mL Solution IV (10mL Vial) $ 21.31 iohexol 300 mg/mL Solution IV (10mL Vial) $ 19.68 iohexol 300 mg/mL Solution IV (30mL Vial) $ 5.83 ipratropium 0.03% Nasal Spray (30mL Bulk) $ 13.03 ipratropium 0.06% Nasal Spray (15mL Bulk) $ 22.33 ipratropium 500mcg/2.5mL {0.02%} Inh Soln (2.5mL UD) $ 3.50 ipratropium CFC free 17 mcg/inh Inh Aer (12.9gm Bulk) $ 117.00 irbesartan 150 mg Tab $ 11.75 irbesartan 300 mg Tab $ 14.12 irbesartan 75 mg Tab $ 10.21 Iron Complex Vitamin with B12 and Folic Acid Cap $ 3.50 iron dextran 50 mg/mL IV Sol $ 50.63 iron polysaccharide (as elemental iron) 200 mg Cap $ 3.50 iron polysaccharide 150 mg Cap $ 3.50 iron sucrose 20 mg/mL IV Sol (10mL) $ 42.00 iron sucrose 20 mg/mL IV Sol (2.5 mL) $ 41.65 iron sucrose 20 mg/mL IV Sol (5 mL) $ 42.00 isavuconazonium 186 mg Cap $ 364.00 isoniazid 100 mg Tab $ 3.50 isoniazid 300 mg Tab $ 4.33 isoproterenol 0.2 mg/mL IV Sol 5 mL $ 1,366.99 isosorbide dinitrate 10 mg Tab $ 3.79 isosorbide dinitrate 20 mg Tab $ 4.17

STANDARD HOSPITAL CHARGES

isosorbide dinitrate 30 mg Tab $ 4.59 isosorbide dinitrate 40 mg Cap-ER $ 14.03 isosorbide dinitrate 40 mg Tab ER $ 8.32 isosorbide dinitrate 5 mg Tab $ 3.50 isosorbide mononitrate 10 mg Tab $ 3.50 isosorbide mononitrate 120 mg ER Tab $ 3.50 isosorbide mononitrate 20 mg Tab $ 3.50 isosorbide mononitrate 30 mg ER Tab $ 3.50 isosorbide mononitrate 60 mg ER Tab $ 7.20 isradipine 2.5 mg Cap $ 4.78 isradipine 5 mg Cap $ 6.99 itraconazole 10 mg/mL Oral Soln (Extemp) $ 8.20 itraconazole 100 mg Cap $ 32.56 IV electrolyte Sol (Lypholyte/Nutrilyte) IV Sol $ 3.50 ivabradine 5 mg Tab $ 30.07 ivabradine 7.5 mg Tab $ 30.07 ivermectin 3 mg Tab $ 19.54 ketamine 100 mg/mL Inj Sol 5mL $ 6.88 ketamine 50 mg/mL Sol $ 3.50 ketoconazole 1% Topical Shampoo (125mL Bulk) $ 3.50 ketoconazole 2% Topical Cream (15gm Bulk) $ 7.21 ketoconazole 2% Topical Cream (60gm Bulk) $ 16.16 ketoconazole 2% Topical Shampoo (120mL Bulk) $ 3.50 ketoconazole 200 mg Tab $ 11.06 ketoprofen 50 mg Cap $ 3.90 ketoprofen 75 mg Cap $ 4.34 ketorolac 0.4% Ophthalmic Solution (5mL Bulk) $ 46.82 ketorolac 0.45% Ophthalmic Solution (1EA UD) $ 42.48 ketorolac 0.5% Ophthalmic Solution (3mL Bulk) $ 56.85 ketorolac 0.5% Ophthalmic Solution (5mL Bulk) $ 74.81 ketorolac 10 mg Tab $ 7.55 ketorolac 15 mg/mL Sol $ 11.05 ketorolac 30 mg/mL IV Sol (1 mL Cart) $ 17.64 ketorolac 30 mg/mL IV Sol (1mL Vial) $ 3.65 ketorolac 30 mg/mL IV Sol (2mL Vial) $ 6.05 ketotifen 0.025% Ophthalmic Solution (10mL Bulk) $ 3.63 ketotifen 0.025% Ophthalmic Solution (5mL Bulk) $ 8.53 labetalol 100 mg Tab $ 7.98 labetalol 200 mg Tab $ 3.50 labetalol 300 mg Tab $ 16.43 labetalol 5 mg/mL IV Sol (20mL Vial) $ 3.50 labetalol 5 mg/mL IV Sol 4mL $ 7.10 lacosamide 100 mg Tab $ 43.75 lacosamide 100mg/10mL Oral Soln (10mL UD Liq) $ 4.71 lacosamide 150 mg Tab $ 50.97 lacosamide 200 mg Tab $ 46.35 lacosamide 200 mg/20 mL Sol $ 11.57

STANDARD HOSPITAL CHARGES

lacosamide 50 mg Tab $ 27.99 lactase 3000 units Tab $ 3.50 lactase 9000 units Tab $ 3.50 Lactated Ringer’s IV sol 1000mL $ 3.50 Lactated Ringer’s IV sol 500mL $ 3.50 lactobacillus acidophilus - Tab Chew $ 3.50 lactobacillus acidophilus and bulgaricus 1packet Oral Granules (1EA UD) $ 7.11 lactobacillus acidophilus and bulgaricus Oral Tab $ 3.50 lactobacillus acidophilus cap $ 4.29 lactobacillus acidophilus tab $ 3.50 lactobacillus acidophilus/casei/rhamnosus - Cap DR $ 6.55 lactobacillus casei-omega-3 fatty acids - Oral Cap $ 3.76 lactobacillus rhamnosus GG - Cap $ 3.50 lactulose 10 g/15 mL Oral Solution (473mL Bulk) $ 3.50 lactulose 10 g/15 mL Rectal Liquid (473mL Bulk) $ 3.50 lactulose 10gm/15mL Oral Syrup (15mL UD) $ 3.50 lactulose 10gm/1packet Oral Powder (1EA UD) $ 29.55 lactulose 20gm/1packet Oral Powder (1EA UD) $ 30.62 lactulose 20gm/30mL Oral Syrup (30mL UD) $ 3.50 lamiVUDine 10 mg/mL Oral Sol (Extemp) $ 3.50 lamiVUDine 100 mg Tab $ 56.39 lamiVUDine 150 mg Tab $ 25.13 lamiVUDine 300 mg Tab $ 37.84 lamiVUDine-zidovudine 150 mg-300 mg Tab $ 25.93 lamoTRIgine 100 mg Tab $ 3.50 lamoTRIgine 100 mg Tab ER $ 49.09 lamoTRIgine 150 mg Tab $ 20.92 lamoTRIgine 200 mg Tab $ 22.77 lamoTRIgine 200 mg Tab ER $ 52.35 lamoTRIgine 25 mg Chew Tab $ 11.19 lamoTRIgine 25 mg Tab $ 3.50 lamoTRIgine 25 mg Tab ER $ 22.92 lamoTRIgine 250 mg Tab-ER $ 71.39 lamoTRIgine 5 mg Tab-Dis $ 10.69 lamoTRIgine 50 mg Tab ER $ 45.83 lanolin-mineral oil Topical Lotion (240mL Bulk) $ 3.50 lansoprazole 15 mg Cap $ 3.50 lansoprazole 15 mg Dis Tab $ 58.11 lansoprazole 3 mg/mL Oral Suspension (5mL UD) $ 3.50 lansoprazole 30 mg Cap $ 19.82 lansoprazole 30 mg Dis Tab $ 55.21 lanthanum carbonate 1000 mg oral Chew Tab $ 50.43 lanthanum carbonate 500 mg Chew Tab $ 45.33 lanthanum carbonate 750 mg oral Chew Tab $ 50.43 latanoprost 0.005% Ophthalmic Solution (2.5mL Bulk) $ 133.00 lecithin 1200 mg Cap $ 3.50 ledipasvir-sofosbuvir 90mg-400mg $ 4,725.00

STANDARD HOSPITAL CHARGES

leflunomide 10 mg Tab $ 22.10 leflunomide 20 mg Tab $ 19.05 lenalidomide 2.5 mg Cap $ 2,921.01 leptospermum honey 80% DS gel (44 mLBulk) $ 53.00 letrozole 2.5 mg Tab $ 63.47 leucovorin 25 mg Tab $ 48.26 leucovorin 5 mg Tab $ 9.80 leuprolide 22.5 mg/3 months Pwd Kit (1EA Bulk) $ 5,691.28 levalbuterol 0.63 mg/3 mL Inh Sol $ 7.82 levalbuterol 1.25 mg/0.5 mL Solution Inhalation (Concentrated) $ 26.08 levalbuterol 1.25 mg/3 mL Inh Sol $ 7.82 levalbuterol CFC free 45 mcg/inh Aerosol (15gm Bulk) $ 17.20 levETIRAcetam 100 mg/mL IV Sol 5mL $ 6.63 levETIRAcetam 1000 mg tab $ 24.63 levETIRAcetam 1000 mg/100 mL NaCL 0.75% IV Sol $ 3.50 levETIRAcetam 250 mg Tab $ 3.50 levETIRAcetam 500 mg Tab $ 3.50 levETIRAcetam 500 mg Tab ER $ 15.56 levETIRAcetam 500 mg/100 mL-NaCl 0.82% IV Sol $ 3.50 levETIRAcetam 500mg/5mL Oral Solution (5mL UD Liq) $ 3.50 levETIRAcetam 750 mg Tab $ 16.66 levETIRAcetam 750 mg Tab ER $ 23.37 levobunolol 0.25% Ophthalmic Solution (5mL Bulk) $ 9.84 levobunolol 0.5% Ophthalmic Solution (10mL Bulk) $ 4.18 levOCARNitine 1000mg/10mL Sol (10mL UD Liq) $ 3.50 levOCARNitine 200 mg/mL Inj Sol 5mL $ 27.82 levOCARNitine 250 mg Cap $ 3.50 levOCARNitine 330 mg Tab $ 3.84 levocetirizine 5 mg Tab $ 3.50 levofloxacin 25 mg/mL IV Sol 20mL $ 7.83 levoFLOXacin 25 mg/mL IV Sol 30mL $ 6.93 levoFLOXACIN 25 mg/mL Oral Soln (Extemp) $ 4.84 levoFLOXACIN 250 mg Tab $ 57.73 levoFLOXACIN 250 mg/50 mL IV Sol $ 3.50 levoFLOXACIN 500 mg Tab $ 66.16 levoFLOXACIN 500 mg/100 mL IV Sol $ 3.50 levoFLOXACIN 750 mg Tab $ 123.88 levoFLOXACIN 750 mg/150 mL IV Sol $ 3.50 levofloxacin ophthalmic 0.5% Sol (5 mL Bulk) $ 54.68 levomilnacipran 20 mg Cap ER $ 41.70 levomilnacipran 40 mg Cap ER $ 41.70 levomilnacipran 80 mg Cap-ER $ 41.70 levothyroxine 100 mcg (0.1 mg) Tab $ 3.50 levothyroxine 100 mcg Powder Vial $ 443.45 levothyroxine 112 mcg (0.112 mg) Tab $ 3.50 levothyroxine 125 mcg (0.125 mg) Tab $ 4.64 levothyroxine 137 mcg (0.137 mg) Tab $ 3.50

STANDARD HOSPITAL CHARGES

levothyroxine 150 mcg (0.15 mg) Tab $ 4.62 levothyroxine 175 mcg (0.175 mg) Tab $ 3.50 levothyroxine 200 mcg (0.2 mg) Tab $ 3.50 levothyroxine 200 mcg Powder Vial $ 886.87 levothyroxine 25 mcg (0.025 mg) Tab $ 3.50 levothyroxine 50 mcg (0.05 mg) Tab $ 3.50 levothyroxine 500mcg Powd Vial $ 2,217.22 levothyroxine 75 mcg (0.075 mg) Tab $ 3.50 levothyroxine 88 mcg (0.088 mg) Tab $ 3.50 lidocaine 0.5% Topical Spray (135mL Bulk) $ 3.50 lidocaine 1% PF Sol vial (10mL) $ 3.50 lidocaine 1% PF Sol vial (2mL) $ 4.29 lidocaine 1% PF Sol vial (30mL) $ 3.50 lidocaine 1% PF Sol vial (5mL) $ 5.34 lidocaine 1% Sol (10mL vial) $ 3.50 lidocaine 1% Sol (2mL Vial) $ 4.20 lidocaine 1.5% PF Sol vial (20mL) $ 3.50 lidocaine 2% IV Solution (20mL MDV Inj) $ 3.50 lidocaine 2% Sol (50 mL Vial) $ 3.50 lidocaine 2% Sol 2mL vial $ 5.46 lidocaine 2% Solution IV PF (2mL Amp) $ 3.50 lidocaine 2% Solution IV PF (2mL Vial) $ 5.34 lidocaine 2% Solution IV PF (5mL Vial) $ 3.50 lidocaine 2% Topical Gel (20mL Bulk) $ 3.50 lidocaine 2% Topical Gel (30mL Bulk) $ 3.50 lidocaine 2% Topical Gel (6mL Bulk) $ 4.17 lidocaine 2% Topical Gel w/Appl (11mL Bulk) $ 3.50 lidocaine 2% Topical Gel w/Appl Uro-Jet (10mL Bulk) $ 3.50 lidocaine 2% Topical Gel w/Appl Uro-Jet (5mL Bulk) $ 4.83 lidocaine 2gm/500mL Solution IV (LVP) $ 3.50 lidocaine 3% Topical Cream (28.3gm Bulk) $ 6.38 lidocaine 4% Solution IV PF (5mL Vial) $ 3.64 lidocaine 4% Topical Cream (15gm Bulk) $ 4.48 lidocaine 4% Topical Cream (30gm Bulk) $ 3.92 lidocaine 4% Topical Cream (5gm Bulk) $ 5.88 lidocaine 4% Topical Cream (76.5 gm Bulk) $ 21.00 lidocaine 4% Topical Film $ 5.80 lidocaine 5% Topical Cream (15gm Bulk) $ 5.60 lidocaine 5% Topical Cream (30gm Bulk) $ 3.50 lidocaine 5% Topical Ointment (30gm Bulk) $ 26.67 lidocaine 5% Topical Ointment (35gm Bulk) $ 31.27 lidocaine 5% Topical Ointment (50gm Bulk) $ 26.67 lidocaine Top 5% film $ 32.76 lidocaine topical 2% Oral Sol 100 mL $ 3.50 lidocaine topical 2% Oral Sol 15 mL $ 3.50 lidocaine topical 4% Top Sol 50 mL $ 3.50 lidocaine-prilocaine 2.5%-2.5% Topical Cream (30 gm) $ 5.37

STANDARD HOSPITAL CHARGES

linaclotide 145 mcg Cap $ 54.19 linaclotide 290 mcg Cap $ 54.19 linaclotide 72 mcg Cap $ 49.26 linagliptin 5 mg Tab $ 52.37 linagliptin-metformin 2.5 mg-500 mg Tab $ 27.43 lindane topical 1% Shampoo (60ml Bulk) $ 7.98 linezolid 100 mg/5 mL Oral Liquid (Extemp) $ 19.13 linezolid 600 mg Tab $ 640.50 linezolid 600mg IV/300ml IV Sol (0.9% NS) $ 3.50 linezolid 600mg IV/300ml IV Sol (D5% fluid) $ 3.50 liothyronine 25 mcg Tab $ 3.90 liothyronine 5 mcg Tab $ 3.50 liothyronine 50 mcg Tab $ 5.56 lipid, 20% IV 250 mL $ 3.50 lipid, 20% IV 500 mL $ 3.50 liraglutide 18 mg/3 mL Sol $ 369.26 lisdexamfetamine 10 mg Cap $ 37.89 lisdexamfetamine 20 mg Cap $ 37.89 lisdexamfetamine 30 mg Cap $ 37.89 lisdexamfetamine 50 mg Cap $ 37.89 lisdexamfetamine 60 mg Cap $ 37.89 lisdexamfetamine 70 mg Cap $ 37.89 lisinopril 10 mg Tab $ 4.33 lisinopril 2.5 mg Tab $ 3.50 lisinopril 20 mg Tab $ 3.50 lisinopril 40 mg Tab $ 5.17 lisinopril 5 mg Tab $ 3.50 lithium 150 mg Cap $ 3.50 lithium 300 mg Cap $ 3.50 lithium 300 mg ER Tab $ 3.50 lithium 300 mg Tab $ 3.50 lithium 300 mg/5 mL Oral Syrup (5mL UD) $ 3.50 lithium 450 mg ER Tab $ 3.50 l-methylfolate 7.5 mg Cap $ 22.57 l-methylfolate 7.5 mg Tab $ 10.37 lomustine 100 mg Oral Cap $ 212.12 loperamide 1 mg/7.5 mL Oral Liquid (15mL UD Liq) $ 3.50 loperamide 1 mg/7.5 mL Oral Suspension (15mL UD Susp) $ 3.50 loperamide 1mg/5mL Oral Liquid (5mL UD) $ 3.50 loperamide 2 mg Cap $ 3.50 loperamide 2 mg Tab $ 3.50 loperamide 2mg/10mL Oral Liquid (10mL UD Liq) $ 3.50 lopinavir-ritonavir 200 mg-50 mg Tab $ 31.44 loratadine 10 mg Tab $ 3.50 loratadine 5 mg/5 mL Oral Syrup (10mL UD) $ 3.50 loratadine-pseudoephedrine 10 mg-240 mg ER Tab 24 hr $ 3.90 loratadine-pseudoephedrine 5 mg-120 mg ER Tab 12 hr $ 3.50

STANDARD HOSPITAL CHARGES

LORazepam 0.5 mg Tab $ 3.50 LORazepam 1 mg Tab $ 3.50 LORazepam 2 mg Tab $ 4.62 LORazepam 2 mg/mL Concentrated Oral Soln (1mL UD Liq) $ 4.42 LORazepam 2 mg/mL Inj Sol $ 4.10 LORazepam 2mg/mL Solution IV (10mL MDV) $ 3.70 LORazepam 4 mg/mL Solution IV (1mL Vial) $ 7.18 LORazepam 4mg/mL Solution IV (10mL MDV) $ 5.03 losartan 100 mg Tab $ 10.77 losartan 25 mg Tab $ 5.87 losartan 50 mg Tab $ 7.88 loteprednol 0.2% Ophthalmic Suspension (5mL Bulk) $ 162.53 loteprednol 0.5% Ophthalmic Gel (5mL Bulk) $ 137.41 loteprednol 0.5% Ophthalmic Suspension (5mL Bulk) $ 171.25 loteprednol 0.5% Opth Oint (3.5gm Bulk) $ 276.21 lovastatin 10 mg Tab $ 4.71 lovastatin 20 mg Tab $ 4.41 lovastatin 40 mg Tab $ 14.95 loxapine 10 mg Cap $ 4.45 loxapine 25 mg Cap $ 6.74 loxapine 5 mg Cap $ 3.50 loxapine 50 mg Cap $ 9.00 lubiprostone 24 mcg oral capsule $ 25.98 lubiprostone 8 mcg Cap $ 25.98 lurasidone 120 mg Tab $ 255.70 lurasidone 20 mg Tab $ 171.28 lurasidone 40 mg Tab $ 171.28 lurasidone 60 mg Tab $ 171.28 lurasidone 80 mg Tab $ 171.28 lutein 20 mg Cap $ 3.50 lysine 500 mg Tab $ 3.50 mafenide 85 mg/g Topical Cream (56.7gm Bulk) $ 4.48 mafenide topical 5% Topical Powder (1EA Bulk) *50gm* $ 562.76 magnesium amino acids chelate 133 mg Tab $ 3.50 magnesium chloride 64 mg ER Tab $ 3.50 magnesium citrate 8.85% Oral Liquid (300mL Bulk) $ 3.50 magnesium gluconate 250 mg Tab $ 3.50 magnesium gluconate 500 mg Tab $ 3.50 magnesium gluconate 54mg/5ml Oral Liquid (5mL UD Liq) $ 3.50 magnesium hydroxide 24% Oral Concentrated Soln (10mL UD Liq) $ 3.50 magnesium hydroxide 311 mg Tab Chew $ 3.50 magnesium hydroxide 8% Oral Susp (30mL UD Liq) $ 3.50 magnesium lactate 84 mg Tab ER $ 3.50 magnesium oxide 140 mg Cap $ 3.50 magnesium oxide 250 mg Tab $ 3.50 magnesium oxide 400 mg Tab $ 3.50 magnesium sulfate 2 gm/50 mL (premix) $ 3.50

STANDARD HOSPITAL CHARGES

magnesium sulfate 4 g/100 mL-sterile water IV Sol $ 3.50 magnesium sulfate 4 gm/50 mL (premix) $ 3.50 magnesium sulfate 50% 1 gm/2 mL Solution IV (2 mL Vial) $ 3.50 magnesium sulfate -Topical Powder (454gm Bulk) $ 3.50 magnesium/potassium/sodium sulfates 1.6 g-3.13 g-17.5 g/177 mL Liq $ 3.50 mannitol 20% IV Sol 500 mL $ 3.50 mannitol 25% IV Sol 50 mL $ 3.50 maprotiline 25 mg Tab $ 4.04 maraviroc 150 mg Tab $ 105.76 measles/mumps/rubella virus vaccine SubQ Inj $ 297.86 meclizine 12.5 mg Tab $ 3.50 meclizine 25 mg Tab $ 3.50 meclizine 25 mg Tab-chew $ 3.50 medroxyPROGESTERone 10 mg Tab $ 3.50 medroxyPROGESTERone 150 mg/mL Sus $ 342.48 medroxyPROGESTERone 2.5 mg Tab $ 3.50 medroxyPROGESTERone 5 mg Tab $ 3.50 megestrol ES 625 mg/5 mL Oral Susp (5mL UD Liq) $ 20.97 megestrol 20 mg Tab $ 3.64 megestrol 200mg/5mL Oral Susp (5mL UD Liq) $ 3.50 megestrol 40 mg Tab $ 3.66 megestrol 400mg/10mL Oral Susp (10mL UD) $ 3.50 megestrol 800mg/20mL Oral Susp (20mL UD) $ 3.50 melatonin 1 mg tab $ 3.50 melatonin 10 mg Cap $ 3.50 melatonin 3 mg tab $ 3.50 melatonin 5 mg Tab $ 3.50 meloxicam 15 mg Tab $ 16.32 meloxicam 7.5 mg Tab $ 10.84 memantine 10 mg Tab $ 21.33 memantine 14 mg Cap ER $ 53.48 memantine 21 mg Cap ER $ 53.48 memantine 28 mg Cap ER $ 53.48 memantine 5 mg Tab $ 21.33 memantine 7 mg Cap ER $ 53.48 meningococcal conjugate vaccine - Powder Inj UD $ 457.24 meningococcal conjugate vaccine IM Sol $ 975.86 menthol 10.5% topical Spray (89mL Bulk) $ 3.50 menthol 4% Topical Gel (118mL Bulk) $ 3.50 menthol 4% Topical Gel (89mL Bulk) $ 3.50 menthol 5% topical-patch $ 10.57 menthol lozenge $ 3.50 menthol Topical Gel (60gm Bulk) $ 3.50 menthol-zinc oxide 0.44%-20.625% Topical Ointment (113gm Bulk) $ 3.50 menthol-zinc oxide 0.44%-20.625% Topical Ointment (3.5gm Bulk) $ 3.50 menthol-zinc oxide 0.44%-20.625% Topical Ointment (71gm Bulk) $ 3.50 meperidine 100 mg/mL Inj Sol $ 21.98

STANDARD HOSPITAL CHARGES

meperidine 25 mg/0.5 mL Inj Sol $ 15.64 meperidine 25 mg/mL Inj Sol $ 22.70 meperidine 50 mg Tab $ 10.57 meperidine 50 mg/mL Inj Sol $ 9.19 meperidine 75 mg/mL Inj Sol $ 21.97 meprobamate 200 mg Tab $ 24.06 meprobamate 400 mg Tab $ 6.41 mercaptopurine 50 mg Tab $ 13.31 meropenem 1 gm/50 mL-NS IV solution (premix) $ 104.40 meropenem 1,000 mg Pow inj $ 84.00 meropenem 500 mg Pow inj $ 42.00 meropenem 500 mg/ 50 mL-NS IV Solution (premix) $ 75.97 mesalamine 0.375 g Cap ER $ 15.32 mesalamine 1.2 gm Tab DR $ 35.38 mesalamine 1000 mg Supp $ 135.04 mesalamine 250 mg ERCap $ 11.70 mesalamine 4 g/60 mL Rectal Enema $ 3.50 mesalamine 400 mg Cap DR $ 12.41 mesalamine 400 mg Tab DR $ 8.83 mesalamine 500 mg ERCap $ 23.40 mesalamine 800 mg Tab DR $ 32.46 metaxalone 400 mg Tab $ 22.41 metaxalone 800 mg Tab $ 20.96 metFORMIN 1000 mg Tab $ 4.80 metFORMIN 500 mg Tab $ 3.50 metFORMIN 500 mg Tab ER $ 4.68 metFORMIN 500 mg/5 mL Oral Solution (5mL UD Liq) $ 5.91 metFORMIN 750 mg Tab ER $ 4.19 metFORMIN 850 mg Tab $ 4.21 metFORMIN-saxagliptin 1000 mg-2.5 mg Tab-ER $ 25.98 metFORMIN-saxagliptin 1000 mg-5 mg Tab-ER $ 51.96 metformin-sitagliptin 500 mg-50 mg $ 30.07 methadone 10 mg Tab $ 3.50 methadone 10 mg/5 mL Oral Soln (5mL UD Liq) $ 3.50 methadone 10 mg/mL Oral Concentrate (1mL UD Liq) $ 3.50 methadone 40 mg Tab Dis $ 3.50 methadone 5 mg Tab $ 3.50 methadone 5 mg/5 mL Oral Soln (5mL UD Liq) $ 3.50 methazolamide 25 mg Tab $ 13.41 methazolamide 50 mg Tab $ 26.82 methenamine hippurate 1 g Tab $ 7.32 methenamine mandelate 0.5 g Tab $ 3.50 methenamine mandelate 1 g Tab $ 5.78 methimazole 10 mg Tab $ 3.50 methimazole 5 mg Tab $ 3.50 methocarbamol 100 mg/mL IV Sol 10mL $ 24.95 methocarbamol 500 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

methocarbamol 750 mg Tab $ 3.50 methotrexate 2.5 mg Tab $ 21.83 methotrexate 25 mg/mL Inj Sol (10 mL Vial) $ 14.11 methotrexate 25 mg/mL Inj Sol 2mL $ 15.04 methotrexate 25 mg/mL Inj Sol PF (10 mL Vial) $ 3.79 methotrexate 25 mg/mL Inj Sol PF 2 mL $ 8.69 methscopolamine 2.5 mg Tab $ 9.76 methscopolamine 5 mg Tab $ 13.88 methyl salicylate Top Crm (150gm Bulk) $ 3.50 methyl salicylate Topical Cream (57gm bulk) $ 3.50 methyl salicylate Topical Cream (90gm bulk) $ 3.50 methyl salicylate Topical Ointment (28gm Bulk) $ 3.50 methyl salicylate topical patch $ 3.50 methylcellulose 2 g/19 g Powder (480gm Bulk) $ 3.50 methylcellulose 500 mg Tab $ 3.50 methyldopa 250 mg Tab $ 3.50 methyldopa 500 mg Tab $ 3.50 methylnaltrexone 12 mg/0.6 mL Sol $ 763.00 methylnaltrexone 150 mg Tab $ 69.36 methylnaltrexone 8 mg/0.4 mL Sol $ 1,144.47 methylphenidate 10 mg Tab $ 3.65 methylphenidate 10 mg/24 hr ER Cap $ 19.61 methylphenidate 10 mg/8 hr ER Tab $ 26.25 methylphenidate 18 mg/24 hr ER Tab $ 21.78 methylphenidate 20 mg Tab $ 5.24 methylphenidate 20 mg/24 hr Cap ER $ 19.61 methylphenidate 20 mg/8 hr ER Tab $ 27.13 methylphenidate 27 mg/24 hr ER Tab $ 34.91 methylphenidate 30 mg/24 hours Cap ER $ 20.31 methylphenidate 36 mg/24 hr ER Tab $ 36.01 methylphenidate 5 mg Tab $ 3.50 methylphenidate 54 mg/24 hr ER Tab $ 39.18 methylPREDNISolone 1 gm Sod Suc PF Pow Vial $ 238.51 methylPREDNISolone 1 gm Sod Suc Pow Vial $ 143.71 methylPREDNISolone 125 mg Sod Suc (PF) $ 40.66 methylPREDNISolone 125 mg Sod Suc Pow Vial $ 48.93 methylPREDNISolone 16 mg Tab $ 12.39 methylPREDNISolone 4 mg Dose Pack $ 5.77 methylPREDNISolone 40 mg Sod Suc PF Pow vial $ 25.21 methylPREDNISolone 40 mg Sod Suc Pow Vial $ 25.54 methylPREDNISolone 40 mg/mL Acetate Susp $ 44.39 methylPREDNISolone 40 mg/mL Acetate Susp-inj (5mL) $ 38.51 methylPREDNISolone 500 mg Sod Suc (PF) Pow Vial $ 163.95 methylPREDNISolone 500 mg Sod Suc Pow Vial $ 97.10 methylPREDNISolone 8 mg Tab $ 7.04 methylPREDNISolone 80 mg/mL Acetate Susp $ 29.30 methylPREDNISolone 80 mg/mL Acetate Susp (5 mL Vial) $ 77.09

STANDARD HOSPITAL CHARGES

metoclopramide 10 mg Tab $ 3.50 metoclopramide 10mg/10mL Oral Syrup (10mL UD) $ 3.50 metoclopramide 5 mg Tab $ 3.50 metoclopramide 5 mg/mL Inj Sol 2 mL $ 3.50 metolazone 10 mg Tab $ 12.28 metolazone 2.5 mg Tab $ 11.50 metolazone 5 mg Tab $ 13.07 metoprolol 1 mg/mL Inj Sol 5 mL $ 3.50 metoprolol 1 mg/mL PF Inj Sol 5mL $ 3.50 metoprolol 100 mg ER succinate Tab $ 6.08 metoprolol 25 mg ER succinate Tab $ 3.69 metoprolol 50 mg ER succinate Tab $ 4.34 metoprolol tartrate 100 mg Tab $ 3.50 metoprolol tartrate 25 mg Tab $ 3.50 metoprolol tartrate 50 mg Tab $ 3.50 metroNIDAZOLE 0.75% Topical Cream (45gm Bulk) $ 14.17 metroNIDAZOLE 0.75% Topical Gel (45gm Bulk) $ 13.48 metroNIDAZOLE 0.75% Vaginal Gel w/Appl (70gm Bulk) $ 7.64 metroNIDAZOLE 1% Topical Gel (60gm Bulk) $ 16.17 metroNIDAZOLE 250 mg Tab $ 3.50 metroNIDAZOLE 500 mg Tab $ 3.50 metroNIDAZOLE 500 mg/100 mL IV Sol $ 3.50 mexiletine 150 mg Cap $ 8.87 mexiletine 200 mg Cap $ 10.59 mexiletine 250 mg Cap $ 12.24 micafungin 100 mg Pow inj $ 785.40 micafungin 50 mg Pow inj $ 392.70 miconazole 2% Topical Cream (142gm Bulk) $ 3.50 miconazole 2% Topical Cream (42.5gm Bulk) $ 3.50 miconazole 2% Topical Ointment (150gm Bulk) $ 3.50 miconazole 2% Topical Ointment (60gm Bulk) $ 3.50 miconazole 2% Topical Powder (113gm Bulk) $ 3.50 miconazole 2% Topical Powder (45gm Bulk) $ 3.50 miconazole 2% Topical Powder (70gm Bulk) $ 3.50 miconazole 2% Topical Powder (90gm Bulk) $ 3.50 miconazole 200 mg Vag Supp $ 61.33 miconazole 200 mg-2% Vag kit $ 35.56 miconazole topical 100 mg Sup $ 5.79 miconazole topical 2% Vaginal Cream (45gm Bulk) $ 3.50 miconazole topical 4% Vaginal Cream (5gm Bulk) $ 3.50 miconazole-zinc oxide 2%-10% Topical Spray (56gm Bulk) $ 3.50 midazolam 1 mg/mL Inj Sol 10mL $ 3.50 midazolam 1 mg/mL Inj Sol 2 mL $ 3.50 midazolam 1 mg/mL Inj Sol 5mL $ 3.50 midazolam 1 mg/mL Inj Sol PF 5mL $ 3.50 midazolam 5 mg/mL Inj Sol 2mL $ 3.50 midodrine 10 mg Tab $ 34.02

STANDARD HOSPITAL CHARGES

midodrine 2.5 mg Tab $ 5.92 midodrine 5 mg Tab $ 4.60 miglitol 25 mg Tab $ 10.98 milnacipran 100 mg Tab $ 24.42 milnacipran 25 mg Tab $ 24.42 milnacipran 50 mg Tab $ 24.42 milrinone 1 mg/mL IV Sol (50mL SDV) $ 3.50 milrinone 20mg/100mL-D5W IV Sol (premix) $ 3.50 milrinone 40mg/200mL-D5W IV Sol (premix) $ 3.50 mineral oil 100% Enema $ 3.50 mineral oil 100% Oral Liquid (30mL UD Liq) $ 3.50 minocycline 100 mg Cap $ 11.89 minocycline 100 mg Powder Inj $ 619.05 minocycline 100 mg Tab $ 15.31 minocycline 50 mg Cap $ 5.95 minocycline 50 mg Tab $ 12.02 minoxidil 10 mg Tab $ 4.52 minoxidil 2.5 mg Tab $ 3.50 mirabegron 25 mg ER Tab $ 29.19 mirabegron 50 mg ER Tab $ 29.19 mirtazapine 15 mg ODT Tab $ 8.24 mirtazapine 15 mg Tab $ 9.48 mirtazapine 30 mg ODT Tab $ 8.49 mirtazapine 30 mg Tab $ 12.24 mirtazapine 7.5 mg Tab $ 9.22 misoprostol 100 mcg Tab $ 3.50 misoprostol 200 mcg Tab $ 4.20 modafinil 100 mg Tab $ 77.00 modafinil 200 mg Tab $ 116.66 moexipril 15 mg Tab $ 5.09 moexipril 7.5 mg Tab $ 4.86 mometasone 0.1% Topical Cream (15gm Bulk) $ 6.80 mometasone 0.1% Topical Cream (45gm Bulk) $ 4.12 mometasone 0.1% Topical Lotion (60mL Bulk) $ 3.50 mometasone 0.1% Topical Ointment (15gm Bulk) $ 6.05 mometasone 110 mcg/inh Pow $ 632.97 mometasone 220 mcg/inh Pow $ 310.63 mometasone 50 mcg/inh Nasal Spray (17gm Bulk) $ 29.65 montelukast 10 mg Tab $ 19.27 montelukast 4 mg Chew Tab $ 19.80 montelukast 5 mg Chew Tab $ 19.80 morphine 0.5 mg/mL preservative-free Sol inj (10mL Vial) $ 3.50 morphine 1 mg/mL PCA 30 mL $ 3.50 morphine 1 mg/mL preservative-free Sol Inj (10mL Vial) $ 3.50 morphine 10 mg Supp $ 21.88 morphine 10 mg/24 hours ER Cap $ 16.56 morphine 10 mg/5 mL Oral Soln (5mL UD Liq) $ 3.50

STANDARD HOSPITAL CHARGES

morphine 10 mg/mL Injection $ 4.24 morphine 10 mg/mL preservative-free Sol inj (1mL Syringe) $ 9.20 morphine 10 mg/mL preservative-free Sol-inj $ 8.06 morphine 100 mg ER Tab $ 26.73 morphine 10mg/0.5ml Concentrated Oral Soln (0.5mL UD Liq) $ 3.50 morphine 15 mg ER Tab $ 6.55 morphine 15 mg IR Tab $ 3.50 morphine 15 mg/mL Injection $ 4.37 morphine 2 mg/mL preservative-free Inj Carpuject $ 7.82 morphine 2 mg/mL preservative-free Sol-inj (SDPF) $ 11.05 morphine 2 mg/mL preservative-free Sol-inj (syringe) $ 9.20 morphine 2 mg/mL preservative-free Sol-inj syringe $ 8.46 morphine 20 mg/24 hours ER Cap $ 18.30 morphine 20 mg/5 mL Oral Soln (2.5mL UD Liq) $ 3.50 morphine 20 mg/5 mL Oral Soln (5mL UD Liq) $ 3.50 morphine 20 mg/mL Concentrated Oral Soln (1mL UD Liq) $ 3.50 morphine 20 mg/mL Oral Sol (1mL UD) $ 15.35 morphine 30 mg ER Tab $ 11.83 morphine 30 mg IR Tab $ 3.50 morphine 30 mg/24 hours ER Cap (AVINza) $ 20.05 morphine 30 mg/24 hours ER Cap (Kadian) $ 19.90 morphine 4 mg/mL Injection $ 7.82 morphine 4 mg/mL preservative-free Sol inj (SDPF Vial) $ 11.05 morphine 4 mg/mL preservative-free Sol inj (SYRN) $ 9.20 morphine 5 mg/mL Injection $ 4.16 morphine 5 mg/mL preservative-free Sol inj $ 9.20 morphine 60 mg ER Tab $ 21.75 morphine 8 mg/mL Injection $ 4.70 morphine 8 mg/mL preservative-free Sol inj $ 8.94 morphine-naltrexone 100 mg-4 mg Cap ER $ 110.78 morphine-naltrexone 20 mg-0.8 mg Cap ER $ 28.08 morphine-naltrexone 30 mg-1.2 mg Cap-ER $ 42.16 moxifloxacin 0.5% Ophthalmic Solution (3mL Bulk) $ 203.39 moxifloxacin 400 mg Tab $ 104.76 moxifloxacin 400 mg/250 mL Sol $ 3.50 Multiple Vitamin with Iron Tab $ 3.50 Multiple Vitamins IV Sol (10mL SDV) $ 4.25 Multiple Vitamins with Minerals (Flintstones Childrens) Tab-chew $ 3.50 Multiple Vitamins with Minerals Oral Liq (Abatron) (5mL UD Liq) $ 3.50 Multiple Vitamins with Minerals Oral Liq (Apetigen Plus) (15mL UD Liq) $ 3.50 Multiple Vitamins with Minerals Oral Liquid (15mL UD Liq) $ 3.50 multivitamin B complex (L-METHYLFOLATE/MCOBAL/B6 PHOS) tab $ 5.05 multivitamin Multiple Vitamins Chewable Tab $ 3.50 multivitamin Pediatric Multiple Vitamins Sol IV $ 9.63 multivitamin Pediatric Oral Liquid )1mL UD Liq) $ 3.50 multivitamin Therapeutic Multiple Vitamins Oral Liquid (5mL UD Liq) $ 3.50 multivitamin Vitamin B Complex with C and Folic Acid Tab $ 3.50

STANDARD HOSPITAL CHARGES

multivitamin Vitamin B12, Folate, and Acetylcysteine Tab $ 22.57 multivitamin w/o vitamin K Tab $ 3.50 multivitamin with fluoride 0.5 mg Chewable Tab $ 3.50 Multivitamin with Iron ChewableTab $ 3.50 multivitamin with iron Vitamin B Complex with C, Folic Acid, Iron and Docusate Tab $ 3.50 multivitamin with iron Vitamin B Complex with Iron Oral Liquid (15 mL UD Liq) $ 3.50 multivitamin with iron Vitamin B12 with C, Iron and Intrinsic Factor Tab $ 4.37 multivitamin with iron Vitamin C with Folic Acid Tab ER (Folitab 500) $ 3.50 multivitamin with minerals (Folgard OS) Tab $ 3.50 multivitamin with minerals (Folgard) Tab $ 3.50 multivitamin with minerals (Hematinic Plus) Tab $ 3.50 multivitamin with minerals (Lysiplex) Oral Liquid (15mL UD Liq) $ 3.50 multivitamin with minerals (Ocuvite) Antioxidant Multiple Vitamins and Minerals Tab $ 3.50 multivitamin with minerals (PreserVision AREDS 2) Antioxidant Multiple Vitamins and Minerals Cap $ 3.50 multivitamin with minerals (Preservision Lutein) Antioxidant Multiple Vitamins and Minerals Cap $ 3.50 multivitamin with minerals Calcium, Folic Acid and Magnesium Tab $ 3.50 multivitamin with minerals Multiple Vitamins with Minerals Cap $ 3.50 multivitamin with minerals Tab $ 3.50 multivitamin with minerals Tab-Chew $ 3.50 multivitamin with minerals with Zinc Liq $ 3.50 multivitamin with minerals, Iron and Docusate Tab ( Max FE) $ 3.50 multivitamin, prenatal Prenatal Multivitamins with Folic Acid 0.8 mg Tab $ 3.50 multivitamin, prenatal Prenatal Multivitamins with Folic Acid 1 mg Cap $ 12.04 multivitamin, prenatal Prenatal Multivitamins with Folic Acid 1 mg Kit UD $ 3.50 multivitamin, prenatal Prenatal Multivitamins with Folic Acid 1 mg Tab $ 3.50 mupirocin 2% Topical Cream (15gm Bulk) $ 34.32 mupirocin 2% Topical Ointment (15gm Bulk) $ 3.98 mupirocin 2% Topical Ointment (22gm Bulk) $ 3.50 mupirocin topical 2% Cream (30gm Bulk) $ 48.48 mycophenolate mofetil 200 mg/mL Oral Susp (Extemp) $ 31.71 mycophenolate mofetil 250 mg Cap $ 13.73 mycophenolate mofetil 500 mg Tab $ 27.74 mycophenolic acid 180 mg Tab EC $ 15.99 mycophenolic acid 360 mg Tab EC $ 31.98 nabumetone 500 mg Tab $ 4.82 nabumetone 750 mg Tab $ 5.36 nadolol 20 mg Tab $ 12.95 nadolol 40 mg Tab $ 25.29 nadolol 80 mg Tab $ 18.83 nafcillin 1 gm Pow inj (addv) $ 67.39 nafcillin 1 gm Pow inj (vial) $ 51.10 nafcillin 10 gm Pow Inj (vial) $ 485.70 nafcillin 2 gm Pow inj (addv) $ 130.73 nafcillin 2 gm Pow inj (vial) $ 98.96 nafcillin 2 gm/100 mL Sol (frozen) $ 3.50

STANDARD HOSPITAL CHARGES

nalbuphine 20 mg/mL Injectable Solution $ 26.15 naloxegol 12.5 mg Tab $ 48.30 naloxegol 25 mg Tab $ 48.30 naloxone 0.4 mg/mL Inj Sol $ 63.70 naloxone 1 mg/mL Inj Sol $ 69.30 naloxone 4 mg/0.1 mL Nasal Spray $ 262.50 naloxone-pentazocine 0.5 mg-50 mg Tab $ 11.55 naltrexone 50 mg Tab $ 15.09 naphazoline 0.012% with glycerin Ophthalmic Solution ( 15mL Bulk) $ 3.50 naphazoline-pheniramine 0.025%-0.3% Ophthalmic Solution (10mL Bulk) $ 3.50 naphazoline-pheniramine 0.025%-0.3% Ophthalmic Solution (15mL Bulk) $ 20.23 naphazoline-pheniramine 0.027%-0.315% Ophthalmic Solution (15mL Bulk) $ 3.50 naproxen 125 mg/5 mL Oral Susp (Extemp) $ 4.50 naproxen 250 mg Tab $ 3.50 naproxen 375 mg Tab $ 3.50 naproxen 500 mg Tab $ 4.17 naproxen 500 mg Tab-DR $ 4.55 naproxen sodium 220 mg Tab $ 3.50 naproxen sodium 275 mg Tab $ 8.02 nateglinide 120 mg Tab $ 6.37 nateglinide 60 mg Tab $ 5.82 nebivolol 10 mg Tab $ 16.65 nebivolol 2.5 mg Tab $ 18.66 nebivolol 20 mg Tab $ 16.65 nebivolol 5 mg Tab $ 18.66 nedocromil 2% Ophthalmic Solution (5mL Bulk) $ 179.60 nefazodone 100 mg Tab $ 16.80 nefazodone 150 mg Tab $ 17.11 nefazodone 200 mg Tab $ 17.44 nefazodone 250 mg Tab $ 17.76 nefazodone 50 mg Tab $ 16.40 neomycin 500 mg Tab $ 4.77 neomycin-polymyxin B sulfate Irrigation Solution $ 44.98 neostigmine 0.5 mg/mL Inj Sol 10mL $ 17.14 nepafenac 0.1% Ophthalmic Suspension (3mL Bulk) $ 345.01 nepafenac 0.3% Ophthalmic Suspension $ 324.16 Nephro-Vite Tab $ 3.50 nevirapine 200 mg Tab $ 37.96 niacin 100 mg Tab $ 3.50 niacin 1000 mg ER Tab $ 3.50 niacin 250 mg Cap ER $ 3.50 niacin 250 mg ER Tab $ 3.50 niacin 250 mg Tab $ 3.50 niacin 50 mg Tab $ 3.50 niacin 500 mg Cap $ 3.50 niacin 500 mg ER Cap $ 3.50 niacin 500 mg ER Tab $ 3.50

STANDARD HOSPITAL CHARGES

niacin 500 mg Tab $ 3.50 niacin 750 mg ER Tab $ 3.50 niCARdipine 20 mg Cap $ 7.80 niCARdipine 30 mg Cap $ 11.17 niCARdipine 30 mg Cap SR $ 6.98 nicotine 10 mg/mL Inhaler device (1EA UD) $ 10.41 nicotine 14 mg/24 hr Transderm ER Film $ 7.47 nicotine 2 mg Gum $ 3.50 nicotine 2 mg Lozenge $ 3.50 nicotine 21 mg/24 hr Transderm ER Film $ 6.73 nicotine 4 mg Gum $ 3.50 nicotine 4 mg Lozenge $ 3.50 nicotine 7 mg/24 hr Transderm ER Film $ 7.50 NIFEdipine 10 mg Cap $ 4.50 NIFEdipine 20 mg Cap $ 8.06 NIFEdipine 30 mg ER Tab $ 4.72 NIFEdipine 60 mg ER Tab $ 8.10 NIFEdipine 90 mg ER Tab $ 10.61 niMODipine 30 mg Cap $ 55.47 niMODipine 60 mg/20 mL Liq UD $ 15.33 nintedanib 150 mg Cap $ 641.09 nisoldipine 8.5 mg ER Tab $ 21.50 nitazoxanide 500 mg Tab $ 438.06 nitrofurantoin 100mg/20mL Oral Susp (20mL UD Liq) $ 11.12 nitrofurantoin macrocrystals 100 mg Cap $ 11.82 nitrofurantoin macrocrystals 50 mg cap $ 7.95 nitrofurantoin macrocrystals-monohydrate 100 mg Cap $ 13.35 nitroglycerin 0.1 mg/hr Transderm ER Film $ 8.94 nitroglycerin 0.2 mg/hr Transderm ER Film $ 5.66 nitroglycerin 0.3 mg sublingual Tab $ 3.50 nitroglycerin 0.3 mg/hr Transderm ER Film $ 66.11 nitroglycerin 0.4 mg Spray (4.1gm Bulk) $ 160.34 nitroglycerin 0.4 mg sublingual Tab $ 3.59 nitroglycerin 0.4 mg/hr Transderm ER Film $ 10.18 nitroglycerin 0.6 mg/hr Transderm ER Film $ 11.04 nitroglycerin 2% Top Ointment (1gm UD) $ 9.64 nitroglycerin 2.5 mg Cap $ 3.50 nitroglycerin 6.5 mg ERCap $ 3.50 nitroglycerin 9 mg ER Cap $ 3.91 nitroprusside 25mg/mL Solution IV (2mL Vial) $ 1,681.73 norepinephrine 1 mg/mL IV Sol $ 9.19 norethindrone 5 mg Tab $ 9.27 norfloxacin 400 mg Tab $ 16.94 nortriptyline 10 mg Cap $ 3.50 nortriptyline 25 mg Cap $ 5.03 nortriptyline 50 mg Cap $ 9.68 nortriptyline 75 mg Cap $ 14.76

STANDARD HOSPITAL CHARGES

nystatin 100,000 units/g Topical Cream (15gm Bulk) $ 4.08 nystatin 100,000 units/g Topical Cream (30 gm Bulk) $ 3.50 nystatin 100,000 units/g Topical Ointment (15gm Bulk) $ 3.92 nystatin 100,000 units/g Topical Ointment (30gm Bulk) $ 3.50 nystatin 100,000 units/g Topical Powder (15gm Bulk) $ 4.09 nystatin 100,000 units/g Topical Powder (60gm Bulk) $ 3.50 nystatin 500,000units/5mL Oral Susp (5mL UD Liq) $ 3.50 nystatin 500000 units Tab $ 3.50 nystatin-triamcinolone 100,000 units/g-0.1% Topical Cream (15gm Bulk) $ 26.12 nystatin-triamcinolone 100,000 units/g-0.1% Topical Cream (30gm Bulk) $ 18.61 nystatin-triamcinolone 100,000 units/g-0.1% Topical Cream (60gm Bulk) $ 13.26 nystatin-triamcinolone 100,000 units/g-0.1% Topical Ointment (15gm Bulk) $ 26.12 nystatin-triamcinolone 100,000 units/g-0.1% Topical Ointment (30gm Bulk) $ 18.61 octreotide 100 mcg/mL Inj Sol $ 41.75 octreotide 1000 mcg/mL Inj Sol (5 ml) $ 417.38 octreotide 200 mcg/mL Inj Sol $ 57.12 octreotide 50 mcg/mL Inj Sol $ 21.25 octreotide 500 mcg/mL Inj Sol $ 208.70 ocular lubricant - Gel FS(10mL Bulk) $ 3.78 ocular lubricant - Gel (10gm Bulk) $ 3.50 ocular lubricant - Gel (15mL Bulk) $ 3.50 ocular lubricant - Ointment (1gm Bulk) $ 12.52 ocular lubricant - Ointment (3.5gm Bulk) $ 7.18 ocular lubricant - Ointment (7gm Bulk) $ 10.14 ocular lubricant - Ophthalmic Solution (Refresh) (15mL Bulk) $ 3.50 ocular lubricant - Ophthalmic Solution {celluvisc} (1EA UD) $ 3.50 ocular lubricant - Ophthalmic Solution {refresh optive sensitive} (1EA UD) $ 3.50 ocular lubricant - Ophthalmic Solution {refresh plus} (1EA UD) $ 3.50 ocular lubricant - Ophthalmic Solution {refresh} (1EA UD) $ 3.50 ocular lubricant - Sol (10mL) $ 3.50 ocular lubricant ( Thera Tears Gel) -Ophthalmic Gel (1EA UD) $ 3.50 ocular lubricant -Ophthalmic Solution (1EA UD) $ 3.50 ocular lubricant Preserved Solution (10mL Bulk) $ 3.65 ocular lubricant Preserved Solution (15mL Bulk) $ 3.50 ofloxacin 0.3% Ophthalmic Solution (10mL Bulk) $ 47.48 ofloxacin 0.3% Ophthalmic Solution (5mL Bulk) $ 49.25 ofloxacin 0.3% Otic Solution (5mL Bulk) $ 94.56 OLANZapine 10 mg IM Inj $ 144.38 OLANZapine 10 mg Tab $ 71.11 OLANZapine 10 mg Tab Dis $ 73.41 OLANZapine 15 mg Tab $ 6.27 OLANZapine 2.5 mg Tab $ 39.19 OLANZapine 20 mg Tab $ 8.36 OLANZapine 5 mg ODT $ 7.50 OLANZapine 5 mg Tab $ 46.26 OLANZapine 7.5 mg Tab $ 56.29 olmesartan 20 mg Tab $ 21.99

STANDARD HOSPITAL CHARGES

olmesartan 40 mg Tab $ 32.08 olmesartan 5 mg Tab $ 18.03 olodaterol 2.5 mcg/inh Aerosol (4gm Bulk) $ 187.22 olopatadine 0.1% Ophthalmic Solution (5mL Bulk) $ 187.03 olopatadine 0.2% Ophthalmic Solution (2.5mL Bulk) $ 251.16 olopatadine 665 mcg/inh Nasal Spray (3.5gm Bulk) $ 31.08 omalizumab 150 mg Powder Injection $ 4,466.24 omega-3 polyunsaturated fatty acids 1000 mg Cap $ 3.50 omega-3 polyunsaturated fatty acids 1000 mg ethyl estersoral capsule $ 7.24 omega-3 polyunsaturated fatty acids 1050 mg Cap $ 3.50 omega-3 polyunsaturated fatty acids 1200 mg Cap $ 3.50 omega-3 polyunsaturated fatty acids 1600 mg/5 mL Liquid (5mL UD) $ 3.50 omega-3 polyunsaturated fatty acids 500 mg Cap $ 3.50 omeprazole 10 mg Oral Powder (1EA UD) $ 40.37 omeprazole 10 mg Cap DR $ 12.95 omeprazole 20 mg Oral Cap DR $ 3.90 omeprazole 2mg/mL Oral Susp (10mL UD Liq) $ 3.50 omeprazole 40 mg Cap DR $ 23.18 omeprazole-sodium bicarbonate 20-1680mg/1packet Oral Powder (1EA UD) $ 366.93 omeprazole-sodium bicarbonate 40-1680mg/1packet Oral Powder (1EA UD) $ 366.93 onabotulinum toxin A 100 units Inj $ 2,210.73 onabotulinum toxin A 200 units Inj $ 4,410.00 ondansetron 2 mg/mL Inj Sol 2 mL $ 3.50 ondansetron 4 mg Tab $ 3.50 ondansetron 4 mg Tab ODT $ 80.90 ondansetron 4 mg/5 mL Oral Soln (Extemp) $ 16.79 ondansetron 8 mg Tab $ 144.45 ondansetron 8 mg Tab ODT $ 128.32 ophthalmic irrigation, extraocular - Ophthalmic Solution (118 mL) $ 3.50 opium 10% Oral Tincture (1mL UD Liq) $ 21.95 opium 2 mg/5 mL Oral Liquid (5mL UD Liq) $ 3.50 orphenadrine 100 mg ER Tab $ 8.08 orphenadrine 30 mg/mL Inj Sol 2mL $ 38.85 oseltamivir 30 mg Cap $ 49.63 oseltamivir 45 mg Cap $ 49.63 oseltamivir 6 mg/mL Oral Powder (12.5mL UD Liq) $ 9.55 oseltamivir 75 mg Cap $ 54.10 oxacillin 1 gm Inj $ 47.25 oxacillin 1 gm Pow Inj (addv) $ 47.64 oxacillin 2 g/50 mL Solution IV $ 3.50 oxacillin 2 gm Inj $ 98.96 oxandrolone 10 mg Tab $ 83.35 oxandrolone 2.5 mg Tab $ 24.26 oxazepam 10 mg Cap $ 3.50 oxazepam 15 mg Cap $ 3.80 oxazepam 30 mg Cap $ 7.36 OXcarbazepine 150 mg Tab $ 5.34

STANDARD HOSPITAL CHARGES

OXcarbazepine 300 mg ER Tab $ 35.78 OXcarbazepine 300 mg Tab $ 9.76 OXcarbazepine 300 mg/5 mL Oral Susp (Extemp) $ 3.50 OXcarbazepine 600 mg Tab $ 16.98 oxybutynin 10 mg ER Tab $ 11.51 oxybutynin 15 mg ER Tab $ 11.81 oxybutynin 3.9 mg/24 hr Transderm ER Film $ 10.42 oxybutynin 5 mg ER Tab $ 11.49 oxybutynin 5 mg Tab $ 3.50 oxybutynin 5 mg/5 mL Oral Syrup (5mL UD) $ 3.50 oxychlorosene sodium 2 g Topical Powder $ 10.04 oxyCODONE 10 mg ER Tab $ 15.37 oxyCODONE 10 mg IR Tab $ 3.50 oxyCODONE 13.5 mg Cap-ER $ 22.81 oxyCODONE 15 mg ER Tab $ 22.63 oxyCODONE 15 mg IR Tab $ 4.38 oxyCODONE 20 mg ER Tab $ 28.67 oxyCODONE 20 mg IR Tab $ 3.86 oxyCODONE 20 mg/mL Oral Concentrated (0.5mL UD Liq) $ 15.71 oxyCODONE 20 mg/mL Oral Concentrated (1mL UD Liq) $ 43.14 oxyCODONE 30 mg ER Tab $ 40.90 oxyCODONE 30 mg IR Tab $ 3.50 oxyCODONE 40 mg ER Tab $ 49.09 oxyCODONE 5 mg IR Tab $ 3.50 oxyCODONE 5 mg/5 mL Oral Soln (5mL UD) $ 5.24 oxyCODONE 60 mg ER Tab $ 69.51 oxyCODONE 80 mg ER Tab $ 87.87 oxyCODONE 9 mg Cap ER $ 15.50 oxymetazoline 0.05% Nasal Spray (15mL Bulk) $ 3.50 oxymetazoline 0.05% Nasal Spray (30mL Bulk) $ 3.50 oxymorphone 10 mg ER Tab $ 16.75 oxymorphone 10 mg IR Tab $ 18.72 oxymorphone 15 mg Tab ER $ 23.23 oxymorphone 20 mg ER Tab $ 29.71 oxymorphone 30 mg ER Tab $ 42.76 oxymorphone 40 mg ER Tab $ 55.81 oxymorphone 5 mg IR Tab $ 11.34 oxymorphone 5 mg oral ER Tab $ 8.72 oxymorphone 7.5 mg tab ER Tab $ 12.74 paliperidone 3 mg Tab-ER $ 106.97 paliperidone 6 mg Tab-ER $ 106.85 paliperidone 9 mg Tab ER $ 160.27 pamidronate 3 mg/mL IV Sol 10 mL $ 14.81 pamidronate 30 mg Pow inj (vial) $ 78.93 pamidronate 9 mg/mL IV Sol (10 mL Vial) $ 15.06 pamidronate 90 mg Pow inj (vial) $ 236.74 pancrelipase (lipase 10,000 units)-42,000units-32,000units Cap $ 12.85

STANDARD HOSPITAL CHARGES

pancrelipase (lipase 10,000 units)-55,000units-34,000units Cap $ 7.64 pancrelipase (lipase 10,500 units)-43,750units-25,000units Cap $ 12.61 pancrelipase (lipase 15,000 units)-51,000 units-82,000 units Cap $ 16.87 pancrelipase (lipase 16,800 units)-98,400units-56,800units Cap $ 20.25 pancrelipase (lipase 20,000 units)-109,000units-68,000units Cap $ 14.99 pancrelipase (lipase 20,000 units)-63,000units-84,000units Cap $ 22.92 pancrelipase (lipase 21,000 units)-83,900units-54,700units Cap $ 25.23 pancrelipase (lipase 24,000 units)-76,000units-120,000units Cap $ 21.39 pancrelipase (lipase 25,000 units)-79,000 units-105,000 units Cap $ 31.20 pancrelipase (lipase 25,000 units)-85,000units-136,000units $ 28.36 pancrelipase (lipase 3,000 units)-9,500units-15,000units Cap $ 4.56 pancrelipase (lipase 3000 units)-10,000 units-16,000 units Cap $ 6.19 pancrelipase (lipase 4,200 units)-17,500units-10,000units Cap $ 5.04 pancrelipase (lipase 4000 units)-14,375 units-15,125 units Cap $ 6.52 pancrelipase (lipase 5,000 units)-24,000units-17,000units Cap $ 6.50 pancrelipase (lipase 5,000 units)-27,000units-17,000units Cap $ 3.50 pancrelipase (lipase 6,000 units)-30,000units-19,000units Cap $ 5.40 pancrelipase (lipase12,000 units)-60,000units-38,000units Cap $ 10.79 pancrelipase (lipase36,000 units)-114,000 units-180,000 units Cap $ 33.65 pancrelipase (lipase40,000 units)-136,000 units-218,000 units Cap $ 45.23 pancrelipase 10,440 units-39,150 units-39,150 units Tab $ 12.34 pancrelipase 20,880 units-78,300 units-78,300 units Tab $ 24.35 pantoprazole 20 mg DR Tab $ 14.28 pantoprazole 40 mg DR Tab $ 18.43 pantoprazole 40 mg IV Inj $ 21.00 pantoprazole 40 mg/1 packet Oral Granules (1EA UD) $ 58.01 paricalcitol 1 mcg oral capsule $ 28.00 paricalcitol 2 mcg/mL IV Sol $ 84.84 paricalcitol 5 mcg/mL IV Sol $ 212.10 paricalcitol 5 mcg/mL IV Solution $ 212.10 PARoxetine 10 mg Tab $ 9.35 PARoxetine 10 mg/5 mL Oral Susp (Extemp) $ 4.86 PARoxetine 12.5 mg ER Tab $ 19.51 PARoxetine 20 mg Tab $ 9.57 PARoxetine 25 mg ER Tab $ 20.37 PARoxetine 30 mg Tab $ 9.85 PARoxetine 37.5 mg ER Tab $ 20.98 PARoxetine 40 mg Tab $ 10.41 patiromer 16.8 gm Oral Powder (1 EA UD) $ 114.91 patiromer 8.4 gm Oral Powder (1 EA UD) $ 153.98 Pediatric Multiple Vitamins with Iron Liq (50mL) $ 3.50 penciclovir 1% Topical Cream (1.5gm Bulk) $ 269.08 penicillin G benzathine 1,200,000 units/2 mL Sus $ 321.15 penicillin G benzathine 2,400,000 units/4 mL Sus $ 338.59 Penicillin G Potassium 2,000,000 units/50 mL Solution IV $ 3.50 Penicillin G Potassium 20,000,000 units Pow $ 483.00 Penicillin G Potassium 3,000,000 units/50 mL Solution IV $ 3.50

STANDARD HOSPITAL CHARGES

Penicillin G Potassium 5,000,000 units Powder Injection $ 115.50 Penicillin G Sodium 5,000,000 units Powder Injection $ 201.59 Penicillin V Potassium 125 mg/5 mL Oral Liquid (Extemp) $ 3.50 Penicillin V Potassium 250 mg Tab $ 3.50 Penicillin V Potassium 250 mg/5 mL Oral Liquid (Extemp) $ 3.50 Penicillin V Potassium 500 mg Tab $ 4.08 pentafluoropropane-tetrafluoroethane Topical Spray (105mL Bulk) $ 3.50 pentafluoropropane-tetrafluoroethane Topical Spray (30mL Bulk) $ 3.50 pentamidine 300 mg Pow $ 700.95 pentosan polysulfate sodium 100 mg Cap $ 33.85 pentoxifylline 400 mg ER Tab $ 5.24 perampanel 0.5 mg/mL Oral Suspension $ 14.28 perampanel 12 mg Tab $ 125.58 perampanel 2 mg Tab $ 63.28 perampanel 4 mg Tab $ 125.58 perampanel 6 mg Tab $ 125.58 permethrin 1% Topical Solution (59mL Bulk) $ 3.50 permethrin 5% Topical Cream (60gm Bulk) $ 7.22 permethrin topical 1% Lot (60mL Bulk) $ 3.50 perphenazine 16 mg Tab $ 13.65 perphenazine 2 mg Tab $ 4.07 perphenazine 4 mg Tab $ 7.36 perphenazine 5 mg/mL Injection Sol $ 27.39 perphenazine 8 mg Tab $ 5.39 petrolatum 100% Topical Ointment (10gm Bulk) $ 3.50 petrolatum 100% Topical Ointment (30gm Bulk) $ 3.50 petrolatum 100% Topical Ointment (390gm Bulk) $ 3.50 petrolatum 100% Topical Ointment (52gm Bulk) $ 3.50 petrolatum 42% Topical Ointment (100gm Bulk) $ 3.50 phenazopyridine 100 mg Tab $ 8.40 phenazopyridine 200 mg Tab $ 14.00 phenazopyridine 95 mg Tab $ 3.50 phenazopyridine 97.5 mg Tab $ 3.50 phenelzine 15 mg Tab $ 3.50 PHENobarbital 100 mg Tab $ 3.50 PHENobarbital 130 mg/mL Inj Sol $ 194.21 PHENobarbital 16.2 mg Tab $ 3.50 PHENobarbital 20 mg/5 mL Oral Elixer (5mL UD Liq) $ 3.50 PHENobarbital 30 mg Tab $ 3.50 PHENobarbital 32.4 mg Tab $ 3.50 PHENobarbital 60 mg Tab $ 3.50 PHENobarbital 64.8 mg Tab $ 3.50 PHENobarbital 65 mg/mL Inj Sol $ 78.00 PHENobarbital 97.2 mg Tab $ 4.17 phenol 1.4% Topical Throat Spray (177mL Bulk) $ 3.50 phenol topical 1.4% Spr (20mL Bulk) $ 3.50 phenol topical 14.5 mg Lozenge $ 3.50

STANDARD HOSPITAL CHARGES

phenol topical 29 mg Lozenge $ 3.50 phenoxybenzamine 10 mg Cap $ 453.06 phentermine 30 mg Cap $ 4.62 phentermine 37.5 mg Tab $ 5.33 phenylephrine 0.25% Nasal Spray (15mL Bulk) $ 3.50 phenylephrine 0.25% rectal Gel (27gm Bulk) $ 3.50 phenylephrine 0.25% Topical Rectal Ointment (28gm Bulk) $ 3.50 phenylephrine 0.25% Topical Rectal Ointment (57gm Bulk) $ 3.50 phenylephrine 0.5% Nasal Spray (15mL Bulk) $ 3.50 phenylephrine 10 mg/mL Inj Sol 5 mL $ 10.50 phenylephrine hydrochloride 10 mg Tab $ 3.50 phenylephrine topical 0.25% Sup $ 3.50 phenylephrine topical 0.25%-3% Sup $ 3.50 phenylephrine-pramoxine Topical Rectal Cream 0.25%-1% (26gm Bulk) $ 3.50 phenylephrine-pramoxine Topical Rectal Cream 0.25%-1% (51gm Bulk) $ 3.50 phenytoin 100 mg ERCap $ 3.50 phenytoin 100mg/4mL Oral Susp (4mL UD Liq) $ 3.50 phenytoin 30 mg Cap ER $ 4.47 phenytoin 300 mg ER Cap $ 7.90 phenytoin 50 mg Chew Tab $ 3.50 phenytoin 50 mg/mL Inj Sol (5mL Bulk) $ 3.50 phenytoin 50 mg/mL Inj Sol 2 mL $ 3.50 physostigmine 1 mg/mL Inj Sol 2 mL $ 77.92 phytonadione 1 mg/0.5 mL Inj Sol $ 39.12 phytonadione 10 mg/mL Inj Sol $ 202.61 phytonadione 100 mcg Tab $ 3.50 phytonadione 1mg/0.5ml SOLN-ORAL (0.5ml UD Liq) $ 16.29 phytonadione 5 mg Tab $ 224.36 pilocarpine 1% Ophthalmic Solution (15mL Bulk) $ 9.52 pilocarpine 2% Ophthalmic Solution (15mL Bulk) $ 23.52 pilocarpine 4% Ophthalmic Solution (15mL Bulk) $ 10.27 pilocarpine 5 mg Tab $ 6.35 pilocarpine 7.5 mg Tab $ 6.99 pimavanserin 17 mg Tab $ 119.15 pimecrolimus Topical Cream (30gm Bulk) $ 35.90 pindolol 10 mg Tab $ 5.24 pindolol 5 mg Tab $ 4.62 pioglitazone 15 mg Tab $ 24.52 pioglitazone 30 mg Tab $ 37.48 pioglitazone 45 mg Tab $ 32.97 piperacillin-tazobactam 12 gm-1.5 gm Powder Inj (Vial) $ 204.12 piperacillin-tazobactam 2 gm-0.25 gm Pow inj (addv) $ 35.71 piperacillin-tazobactam 2 gm-0.25 gm Powder Inj (vial) $ 38.85 piperacillin-tazobactam 2 gm-0.25 gm/50 mL Solution IV (frozen) $ 3.50 piperacillin-tazobactam 3 gm-0.375 gm Pow inj (addv) $ 50.13 piperacillin-tazobactam 3 gm-0.375 gm Powder Inj (vial) $ 76.14 piperacillin-tazobactam 3 gm-0.375 gm/50 mL Solution IV (frozen) $ 3.50

STANDARD HOSPITAL CHARGES

piperacillin-tazobactam 36 g-4.5 g Powder Inj (Vial) $ 616.42 piperacillin-tazobactam 4 gm-0.5 gm Pow inj (addv) $ 64.55 piperacillin-tazobactam 4 gm-0.5 gm Powder Inj (vial) $ 81.85 piperacillin-tazobactam 4 gm-0.5 gm/100 mL Solution IV (frozen) $ 3.50 piperonyl butoxide-pyrethrins 4%-0.33% Topical Shampoo (118mL Bulk) $ 3.50 pirfenidone 267 mg Tab $ 132.50 piroxicam 10 mg Cap $ 9.12 piroxicam 20 mg Cap $ 4.50 pitavastatin 1 mg Tab $ 38.68 pitavastatin 2 mg Tab $ 38.68 pitavastatin 4 mg Tab $ 38.68 pneumococcal 13-valent conjugate vaccine -Inj Sus UD $ 1,410.94 pneumococcal 23-polyvalent vaccine - Inj Sol 0.5mL $ 793.92 pneumococcal 23-valent vaccine Inj Sol $ 793.92 polycarbophil 500 mg Tab-Chew $ 3.50 polycarbophil 625 mg Tab $ 3.50 polyethylene glycol 3350 - Pow (119 gm) $ 3.50 polyethylene glycol 3350 - Pow (238gm) $ 3.50 polyethylene glycol 3350 Oral Pwdr-Reconstit {17gm} (1EA UD) $ 6.54 polyethylene glycol 3350 with electrolytes - Oral Powder (4000mL Bulk) $ 3.50 polymyxin B sulfate 500,000 units Inj $ 47.25 polymyxin B-trimethoprim 10,000 units-1 mg/mL Ophthalmic Solution (10mL Bulk) $ 4.57 posaconazole 100 mg Tab DR $ 249.21 posaconazole 40 mg/mL Oral Susp (Extemp) $ 51.95 potassium acetate 2 mEq/mL IV Sol (20mL Vila) $ 3.50 potassium acid phosphate 500 mg Tab $ 3.50 potassium bicarbonate 25 mEq Tab Eff $ 3.50 potassium bicarbonate-potassium chloride 25 mEq Tab Eff (1EA UD) $ 5.00 potassium chloride 10 mEq Cap $ 18.51 potassium chloride 10 mEq ER Tab $ 3.50 potassium chloride 10 mEq/100 mL IV Sol $ 3.50 potassium chloride 10 mEq/50 mL IV Sol $ 3.50 potassium chloride 2 mEq/mL IV Sol (10mL Vial) $ 3.50 potassium chloride 2 mEq/mL IV Sol (20mL Vial) $ 3.50 potassium chloride 2 mEq/mL IV Sol (5mL Vial) $ 3.50 potassium chloride 20 mEq ER Tab $ 3.50 potassium chloride 20 mEq/100 mL IV Sol $ 3.50 potassium chloride 20 mEq/15 mL Oral Liquid (15mL UD) $ 4.34 potassium chloride 20 mEq/1packet Oral Powder (1EA UD) $ 37.59 potassium chloride 20 mEq/50 mL IV Sol $ 3.50 potassium chloride 25mEq/1packet Oral Powder (1EA UD) $ 24.22 potassium chloride 40 mEq/100 mL IV Sol $ 3.50 potassium chloride 40 mEq/30 mL Oral Liquid (30mL UD Liq) $ 3.50 potassium chloride 40mEq/15mL Oral Liquid (15mL UD Liq) $ 3.50 potassium chloride 8 mEq ER Cap $ 3.50 potassium chloride 8 mEq ER Tab $ 3.50 potassium chloride-sodium chloride 15 mg-457 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

potassium citrate 10 mEq ER Tab $ 9.65 potassium citrate 15 mEq ER Tab $ 9.32 potassium citrate 5 mEq ER Tab $ 6.89 potassium gluconate 595 mg Tab $ 3.50 potassium iodide 1 g/mL Oral Solution (30mL Bulk) $ 3.50 potassium phosphate 3 mmol/mL IV Sol (15mL Vial) $ 3.91 potassium phosphate 3 mmol/mL IV Sol (5mL Vial) $ 12.44 potassium phosphate-sodium phosphate 250 mg-45 mg-298 mg Tab $ 3.50 potassium phosphate-sodium phosphate 250-280-160mg Oral Powder (1EA UD) $ 3.50 potassium phosphate-sodium phosphate 305 mg-700 mg Tab $ 3.50 povidone iodine 10% Topical Oin (28.35gm Bulk) $ 3.50 pramipexole 0.125 mg Tab $ 10.32 pramipexole 0.25 mg Tab $ 3.50 pramipexole 0.375 mg Tab ER $ 56.48 pramipexole 0.5 mg Tab $ 10.32 pramipexole 0.75 mg Tab ER $ 56.48 pramipexole 1 mg Tab $ 10.32 pramipexole 1.5 mg Tab $ 11.70 pramipexole 1.5 mg Tab ER $ 62.27 pramoxine 1% Topical Lotion (240mL Bulk) $ 3.50 pramoxine 1% topical Cream (30gm Bulk) $ 3.50 pramoxine 1% Topical Lotion (222mL Bulk) $ 3.50 pramoxine 1% Topical Rectal Foam (15gm Bulk) $ 12.23 pramoxine-zinc oxide 1%-12.5% Topical Ointment (28.3gm Bulk) $ 3.50 prasugrel 10 mg Tab $ 57.73 prasugrel 5 mg Tab $ 57.73 pravastatin 10 mg Tab $ 10.13 pravastatin 20 mg Tab $ 11.43 pravastatin 40 mg Tab $ 16.70 pravastatin 80 mg Tab $ 16.78 praziquantel 600 mg Tab $ 313.87 prazosin 1 mg Cap $ 6.34 prazosin 2 mg Cap $ 8.83 prazosin 5 mg Cap $ 15.08 prednisoLONE 15 mg/5 mL Oral Syrup (5mL UD) $ 3.50 prednisoLONE 5 mg Tab $ 59.03 prednisoLONE acetate 0.12% Ophthalmic Suspension (5mL Bulk) $ 116.50 prednisoLONE acetate 1% Ophthalmic Suspension (10mL Bulk) $ 38.69 prednisoLONE acetate 1% Ophthalmic Suspension (1mL Bulk) $ 116.51 prednisoLONE acetate 1% Ophthalmic Suspension (5mL Bulk) $ 11.03 prednisoLONE opth sod phos 1% Sol (10ml Bulk) $ 20.31 prednisoLONE sodium phosphate 15mg/5mL Oral Liquid (Extemp) $ 3.50 prednisoLONE-sodium sulfacetamide 0.2%-10% Ophthalmic Suspension (5mL Bulk) $ 116.50 prednisoLONE-sulfacetamide sodium 0.2%-10% Opth Oint (3.5gm Bulk) $ 166.43 prednisoLONE-sulfacetamide sodium 0.25% -10% Opth Sol (10mL Bulk) $ 8.75 prednisoLONE-sulfacetamide sodium 0.25% -10% Opth Sol (5mL Bulk) $ 13.13 predniSONE 1 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

predniSONE 10 mg Tab $ 3.50 predniSONE 2.5 mg Tab $ 3.50 predniSONE 20 mg Tab $ 3.50 predniSONE 5 mg Tab $ 3.50 predniSONE 5 mg/5 mL Sol (5 ml UD) $ 3.50 predniSONE 5 mg/mL Oral Sol (1 mL UD) $ 18.20 predniSONE 50 mg Tab $ 3.50 pregabalin 100 mg oral capsule $ 31.50 pregabalin 150 mg oral capsule $ 31.50 pregabalin 200 mg oral capsule $ 28.63 pregabalin 25 mg oral capsule $ 28.63 pregabalin 300 mg oral capsule $ 28.63 pregabalin 50 mg oral capsule $ 31.50 pregabalin 75 mg oral capsule $ 31.50 primaquine 15 mg Tab $ 6.30 primidone 250 mg Tab $ 3.50 primidone 50 mg Tab $ 3.50 probenecid 500 mg Tab $ 4.01 procainamide 100mg/mL Solution IV (10mL MDV) $ 36.28 procainamide 500 mg/mL Inj Sol $ 150.53 prochlorperazine 10 mg Tab $ 3.50 prochlorperazine 25 mg Supp $ 42.90 prochlorperazine 5 mg Tab $ 3.50 prochlorperazine 5 mg/mL Inj Sol 2 mL $ 38.85 progesterone 100 mg Cap $ 7.35 progesterone 200 mg Cap $ 34.38 promethazine 12.5 mg Sup $ 61.97 promethazine 12.5 mg Tab $ 3.50 promethazine 25 mg Supp $ 61.97 promethazine 25 mg Tab $ 3.50 promethazine 25 mg/mL Inj Sol $ 4.95 promethazine 50 mg/mL Inj Sol $ 7.77 promethazine 6.25 mg/5 mL Oral Syrup (5mL UD) $ 3.50 propafenone 150 mg Tab $ 3.50 propafenone 225 mg ERCap $ 27.62 propafenone 225 mg Tab $ 8.15 propafenone 325 mg Oral ER Cap $ 35.00 propafenone 425 mg Oral ER Cap $ 35.00 propofol 10 mg/mL Emulsion (20mL Bulk) $ 3.50 propranolol LA 80 mg Cap $ 8.43 propranolol 10 mg Tab $ 3.50 propranolol 20 mg Tab $ 3.50 propranolol 20mg/5mL Oral Soln (5mL UD Liq) $ 3.50 propranolol 40 mg Tab $ 3.50 propranolol 80 mg Tab $ 3.50 propranolol LA 60 mg Cap $ 7.69 propranolol LA 120 mg Cap $ 10.44

STANDARD HOSPITAL CHARGES

propranolol LA 160 mg Cap $ 13.67 propylthiouracil 50 mg Tab $ 3.50 protamine 10 mg/mL Inj Sol 25 mL $ 6.19 protamine 10 mg/mL Inj Sol 5 mL $ 10.32 protriptyline 5 mg Tab $ 14.29 pseudoephedrine 120 mg ER Tab $ 3.50 pseudoephedrine 30 mg Tab $ 3.50 pseudoephedrine 30 mg/5 mL Oral Liquid (Extemp) $ 3.50 pseudoephedrine 60 mg Tab $ 3.50 psyllium 3.4gm in 12.2gm Packet Powder-Pkt (1EA UD) $ 3.50 psyllium 3.4gm in 5.8gm Packet Powder-Pkt (1EA UD) $ 3.50 psyllium 3.5 g/3.7 g Packet Powder-Recon (1 Ea UD) $ 3.50 psyllium 500 mg Cap $ 3.50 psyllium 520 mg Cap $ 3.50 psyllium cap $ 3.50 pyrazinamide 500 mg Tab $ 22.73 pyridostigmine 180 mg ER Tab $ 86.91 pyridostigmine 60 mg Tab $ 4.46 pyridostigmine 60 mg/5 mL Oral Syrup (5mL UD Liq) $ 9.62 pyridoxine 100 mg Tab $ 3.50 pyridoxine 100 mg/mL Inj Sol $ 63.84 pyridoxine 25 mg Tab $ 3.50 pyridoxine 50 mg Tab $ 3.50 pyrimethamine 25 mg Tab $ 3,150.00 QUEtiapine 100 mg Tab $ 3.50 QUEtiapine 150 mg ER Tab $ 55.74 QUEtiapine 200 mg ER Tab $ 3.71 QUEtiapine 200 mg Tab $ 42.61 QUEtiapine 25 mg Tab $ 3.50 QUEtiapine 300 mg ER Tab $ 4.27 QUEtiapine 300 mg Tab $ 59.72 QUEtiapine 400 mg ER Tab $ 94.53 QUEtiapine 400 mg Tab $ 69.10 QUEtiapine 50 mg ER Tab $ 3.50 QUEtiapine 50 mg Tab $ 22.99 quinapril 10 mg Tab $ 4.28 quinapril 20 mg Tab $ 4.28 quinapril 5 mg Tab $ 4.28 quiNIDine 200 mg Tab $ 3.50 quiNIDine 300 mg Tab $ 3.50 quiNIDine 324 mg ER Tab $ 31.72 quiNINE 324 mg oral capsule $ 25.64 RABEprazole 20 mg Tab-EC $ 40.11 racepinephrine 2.25% Solution (0.5mL UD) $ 6.56 raloxifene 60 mg Tab $ 24.95 raltegravir 100 mg Tab-chew $ 25.16 raltegravir 400 mg Tab $ 104.04

STANDARD HOSPITAL CHARGES

ramelteon 8 mg Tab $ 52.88 ramipril 1.25 mg Cap $ 5.36 ramipril 10 mg Cap $ 7.76 ramipril 2.5 mg Cap $ 6.32 ramipril 5 mg Cap $ 3.50 ranitidine 150 mg Tab $ 3.50 ranitidine 150mg/10mL Oral Syrup (10mL UD Liq) $ 3.50 ranitidine 25 mg/mL Inj Sol 2mL $ 27.07 ranitidine 75 mg Tab $ 3.50 ranolazine 1000 mg oral ER Tab $ 28.23 ranolazine 500 mg oral ER Tab $ 17.19 rasagiline 0.5 mg oral tablet $ 87.44 rasagiline 1 mg oral tablet $ 87.44 renal caps $ 3.50 repaglinide 0.5 mg Tab $ 12.81 repaglinide 1 mg Tab $ 12.81 repaglinide 2 mg Tab $ 12.81 ribavirin 200 mg Cap $ 34.72 riboflavin 100 mg Tab $ 3.50 rifabutin 150 mg Cap $ 61.40 rifAMPIN 150 mg Cap $ 5.10 rifAMPIN 300 mg Cap $ 4.77 rifAMPIN 600 mg IV Inj $ 642.60 rifAXIMIN 200 mg Tab $ 80.61 rifAXIMIN 550 mg Tab $ 153.65 rilpivirine 25 mg Tab $ 132.76 riluzole 50 mg Tab $ 129.29 rimabotulinumtoxinB 5000 units/mL Inj Soln. $ 2,440.20 rimantadine 100 mg Tab $ 11.37 risedronate 150 mg Tab $ 816.87 risedronate 35 mg Tab $ 216.83 risedronate 35 mg Tab DR $ 183.07 risedronate 5 mg Tab $ 30.99 risperiDONE 0.25 mg Tab $ 13.63 risperiDONE 0.5 mg Tab $ 13.76 risperiDONE 0.5 mg Tab Dis $ 17.21 risperiDONE 1 mg Tab $ 15.89 risperiDONE 1 mg/mL Oral Solution $ 17.78 risperiDONE 2 mg Tab $ 26.56 risperiDONE 2 mg Tab Dis $ 31.31 risperiDONE 4 mg Tab $ 42.00 ritonavir 100 mg packet Oral Powder-Recon (1 EA UD) $ 36.00 ritonavir 100 mg Cap $ 31.58 ritonavir 100 mg Tab $ 32.40 rivaroxaban 10 mg tab $ 58.67 rivaroxaban 15 mg Tab $ 58.67 rivaroxaban 20 mg Tab $ 58.67

STANDARD HOSPITAL CHARGES

rivastigmine 1.5 mg Cap $ 14.85 rivastigmine 13.3 mg/24 hr TD film, ER $ 56.71 rivastigmine 3 mg Cap $ 14.12 rivastigmine 4.5 mg Cap $ 14.77 rivastigmine 4.6 mg/24 hr TD film, ER $ 56.71 rivastigmine 6 mg Cap $ 14.77 rivastigmine 9.5 mg/24 hr TD film, ER $ 56.71 rizatriptan 10 mg Dis Tab $ 127.30 rizatriptan 10 mg Tab $ 116.38 rizatriptan 5 mg Tab $ 116.38 rizatriptan 5 mg Tab-Dis $ 127.30 roflumilast 500 mcg Tab $ 49.09 rOPINIRole 0.25 mg Tab $ 8.77 rOPINIRole 0.5 mg Tab $ 8.77 rOPINIRole 1 mg Tab $ 8.75 rOPINIRole 12 mg Tab XL $ 47.89 rOPINIRole 2 mg Tab $ 8.77 rOPINIRole 2 mg Tab XL $ 9.57 rOPINIRole 3 mg Tab $ 3.50 rOPINIRole 4 mg Tab $ 3.50 rOPINIRole 4 mg Tab XL $ 19.15 rOPINIRole 5 mg Tab $ 9.10 rOPINIRole 6 mg Tab XL $ 28.72 rOPINIRole 8 mg Tab XL $ 28.72 ropivacaine 0.2% Sol $ 3.50 rosiglitazone 4 mg Tab $ 21.57 rosuvastatin 10 mg Tab $ 31.27 rosuvastatin 20 mg Tab $ 5.05 rosuvastatin 40 mg Tab $ 31.31 rosuvastatin 5 mg Tab $ 5.06 rotigotine 1 mg/24 hr Film ER $ 90.53 rotigotine 2 mg/24 hr Film ER $ 90.53 rotigotine 3 mg/24 hr Film ER $ 90.53 rotigotine 4 mg/24 hr Film ER $ 90.53 rotigotine 6 mg/24 hr Film ER $ 90.53 rotigotine 8 mg/24 hr Film ER $ 90.53 rufinamide 200 mg Tab $ 45.92 rufinamide 400 mg Tab $ 91.84 saccharomyces boulardii lyo 250 mg oral capsule $ 3.50 saccharomyces boulardii lyo 250mg/1packet Oral Powder (1EA UD) $ 3.50 sacubitril-valsartan 24 mg-26 mg Tab $ 30.08 sacubitril-valsartan 49 mg-51 mg Tab $ 29.48 sacubitril-valsartan 97 mg-103 mg Tab $ 30.08 salicylic acid 17% Topical Liquid (9.3mL Bulk) $ 3.50 salicylic acid 3% Topical Shampoo (120mL Bulk) $ 3.50 salicylic acid 3% Topical Shampoo (133mL Bulk) $ 3.50 saliva substitute Oral Spray *Mouth Kote* (60mL Bulk) $ 3.50

STANDARD HOSPITAL CHARGES

saliva substitutes - Loz $ 3.50 saliva substitutes Oral Spray ""Oasis"" (30mL Bulk) $ 3.50 salmeterol 50 mcg Inh Pwdr $ 33.32 salsalate 500 mg Tab $ 5.98 salsalate 750 mg Tab $ 9.00 saw palmetto 160 mg Cap $ 3.50 saxagliptin 2.5 mg Tab $ 51.96 saxagliptin 5 mg Tab $ 51.96 scopolamine 1.5 mg Transderm ER Film $ 74.90 scopolamine ophthalmic 0.25% Sol $ 25.49 selegiline 5 mg Cap $ 8.06 selegiline 5 mg Tab $ 10.37 selegiline 6 mg/24 hr TD film $ 209.39 selenium 100 mcg Tab $ 3.50 selenium 200 mcg Tab $ 3.50 selenium 40 mcg/mL IV Sol (10mL Vial) $ 7.76 selenium 50 mcg Tab $ 3.50 selenium sulfide 1% Topical Shampoo (207mL Bulk) $ 3.50 selenium sulfide 1% Topical Shampoo (210mL Bulk) $ 20.44 selenium sulfide 2.5% Topical Lotion (118mL Bulk) $ 3.50 senna 8.6 mg Tab $ 3.50 senna 8.8 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 senna leaf extract 528mg/15mL Oral Syrup (15mL UD Liq) $ 3.50 sertraline 100 mg Tab $ 9.95 sertraline 20 mg/mL Oral Concentrate (Extemp) $ 3.91 sertraline 25 mg Tab $ 9.98 sertraline 50 mg Tab $ 3.50 sevelamer carbonate 0.8gm/1packet Oral Powder (1EA UD) $ 64.00 sevelamer carbonate 2.4gm/1packet Oral Powder (1EA UD) $ 39.71 sevelamer carbonate 800 mg Tab $ 13.24 sevelamer HCl 400 mg Tab $ 13.82 sevelamer HCl 800 mg Tab $ 29.64 sildenafil 100 mg Tab $ 232.62 sildenafil 20 mg Tab $ 70.01 sildenafil 25 mg Tab $ 232.62 sildenafil 50 mg Tab $ 232.62 silodosin 4 mg Cap $ 35.00 silodosin 8 mg Cap $ 34.90 silver nitrate Top Stick (1EA UD) $ 3.50 silver sulfADIAZINE 1% Topical Cream (20gm Bulk) $ 3.50 silver sulfADIAZINE 1% Topical Cream (25gm Bulk) $ 3.50 silver sulfADIAZINE 1% Topical Cream (400gm Bulk) $ 3.50 silver sulfADIAZINE 1% Topical Cream (50gm Bulk) $ 3.50 silver topical - Gel (45mL Bulk) $ 3.50 simethicone 125 mg Cap $ 3.50 simethicone 125 mg Chew Tab $ 3.50 simethicone 40 mg/0.6 mL Liquid $ 3.50

STANDARD HOSPITAL CHARGES

simethicone 80 mg Chew Tab $ 3.50 simvastatin 10 mg Tab $ 3.50 simvastatin 20 mg Tab $ 3.53 simvastatin 40 mg Tab $ 17.21 simvastatin 5 mg Tab $ 3.50 simvastatin 80 mg Tab $ 16.88 sirolimus 0.5 mg Tab $ 29.66 sirolimus 1 mg Tab $ 59.32 sirolimus 1mg/mL Oral Soln (Extemp) $ 116.96 sitaGLIPtin 100 mg Tab $ 60.14 sitaGLIPtin 25 mg tablet $ 60.14 sitaGLIPtin 50 mg tablet $ 60.14 SMOG Enema (Bulk) $ 46.68 sodium acetate 2 mEq/mL IV Sol $ 3.50 sodium bicarbonate 325 mg Tab $ 3.50 sodium bicarbonate 4% Inhalation Sol $ 5.42 sodium bicarbonate 4.2% Sol 10mL $ 4.35 sodium bicarbonate 4.2% Sol 5mL $ 3.50 sodium bicarbonate 650 mg Tab $ 3.50 sodium bicarbonate 8.4% (50 mEq/50 mL) IV Sol 50 mL $ 3.50 sodium biphosphate-sodium phosphate 19 g-7 g Rectal Enema 133 mL $ 3.50 sodium biphosphate-sodium phosphate 3.5 g-9.5 g Ene $ 3.50 Sodium Chloride 0.45% + 20mEq KCL $ 3.50 Sodium Chloride 0.45% IV Sol 1000mL $ 3.50 Sodium Chloride 0.45% IV Sol IVPB 250mL $ 3.50 Sodium Chloride 0.45% IV Sol LVP 500mL CONT $ 3.50 sodium chloride 0.45% Solution IV (100mL IVPB) $ 3.50 sodium chloride 0.65% Nasal Gel (14.1gm Bulk) $ 3.50 sodium chloride 0.65% Nasal Gel (22gm Bulk) $ 3.50 sodium chloride 0.65% Nasal Spray (30mL Bulk) $ 3.50 sodium chloride 0.65% Nasal Spray (45mL Bulk) $ 3.50 Sodium Chloride 0.9% + 20mEq KCL $ 3.50 Sodium Chloride 0.9% + 40mEq KCL $ 3.50 Sodium Chloride 0.9% Inhalation Sol (15mL UD) $ 3.50 Sodium Chloride 0.9% Inhalation Sol (3mL UD) $ 3.50 Sodium Chloride 0.9% Irrigation Sol 1000mL $ 3.50 Sodium Chloride 0.9% Irrigation Sol 250mL $ 3.50 Sodium Chloride 0.9% Irrigation Sol 500mL $ 3.50 Sodium Chloride 0.9% IV Sol ADDV 100mL $ 3.50 Sodium Chloride 0.9% IV Sol ADDV 250mL $ 3.50 Sodium Chloride 0.9% IV Sol ADDV 50mL $ 3.50 Sodium Chloride 0.9% IV Sol Flush (10mL) - PF $ 3.50 sodium chloride 0.9% IV Sol Flush 2.5mL $ 4.93 sodium chloride 0.9% IV Sol Flush 3mL $ 3.50 sodium chloride 0.9% IV Sol Flush 5mL - PF $ 3.50 Sodium Chloride 0.9% IV Sol IVPB (50mL SDPF Vial) $ 3.50 Sodium Chloride 0.9% IV Sol IVPB 100mL $ 3.50

STANDARD HOSPITAL CHARGES

Sodium Chloride 0.9% IV Sol IVPB 150mL $ 3.50 Sodium Chloride 0.9% IV Sol IVPB 250mL $ 3.50 Sodium Chloride 0.9% IV Sol IVPB 25mL $ 3.50 Sodium Chloride 0.9% IV Sol IVPB 50mL $ 3.50 Sodium Chloride 0.9% IV Sol LVP 1000mL BOLUS $ 3.50 Sodium Chloride 0.9% IV Sol LVP 500mL BOLUS $ 3.50 Sodium Chloride 0.9% IV Sol MB+ 100mL $ 3.50 Sodium Chloride 0.9% IV Sol MB+ 50mL $ 3.50 Sodium Chloride 0.9% IV Sol Recon 10mL bacteriostatic $ 3.50 Sodium Chloride 0.9% IV Sol Recon 30mL bacteriostatic $ 3.50 sodium chloride 0.9% Sol Inj - Diluent (20mL)PF $ 3.50 sodium chloride 0.9% Sterile Field IV Sol 10mL $ 3.50 Sodium Chloride 1 gm Tab $ 3.50 sodium chloride 2% Ophthalmic Solution (15mL Bulk) $ 4.25 Sodium chloride 23.4% concentrated IV Sol 30 mL $ 3.50 sodium chloride 23.4% Sol 100 mL $ 3.50 Sodium Chloride 3% Inhalation Sol (15mL) $ 3.50 Sodium Chloride 3% IV Sol LVP 500mL $ 3.50 sodium chloride 3% Nasal Spray (44mL Bulk) $ 21.56 sodium chloride 5% Ophthalmic Ointment (3.5gm Bulk) $ 19.18 sodium chloride 5% Ophthalmic Solution (15ml Bulk) $ 3.50 sodium chloride 6% Inhalation Sol (4mL) $ 3.50 Sodium Chloride 7% Inhalation Sol $ 3.50 sodium ferric gluconate complex 12.5 mg/mL IV Sol $ 26.71 sodium hyaluronate 10 mg/mL IA Sol 2mL $ 399.00 sodium hypochlorite 0.0125% Topical Solution (473mL Bulk) $ 3.50 sodium hypochlorite 0.125% Topical Solution (473mL Bulk) $ 3.50 sodium hypochlorite 0.25% Topical Solution (473mL Bulk) $ 3.50 sodium hypochlorite 0.5% Topical Solution (473mL Bulk) $ 3.50 sodium phosphate 3 mmol/mL Inj Sol (15mL) $ 3.91 sodium phosphate 3 mmol/mL Inj Sol (5mL) $ 12.44 sodium polystyrene sulfonate Powder-recon (15gm UD) $ 3.50 sodium polystyrene sulfonate Powder-recon (454gm Bulk) $ 3.50 sodium polystyrene sulfonate 15 g/60 mL Oral Susp (60mL UD) $ 3.50 sodium thiosulfate 25% IV Soln 50 mL $ 7.49 solifenacin 10 mg Tab $ 50.92 solifenacin 5 mg Tab $ 50.92 somatropin 0.4 mg SubQ Inj $ 203.92 somatropin 5 mg/1.5 mL SubQ Inj $ 1,667.28 SORAfenib 200 mg Tab $ 625.88 sorbitol 70% Oral Liquid (30mL UD Liq) $ 3.50 sotalol 120 mg Tab $ 12.12 sotalol 80 mg Tab $ 8.97 SpecCharRmvd magnesium sulfate 1 gm/100 mL (premix) $ 3.50 spironolactone 100 mg Tab $ 4.99 spironolactone 25 mg Tab $ 3.50 spironolactone 50 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

stavudine 40 mg Cap $ 29.04 sterile water - IV Sol 1000mL $ 3.50 sterile water - IV Sol 3,000 mL $ 3.50 sterile water - Sol 10 mL (vial) $ 3.50 sterile water - Sol 20 mL (vial) $ 3.50 sterile water - Sol 5 mL (vial) $ 3.50 sterile water - Sol 50 mL (vial) $ 3.50 sterile water Irr Sol 1000 mL $ 3.50 sterile water Irr Sol 3000 mL $ 3.50 sterile water Irr- Sol 500 mL $ 3.50 sterile water IRRIGATION Solution 250 mL $ 3.50 sucralfate 1 gm Tab $ 3.50 sucralfate 1gm/10 mL Oral Susp (10mL UD) $ 4.90 sucroferric oxyhydroxide 500mg Tab Chew $ 53.12 SUFentanil 50 mcg/mL IV Sol $ 18.83 SUFentanil 50 mcg/mL IV Sol (5mL Amp) $ 13.44 sulfacetamide sodium 10% Ophthalmic Solution (15mL Bulk) $ 14.23 sulfacetamide sodium 10% Ophthalmic Solution (5mL Bulk) $ 26.25 sulfacetamide sodium ophthalmic 10% Oint (3.5gm Bulk) $ 65.86 sulfADIAZINE 500 mg Tab $ 17.67 sulfamethoxazole-trimethoprim 400 mg-80 mg Tab $ 3.50 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol (30mL Vial) $ 4.83 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol (5mL Vial) $ 4.83 sulfamethoxazole-trimethoprim 80 mg-16 mg/mL IV Sol 10 mL $ 4.68 sulfamethoxazole-trimethoprim 800 mg-160 mg Tab $ 3.50 sulfamethoxazole-trimethoprim 800mg-160mg/20mL Oral Susp (20mL UD Liq) $ 3.50 sulfaSALAzine 500 mg Tab $ 3.50 sulfaSALAzine 500 mg Tab EC $ 3.50 sulindac 150 mg Tab $ 3.50 sulindac 200 mg Tab $ 5.35 SUMAtriptan 100 mg Tab $ 87.99 SUMAtriptan 25 mg Tab $ 94.68 SUMAtriptan 50 mg Tab $ 87.99 SUMAtriptan 6 mg/0.5 mL SubQ Sol $ 595.00 suvorexant 10 mg Tab $ 42.19 suvorexant 20 mg Tab $ 42.19 suvorexant 5 mg Tab $ 42.19 tacrolimus 0.1% Topical Ointment (30gm Bulk) $ 30.39 tacrolimus 0.5 mg Oral Cap $ 7.80 tacrolimus 0.5 mg/mL Oral Susp (Extemp) $ 3.50 tacrolimus 1 mg Cap $ 15.61 tacrolimus 1 mg Tab ER $ 16.34 tacrolimus 4 mg Tab-ER $ 65.35 tacrolimus 5 mg Cap $ 78.04 tadalafil 2.5 mg Tab $ 47.88 tadalafil 20 mg Tab $ 280.56 tadalafil 5 mg Tab $ 47.88

STANDARD HOSPITAL CHARGES

tafluprost 0.0015% Opht Soln (1EA UD) $ 25.72 tamoxifen 10 mg Tab $ 3.50 tamoxifen 20 mg Tab $ 13.26 tamsulosin 0.4 mg Oral Cap $ 14.75 tapentadol 100 mg Tab $ 37.86 tapentadol 200 mg ER Tab $ 79.30 tapentadol 50 mg ER Tab $ 26.18 tapentadol 50 mg Tab $ 24.31 tapentadol 75 mg Tab $ 28.41 tbo-filgrastim 300 mcg/0.5 mL Inj Sol $ 1,908.02 tbo-filgrastim 480 mcg/0.8 mL Inj Sol $ 1,908.56 tedizolid 200 mg Tab $ 1,326.59 telavancin 750 mg Powder Inj $ 1,730.13 telmisartan 20 mg Tab $ 15.19 telmisartan 40 mg Tab $ 19.32 telmisartan 80 mg Tab $ 19.32 temazepam 15 mg Cap $ 3.50 temazepam 30 mg Cap $ 3.50 temazepam 7.5 mg Cap $ 16.55 temozolomide 100 mg Cap $ 848.65 temozolomide 140 mg Oral Cap $ 1,237.62 temozolomide 180 mg Cap $ 1,527.58 temozolomide 20 mg Oral Cap $ 201.44 temozolomide 250 mg Oral Cap $ 2,516.50 temozolomide 5 mg Oral Cap $ 50.62 tenofovir 150 mg Tab $ 107.61 tenofovir 300 mg Tab $ 141.86 tenofovir alafenamide 25 mg Tab $ 149.33 terazosin 1 mg Cap $ 5.62 terazosin 2 mg Cap $ 5.62 terazosin 5 mg Cap $ 5.62 terbinafine 1% Topical Cream (15gm Bulk) $ 3.50 terbinafine 1% Topical Cream (30gm Bulk) $ 3.50 terbinafine 250 mg Tab $ 45.71 terbutaline 1 mg/mL Sol $ 75.57 terbutaline 2.5 mg Tab $ 48.05 terbutaline 5 mg Tab $ 23.26 terconazole topical 0.4% Vaginal Cream (45gm Bulk) $ 3.50 terconazole topical 0.8% Vaginal Cream (20gm Bulk) $ 7.13 teriparatide 600 mcg/2.4 mL Dev $ 5,765.73 testosterone 2 mg/24 hr Film $ 35.79 testosterone 20.25 mg/1.25gm Topical Gel (1.25gm UD) $ 69.78 testosterone 25mg/2.5gm Topical Gel (2.5gm UD) $ 20.41 testosterone 30 mg/1.5 mL Topical Solution (90mL Bulk) $ 11.78 testosterone 4 mg/24 hr Film $ 71.59 testosterone 50mg/5gm Topical Gel (5gm UD) $ 9.64 testosterone cypionate 100 mg/mL IM Sol 10mL $ 30.87

STANDARD HOSPITAL CHARGES

testosterone cypionate 200 mg/mL IM Sol 10 mL $ 48.78 testosterone enanthate 200 mg/mL IM Sol $ 53.40 tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2 units-15.5 mcg/0.5 mL Sus $ 368.47 tetanus/diphth/pertuss (Tdap) adult/adol 5 units-2.5 units-18.5 mcg/0.5 mL Sus $ 285.85 tetanus-diphth toxoids (Td) adult/adol IM 2 units-2 units/0.5 mL $ 200.98 tetanus-diphtheria toxoids adult IM 5 units-2units/0.5 mL $ 274.17 tetracaine 0.5% ophthalmic Solution (15mL Bulk) $ 3.50 tetracycline 250 mg Cap $ 27.56 tetracycline 500 mg Cap $ 55.14 tetrahydrozoline 0.05% Ophthalmic Solution (15mL Bulk) $ 3.50 theophylline 100 mg ER Tab $ 3.50 theophylline 100 mg/24 hours CapER $ 7.64 theophylline 200 mg ER Tab $ 3.50 theophylline 200 mg/24 hours ERCap $ 11.35 theophylline 300 mg ER Tab $ 15.04 theophylline 300 mg/24 hours ERCap $ 13.95 theophylline 400 mg/24 hours Cap-ER $ 19.63 theophylline 400 mg/24 hours ER Tab $ 4.35 theophylline 450 mg ERTab $ 21.16 theophylline 600 mg/24 hours ER Tab $ 6.29 theophylline 80 mg/15 mL Oral Elixir (15 mL UD) $ 3.50 theophylline 80 mg/15 mL Oral Elixir (Extemp) $ 3.50 theophylline 80 mg/15 mL Oral Sol (Extemp) $ 3.50 theophylline 80 mg/15 mL Oral Solution (15 mL UD) $ 3.50 Therapeutic Multiple Vitamins Tab $ 3.50 thiamine 100 mg/mL Inj Sol 2 mL $ 21.77 thiamine 50 mg Tab $ 3.50 thioridazine 10 mg Tab $ 3.50 thioridazine 100 mg Tab $ 3.80 thioridazine 25 mg Tab $ 3.50 thioridazine 50 mg Tab $ 3.50 thiothixene 1 mg Cap $ 4.16 thiothixene 10 mg Cap $ 11.75 thiothixene 2 mg Cap $ 8.36 thiothixene 5 mg Cap $ 12.68 thyroid desiccated 15 mg Tab $ 3.50 thyroid desiccated 180 mg Tab $ 4.41 thyroid desiccated 240 mg Tab $ 5.34 thyroid desiccated 30 mg Tab $ 3.50 thyroid desiccated 32.5 mg Tab $ 3.50 thyroid desiccated 60 mg Tab $ 3.50 thyroid desiccated 65 mg $ 3.50 thyroid desiccated 90 mg Tab $ 4.48 thyroid desiccated 97.5 mg Tab $ 3.50 tiaGABine 2 mg Tab $ 23.44 tiaGABine 4 mg Tab $ 23.44 ticagrelor 60 mg Tab $ 24.71

STANDARD HOSPITAL CHARGES

ticagrelor 90 mg Tab $ 22.46 ticarcillin-clavulanate 3 g-100 mg/100 mL Sol (frozen) $ 3.50 ticlopidine 250 mg Tab $ 7.13 tigecycline 50 mg Pow inj $ 655.20 timolol 0.5% ophthalmic Solution (10mL Bulk) $ 11.32 timolol 0.5% ophthalmic Solution (15mL Bulk) $ 11.38 timolol 0.5% ophthalmic Solution (5mL Bulk) $ 4.22 timolol 0.25% Gel forming Ophthalmic Solution (5mL Bulk) $ 34.65 timolol 0.25% Ophthalmic Solution (10mL Bulk) $ 9.71 timolol 0.25% Ophthalmic Solution (15mL Bulk) $ 9.80 timolol 0.25% Ophthalmic Solution (5mL Bulk) $ 10.50 timolol 0.5% Gel forming Ophthalmic Solution (5mL Bulk) $ 40.95 timolol 20 mg Tab $ 11.00 timolol 5 mg Tab $ 4.82 timolol hemihydrate 0.5% Ophthalmic Solution (5mL Bulk) $ 102.20 tioconazole topical 6.5% Vaginal Ointment (4.6gm Bulk) $ 11.01 tiotropium 18 mcg Inh Cap $ 55.67 tiotropium 2.5 mcg/inh Aerosol (4gm Bulk) $ 379.58 tiZANidine 2 mg Tab $ 3.50 tiZANidine 4 mg Tab $ 8.92 tobramycin 0.3% Ophthalmic Ointment (3.5gm Bulk) $ 257.23 tobramycin 0.3% Ophthalmic Soln (5mL Bulk) $ 10.19 tobramycin 1.2 g Powder Vial $ 735.00 tobramycin 10 mg/mL Inj Sol (2mL Vial) $ 8.02 tobramycin 40 mg/mL Inj Sol (2mL Vial) $ 4.16 tobramycin 40mg/mL Solution IV (30mL MDV) $ 3.50 tobramycin 60 mg/mL Sol-Inh $ 90.14 tobramycin 75 mg/mL Sol-Inh $ 106.41 tobramycin 80 mg/100 mLNS IV premix $ 3.50 tofacitinib 5 mg Tab $ 286.69 tolcapone 100 mg Tab $ 411.06 tolnaftate 1% Topical Cream (30gm Bulk) $ 3.50 tolnaftate 1% Topical Powder (45gm Bulk) $ 3.50 tolterodine 1 mg Tab $ 11.58 tolterodine 2 mg ER Cap $ 28.09 tolterodine 2 mg Tab $ 11.89 tolterodine 4 mg ERCap $ 28.12 tolvaptan 15 mg Tab $ 1,803.19 tolvaptan 30 mg Tab $ 1,870.60 topiramate 100 mg Tab $ 21.70 topiramate 15 mg Cap $ 8.46 topiramate 200 mg Tab $ 25.43 topiramate 25 mg Tab $ 7.35 topiramate 50 mg Cap ER $ 36.67 topiramate 50 mg Tab $ 17.85 torsemide 10 mg Tab $ 3.50 torsemide 100 mg Tab $ 10.65

STANDARD HOSPITAL CHARGES

torsemide 20 mg Tab $ 3.50 torsemide 5 mg Tab $ 3.50 trace elements 1 mcg-0.1 mg-0.025 mg-1.0 mg/mL IV Sol (3mL) $ 15.68 trace elements 10.0 mcg-1 mg-0.5 mg-5 mg/mL IV Sol (1mL Vial) $ 35.00 trace elements 4 mcg-0.4 mg-0.1 mg-1 mg/mL IV Sol (10mL Vial) $ 14.99 trace elements with selenium 10 mcg-1 mg-0.5 mg-60 mcg-5 mg/mL IV Sol (1mL) $ 54.69 traMADol 100 mg ER Tab $ 12.74 traMADol 200 mg ER Tab $ 27.24 traMADol 300 mg ER Tab $ 38.01 traMADol 50 mg Tab $ 3.50 trandolapril 1 mg Tab $ 4.34 trandolapril 2 mg Tab $ 4.34 trandolapril 4 mg Tab $ 4.34 tranexamic acid 650 mg Tab $ 18.27 tranylcypromine 10 mg Tab $ 12.63 travoprost 0.004% Ophthalmic Solution (2.5mL Bulk) $ 286.02 travoprost 0.004% Ophthalmic Solution (5mL Bulk) $ 264.85 traZODone 100 mg Tab $ 4.87 traZODone 150 mg Tab $ 9.77 traZODone 50 mg Tab $ 3.50 triamcinolone 0.025% Topical Cream (15gm Bulk) $ 3.50 triamcinolone 0.025% Topical Cream (454gm Bulk) $ 3.50 triamcinolone 0.025% Topical Cream (80gm Bulk) $ 3.50 triamcinolone 0.025% Topical Ointment (15gm Bulk) $ 3.50 triamcinolone 0.025% Topical Ointment (80gm Bulk) $ 3.50 triamcinolone 0.1% Oral Paste (5gm Bulk) $ 58.12 triamcinolone 0.1% Topical Cream (15gm Bulk) $ 3.50 triamcinolone 0.1% Topical Cream (30gm Bulk) $ 3.50 triamcinolone 0.1% Topical Cream (454gm Bulk) $ 3.50 triamcinolone 0.1% Topical Cream (80gm Bulk) $ 3.50 triamcinolone 0.1% Topical Lotion (60mL Bulk) $ 3.50 triamcinolone 0.5% Topical Cream (15gm Bulk) $ 3.50 triamcinolone 0.5% Topical Ointment (15gm Bulk) $ 3.50 triamcinolone 10 mg/mL Suspension Injection (5 mL vial) $ 10.16 triamcinolone 20mg/mL Suspension Injection (5mL Vial) $ 29.95 triamcinolone 55 mcg/inh Nasal Spray (10.8 mL Bulk) $ 4.60 triamcinolone 55 mcg/inh Nasal Spray (16.5gm Bulk) $ 27.18 triamcinolone acetonide 40 mg/mL Inj Susp $ 35.70 triamcinolone acetonide 40 mg/mL Inj Susp (5mL Vial) $ 36.41 triamcinolone topical 0.1% Oin (15gm bulk) $ 3.50 triamcinolone topical 0.1% Oin (454 gm Bulk) $ 3.50 triamcinolone topical 0.1% Oin (80gm bulk) $ 3.50 triamterene 50 mg Cap $ 44.22 triazolam 0.125 mg Tab $ 12.83 triazolam 0.25 mg Tab $ 12.83 trifluoperazine 1 mg Tab $ 3.50 trifluoperazine 2 mg Tab $ 4.51

STANDARD HOSPITAL CHARGES

trifluoperazine 5 mg Tab $ 5.68 trifluridine 1% Ophthalmic Solution (7.5mL Bulk) $ 72.01 trihexyphenidyl 2 mg Tab $ 3.50 trihexyphenidyl 2 mg/5 mL Elixer $ 3.50 trihexyphenidyl 5 mg Tab $ 3.85 trimethobenzamide 100 mg/mL IM Sol 2 mL $ 66.96 trimethobenzamide 300 mg Cap $ 7.29 trimethoprim 100 mg Tab $ 3.50 trolamine salicylate 10% Topical Cream (37gm Bulk) $ 3.50 trolamine salicylate 10% Topical Cream (85gm Bulk) $ 3.50 trolamine salicylate 10% Topical Cream (90gm Bulk) $ 3.50 trolamine salicylate 10% Topical Lotion (177.4mL Bulk) $ 3.50 trospium 20 mg Tab $ 9.93 trospium 60 mg Cap ER $ 23.64 tuberculin purified protein derivative 5 TUnits/0.1 mL ID Sol $ 309.73 tyrosine 500 mg Cap $ 3.50 ubiquinone 10 mg Cap $ 3.50 ubiquinone 100 mg Cap $ 3.50 ubiquinone 200 mg Cap $ 3.50 ubiquinone 30 mg Cap $ 3.50 ubiquinone 50 mg Cap $ 3.50 ubiquinone 60 mg Cap $ 3.50 umeclidinium 62.5 mcg (0.0625 mg) Inh Powdr (30 count) $ 41.24 umeclidinium 62.5 mcg (0.0625 mg) Inh Powdr (7 count) $ 37.81 umeclidinium-vilanterol 62.5 mcg-25 mcg Inh Powder (30 EA) $ 50.61 umeclidinium-vilanterol 62.5 mcg-25 mcg Inh Powder (7 EA) $ 52.13 urea 10% Topical Cream (142gm Bulk) $ 3.50 urea 10% Topical Cream (57gm Bulk) $ 3.50 urea 10% Topical Cream (85gm Bulk) $ 3.50 urea 10% Topical Lotion (240mL Bulk) $ 3.50 urea 15 g Oral Powder Packet (1 EA UD) $ 14.69 urea 20% Topical Cream (113.4gm Bulk) $ 3.50 urea 20% Topical Cream (85gm Bulk) $ 3.50 urea 40% Topical Cream (198.4gm Bulk) $ 3.50 urea 40% topical Cream (28.3gm Bulk) $ 12.79 urea 40% Topical Cream (85gm Bulk) $ 6.63 urea 40% Topical Lotion (237mL Bulk) $ 3.50 urea topical 40% Topical Cream (210gm Bulk) $ 3.50 ursodiol 250 mg Tab $ 9.39 ursodiol 300 mg Cap $ 18.45 ursodiol 500 mg Tab $ 16.64 valACYclovir 1 g Tab $ 44.25 valACYclovir 500 mg Tab $ 25.28 valGANciclovir 450 mg Tab $ 240.72 valGANciclovir 50 mg/mL Oral Liquid (Extemp) $ 51.08 valproic acid 100 mg/mL Inj Sol 5 mL $ 5.63 valproic acid 250 mg Cap $ 3.50

STANDARD HOSPITAL CHARGES

valproic acid 250 mg/5 mL Oral Syrup (5mL UD Liq) $ 3.50 valproic acid 500mg/10mL Oral Syrup (10mL UD) $ 3.50 valsartan 160 mg Tab $ 17.49 valsartan 320 mg Tab $ 22.17 valsartan 40 mg Tab $ 26.03 valsartan 80 mg Tab $ 16.97 vancomycin 0.25 mg/0.01 mL Oral Soln (Extemp) $ 3.50 vancomycin 0.5 gm Pow inj (addv) $ 44.90 vancomycin 0.5 gm Pow inj (vial) $ 33.77 vancomycin 0.75 gm Pow inj (addv) $ 46.07 vancomycin 0.75 gm Pow inj (vial) $ 40.70 vancomycin 1 g/200 mL- D5% Sol (frozen) $ 3.50 vancomycin 1 g/200 mL-NaCl 0.9% Sol (Frozen) $ 3.50 vancomycin 1 gm Pow inj (addv) $ 86.73 vancomycin 125 mg (capsule) $ 109.64 vancomycin 125 mg/1.25 ml Oral Soln (1.25mL UD Liq) $ 4.38 vancomycin 125mg/2.5ml Oral Soln (2.5mL UD Liq) $ 8.75 vancomycin 125mg/5ml Oral Soln (5mL UD Liq) $ 17.50 vancomycin 25 mg/mL Oral Susp (10mL UD Liq RXD2) $ 3.50 vancomycin 250 mg (capsule) $ 202.01 vancomycin 250 mg/2.5 ml Oral Soln (2.5mL UD Liq) $ 17.50 vancomycin 250mg/10mL Oral Soln (10mL UD Liq) $ 35.00 vancomycin 250mg/5mL Oral Soln (5mL UD Liq) $ 17.50 vancomycin 5 gm Pow inj (vial) $ 373.51 vancomycin 50 mg/mL Oral Susp (10mL UD Liq RXD2) $ 3.50 vancomycin 500 mg/100 mL -D5% Sol (frozen) $ 3.50 vancomycin 500mg/20mL Oral Soln (20mL UD Liq) $ 70.00 vancomycin 750 mg/150 mL-D5% Sol (frozen) $ 3.50 varenicline 0.5 mg Tab $ 27.61 varenicline 1 mg Tab $ 27.61 vasopressin 20 units/mL Inj Sol $ 702.43 venlafaxine 100 mg Tab $ 3.50 venlafaxine 150 mg ERCap $ 3.50 venlafaxine 25 mg Tab $ 6.80 venlafaxine 37.5 mg ER Tab $ 31.16 venlafaxine 37.5 mg ERCap $ 13.10 venlafaxine 37.5 mg Tab $ 6.99 venlafaxine 50 mg Tab $ 7.21 Venlafaxine 75 mg $ 7.63 venlafaxine 75 mg ER Tab $ 12.14 venlafaxine 75 mg ERCap $ 16.33 verapamil 100 mg/24 hours Cap-ER $ 6.86 verapamil 120 mg ER Tab $ 8.11 verapamil 120 mg Tab $ 3.50 verapamil 120 mg/24 hours Cap ER $ 6.79 verapamil 180 mg ER Tab $ 5.04 verapamil 180 mg/24 hours Cap-ER $ 7.11

STANDARD HOSPITAL CHARGES

verapamil 2.5 mg/mL Injection Sol (2mL Vial) $ 33.17 verapamil 2.5 mg/mL Injection Sol (4mL Vial) $ 29.29 verapamil 240 mg ER Tab $ 5.72 verapamil 240 mg/24 hours Cap ER $ 7.22 verapamil 300 mg/24 hours Cap-ER $ 12.85 verapamil 40 mg Tab $ 3.50 verapamil 80 mg Tab $ 3.50 vilazodone 10 mg Tab $ 31.64 vilazodone 20 mg Tab $ 31.64 vilazodone 40 mg Tab $ 31.64 vitamin A & D Topical Ointment (113gm Bulk) $ 3.50 vitamin A & D Topical Ointment (45gm Bulk) $ 3.50 vitamin A & D Topical Ointment (5gm Bulk) $ 3.50 vitamin A & D Topical Ointment (60gm Bulk) $ 3.50 vitamin A 10,000 units Cap $ 3.50 vitamin A 8000 units Cap $ 3.50 Vitamin A and D Cap (Cod Liver Oil) $ 3.50 Vitamin B Complex Cap $ 7.20 Vitamin B Complex Tab $ 3.50 Vitamin B Complex Tab #1 $ 3.50 Vitamin B Complex Tab ER $ 3.50 Vitamin B Complex with C and Zinc Tab $ 3.50 Vitamin B Complex with C and Zinc Tab (Z-Bec) $ 3.50 Vitamin B Complex with C Tab $ 3.50 Vitamin B Complex with C, Folic Acid and Iron Cap $ 3.50 Vitamin B Complex with C, Folic Acid and Iron Tab $ 4.37 Vitamin B Complex with C, Folic Acid and Zinc Tab (Folbee Plus) $ 3.50 Vitamin B Complex with Folic Acid Tab $ 3.50 Vitamin B Complex with Iron and Intrinsic Factor Cap $ 3.50 vitamin D3 5000 units tab $ 3.50 vitamin E 100 intl units Cap $ 3.50 vitamin E 1000 intl units Cap $ 3.50 vitamin E 200 intl units Cap $ 3.50 vitamin E 400 intl units Cap $ 3.50 vitamin E topical Cream 60gm $ 3.50 vorapaxar 2.08 mg Tab $ 44.42 voriconazole 200 mg IV Inj $ 535.57 voriconazole 200 mg Tab $ 138.34 voriconazole 200mg/5mL Oral Liquid (5mL UD Liq) $ 49.39 voriconazole 50 mg Tab $ 35.83 vortioxetine 10 mg Tab $ 48.11 vortioxetine 20 mg Tab $ 48.11 vortioxetine 5 mg Tab $ 48.11 Warfarin 0.5 mg tab $ 3.50 warfarin 1 mg Tab $ 3.50 warfarin 10 mg Tab $ 3.50 warfarin 2 mg Tab $ 3.50

STANDARD HOSPITAL CHARGES

warfarin 2.5 mg Tab $ 3.50 warfarin 3 mg Tab $ 3.50 warfarin 4 mg Tab $ 3.50 warfarin 5 mg Tab $ 3.50 warfarin 6 mg Tab $ 3.50 warfarin 7.5 mg Tab $ 3.50 wheat dextrin 100% 4gm Powder recon $ 3.50 witch hazel topical 50% Pad (10 count Bulk) $ 3.50 witch hazel topical 50% Pad (100 count Bulk) $ 3.50 witch hazel topical 50% Pad (40 count Bulk) $ 3.50 zafirlukast 10 mg Tab $ 7.57 zafirlukast 20 mg Tab $ 7.57 zaleplon 10 mg Cap $ 13.26 zaleplon 5 mg Cap $ 12.91 zanamivir 5 mg Inh Pwdr $ 12.39 zidovudine 100 mg Cap $ 7.07 zidovudine 300 mg Tab $ 21.06 zinc gluconate 50 mg Tab $ 3.50 zinc oxide 10% Topical Spray (100gm Bulk) $ 3.50 zinc oxide 11.3% Topical Cream (85gm Bulk) $ 3.50 zinc oxide 13% Topical Cream (57gm Bulk) $ 3.50 zinc oxide 13% Topical Cream (113gm Bulk) $ 3.50 zinc oxide 15% Topical Powder (50gm Bulk) $ 3.50 zinc oxide 16% Topical Ointment (113 gm Bulk) $ 3.50 zinc oxide 16% Topical Ointment (30gm Bulk) $ 3.50 zinc oxide 16% Topical Ointment (57gm Bulk) $ 3.50 zinc oxide 20% Topical Ointment (30gm Bulk) $ 3.50 zinc oxide 25% Topical Spray (56gm Bulk) $ 3.50 zinc oxide 40% Topical Ointment (113gm Bulk) $ 14.42 zinc oxide 40% Topical Ointment (57gm Bulk) $ 3.50 zinc oxide Topical Ointment (113gm Bulk) $ 3.50 zinc sulfate 1 mg/mL IV Sol (10mL Vial) $ 11.17 zinc sulfate 110 mg Tab $ 3.50 zinc sulfate 220 mg Cap $ 3.50 zinc sulfate 220 mg Tab $ 3.50 ziprasidone 20 mg Cap $ 31.37 ziprasidone 20 mg IM Inj $ 208.62 ziprasidone 40 mg Cap $ 29.63 ziprasidone 60 mg Cap $ 6.30 ziprasidone 80 mg Cap $ 6.30 zoledronic acid 4 mg/100 mL IV Sol $ 7.56 zoledronic acid 4 mg/5 mL IV Sol $ 586.80 ZOLMitriptan 2.5 mg Tab $ 86.10 ZOLMitriptan 5 mg Tab $ 86.10 zolpidem 10 mg Tab $ 3.50 zolpidem 12.5 mg ER Tab $ 21.41 zolpidem 5 mg Tab $ 16.17

STANDARD HOSPITAL CHARGES

zolpidem 6.25 mg ER Tab $ 21.41 zonisamide 100 mg Cap $ 7.68 zonisamide 25 mg Cap $ 3.50 zonisamide 50 mg Cap $ 3.84

Other Medical Supplies14 FR STRAIGHT CATH $ 8.00 24 OZ URINE HAT $ 7.00 2X2 STERILE GAUZE, B $ 5.00 8X4 STERILE GAUZE, B $ 12.00 ABD SURG COMBINE PAD $ 5.82 ABDOMINAL BINDER $ 68.00 ACE BANDAGE $ 3.09 ADAPTIC $ 5.00 ALLEVYN DRESSING - H $ 26.70 ALLEVYN DRESSING 3X3 $ 8.73 ALLEVYN DRESSING 6X6 $ 25.44 ALLEVYN DRESSINGS 5X $ 13.95 ANTIEMB KNEE $ 25.32 ANTIEMB THIGH $ 33.32 AQUACEL SILVER DRESS $ 32.46 AQUACEL SILVER DRESS $ 73.08 ARM BOARD LARGE $ 6.00 BORDERED GAUZE DRESS $ 1.50 BORDERED GAUZE DRESS $ 1.29 CAST PADDING/RL 4" $ 8.00 CAST SHOE $ 37.00 CERVICAL COLLAR $ 38.00 COBAN WRAP $ 9.00 CPM DAILY $ 95.00 CPM START UP $ 146.00 CULTURETTE $ 8.00 CVA SLINGS $ 45.00 CYLINDRICAL FOAM $ 15.00 DENTAL MIRROR $ 47.00 DERMAGRAN 4X4 $ 5.16 DRAIN SPONGE $ 2.00 DRESSING KIT $ 17.58 DRESSING, AQUACEL 4X $ 25.00 DRESSING, AQUACEL 6X $ 37.00 ELASTIC SHOE LACES $ 8.00 ELASTOPLASTIC TAPE $ 29.03 ELECTRODE DISPOSABLE $ 5.00 EXUDERM LP 4X4 $ 6.63 EYE PATCH $ 7.00 FEEDING PUMP DAILY $ 30.00 FEEDING TUBE $ 36.00

STANDARD HOSPITAL CHARGES

FOAM ARM POSITIONER $ 57.00 FOLEY CATH TRAY W/BA $ 29.00 FOLEY CATHETER $ 19.00 FOLEY STAT LOCK $ 9.30 FX BEDPAN $ 5.00 GAIT BELT (SAFETY EQ $ 18.00 GAIT BELTS $ 25.00 GAUZE, STER 4X4 BOX $ 5.26 GRADUATE $ 0.79 HAND CONTRL MITTN/PO $ 60.00 HEEL BO $ 28.00 HIGH COMPRESSION BAN $ 80.00 ICE PACK - TECHNOL $ 14.00 IRRIGATING SYRINGE 2 $ 5.43 IRRIGATION TRAY $ 16.00 ISLAND DRESSING 4X10 $ 5.01 ISLAND DRESSING 4X4 $ 2.47 ISLAND DRESSING 6X6 $ 1.97 ISOTONER GLOVES PR $ 38.00 IV PUMP DAILY $ 30.00 IV START KIT $ 12.56 KERLIX, ROLL $ 5.10 KINESIOTAPING (12") $ 4.00 KNEE IMMOBILIZER $ 57.00 KNEE SPREADERS $ 79.00 K-PAD REPLACEMENT $ 28.09 LEG BAG $ 9.00 LEG LIFTER $ 37.00 L'NARD BOOT $ 268.00 LONG HANDLED MIRROR $ 35.00 MEDIHONEY DRESSING 4 $ 26.58 MESALT 4X4 $ 3.57 MISC SPECIAL DRESSIN $ 64.89 OPSITE DRESSING 2X2 $ 0.81 OPSITE DRESSING 4X4 $ 2.73 OPSITE DRESSING 5X10 $ 5.52 OPSITE FLEXIGRID 4X4 $ 6.00 OPTIFOAM DRESSING 4X $ 7.69 OPTIFOAM DRESSING 6X $ 13.59 PELVIC HOLDER $ 18.00 PEROXIDE $ 5.00 PHILADELPHIA COLLAR $ 53.00 REACHER $ 20.00 RECLINING WHEELCHAIR $ 28.00 SALINE - LARGE $ 2.16 SALINE - SMALL $ 2.16 SANITARY PADS $ 3.00

STANDARD HOSPITAL CHARGES

SARAS ORIGINAL HORN $ 30.00 SHEEPSKIN $ 31.00 SHOE HORN $ 13.00 SILVASORB SITE $ 9.48 SKIN STAPLE REMOVER $ 18.00 SLING & SWATHE $ 57.00 SOCK AIDE $ 20.00 SOFT WICK 2X2 $ 5.00 STAGE IV DAILY $ 95.00 STERI STRIP $ 8.00 STERING KLING 3" $ 5.00 STOCKINGETTE PER FOO $ 3.00 STRAW $ 106.73 STRT CATH TRAY W/CAT $ 29.31 SUTURE REMOVAL TRAY $ 12.00 TELFA 8X3 $ 2.00 TEXAS CATHETER $ 11.11 THERAPUTTY 4OZ $ 24.00 THERAPY BOOKS $ 10.00 TOILET AID $ 32.00 TOOTHETTES $ 3.00 TRAPEZE FRAME DAILY $ 30.00 UNNA'S BOOT DRESSING $ 13.00 URINARY DRAINAGE BAG $ 16.93 W/C GLOVES $ 67.00 W/C LIMB SUPPORT-ARM $ 6.00 WANDER GUARD PURCHAS $ 108.00 XEROFORM GAUZE $ 7.00