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7.68k
|
---|---|---|---|---|---|
SUBTOTAL: 14821.00
| 278-SUPPLY/ IMPLANTS | (1, 1) | ncp-6-1 | 20 | 4,687 |
272-STERILE SUPPLIES
| SUBTOTAL : 42944 .00 | (2.25, 2.25) | ncp-6-1 | 20 | 2,244 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700079 INTERNAL USE: GLO .00 | (3.25, 3.25) | ncp-4-0 | 20 | 1,523 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700079 INTERNAL USE: GLO .00 | (2.25, 2.25) | ncp-4-0 | 20 | 1,495 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4/5/2013 SIMVASTATIN TAB 20MG 1 $57.035 | (1, 1) | ncp-1-3 | 20 | 2,509 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700079 INTERNAL USE: GLO .00 | (1, 1) | ncp-4-0 | 20 | 1,466 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700098 COPAY/COINSURANCE .00 | (3.25, 3.25) | ncp-4-0 | 20 | 1,434 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05 | (2.25, 2.25) | ncp-1-3 | 20 | 2,545 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700098 COPAY/COINSURANCE .00 | (2.25, 2.25) | ncp-4-0 | 20 | 1,406 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700098 COPAY/COINSURANCE .00 | (1, 1) | ncp-4-0 | 20 | 1,377 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05 | (3.25, 3.25) | ncp-1-3 | 20 | 2,581 |
272-STERILE SUPPLIES
| GUARANTOR NO: | (3.25, 3.25) | ncp-6-1 | 20 | 2,258 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 4152013 PANTOPRAZOLE EC TAB 40MG 1 S47.46 | (0.5, 0.5) | ncp-1-3 | 20 | 2,754 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700079 INTERNAL USE: GLO .00 | (3.25, 3.25) | ncp-4-0 | 20 | 1,068 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 44612013 DOCUSATE CAP 100MG 2 50.86 | (0.5, 0.5) | ncp-1-3 | 20 | 2,767 |
SUBTOTAL: 14821.00
| 278-SUPPLY/ IMPLANTS | (0.5, 0.5) | ncp-6-1 | 20 | 4,639 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 47612013 DOXYCYCLINE CAP 50MG 2 $17.00 | (0.5, 0.5) | ncp-1-3 | 20 | 2,768 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700079 INTERNAL USE: GLO .00 | (2.25, 2.25) | ncp-4-0 | 20 | 1,040 |
272-STERILE SUPPLIES
| GUARANTOR NO: | (2.25, 2.25) | ncp-6-1 | 20 | 2,210 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700079 INTERNAL USE: GLO .00 | (1, 1) | ncp-4-0 | 20 | 1,011 |
272-STERILE SUPPLIES
| SUBTOTAL : 42944 .00 | (1, 1) | ncp-6-1 | 20 | 2,196 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700098 COPAY/COINSURANCE .00 | (3.25, 3.25) | ncp-4-0 | 20 | 979 |
272-STERILE SUPPLIES
| GUARANTOR NO: | (1, 1) | ncp-6-1 | 20 | 2,162 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700098 COPAY/COINSURANCE .00 | (2.25, 2.25) | ncp-4-0 | 20 | 951 |
272-STERILE SUPPLIES
| GUARANTOR NO: | (0.5, 0.5) | ncp-6-1 | 20 | 2,114 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700098 COPAY/COINSURANCE .00 | (1, 1) | ncp-4-0 | 20 | 922 |
272-STERILE SUPPLIES
| /618 o7k B | (0.5, 0.5) | ncp-0-1 | 20 | 1,761 |
272-STERILE SUPPLIES
| 2 nber tmegingten e | (0.5, 0.5) | ncp-0-1 | 20 | 1,793 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4162013 LORATADINE TAB 10MG 1 $3.49 | (0.5, 0.5) | ncp-1-3 | 20 | 2,481 |
4/6/2013 LORATADINE TAB 10MG 1 $3.49
| 4/6/2013 . PANTOPRAZOLE EC TAB 40MG [ $47.46 | (2.25, 2.25) | ncp-1-3 | 20 | 4,715 |
4/6/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46 | 4/4/2013 SIMVASTATIN TAB 20MG 1 $57.05 | (1, 1) | ncp-1-3 | 20 | 4,938 |
4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00
| 4162013 LORATADINE TAB 10MG 1 $3.49 | (0.5, 0.5) | ncp-1-3 | 20 | 2,049 |
278-SUPPLY/IMPLANTS
| CARTHAGE MS 39051 | (2.25, 2.25) | ncp-4-0 | 20 | 2,289 |
278-SUPPLY/IMPLANTS
| I | (3.25, 3.25) | ncp-4-0 | 20 | 2,312 |
278-SUPPLY/IMPLANTS
| CARTHAGE MS 39051 | (3.25, 3.25) | ncp-4-0 | 20 | 2,318 |
SUBTOTAL: 42944.00
| MaHE an Sk STASW O gt | (0.5, 0.5) | ncp-4-0 | 20 | 2,703 |
4/6/2013 LORATADINE TAB 10MG 1 $3.49
| 4/6/2013 . PANTOPRAZOLE EC TAB 40MG | $47.46 | (1, 1) | ncp-1-3 | 20 | 4,679 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 42944 .00 | (3.25, 3.25) | ncp-6-1 | 20 | 4,980 |
4/6/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 SIMVASTATIN TAB 20MG 1 $57.035 | (1, 1) | ncp-1-3 | 20 | 4,381 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 14821.00 | (3.25, 3.25) | ncp-6-1 | 20 | 4,974 |
SUBTOTAL: 42944.00
| | | (2.25, 2.25) | ncp-4-0 | 20 | 2,733 |
278-SUPPLY/IMPLANTS
| SUBTOTAL : 42944 .00 | (2.25, 2.25) | ncp-6-1 | 20 | 4,932 |
4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00
| 4/412013 SIMVASTATIN TAB 20MG 1 $57.05 | (0.5, 0.5) | ncp-1-3 | 20 | 2,022 |
4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00
| 47572013 SIMVASTATIN TAB 20MG 1 $57.05 | (0.5, 0.5) | ncp-1-3 | 20 | 2,041 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 14821.00 | (2.25, 2.25) | ncp-6-1 | 20 | 4,926 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71 | (3.25, 3.25) | ncp-1-3 | 20 | 2,289 |
278-SUPPLY/IMPLANTS
| SUBTOTAL : 42944 .00 | (1, 1) | ncp-6-1 | 20 | 4,884 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 14821.00 | (1, 1) | ncp-6-1 | 20 | 4,878 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 42944.00 | (0.5, 0.5) | ncp-6-1 | 20 | 4,836 |
278-SUPPLY/IMPLANTS
| SUBTOTAL: 14821.00 | (0.5, 0.5) | ncp-6-1 | 20 | 4,830 |
SUBTOTAL: 42944.00
| I | (3.25, 3.25) | ncp-4-0 | 20 | 2,762 |
SUBTOTAL: 14821.00
| 278-SUPPLY/ IMPLANTS | (3.25, 3.25) | ncp-6-1 | 20 | 4,783 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/4/2013 SIMVASTATIN TAB 20MG 1 $57.05 | (1, 1) | ncp-1-3 | 20 | 2,202 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71 | (1, 1) | ncp-1-3 | 20 | 2,217 |
4/6/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/4/2013 SIMVASTATIN TAB 20MG 1 $57.05 | (1, 1) | ncp-1-3 | 20 | 4,362 |
SUBTOTAL: 14821.00
| 278-SUPPLY/ IMPLANTS | (2.25, 2.25) | ncp-6-1 | 20 | 4,735 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71 | (2.25, 2.25) | ncp-1-3 | 20 | 2,253 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 14821.00 | (0.5, 0.5) | ncp-6-1 | 20 | 606 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 4/6/2013 . PANTOPRAZOLE EC TAB 40MG 1 $47.46 | (3.25, 3.25) | ncp-1-3 | 20 | 2,879 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| 4/52013 DOXYCYCLINE CAP 50MG Z $17.00 | (0.5, 0.5) | ncp-1-3 | 20 | 2,895 |
278-SUPPLY/IMPLANTS
| CARTHAGE MS 39051 | (1, 1) | ncp-4-0 | 20 | 2,260 |
TOTAL CHARGES: 5068.00
| FEDERAL ID NO: 746001118 | (1, 1) | ncp-4-0 | 20 | 8 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/572013 DOCUSATE CAP 100MG 2 50.86 | (0.5, 0.5) | ncp-1-3 | 20 | 3,472 |
278-SUPPLY/IMPLANTS
| 01/14/18 03:20 PM | (3.25, 3.25) | ncp-0-1 | 20 | 4,120 |
278-SUPPLY/IMPLANTS
| 01/14/18 | (3.25, 3.25) | ncp-0-1 | 20 | 4,123 |
TOTAL CHARGES: 5068.00
| UNITED STATES | (2.25, 2.25) | ncp-4-0 | 20 | 40 |
SUBTOTAL: 42944.00
| ouissie | (0.5, 0.5) | ncp-0-1 | 20 | 4,802 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46 | (1, 1) | ncp-1-3 | 20 | 3,510 |
SUBTOTAL: 42944.00
| address | (1, 1) | ncp-0-1 | 20 | 4,835 |
TOTAL CHARGES: 5068.00
| FEDERAL ID NO: 746001118 | (2.25, 2.25) | ncp-4-0 | 20 | 37 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/6/2013 DOCUSATE CAP 100MG 2 $0.86 | (1, 1) | ncp-1-3 | 20 | 3,523 |
TOTAL CHARGES: 5068.00
| UNITED STATES | (1, 1) | ncp-4-0 | 20 | 11 |
SUBTOTAL: 42944.00
| address | (2.25, 2.25) | ncp-0-1 | 20 | 4,877 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/6/2013 DOCUSATE CAP 100MG 2 $0.86 | (2.25, 2.25) | ncp-1-3 | 20 | 3,559 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 275.00 | (0.5, 0.5) | ncp-6-1 | 20 | 592 |
278-SUPPLY/IMPLANTS
| 01/14/18 | (2.25, 2.25) | ncp-0-1 | 20 | 4,081 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46 | (3.25, 3.25) | ncp-1-3 | 20 | 3,582 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 42944 .00 | (3.25, 3.25) | ncp-6-1 | 20 | 756 |
4/5/2013 SIMVASTATIN TAB 20MG 1 $57.05
| 4/6/2013 DOCUSATE CAP 100MG 2 $0.86 | (3.25, 3.25) | ncp-1-3 | 20 | 3,595 |
SUBTOTAL: 42944.00
| address | (3.25, 3.25) | ncp-0-1 | 20 | 4,919 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 14821.00 | (3.25, 3.25) | ncp-6-1 | 20 | 750 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL : 275.00 | (3.25, 3.25) | ncp-6-1 | 20 | 736 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL : 42944 .00 | (2.25, 2.25) | ncp-6-1 | 20 | 708 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 14821.00 | (2.25, 2.25) | ncp-6-1 | 20 | 702 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL : 275.00 | (2.25, 2.25) | ncp-6-1 | 20 | 688 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL : 42944 .00 | (1, 1) | ncp-6-1 | 20 | 660 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL: 14821.00 | (1, 1) | ncp-6-1 | 20 | 654 |
DISCHARGE DATE: 02/26/10
| SUBTOTAL : 275.00 | (1, 1) | ncp-6-1 | 20 | 640 |
TOTAL CHARGES: 5068.00
| FEDERAL ID NO: 746001118 | (3.25, 3.25) | ncp-4-0 | 20 | 66 |
TOTAL CHARGES: 5068.00
| UNITED STATES | (3.25, 3.25) | ncp-4-0 | 20 | 69 |
272-STERILE SUPPLIES
| 02/07/18 07:40 PM 24 | (1, 1) | ncp-0-1 | 20 | 1,797 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| | 4/4/2013 SIMVASTATIN TAB 20MG | $57.05 | (3.25, 3.25) | ncp-1-3 | 20 | 2,994 |
272-STERILE SUPPLIES
| 02/07/18 07:40 PM 24 | (2.25, 2.25) | ncp-0-1 | 20 | 1,839 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| 4/5/2013 17506 PREDNISONE TAB 10MG 3 s1.98 | (0.5, 0.5) | ncp-1-3 | 20 | 2,902 |
272-STERILE SUPPLIES
| 02/07/18 07:40 PM 24 | (3.25, 3.25) | ncp-0-1 | 20 | 1,881 |
SUBTOTAL: 14821.00
| ouissie | (0.5, 0.5) | ncp-0-1 | 20 | 3,842 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| 4/5/2013 DOCUSATE CAP 100MG 2 $0.86 | (1, 1) | ncp-1-3 | 20 | 2,932 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| 4/6/2013 DOXYCYCLINE CAP 50MG 2 $17.00 | (1, 1) | ncp-1-3 | 20 | 2,948 |
SUBTOTAL: 14821.00
| address | (1, 1) | ncp-0-1 | 20 | 3,875 |
4/5/2013 BENAZEPRIL TAB 10MG 1 $11.71
| 4/5/2013 DOCUSATE CAP 100MG 2 $0.86 | (2.25, 2.25) | ncp-1-3 | 20 | 2,968 |