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7.68k
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|---|---|---|---|---|---|
040217 02B661+ 0736 290116 82550 2 CREAT KINASE (CK) TOTA 606.00
| 040217 02B661+ 0736 290116 82550 2 CREAT KINASE (CK) TOTA 606.00 | (0.5, 0.5) | ncp-6-1 | 2 | 6,182 |
4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00
| 4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00 | (1, 1) | ncp-1-3 | 2 | 2,067 |
4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00
| 4/5/2013 DOXYCYCLINE CAP 50MG 2 $17.00 | (2.25, 2.25) | ncp-1-3 | 2 | 2,103 |
301-LAB/CHEMISTRY
| 301-LAB/CHEMISTRY | (3.25, 3.25) | ncp-6-1 | 2 | 6,133 |
033110 4700824 MEDICARE CONTRACTUAL - O/P -4196.07
| 033110 4700824 MEDICARE CONTRACTUAL - O/P -4196.07 | (2.25, 2.25) | ncp-4-0 | 2 | 1,769 |
Date Code Description Quantity Amount
| Date Code Description Quantity Amount | (3.25, 3.25) | ncp-1-3 | 2 | 109 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 DOCUSATE CAP 100MG 2 $0.86 | (1, 1) | ncp-1-3 | 2 | 2,212 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 DOCUSATE CAP 100MG 2 $0.86 | (2.25, 2.25) | ncp-1-3 | 2 | 2,248 |
033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21
| 033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21 | (3.25, 3.25) | ncp-4-0 | 2 | 1,888 |
301-LAB/CHEMISTRY
| 301-LAB/CHEMISTRY | (2.25, 2.25) | ncp-6-1 | 2 | 6,085 |
033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21
| 033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21 | (2.25, 2.25) | ncp-4-0 | 2 | 1,860 |
4/5/2013 DOCUSATE CAP 100MG 2 $0.86
| 4/5/2013 DOCUSATE CAP 100MG 2 $0.86 | (3.25, 3.25) | ncp-1-3 | 2 | 2,284 |
301-LAB/CHEMISTRY
| 301-LAB/CHEMISTRY | (1, 1) | ncp-6-1 | 2 | 6,037 |
033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21
| 033110 4700824 MEDICARE CONTRACTUAL - O/P 4070.21 | (1, 1) | ncp-4-0 | 2 | 1,831 |
4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06
| 4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06 | (3.25, 3.25) | ncp-1-3 | 2 | 1,559 |
4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06
| 4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06 | (1, 1) | ncp-1-3 | 2 | 1,487 |
4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06
| 4/5/2013 J3010 FENTANYL INJ 100MCG/2ML VL 1 $14.06 | (0.5, 0.5) | ncp-1-3 | 2 | 1,451 |
4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44
| 4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44 | (3.25, 3.25) | ncp-1-3 | 2 | 1,414 |
01/14/18
| 01/14/18 | (3.25, 3.25) | ncp-0-1 | 2 | 123 |
040217 02B645 0736 290906 82553 1 CK MB 436.00
| 040217 02B645 0736 290906 82553 1 CK MB 436.00 | (1, 1) | ncp-6-1 | 2 | 7,195 |
01/14/18
| 01/14/18 | (2.25, 2.25) | ncp-0-1 | 2 | 81 |
040217 02B645 0736 290906 82553 1 CK MB 436.00
| 040217 02B645 0736 290906 82553 1 CK MB 436.00 | (0.5, 0.5) | ncp-6-1 | 2 | 7,147 |
01/14/18
| 01/14/18 | (1, 1) | ncp-0-1 | 2 | 39 |
4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93
| 4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93 | (1, 1) | ncp-1-3 | 2 | 907 |
4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93
| 4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93 | (2.25, 2.25) | ncp-1-3 | 2 | 943 |
040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00
| 040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00 | (3.25, 3.25) | ncp-6-1 | 2 | 7,098 |
4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93
| 4/4/2013 SALINE LOCK IRRIG PFS 0.9% 2ML 1 $33.93 | (3.25, 3.25) | ncp-1-3 | 2 | 979 |
040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00
| 040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00 | (2.25, 2.25) | ncp-6-1 | 2 | 7,050 |
040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00
| 040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00 | (1, 1) | ncp-6-1 | 2 | 7,002 |
040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00
| 040217 02B645 0736 294021 83880 1 NATRIURETIC PEPTIDE 460.00 | (0.5, 0.5) | ncp-6-1 | 2 | 6,954 |
4/4/2013 THEOPHYLLINE 200MG TAB -1 ($5.00)
| 4/4/2013 THEOPHYLLINE 200MG TAB -1 ($5.00) | (1, 1) | ncp-1-3 | 2 | 1,052 |
4/4/2013 THEOPHYLLINE 200MG TAB -1 ($5.00)
| 4/4/2013 THEOPHYLLINE 200MG TAB -1 ($5.00) | (3.25, 3.25) | ncp-1-3 | 2 | 1,124 |
040217 02B694 0736 294718 80307 1 DRUG SCR ANY NBR PER D 492.00
| 040217 02B694 0736 294718 80307 1 DRUG SCR ANY NBR PER D 492.00 | (0.5, 0.5) | ncp-6-1 | 2 | 6,761 |
4/4/2013 ROOM RATE 5B MEDSURG ENDO/RENAL 1 $7,099.25
| 4/4/2013 ROOM RATE 5B MEDSURG ENDO/RENAL 1 $7,099.25 | (1, 1) | ncp-1-3 | 2 | 1,197 |
040217 02B661+ 0736 290906 82553 2 CK MB 872.00
| 040217 02B661+ 0736 290906 82553 2 CK MB 872.00 | (0.5, 0.5) | ncp-6-1 | 2 | 6,568 |
4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44
| 4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44 | (1, 1) | ncp-1-3 | 2 | 1,342 |
4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44
| 4/5/2013 J2060 LORAZEPAM INJ 2MG/ML 1 $10.44 | (2.25, 2.25) | ncp-1-3 | 2 | 1,378 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700079 INTERNAL USE: GLO .00 | (1, 1) | ncp-4-0 | 2 | 921 |
301-LAB/CHEMISTRY
| 301-LAB/CHEMISTRY | (0.5, 0.5) | ncp-6-1 | 2 | 5,989 |
4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00
| 4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00 | (1, 1) | ncp-1-3 | 2 | 2,357 |
031610 4700807 MEDICARE PAYMENT -659.69
| 031610 4700807 MEDICARE PAYMENT -659.69 | (3.25, 3.25) | ncp-4-0 | 2 | 1,160 |
033010 4700648 TRICARE/USFHP PYMT -174.10
| 033010 4700648 TRICARE/USFHP PYMT -174.10 | (2.25, 2.25) | ncp-4-0 | 2 | 1,314 |
040317 03B881 0717 322650 C1874 1 STENT SYNERGY 4X16MM 19708.00
| 040317 03B881 0717 322650 C1874 1 STENT SYNERGY 4X16MM 19708.00 | (0.5, 0.5) | ncp-6-1 | 2 | 5,217 |
033010 4700648 TRICARE/USFHP PYMT -174.10
| 033010 4700648 TRICARE/USFHP PYMT -174.10 | (1, 1) | ncp-4-0 | 2 | 1,285 |
4/5/2013 J1650 ENOXAPARIN PFS 30MG/0.3ML 1 $345.34
| 4/5/2013 J1650 ENOXAPARIN PFS 30MG/0.3ML 1 $345.34 | (1, 1) | ncp-1-3 | 2 | 2,647 |
031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21
| 031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21 | (3.25, 3.25) | ncp-4-0 | 2 | 1,251 |
031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21
| 031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21 | (2.25, 2.25) | ncp-4-0 | 2 | 1,223 |
040317 03B881 0717 322643 C1874 1 STENT SYNERGY 3.5X12MM 19708.00
| 040317 03B881 0717 322643 C1874 1 STENT SYNERGY 3.5X12MM 19708.00 | (0.5, 0.5) | ncp-6-1 | 2 | 5,024 |
4/5/2013 J1650 ENOXAPARIN PFS 30MG/0.3ML 1 $345.34
| 4/5/2013 J1650 ENOXAPARIN PFS 30MG/0.3ML 1 $345.34 | (2.25, 2.25) | ncp-1-3 | 2 | 2,683 |
031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21
| 031610 4700824 MEDICARE CONTRACTUAL - O/P -4070.21 | (1, 1) | ncp-4-0 | 2 | 1,194 |
Date Code Description Quantity Amount
| Date Code Description Quantity Amount | (1, 1) | ncp-1-3 | 2 | 37 |
033110 4700824 MEDICARE CONTRACTUAL - O/P -4196.07
| 033110 4700824 MEDICARE CONTRACTUAL - O/P -4196.07 | (1, 1) | ncp-4-0 | 2 | 1,740 |
031610 4700807 MEDICARE PAYMENT -659.69
| 031610 4700807 MEDICARE PAYMENT -659.69 | (2.25, 2.25) | ncp-4-0 | 2 | 1,132 |
Date Code Description Quantity Amount
| Date Code Description Quantity Amount | (2.25, 2.25) | ncp-1-3 | 2 | 73 |
031610 4700807 MEDICARE PAYMENT -659.69
| 031610 4700807 MEDICARE PAYMENT -659.69 | (1, 1) | ncp-4-0 | 2 | 1,103 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700098 COPAY/COINSURANCE .00 | (2.25, 2.25) | ncp-4-0 | 2 | 1,041 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700098 COPAY/COINSURANCE .00 | (1, 1) | ncp-4-0 | 2 | 1,012 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 4/5/2013 LORATADINE TAB 10MG 1 $3.49 | (1, 1) | ncp-1-3 | 2 | 2,792 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700079 INTERNAL USE: GLO .00 | (3.25, 3.25) | ncp-4-0 | 2 | 978 |
4/5/2013 LORATADINE TAB 10MG 1 $3.49
| 4/5/2013 LORATADINE TAB 10MG 1 $3.49 | (2.25, 2.25) | ncp-1-3 | 2 | 2,828 |
031610 4700079 INTERNAL USE: GLO .00
| 031610 4700079 INTERNAL USE: GLO .00 | (2.25, 2.25) | ncp-4-0 | 2 | 950 |
033010 4700648 TRICARE/USFHP PYMT -174.10
| 033010 4700648 TRICARE/USFHP PYMT -174.10 | (3.25, 3.25) | ncp-4-0 | 2 | 1,342 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700079 INTERNAL USE: GLO .00 | (1, 1) | ncp-4-0 | 2 | 1,376 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46 | (3.25, 3.25) | ncp-1-3 | 2 | 2,574 |
033110 4700807 MEDICARE PAYMENT -688.31
| 033110 4700807 MEDICARE PAYMENT -688.31 | (2.25, 2.25) | ncp-4-0 | 2 | 1,587 |
4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00
| 4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00 | (2.25, 2.25) | ncp-1-3 | 2 | 2,393 |
033110 4700807 MEDICARE PAYMENT 659.69
| 033110 4700807 MEDICARE PAYMENT 659.69 | (3.25, 3.25) | ncp-4-0 | 2 | 1,706 |
SUBTOTAL: 42944.00
| SUBTOTAL: 42944.00 | (0.5, 0.5) | ncp-6-1 | 2 | 5,796 |
033110 4700807 MEDICARE PAYMENT 659.69
| 033110 4700807 MEDICARE PAYMENT 659.69 | (2.25, 2.25) | ncp-4-0 | 2 | 1,678 |
040317 03B881 0717 693619 C1874 1 STN DES RESOL RX 4X15 1764.00
| 040317 03B881 0717 693619 C1874 1 STN DES RESOL RX 4X15 1764.00 | (1, 1) | ncp-6-1 | 2 | 5,651 |
033110 4700807 MEDICARE PAYMENT 659.69
| 033110 4700807 MEDICARE PAYMENT 659.69 | (1, 1) | ncp-4-0 | 2 | 1,649 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700079 INTERNAL USE: GLO .00 | (2.25, 2.25) | ncp-4-0 | 2 | 1,405 |
033110 4700807 MEDICARE PAYMENT -688.31
| 033110 4700807 MEDICARE PAYMENT -688.31 | (3.25, 3.25) | ncp-4-0 | 2 | 1,615 |
040317 03B881 0717 693619 C1874 1 STN DES RESOL RX 4X15 1764.00
| 040317 03B881 0717 693619 C1874 1 STN DES RESOL RX 4X15 1764.00 | (0.5, 0.5) | ncp-6-1 | 2 | 5,603 |
4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00
| 4/5/2013 THEOPHYLLINE 200MG TAB 1 $5.00 | (3.25, 3.25) | ncp-1-3 | 2 | 2,429 |
033110 4700807 MEDICARE PAYMENT -688.31
| 033110 4700807 MEDICARE PAYMENT -688.31 | (1, 1) | ncp-4-0 | 2 | 1,558 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700098 COPAY/COINSURANCE .00 | (3.25, 3.25) | ncp-4-0 | 2 | 1,524 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700098 COPAY/COINSURANCE .00 | (2.25, 2.25) | ncp-4-0 | 2 | 1,496 |
4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46
| 4/5/2013 PANTOPRAZOLE EC TAB 40MG 1 $47.46 | (1, 1) | ncp-1-3 | 2 | 2,502 |
033110 4700098 COPAY/COINSURANCE .00
| 033110 4700098 COPAY/COINSURANCE .00 | (1, 1) | ncp-4-0 | 2 | 1,467 |
040317 03B881 0717 693618 C1874 1 STN DES RESOL RX 4X12 1764.00
| 040317 03B881 0717 693618 C1874 1 STN DES RESOL RX 4X12 1764.00 | (0.5, 0.5) | ncp-6-1 | 2 | 5,410 |
033110 4700079 INTERNAL USE: GLO .00
| 033110 4700079 INTERNAL USE: GLO .00 | (3.25, 3.25) | ncp-4-0 | 2 | 1,433 |
031610 4700098 COPAY/COINSURANCE .00
| 031610 4700098 COPAY/COINSURANCE .00 | (3.25, 3.25) | ncp-4-0 | 2 | 1,069 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (2.25, 2.25) | ncp-0-1 | 1 | 5,554 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (2.25, 2.25) | ncp-0-1 | 1 | 5,555 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (1, 1) | ncp-0-1 | 1 | 5,513 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (3.25, 3.25) | ncp-0-1 | 1 | 5,596 |
040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | 040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | (3.25, 3.25) | ncp-6-1 | 1 | 7,677 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (1, 1) | ncp-0-1 | 1 | 5,512 |
041310 4700648 TRICARE/USFHP PYMT -9.52 | 041310 4700648 TRICARE/USFHP PYMT -9.52 | (3.25, 3.25) | ncp-4-0 | 1 | 1,979 |
041310 4700648 TRICARE/USFHP PYMT -9.52 | 041310 4700648 TRICARE/USFHP PYMT -9.52 | (2.25, 2.25) | ncp-4-0 | 1 | 1,951 |
041310 4700648 TRICARE/USFHP PYMT -9.52 | 041310 4700648 TRICARE/USFHP PYMT -9.52 | (1, 1) | ncp-4-0 | 1 | 1,922 |
040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | 040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | (2.25, 2.25) | ncp-6-1 | 1 | 7,629 |
040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | 040217 02B645 0736 290299 80076 1 HEPATIC FUNCTION PANEL 718.00 | (0.5, 0.5) | ncp-6-1 | 1 | 7,533 |
7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | 7020001188 301 BASIC METABOLIC PNL 1 218.00 218.00 | (3.25, 3.25) | ncp-0-1 | 1 | 5,597 |