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Facility Service Setting Cdm Descripion Revenue Code

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Facility Service Setting Cdm Descripion Revenue Code FACILITY SERVICE_SETTING CDM DESCRIPION REVENUE_CODE PHARMACY RX 80000007 INVESTIGATIONAL SOLANEZUMAB 20MG\/ML SOLN 1 EACH VIAL 250 PHARMACY RX 80000006 INVESTIGATIONAL PERTUZUMAB 420MG\/14ML SOLN 14 ML VIAL 636 PHARMACY RX 80000006 INVESTIGATIONAL NIVOLUMAB (OPDIVO) 100MG\/10ML SOLN 10 ML VIAL 636 PHARMACY RX 80000006 INVESTIGATIONAL AVELUMAB 20MG\/ML INJ 10 ML VIAL 636 PHARMACY RX 80000007 INVESTIGATIONAL ATEZOLIZUMAB 1200MG\/20ML SOLN 20 ML VIAL 250 PHARMACY RX 80000007 INVESTIGATIONAL IMCGP100 0.5MG\/ML INJ 0.4 ML 636 PHARMACY RX 80000007 INVESTIGATIONAL TERLIPRESSIN 1MG SOLR 250 PHARMACY RX 81000008 ALEMTUZUMAB 30MG\/ML SOLN 636 PHARMACY RX 81000008 MIDAZOLAM 1MG\/ML SOLN 250 PHARMACY RX 80000001 NACL 7% NEBU 250 PHARMACY RX 80000001 PEDIATRIC MULTIVITAMINS+MINERALS 250 PHARMACY RX 80000001 MENTHOL 3 MG LOZG 250 PHARMACY RX 80000001 CLOTRIMAZOLE 1% 28.35 G TUBE 250 PHARMACY RX 80000001 VITAMIN B COMPLEX 250 PHARMACY RX 80000001 BENZOCAINE-MENTHOL 15-4 MG LOZG 250 PHARMACY RX 80000001 MULTIVITAMINS+MINERALS 250 PHARMACY RX 80000001 CYANOCOBALAMIN SL 2500 MCG SUBL 250 PHARMACY RX 80000001 VITAMIN B COMPLEX 250 PHARMACY RX 80000001 MULTIVITAMINS 250 PHARMACY RX 80000001 PHENYLEPHRINE 0.125% SOLN 15 ML BOTTLE 250 PHARMACY RX 80000001 VITAMIN B COMPLEX+VITAMIN C 250 PHARMACY RX 80000001 PRENATAL VITAMINS+FOLATE 250 PHARMACY RX 80000001 MULTIVITAMINS+MINERALS TABS 250 PHARMACY RX 80000003 DIPHENHYDRAMINE 12.5MG\/5ML LIQD 250 PHARMACY RX 80000003 DIPHENHYDRAMINE 12.5MG\/5ML ELIX 250 PHARMACY RX 80000003 DIPHENHYDRAMINE 25MG CAPS 250 PHARMACY RX 80000003 DIPHENHYDRAMINE 50MG CAPS 250 PHARMACY RX 81000000 CALCIUM CARBONATE 500MG CHEW 250 PHARMACY RX 81000000 MULTIVITAMINS TABS 250 PHARMACY RX 81000000 DOCUSATE SODIUM 10MG\/ML LIQD 250 PHARMACY RX 81000000 MAGNESIUM CHLORIDE CR 64MG TBCR 250 PHARMACY RX 81000000 CHLORPHENIRAMINE 4MG TABS 250 PHARMACY RX 81000000 MICONAZOLE 2 % OINT 71 G TUBE 250 PHARMACY RX 81000000 MULTIVITAMIN CHEW 250 PHARMACY RX 81000000 POLYETHYL GLYCOL\/PROPYL GLYCOL 0.4\/0.3% SOLN 250 PHARMACY RX 81000000 MAGNESIUM CARBONATE 54MG\/5ML LIQD 250 PHARMACY RX 81000000 NAPROXEN 500MG TABS 250 PHARMACY RX 81000000 PHENAZOPYRIDINE 100MG TABS 250 PHARMACY RX 81000000 MAGNESIUM OXIDE 400MG TABS 250 PHARMACY RX 81000000 PRENATAL PLUS\/IRON 27-1 MG TABS 250 PHARMACY RX 81000000 HYDROCORTISONE 2.5% LOTN 118 ML BOTTLE 250 PHARMACY RX 81000000 PSYLLIUM 28.3 % PACK 250 PHARMACY RX 81000000 FLEET MINERAL OIL ENEM 250 PHARMACY RX 81000000 PYRIDOXINE 25MG TABS 250 PHARMACY RX 81000000 CARBAMIDE PEROXIDE 6.5% SOLN 15 ML BOTTLE 250 PHARMACY RX 81000000 HYDROCORTISONE 2.5% CREA 28 G TUBE 250 PHARMACY RX 81000000 NACL 3% NEBU 250 PHARMACY RX 81000000 SACCHAROMYCES BOULARDII 250MG CAPS 250 PHARMACY RX 81000000 PSEUDOEPHEDRINE 60MG TABS 250 PHARMACY RX 81000000 POLYVINYL ALCOHOL 1.4% SOLN 15 ML BOTTLE 250 PHARMACY RX 81000000 CARBOXYMETHYLCELLULOSE 0.5% SOLN 250 PHARMACY RX 81000000 IODINE\/POTASSIUM IODIDE 5%\/10% SOLN 8 ML BOTTLE 250 PHARMACY RX 81000000 CHOLECALCIFEROL 1,000 UNITS TABS 250 PHARMACY RX 81000000 OMEGA-3 FATTY ACIDS DR 1000MG CPDR 250 PHARMACY RX 81000000 TETRAHYDROZOLINE 0.05% SOLN 15 ML BOTTLE 250 PHARMACY RX 81000000 FERROUS SULFATE 220MG(44 FE)\/5ML ELIX 250 PHARMACY RX 81000000 CARBOXYMETHYLCELLULOSE PF 1% GEL 250 PHARMACY RX 81000000 ZINC SULFATE 50MG CAPS 250 PHARMACY RX 81000000 CARBOXYMETHYLCELLULOSE PF 1% SOLN 250 PHARMACY RX 81000000 PHENYLEPHRINE 1% SOLN 15 ML BOTTLE 250 PHARMACY RX 81000000 BENZOCAINE 10% GEL 250 PHARMACY RX 81000000 SENNOSIDES 8.6 MG TABS 250 PHARMACY RX 81000000 GLUCOSAMINE\/CHONDROITIN 500MG\/400MG CAPS 250 PHARMACY RX 81000000 FERROUS SULFATE 300MG(60FE)\/5ML SYRP 250 PHARMACY RX 81000000 PSEUDOEPHEDRINE 30MG TABS 250 PHARMACY RX 81000000 NIACIN 100MG TABS 250 PHARMACY RX 81000000 POTASSIUM CHLORIDE 10% LIQD 250 PHARMACY RX 81000000 LIDOCAINE 4% CREA 5 G TUBE 250 PHARMACY RX 81000000 DOXYLAMINE 25MG TABS 250 PHARMACY RX 81000000 PRESERVISION AREDS CAPS 250 PHARMACY RX 81000000 SALINE 0.65% SOLN 44 ML BOTTLE 250 PHARMACY RX 81000000 DOCUSATE SODIUM 50MG CAPS 250 PHARMACY RX 81000000 MENTHOL\/METHYL SALICYLATE 7.6%\/29% OINT 99.2 G JAR 250 PHARMACY RX 81000000 UREA POWD 250 PHARMACY RX 81000000 DEXTROMETHORPHAN\/GUAIFENESIN 10MG\/100MG\/5ML LIQD 250 PHARMACY RX 81000000 NIACIN 500MG TABS 250 PHARMACY RX 81000000 CHARCOAL ACTIVATED 25GM\/120ML LIQD 250 PHARMACY RX 81000000 ZINC OXIDE 16% OINT 113 G TUBE 250 PHARMACY RX 81000000 OMEGA-3 FATTY ACIDS 1000MG CAPS 250 PHARMACY RX 81000000 LOPERAMIDE 1MG\/7.5ML SUSP 250 PHARMACY RX 81000000 SALIVA SUBSTITUTE 250 PHARMACY RX 81000000 MINERAL OIL OIL 10 ML VIAL 250 PHARMACY RX 81000000 CASTOR OIL OIL 250 PHARMACY RX 81000000 BENZOCAINE 7.5% GEL 250 PHARMACY RX 81000000 NIACIN CR 250MG CPCR 250 PHARMACY RX 81000000 SALINE 0.65% SOLN 44 ML BOTTLE 250 PHARMACY RX 81000000 CAMPHOR\/MENTHOL LOTN 222 ML BOTTLE 250 PHARMACY RX 81000000 ASPIRIN-APAP-CAFFEINE 250MG\/250MG\/65MG TABS 250 PHARMACY RX 81000000 DIPHENHYDRAMINE 25MG TABS 250 PHARMACY RX 81000000 CALCIUM CITRATE\/VITAMIN D 315-250 MG-UNIT TABS 250 PHARMACY RX 81000000 MELATONIN 5MG TABS 250 PHARMACY RX 81000000 LOPERAMIDE 2MG CAPS 250 PHARMACY RX 81000000 HYPROMELLOSE 0.3% GEL 10 G TUBE 250 PHARMACY RX 81000000 GLYCERIN (ADULT) 2G SUPP 250 PHARMACY RX 81000000 PHENYLEPH-SHARK LIV OIL-MO-PETR OINT 57 G TUBE 250 PHARMACY RX 81000000 SYSTANE NIGHTTIME OINT 3.5 G TUBE 250 PHARMACY RX 81000000 LACTOBACILLUS SOLN 250 PHARMACY RX 81000000 PURALUBE 85-15 % OINT 250 PHARMACY RX 81000000 CASTOR OIL 100 % OIL 59 ML BOTTLE 250 PHARMACY RX 81000000 FAMOTIDINE 40MG\/5ML SUSR 250 PHARMACY RX 81000000 LACTASE 9,000 UNITS TABS 250 PHARMACY RX 81000000 NAPROXEN SODIUM 220MG TABS 250 PHARMACY RX 81000000 DEXTROMETHORPHAN-GUAIFENESIN 10-100MG\/5ML LIQD 250 PHARMACY RX 81000000 ACETYLCYSTEINE 600MG CAPS 250 PHARMACY RX 81000000 HYDROCORTISONE 2.5% OINT 28.35 G TUBE 250 PHARMACY RX 81000000 HYDROCORTISONE 0.5% OINT 28.35 G TUBE 250 PHARMACY RX 81000000 SIMETHICONE 40MG\/0.6ML SUSP 250 PHARMACY RX 81000000 SENNOSIDES\/DOCUSATE 8.6MG\/50MG TABS 250 PHARMACY RX 81000000 CHLORHEXIDINE 4% LIQD 15 ML PACKAGE 250 PHARMACY RX 81000000 DOCOSANOL 10% CREA 2 G PUMP BTL 250 PHARMACY RX 81000000 MAGNESIUM CHLORIDE EC 64MG TBEC 250 PHARMACY RX 81000000 HYDROGEN PEROXIDE 1.5% SOLN 15 ML PACKET 250 PHARMACY RX 81000000 PSYLLIUM 95% PACK 250 PHARMACY RX 81000000 FERROUS SULFATE 325MG TABS 250 PHARMACY RX 81000000 GLYCERIN 1G SUPP 250 PHARMACY RX 81000000 SODIUM PHOSPHATES 3.5\/9.5G\/59ML ENEM 250 PHARMACY RX 81000000 POLYCARBOPHIL 625MG TABS 250 PHARMACY RX 81000000 CADEXOMER IODINE 0.9% GEL 40 G TUBE 250 PHARMACY RX 81000000 PREPARATION H 1-0.25-14.4-15 % CREA 26 G TUBE 250 PHARMACY RX 81000000 MULTIVITAMIN LIQD 250 PHARMACY RX 81000000 NACL 5% SOLN 15 ML BOTTLE 250 PHARMACY RX 81000000 NEOSPORIN 400-5-5000 OINT 250 PHARMACY RX 81000000 VITAMIN A & D OINT 5 G BOX 250 PHARMACY RX 81000000 BIOTIN 5 MG CAPS 250 PHARMACY RX 81000000 HYDROCERIN CREA 250 PHARMACY RX 81000000 DOCUSATE SODIUM 250MG\/25ML LIQD 250 PHARMACY RX 81000000 LEVONORGESTREL 1.5MG TABS 250 PHARMACY RX 81000000 FERROUS SULFATE 324 (65 FE) MG TBEC 250 PHARMACY RX 81000000 ARTIFICIAL SALIVA GEL 42 G TUBE 250 PHARMACY RX 81000000 NAPROXEN 250MG TABS 250 PHARMACY RX 81000000 BENZOCAINE\/MENTHOL AERO 56 G CAN 250 PHARMACY RX 81000000 MAGNESIUM CHLORIDE CR 64MG TBEC 250 PHARMACY RX 81000000 FOLIC ACID 400 MCG TABS 250 PHARMACY RX 81000000 MELATONIN 5 MG CAPS 250 PHARMACY RX 81000000 TOTAL B\/C TABS 250 PHARMACY RX 81000000 EUCERIN CREA 57 G TUBE 250 PHARMACY RX 81000000 SIMETHICONE 80MG CHEW 250 PHARMACY RX 81000000 THIAMINE 50MG TABS 250 PHARMACY RX 81000000 D-ALPHA TOCOPHEROL 400 UNITS CAPS 250 PHARMACY RX 81000000 FERRIC SUBSULFATE 259MG\/G SOLN 250 PHARMACY RX 81000000 BACITRACIN\/POLYMYXIN B OINT 250 PHARMACY RX 81000000 ERGOCALCIFEROL 8,000 UNITS\/ML SOLN 250 PHARMACY RX 81000000 IODINE\/POTASSIUM IODIDE 5% SOLN 250 PHARMACY RX 81000000 MENTHOL 3.3 MG LOZG 20 EACH BOX 250 PHARMACY RX 81000000 FERROUS SULFATE 300MG(60FE)\/5ML SYRP 250 PHARMACY RX 81000000 GLYCERIN 1.2G SUPP 250 PHARMACY RX 81000000 MISC INTESTINAL FLORA REGULATOR PACK 250 PHARMACY RX 81000000 AMMONIUM LACTATE 5% LOTN 222 ML BOTTLE 250 PHARMACY RX 81000000 FEXOFENADINE 60MG TABS 250 PHARMACY RX 81000000 DIBUCAINE 1% OINT 28.35 G TUBE 250 PHARMACY RX 81000000 VITAMIN B-1 50 MG TABS 250 PHARMACY RX 81000000 CAPSAICIN 0.1 % CREA 250 PHARMACY RX 81000000 MECLIZINE 12.5MG TABS 250 PHARMACY RX 81000000 CALCIUM CARBONATE 1500MG TABS 250 PHARMACY RX 81000000 MECLIZINE 25MG TABS 250 PHARMACY RX 81000000 MENTHOL\/ZINC OXIDE 0.44-20.625 % OINT 113 G TUBE 250 PHARMACY RX 81000000 TERBINAFINE 1 % CREA 30 G TUBE 250 PHARMACY RX 81000000 LACTOBACILLUS PACK 250 PHARMACY RX 81000000 NACL 1G TABS 250 PHARMACY RX 81000000 DOCUSATE SODIUM 250MG CAPS 250 PHARMACY RX 81000000 POLY-VITAMINS\/IRON 10MG\/ML SOLN 250 PHARMACY RX 81000000 LACTINEX CHEW 250 PHARMACY RX 81000000 OYSTER SHELL CALCIUM CARBONATE\/VITAMIN D 250MG\/125 UNITS TABS 250 PHARMACY RX 81000000 MAGNESIUM CITRATE SOLN 296 ML BOTTLE 250 PHARMACY RX 81000000 BENZOYL PEROXIDE 10% LOTN 29.5 ML BOTTLE 250 PHARMACY RX 81000000 THERA-M TABS 250 PHARMACY RX 81000000 BISACODYL EC 5MG TBEC 250 PHARMACY RX 81000000 LACTOBACILLUS CAPS 250 PHARMACY RX 81000000 LANSOPRAZOLE 3MG\/ML SUSP 250 PHARMACY RX 81000000 DEXTROMETHORPHAN POLISTIREX CR 30MG\/5ML SUER 250 PHARMACY RX 81000000 THERABREATH LIQD 473 ML BOTTLE 250 PHARMACY RX 81000000 ASTROGLIDE GEL 250 PHARMACY RX 81000000 GUAIFENESIN 12HR-ER 600MG TB12 250 PHARMACY RX 81000000 ARTIFICIAL TEARS 0.1%-0.3% SOLN
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