Price Master for OCHA File Item Code Item Description Item Price 1210000001 FS-SIXTH SEMI-PRIVATE 2365 1210000006 MED/SUR OVERFLOW SEMI-PVT 2365 1210000007 ED OVERFLOW SEMI-PRIV BED 2365 1210000008 SAME DAY ADMIT SEMI-PRIV BED 2365 1210000009 GS-SEVENTH SEMI-PRIV 1BED 2365 1210000010 ICU-MED/SUR SEMI-PRIV BED 2365 1220000001 OB SEMI-PRIVATE 2420 1230000001 G3 PEDIATRICS SEMI PRIVATE 2150 1240000001 PSYCHIATRIC SEMI PRIVATE 2090 1240000002 ED HOLD PSYCH SEMI PRIVATE 2090 1240000003 SBHU SEMI PRIVATE 2090 1260000001 PSYCH DETOX SEMI PRIVATE 2200 1260000002 ED HOLD PSYCH DETOX SEMI PRIV 2200 1700000002 NURSERY ROOM RATE 1650 2000000001 ICU OVERFLOW PACU 3630 2000000002 INTENSIVE CARE 3630 2060000001 FS ISOLATION 2365 2060000002 FS TELEMETRY BED 2365 2060000003 FS TELEMETRY/ISOLATION 2365 2060000005 GS ISOLATION 2365 2060000006 GS TELEMETRY 2365 2060000007 GS TELEMETRY/ISOLATION 2365 2060000008 ICU ISOLATION 2365 2060000009 ED ISOLATION 2365 2060000010 ED TELEMETRY BED 2365 2060000011 ED TELEMETRY/ISOLATION 2150 2500000001 SODIUM CHLORIDE 0.9% RESP 3 ML NEBULIZATION SOLUTION 1.285 2500000002 ALBUTEROL 1.25 MG/3 ML VIAL.NEB 12.336 2500000003 ALBUTEROL 0.63 MG/3 ML VIAL.NEB 8.523 2500000004 ALBUTEROL/IPRATROPIUM 3 ML INH SOL 2.197 2500000005 RACEPINEPHRINE 2.25% 0.5 ML NEB 14.103 2500000006 ALBUTEROL 5 MG/ML 20 ML NEB SOL 80.6415 2500000007 IPRATROPIUM BROMIDE 0.5 MG/2.5 ML NEB 1.517 2500000009 ALBUTEROL 2.5 MG/3 ML VIAL.NEB 1.533 2500000010 ACETYLCYSTEINE-NONFORMULARY 10% 4 ML VIAL 11.8916 2500000011 TIAGABINE HCL 4 MG TAB 31.496 2500000012 ACAMPROSATE-NF 333 MG TABLET.EC 7.592 2500000013 PALIPERIDONE 3 MG TAB.ER.24 87.70887 2500000014 SILDENAFIL-NF 20 MG TAB 7.933 2500000018 LETROZOLE-NF 2.5 MG TAB 0.9 2500000019 BICALUTAMIDE-NF 50 MG TAB 13.44 2500000020 RANOLAZINE 500 MG TAB.ER.12H 34.75906 2500000021 CINACALCET HCL 30 MG TAB 140.674185 2500000022 SODIUM CHLORIDE 1 GM TAB 0.602 2500000023 AZITHROMYCIN 250 MG TAB 14.14 2500000024 LOXAPINE SUCCINATE 25 MG CAP 7.71 2500000025 URSODIOL 300 MG CAP 18.14616 2500000026 BENAZEPRIL 10 MG TAB 0.463 2500000028 ALFUZOSIN-NF 10 MG TAB.ER.24H 3.22 2500000029 SEVELAMER HCL 400 MG TAB 20.46496 2500000030 ANASTROZOLE 1 MG TAB 3.247 2500000031 LOSARTAN POTASSIUM 25 MG TAB 0.357 2500000031 LOSARTAN POTASSIUM 12.5 MG HALFTAB 8.167 2500000032 THEOPHYLLINE 400 MG TAB.ER.24H 8.802 2500000033 SUMAtriptan succinate 100 MG TAB 6.144 2500000034 AMOXICILLIN/POTASSIUM CLAV 875-125 TABLET 4.524 2500000035 MEMANTINE HCL 10 MG TAB 3.833 2500000036 IRBESARTAN-NF 75 MG HALFTAB 0.961 2500000036 IRBESARTAN-NF 150 MG TAB 1.921 2500000037 TRAZODONE HYDROCHLORIDE 25 MG HALFTAB 0.437 2500000037 TRAZODONE HCL 50 MG TAB 0.612 2500000037 TRAZODONE HCL 12.5 MG QUARTERTAB 0.873 2500000038 SACCHAROMYCES BOULARDII 250 MG CAP 5.344 2500000039 MEMANTINE HCL 2.5 MG HALFTAB 1.917 2500000039 MEMANTINE HCL 5 MG TAB 3.833 2500000040 PYRAZINAMIDE 500 MG TAB 12.34916 2500000041 FELODIPINE-NF 5 MG TAB.ER.24H 8.827 2500000043 DILTIAZEM 60 MG TAB 1.612 2500000044 CHLORTHALIDONE 12.5 MG QUARTERTAB 0.268 2500000044 CHLORTHALIDONE 25 MG HALFTAB 0.536 2500000044 CHLORTHALIDONE 50 MG TAB 8.527 2500000045 NADOLOL 10 MG HALFTAB 7.416 2500000045 NADOLOL 20 MG TAB 14.831 2500000047 PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE 4.508 2500000048 LITHIUM CARBONATE 150 MG HALFTAB 1.859 2500000048 LITHIUM CARBONATE 300 MG TAB 1.927 2500000049 FLUDROCORTISONE ACETATE 0.1 MG TAB 6.554 2500000050 DEXAMETHASONE 0.5 MG TAB 0.605 2500000051 ISONIAZID 100 MG TAB 12.443 2500000052 LITHIUM CARBONATE ER 300 MG TABLET.ER 3.142 2500000053 LEVOTHYROXINE SODIUM 12.5 MCG HALFTAB 0.55 2500000053 LEVOTHYROXINE SODIUM 25 MCG TAB 2.605 2500000054 MEGESTROL ACETATE 20 MG HALFTAB 0.934 2500000054 MEGESTROL ACETATE 40 MG TAB 1.942 2500000055 NITROGLYCERIN 0.3 MG TAB.SUBL 5.33 2500000056 NITROGLYCERIN 0.4 MG TAB.SUBL 10.625 2500000057 NITROGLYCERIN 0.6 MG TAB.SUBL 1.78 2500000058 BROMOCRIPTINE MESYLATE 2.5 MG TAB 3.553 2500000059 NIFEdipine 10 MG SGL - LIQUID FILLED CAPSULE 5.055 2500000060 SODIUM BICARBONATE 650 MG TAB 0.134 2500000061 ATENOLOL 12.5 MG HALFTAB 0.373 2500000061 ATENOLOL 25 MG TAB 1.579 2500000062 ENALAPRIL MALEATE 10 MG TAB 4.725 2500000063 hydrALAZINE 10 MG TAB 0.792 2500000064 PERPHENAZINE 8 MG TAB 16.448 2500000065 PRENATAL VITAMIN 1 TABLET 0.277 2500000066 rifAMPin 300 MG CAP 5.25 2500000067 DOCUSATE SODIUM/SENNA 1 TAB 0.323 2500000068 TAMOXIFEN CITRATE 10 MG TAB 3.694 2500000069 ARIPIPRAZOLE 15 MG TAB 12.89 2500000070 ARIPIPRAZOLE 10 MG TAB 14.297 2500000071 FLUOXETINE HCL 20 MG CAP 0.718 2500000072 LISINOPRIL 5 MG TABLET 0.47 2500000073 LISINOPRIL 10 MG TABLET 0.432 2500000074 LISINOPRIL 20 MG TABLET 0.674 2500000075 CLONIDINE TTS-1 PATCH.TDWK 82.695 2500000076 CLONIDINE TTS-2 PATCH.TDWK 121.336875 2500000077 DILTIAZEM S R 60 MG CAP.ER.12H 9.307 2500000078 DILTIAZEM S R 90 MG CAPSULE.SR 16.77596 2500000079 NORTRIPTYLINE 25 MG CAPSULE 1.158 2500000080 CLOZAPINE 12.5 MG HALFTAB 2.002 2500000080 CLOZAPINE 25 MG TAB 4.004 2500000081 NEFAZODONE HCL 50 MG HALFTAB 1.915 2500000081 NEFAZODONE HCL 100 MG TAB 3.83 2500000082 PRAVASTATIN SODIUM 10 MG HALFTAB 1.176 2500000082 PRAVASTATIN SODIUM 20 MG TAB 3.939 2500000083 TORSEMIDE 5 MG QUARTERTAB 0.193 2500000083 TORSEMIDE 10 MG HALFTAB 0.385 2500000083 TORSEMIDE 20 MG TAB 1.129 2500000084 METFORMIN HCL 850 MG TAB 0.739 2500000085 METFORMIN 250 MG HALFTAB 0.767 2500000085 METFORMIN HCL 500 MG TAB 0.776 2500000086 GLIMEPIRIDE 2 MG TAB 0.287 2500000087 CEFPODOXIME PROXETIL 200 MG TAB 31.6324 2500000088 sulfADIAZINE 500 MG TAB - NF 11.97096 2500000089 SUCCIMER 100 MG CAP 44.99607 2500000090 ZAFIRLUKAST 10 MG HALFTAB 2.709 2500000090 ZAFIRLUKAST 20 MG TAB 5.417 2500000091 OLANZAPINE 5 MG TABLET 2.079 2500000093 MIRTAZAPINE 15 MG TAB 1.399 2500000093 MIRTAZAPINE 3.75 MG HALFTAB 5.958 2500000094 LORATADINE 5 MG HALFTAB 1.02 2500000094 LORATADINE 10 MG TABLET 2.045 2500000095 LISINOPRIL 1.25 MG HALFTAB 0.064 2500000095 LISINOPRIL 2.5 MG TAB 0.153 2500000096 PROPAFENONE HCL 225 MG TAB 2.404 2500000097 WARFARIN 0.5 MG HALFTAB 0.17 2500000097 WARFARIN 1 MG TAB 0.339 2500000098 ZINC SULFATE 220 MG CAP 0.375 2500000099 CIPROFLOXACIN 250 MG TAB 2.864 2500000100 CIPROFLOXACIN 500 MG TAB 1.603 2500000101 ASPIRIN 81 MG TABLET.EC 0.395 2500000102 OLANZAPINE 10 MG TAB 3.114 2500000103 DONEPEZIL HCL 10 MG TAB 1.267 2500000104 LOSARTAN POTASSIUM 50 MG TAB 0.303 2500000105 QUINAPRIL HCL 10 MG TAB 0.778 2500000106 VITAMIN B w/ VIT C (RENAL) 1 CAPSULE 3.392 2500000107 MESALAMINE 400 MG TABLET.EC 18.89946 2500000108 BENAZEPRIL 5 MG TAB 0.459 2500000109 OMEPRAZOLE-NF 20 MG CAPSULE.DR 3.488 2500000110 CALCIUM ACETATE 667 MG CAPSULE 2.258 2500000111 ROPINIROLE HCL 0.5 MG TABLET 0.859 2500000112 ROPINIROLE HCL 1 MG TABLET 1.115 2500000113 OXCARBAZEPINE 75 MG HALFTAB 1.097 2500000113 OXCARBAZEPINE 150 MG TAB 1.884 2500000114 rOPINIRole HYDROCHLORIDE 0.25 MG TAB 2.368 2500000115 glipiZIDE XL 5 MG TAB.ER.24 2.839 2500000116 CLOPIDOGREL 75 MG TAB 2.219 2500000117 OLANZAPINE 2.5 MG TAB 1.764 2500000118 AMLODIPINE BESYLATE 2.5 MG TAB 1.362 2500000119 PAROXETINE HCL 10 MG TAB 0.827 2500000119 PAROXETINE HYDROCHLORIDE 5 MG HALFTAB 1.162 2500000120 DEMECLOCYCLINE HCL 150 MG TAB 14.6 2500000121 SITAGLIPTIN 25 MG HALFTAB 34.68306 2500000121 SITAGLIPTIN 50 MG TAB 69.36612 2500000122 TRIHEXYPHENIDYL 2.5 MG HALFTAB 0.43 2500000122 TRIHEXYPHENIDYL HCL 5 MG TAB 6.885 2500000123 IMIPRAMINE HCL 25 MG TAB 2.009 2500000124 VALSARTAN 80 MG TAB 0.942 2500000125 DANTROLENE 25 MG CAP 15.343 2500000126 BUDESONIDE 3 MG CAPDR...ER CAPSULE, DELAYED, AND EXTENDED40.47282 RELEASE 2500000127 VALACYCLOVIR HCL 500 MG TAB 3.77 2500000129 MEXILETINE HCL 200 MG CAP 2.163 2500000130 MELOXICAM 7.5 MG TAB 1.558 2500000131 ENTACAPONE 100 MG HALFTAB 11 2500000131 ENTACAPONE 200 MG TAB 14.28232 2500000132 METHYLDOPA 250 MG TAB 1.582 2500000133 AMITRIPTYLINE HCL 50 MG TABLET 4.023 2500000134 ASPIRIN 325 MG TABLET.DR 0.099 2500000135 SULFAMETHOXAZOLE/TRIMETHOPRIM 800/160 TABLET 1.263 2500000136 ASPIRIN 325 MG TABLET 0.576 2500000138 diphenhydrAMINE HYDROCHLORID 25 MG CAPSULE 0.305 2500000139 PROBENECID 500 MG TAB 4.246 2500000140 DICYCLOMINE HCL 10 MG CAP 0.395 2500000141 BETHANECHOL 12.5 MG HALFTAB 2.075 2500000141 BETHANECHOL CHLORIDE 25 MG TAB 4.287 2500000142 TERBUTALINE SULFATE 5 MG TAB 30.23864 2500000143 TERBUTALINE SULFATE 2.5 MG TAB 24.78512 2500000144 CAPTOPRIL 6.25 MG HALFTAB 0.255 2500000144 CAPTOPRIL 12.5 MG TAB 7.226 2500000145 SUCRALFATE 1 GM TAB 3.58 2500000146 DILTIAZEM 15 MG HALFTAB 0.291 2500000146 DILTIAZEM 30 MG TAB 1.014 2500000147 CLONIDINE HCL 0.1 MG TAB 0.432 2500000148 CLINDAMYCIN HCL 150 MG CAP 2.3 2500000149 BENZTROPINE MESYLATE 0.25 MG HALFTAB 1.493 2500000149 BENZTROPINE MESYLATE 0.5 MG TABLET 2.963 2500000149 BENZTROPINE MESYLATE 1 MG TAB 3.735 2500000150 PREDNISONE 20 MG TABLET 1.863 2500000151 TRAZODONE HCL 100 MG TAB 1.66 2500000152 ACETAZOLAMIDE 250 MG TAB 11.3336 2500000153 PHENYTOIN 50 MG TAB.CHEW 10.786 2500000154 DOCUSATE SODIUM 100 MG CAPSULE 0.267 2500000155 DOXYCYCLINE HYCLATE 100 MG TAB 1.451 2500000156 FERROUS SULFATE 325 MG TABLET.DR 3.583 2500000157 CYCLOBENZAPRINE HCL 2.5 MG HALFTAB 0.196 2500000157 CYCLOBENZAPRINE HCL 10 MG TAB 0.446 2500000158 FOLIC ACID 1 MG TAB 0.662 2500000159 FUROSEMIDE 20 MG TAB 0.611 2500000159 FUROSEMIDE 10 MG HALFTAB 0.649 2500000160 FUROSEMIDE 40 MG TAB 0.415 2500000161 HALOPERIDOL 5 MG TAB 2.143 2500000162 DEXAMETHASONE 2 MG HALFTAB 0.56 2500000162 DEXAMETHASONE 4 MG TAB 1.185 2500000163 hydroCHLOROthiazide 6.25 MG QUARTER TABLET 0.043 2500000163 hydroCHLOROthiazide 25 MG TABLET 0.172 2500000164 hydroCHLOROthiazide