FPV Practice Exam 2-05
30341339
1/20/20XX
Betty Moore
George Platz
Take 1 or 2 tablets by mouth every 6 hours as needed for pain.
Acetaminophen/Codeine 300 mg/30 mg Tablet
12
1
1/18/20XX
Teva
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00093-0150-10
Quantity: 12
Days Supply: 2
AWP Cost/Unit: $0.28
Total Drug Cost: $3.36
Dispensing Fee: $2.00
Total Billed: $5.36
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00093-0150-10
Quantity: 12
Days Supply: 2
AWP Cost/Unit: $0.28
Total Drug Cost: $3.36
Dispensing Fee: $2.00
Total Billed: $5.36
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 30341339
Dispensing Date: 1/18/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 1/18/20XX
Initials: RPh
Drug Manu: Teva
Rx Documentation
Dispensing Date: 1/18/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 1/18/20XX
Initials: RPh
Drug Manu: Teva