Medication Charges Part 12

LEVETIRACETAM IN NACL (ISO-OS) 1000 MG/100 ML IV IVPB 14789-220-10 100 mL Bag 0.108 mL 100 mL $179.55
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV IVPB 55150-248-47 100 mL Bag 0.115 mL 100 mL $180.34
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV IVPB 44567-503-10 100 mL Bag 0.14 mL 100 mL $182.75
LEVETIRACETAM IN NACL (ISO-OS) 1500 MG/100 ML IV IVPB 44567-503-01 100 mL Bag 0.14 mL 100 mL $182.75
LEVOBUNOLOL 0.5 % OPHT DROPS 24208-505-05 5 mL DROP BTL 2.03 mL 5 mL $70.90
LEVOCARNITINE 200 MG/ML IV SOLUTION 54482-147-01 5 mL Vial 6.792 mL 5 mL $202.71
LEVOCARNITINE 20MG/ML IV NICU DILUTION UHCS-0004-33 1 each each Vial 1 each $0.00
LEVOFLOXACIN 250 MG ORAL TAB 0904-6351-61 100 each each 0.153 each 1 each $12.30
LEVOFLOXACIN 500 MG ORAL TAB 0904-6352-61 100 each each 0.168 each 1 each $12.32
LEVOFLOXACIN 750 MG ORAL TAB 0904-6353-61 100 each each 0.314 each 1 each $12.46
LEVOFLOXACIN IN D5W 500 MG/100 ML IV IVPB 0143-9316-24 100 mL Bag 0.019 mL 100 mL $170.65
LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB 0143-9317-24 150 mL Bag 0.014 mL 150 mL $170.85
LEVOFLOXACIN IN D5W 750 MG/150 ML IV IVPB 0143-9317-01 150 mL Bag 0.014 mL 150 mL $170.85
LEVONORGESTREL 1.5 MG ORAL TAB 0536-1142-63 1 each each 6.96 each 1 each $17.76
LEVONORGESTREL 17.5 MCG/24 HRS (5 YRS) 19.5 MG IU IUD 50419-424-01 1 each each 1101.7 each 1 each "$2,217.17"
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG IU IUD 50419-423-01 1 each each 1101.7 each 1 each "$2,217.17"
LEVOTHYROXINE 20 MCG/ML ORAL SOLUTION 66689-105-04 100 mL Bottle 1.011 mL 100 mL $122.70
LEVOTHYROXINE 20 MCG/ML ORAL SOLUTION 66689-105-02 100 mL Bottle 1.011 mL 100 mL $122.70
LEVOTHYROXINE 25 MCG ORAL TAB 51079-444-20 100 each each 0.317 each 1 each $12.47
LEVOTHYROXINE 50 MCG ORAL TAB 51079-440-20 100 each each 0.354 each 1 each $12.50
LEVOTHYROXINE 50 MCG ORAL TAB 51079-440-01 1 each each 0.354 each 1 each $12.50
LEVOTHYROXINE 75 MCG ORAL TAB 51079-441-20 100 each each 0.398 each 1 each $12.55
LEVOTHYROXINE 75 MCG ORAL TAB 51079-441-01 1 each each 0.398 each 1 each $12.55
LEVOTHYROXINE 88 MCG ORAL TAB 42292-038-20 100 each each 0.366 each 1 each $12.52
LEVOTHYROXINE 88 MCG ORAL TAB 42292-038-01 1 each each 0.366 each 1 each $12.52
LEVOTHYROXINE (SYNTHROID) IV 20 MCG/ML (NICU) UHCS-0000-32 1 each each 61.89 each 1 each $230.64
LEVOTHYROXINE (THYQUIDITY) PO 20 MCG/ML (NICU) UHCS-0005-67 100 mL Bottle 1.012 Bottle 100 mL $22.61
LEVOTHYROXINE 100 MCG IV VIAL 42023-201-01 1 each each 61.89 each 1 each $230.64
LEVOTHYROXINE 100 MCG IV VIAL 70860-451-10 1 each each 64.89 each 1 each $233.64
LEVOTHYROXINE 100 MCG IV VIAL 63323-649-16 1 each each 77.66 each 1 each $246.41
LEVOTHYROXINE 100 MCG ORAL TAB 51079-442-20 100 each each 0.408 each 1 each $12.56
LEVOTHYROXINE 112 MCG ORAL TAB 42292-039-20 100 each each 0.426 each 1 each $12.58
LEVOTHYROXINE 125 MCG ORAL TAB 51079-443-20 100 each each 0.48 each 1 each $12.63
LEVOTHYROXINE 137 MCG ORAL TAB 42292-041-20 100 each each 0.559 each 1 each $12.71
LEVOTHYROXINE 137 MCG ORAL TAB 42292-041-01 1 each each 0.559 each 1 each $12.71
LEVOTHYROXINE 150 MCG ORAL TAB 51079-445-20 100 each each 0.493 each 1 each $12.64
LEVOTHYROXINE 150 MCG ORAL TAB 51079-445-01 1 each each 0.493 each 1 each $12.64
LEVOTHYROXINE 175 MCG ORAL TAB 42292-040-20 100 each each 0.529 each 1 each $12.68
LEVOTHYROXINE 200 MCG ORAL TAB 0074-7148-11 100 each each 1.387 each 1 each $13.54
LEVOTHYROXINE 500 MCG IV VIAL 42023-203-01 1 each each 487.52 each 1 each $981.13
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLUTION 73293-0001-1 5 mL Vial 0.277 mL 5 mL $170.14
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLUTION 55150-162-05 5 mL Vial 0.286 mL 5 mL $170.18
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLUTION 0143-9595-01 5 mL Vial 0.454 mL 5 mL $171.02
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLUTION 0143-9595-25 5 mL Vial 0.454 mL 5 mL $171.02
LIDOCAINE (PF) 10 MG/ML (1 %) INJ SOLUTION 63323-492-37 30 mL Vial 0.237 mL 30 mL $175.86
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE 0409-1323-05 5 mL Syringe 0.746 mL 5 mL $172.48
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLUTION 0409-4277-16 20 mL Vial 0.094 mL 20 mL $170.63
LIDOCAINE (PF) 20 MG/ML (2 %) INJ SOLUTION 0143-9594-25 5 mL Vial 0.408 mL 5 mL $170.79
LIDOCAINE (PF) 3.5 % OPHT GEL 17478-792-01 1 mL Tube 21.57 mL 1 mL $45.87
LIDOCAINE (PF) 3.5 % OPHT GEL 17478-792-25 1 mL Tube 21.575 mL 1 mL $45.88
LIDOCAINE 4 % TP MED PATCH 71399-3884-6 6 each each 0.573 each 1 each $24.87
LIDOCAINE 4 % TP MED PATCH 46581-830-06 6 each each 1.142 each 1 each $25.44
LIDOCAINE 4 % TP MED PATCH 46581-830-01 15 each each 2.148 each 1 each $26.45
LIDOCAINE 5 % TP OINTMENT 52565-008-14 35.44 g Tube 0.274 g 35.44 g $63.71
LIDOCAINE HCL 2 % MM JELLY 25021-673-77 11 mL Syringe 0.418 mL 11 mL $58.60
LIDOCAINE HCL 2 % MM SOLUTION 63629-2095-1 100 mL Bottle 0.056 mL 100 mL $54.20
LIDOCAINE HCL 2 % MM SOLUTION 50383-775-17 15 mL Cup 0.055 mL 15 mL $54.83
LIDOCAINE HCL 2 % MM SOLUTION 50383-775-04 100 mL Bottle 0.067 mL 100 mL $55.30
LIDOCAINE HCL 4 % LATR SOLUTION 0409-4698-01 4 mL KIT 1.319 mL 4 mL $0.00
LIDOCAINE HCL (BULK) 100 % MISC POWDER 51552-0106-9 4 g Jar 1.55 g 4 g $60.20
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLUTION 0409-4276-01 20 mL Vial 0.04 mL 20 mL $169.55
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLUTION 0409-4276-16 20 mL Vial 0.04 mL 20 mL $169.55
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLUTION 63323-485-41 20 mL Vial 0.102 mL 20 mL $170.79
LIDOCAINE HCL 10 MG/ML (1 %) INJ SOLUTION(REGIONAL BLOCK) 0409-4276-01 20 mL Vial 0.04 mL 20 mL $169.55
LIDOCAINE HCL 20 MG/ML (2 %) INJ SOLUTION 0409-4277-01 20 mL Vial 0.094 mL 20 mL $170.63
LIDOCAINE HCL 4 % (40 MG/ML) MM SOLUTION 0054-3505-47 50 mL Bottle 0.739 mL 50 mL $90.95
LIDOCAINE HCL 5 MG/ML (0.5 %) INJ SOLUTION 0409-4275-01 50 mL Vial 0.083 mL 50 mL $172.90
LIDOCAINE IN 5 % DEXTROSE (PF) 4 MG/ML (0.4 %) IV BAG 0338-0409-03 500 mL Bag 0.01 mL 500 mL $144.05
"LIDOCAINE-EPINEPHRINE (MPF) 2 %-1:200,000 INJ SOLUTION" 0409-3183-01 20 mL Vial 0.13 mL 20 mL $171.35
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200000 INJ SOLUTION 63323-487-17 10 mL Vial 0.681 mL 10 mL $175.56
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200000 INJ SOLUTION 0409-3183-11 20 mL Vial 0.13 mL 20 mL $171.35
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200000 INJ SOLUTION 63323-489-21 20 mL Vial 0.444 mL 20 mL $177.63
LIDOCAINE-EPINEPHRINE 0.5 %-1:200000 INJ SOLUTION 0409-3177-01 50 mL Vial 0.041 mL 50 mL $170.80
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION UHCS-0005-74 10 mL Vial 0.04 mL 10 mL $169.15
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION 0409-3178-01 20 mL Vial 0.056 mL 20 mL $169.87
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION UHCS-0005-76 30 mL Vial 0.054 mL 30 mL $170.37
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION 63323-482-41 20 mL Vial 0.13 mL 20 mL $171.35
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION UHCS-0005-77 50 mL Vial 0.069 mL 50 mL $172.20
LIDOCAINE-EPINEPHRINE 1 %-1:100000 INJ SOLUTION UHCS-0005-75 20 mL Vial 0.186 mL 20 mL $172.47
LIDOCAINE-EPINEPHRINE 2 %-1:100000 INJ SOLUTION 63323-483-27 20 mL Vial 0.132 mL 20 mL $171.39
LIDOCAINE-EPINEPHRINE BIT 2 %-1:100000 INJ CARTRIDGE 31382-898-05 1.7 mL Cartridge 0.66 Cartridge 1.7 mL $179.38
LIDOCAINE-PRILOCAINE 2.5-2.5 % TP CREAM 50383-667-30 30 g Tube 0.561 g 30 g $70.83
LIDOCAINE-PRILOCAINE 2.5-2.5 % TP KIT 0168-0357-56 5 g Tube 1.107 g 5 g $59.54
LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05-0.5 % TP GEL 70092-1612-43 1.5 mL Syringe 11.42 Syringe 1.5 mL $180.17
LIDOCAINE-RACEPINEP-TETRACAINE 4-0.05-0.5 % TP GEL 70092-1137-43 1.5 mL Syringe 11.58 Syringe 1.5 mL $180.33
LINACLOTIDE 72 MCG ORAL CAP 0456-1203-04 4 each each 13.704 each 1 each $25.85
LINACLOTIDE 72 MCG ORAL CAP 0456-1203-30 30 each each 15.854 each 1 each $28.00
LINACLOTIDE 145 MCG ORAL CAP 0456-1201-04 4 each each 15.105 each 1 each $27.26
LINACLOTIDE 145 MCG ORAL CAP 0456-1201-30 30 each each 15.854 each 1 each $28.00
LINACLOTIDE 290 MCG ORAL CAP 0456-1202-04 4 each each 0 Bottle 1 each $0.00
LINACLOTIDE 290 MCG ORAL CAP 0456-1202-30 30 each each 15.854 each 1 each $28.00
LINAGLIPTIN 5 MG ORAL TAB 0597-0140-30 30 each each 12.61 each 1 each $24.76
LINDANE 1 % TP SHAMPOO 60432-834-60 60 mL Bottle 1.686 mL 60 mL $155.16
LINEZOLID (ZYVOX) PO 50MG/ML (NICU) UHCS-0000-31 1 each each 102.551 each 1 each $124.15
LINEZOLID 600 MG ORAL TAB 0904-6553-04 30 each each 3.022 each 1 each $15.17
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV IVPB 55150-242-51 300 mL Bag 0.028 mL 300 mL $177.15
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV IVPB 66794-219-43 300 mL Bag 0.034 mL 300 mL $178.95
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV IVPB 66794-219-63 300 mL Bag 0.034 mL 300 mL $178.95
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV IVPB 57664-683-31 300 mL Bag 0.108 mL 300 mL $201.15
LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV IVPB 57664-683-57 300 mL Bag 0.108 mL 300 mL $201.15
LIOTHYRONINE 5 MCG ORAL TAB 0093-2179-01 100 each each 0.397 each 1 each $12.55
LIP PROTECTANT 0.6-0.5-1.1-0.5 % TP OINTMENT 4138821020 6 g Tube 1.313 Tube 6 g $14.81
"LIPASE-PROTEASE-AMYLASE 10,440-39,150- 39,150 UNIT ORAL TAB" 58914-112-10 100 each each 3.05 each 1 each $15.20
"LIPASE-PROTEASE-AMYLASE 10,440-39,150- 39,150 UNIT ORAL TAB" 73562-104-10 100 each each 3.34 each 1 each $15.49
"LIPASE-PROTEASE-AMYLASE 12000-38,00-60000 UNIT ORAL EC CAP" 0032-1212-01 100 each each 3.653 each 1 each $15.80
"LIPASE-PROTEASE-AMYLASE 12000-38,00-60000 UNIT ORAL EC CAP" 0032-1212-07 250 each each 3.653 each 1 each $15.80
"LIPASE-PROTEASE-AMYLASE 36,000-114,000- 180,000 UNIT ORAL EC CAP" 0032-3016-13 100 each each 10.994 each 1 each $23.14
LIPASE-PROTEASE-AMYLASE 6000-19000-30000 UNIT ORAL EC CAP 0032-1206-01 100 each each 1.828 each 1 each $13.98
LISINOPRIL 5 MG ORAL TAB 0904-6797-61 100 each each 0.046 each 1 each $12.20
LISINOPRIL 10 MG ORAL TAB 0904-6798-61 100 each each 0.038 each 1 each $12.19
LISINOPRIL 20 MG ORAL TAB 0904-6799-61 100 each each 0.049 each 1 each $12.20
LITHIUM CARBONATE 300 MG ORAL CAP 0054-8527-25 100 each each 0.162 each 1 each $12.31
LITHIUM CARBONATE 300 MG ORAL TBER 68462-223-01 100 each each 0.15 each 1 each $12.30
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID 0904-6256-20 120 mL Bottle 0.02 mL 120 mL $51.00
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID 70677-0054-1 120 mL Bottle 0.025 mL 120 mL $51.60
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID 0904-6836-20 120 mL Bottle 0.028 mL 120 mL $51.96
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID 45013404 120 mL Bottle 0.034 mL 120 mL $52.68
LOPERAMIDE 2 MG ORAL CAP 60687-229-01 100 each each 0.45 each 1 each $12.60
LOPINAVIR-RITONAVIR 200-50 MG ORAL TAB 0074-6799-22 120 each each 8.278 each 1 each $20.43
LORATADINE 10 MG ORAL TAB 0904-6852-61 100 each each 0.163 each 1 each $12.31
LORATADINE 5 MG/5 ML ORAL SOLUTION UHCS-0002-58 60 mL Bottle 0.043 mL 60 mL $51.18
LORATADINE 5 MG/5 ML ORAL SOLUTION 54838-558-40 120 mL Bottle 0.043 mL 120 mL $53.76
LORATADINE-PSEUDOEPHEDRINE 10-240 MG ORAL TB24 51660-724-15 15 each each 0.285 each 1 each $12.44
LORAZEPAM (ATIVAN) IV 0.2 MG/ML (NICU) UHCS-0000-30 10 mL Vial 0.514 mL 10 mL $173.89
LORAZEPAM 0.5 MG ORAL TAB 0904-6007-61 100 each each 0.04 each 1 each $16.24
LORAZEPAM 1 MG ORAL TAB 0904-6008-61 100 each each 0.05 each 1 each $16.25
LORAZEPAM 1MG (ATIVAN) SYRINGE (MIXED IN IV ROOM) $125.35
LORAZEPAM 2 MG/ML INJ SOLUTION 0641-6048-25 1 mL Vial 0.454 mL 1 mL $169.20
LORAZEPAM 2 MG/ML INJ SOLUTION 0641-6048-01 1 mL Vial 0.454 mL 1 mL $169.20
LORAZEPAM 2 MG/ML INJ SOLUTION 0641-6044-01 1 mL Vial 0.454 mL 1 mL $169.20
LORAZEPAM 2 MG/ML INJ SOLUTION 0641-6050-10 10 mL Vial 0.416 mL 10 mL $172.91
LORAZEPAM 2 MG/ML INJ SOLUTION (ANESTHESIA) UHCS-ANES-13 1 vial vial Vial 1 vial $0.00
LORAZEPAM 2 MG/ML INJ SYRINGE 0409-1985-30 1 mL Cartridge 2.346 mL 1 mL $171.10
LORAZEPAM 2MG (ATIVAN) SYRINGE (MIXED IN IV ROOM) $125.35
LOSARTAN 25 MG ORAL TAB 50268-504-15 50 each each 0.247 each 1 each $12.40
LOSARTAN 25 MG ORAL TAB 68084-346-11 1 each each 0.344 each 1 each $12.49
LOSARTAN 25 MG ORAL TAB 68084-346-01 100 each each 0.344 each 1 each $12.49
LOSARTAN 50 MG ORAL TAB 63739-686-10 100 each each 0.198 each 1 each $12.35
LOSARTAN-HYDROCHLOROTHIAZIDE 100-25 MG ORAL TAB 16714-225-02 90 each each 0.208 each 1 each $12.36
LOSARTAN-HYDROCHLOROTHIAZIDE 50-12.5 MG ORAL TAB 0093-7367-98 90 each each 0.127 each 1 each $12.28
LOVASTATIN 20 MG ORAL TAB 68180-468-01 100 each each 0.035 each 1 each $12.19
LOVASTATIN 20 MG ORAL TAB 68084-559-11 100 each each 0.181 each 1 each $12.33
LOVASTATIN 20 MG ORAL TAB 63739-281-10 100 each each 0.654 each 1 each $12.80
LUBIPROSTONE 8 MCG ORAL CAP 0254-3028-02 60 each each 3.512 each 1 each $15.66
LUBIPROSTONE 8 MCG ORAL CAP 64764-080-60 60 each each 5.656 each 1 each $17.81
LUBIPROSTONE 24 MCG ORAL CAP 0254-3029-02 60 each each 3.512 each 1 each $15.66
LUBIPROSTONE 24 MCG ORAL CAP 64764-240-60 60 each each 5.656 each 1 each $17.81
LURASIDONE 40 MG ORAL TAB 63402-304-30 30 each each 37.13 each 1 each $49.28
MAC ARROW TWO-LUMEN CENTRAL VENOUS KIT REF AK-21142-SK UHCS-0005-50 1 each each 108.55 each 1 each $429.85
MAFENIDE ACETATE 85 MG/G TP CREAM 16571-723-60 56.7 g Tube 1.082 g 56.7 g $115.35
MAGIC MOUTHWASH UHCS-0002-04 180 mL Bottle 5.86 Bottle 180 mL $66.61

See Part 13