Medication Charges Part 16

NYSTATIN 100000 UNITS/ML ORAL SUSPENSION 68094-599-59 5 mL Cup 0.203 mL 5 mL $13.17
NYSTATIN 100000 UNITS/ML ORAL SUSPENSION 68094-599-61 5 mL Cup 0.255 mL 5 mL $13.43
NYSTATIN 100000 UNITS/ML ORAL SUSPENSION 63739-160-70 5 mL Cup 0.255 mL 5 mL $13.43
NYSTATIN 100000 UNITS/ML ORAL SUSPENSION 60432-537-60 60 mL DROP BTL 0.196 mL 60 mL $60.36
"NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TP CREAM" 68462-314-35 30 g Tube 0.906 g 30 g $81.18
"NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TP OINTMENT" 52565-042-30 30 g Tube 0.261 g 30 g $61.83
OBINUTUZUMAB 1000 MG/40 ML IV SOLUTION 50242-070-01 40 mL Vial 194.383 mL 40 mL "$15,647.83"
OCRELIZUMAB 30 MG/ML IV SOLUTION 50242-150-01 10 mL Vial 1877.56 mL 10 mL "$37,785.90"
"OCTOXYNOL9-SOD CIT-BENZ,CIT AC VAGL SOLUTION" 4160808740 266 mL Bottle 0.001 mL 266 mL $54.27
OCTREOTIDE ACETATE 50 MCG/ML INJ SOLUTION 25021-451-01 1 mL Vial 3.833 mL 1 mL $172.58
OCTREOTIDE ACETATE 100 MCG/ML INJ SOLUTION 63323-376-01 1 mL Vial 2.318 mL 1 mL $171.07
OCTREOTIDE ACETATE 500 MCG/ML (1 ML) INJ SYRINGE 67457-246-00 1 mL Syringe 17.458 mL 1 mL $186.21
"OCTREOTIDE,MICROSPHERES 20 MG IM SERR" 0078-0818-81 1 each each 4177.33 each 1 each "$8,406.88"
"OCTREOTIDE,MICROSPHERES 30 MG IM SERR" 0078-0825-81 1 each each 6255.26 each 1 each "$12,588.71"
OFATUMUMAB 100 MG/5 ML IV SOLUTION 0078-0669-13 5 mL Vial 117.355 mL 5 mL "$1,180.89"
OFATUMUMAB 1000 MG/50 ML IV SOLUTION 0078-0690-61 50 mL Vial 117.355 mL 50 mL "$11,808.85"
OFLOXACIN 0.3 % OTIC DROPS 69238-1615-3 5 mL DROP BTL 2.13 mL 5 mL $71.40
OFLOXACIN 0.3 % OTIC DROPS 60505-0363-1 5 mL DROP BTL 12.008 mL 5 mL $120.79
OLANZAPINE 2.5 MG ORAL TAB 0904-6283-61 100 each each 0.247 each 1 each $12.40
OLANZAPINE 5 MG ORAL RD TAB 59746-306-32 30 each each 0.79 each 1 each $12.94
OLANZAPINE 5 MG ORAL TAB 60505-3111-0 100 each each 0.16 each 1 each $12.31
OLANZAPINE 10 MG IM VIAL 55150-308-01 1 each each 17.38 each 1 each $186.13
OLANZAPINE 10 MG IM VIAL 0517-0955-01 1 each each 22.22 each 1 each $190.97
OLANZAPINE 10 MG ORAL TAB 60505-3113-0 100 each each 0.241 each 1 each $12.39
OLANZAPINE 10 MG ORAL TAB 0904-6376-61 100 each each 0.343 each 1 each $12.49
OLMESARTAN 20 MG ORAL TAB 68462-437-30 30 each each 0.098 each 1 each $12.25
OLMESARTAN 40 MG ORAL TAB 68462-438-30 30 each each 0.129 each 1 each $12.28
OMADACYCLINE 100 MG IV VIAL 71715-001-02 1 each each 378.992 each 1 each $762.72
OMADACYCLINE 150 MG ORAL TAB 71715-002-21 6 each each 228.205 each 1 each $240.36
OMALIZUMAB 75 MG SUBQ SYRINGE 50242-214-01 0.5 mL Syringe 1282.2 mL .5 mL "$1,290.21"
OMALIZUMAB 150 MG/ML SUBQ SYRINGE 50242-215-01 1 mL Syringe 1282.21 mL 1 mL "$2,580.45"
"OMEGA 3-DHA-EPA-FISH OIL 300-1,000 MG ORAL CAP" 4843311001 100 each each 0.193 each 1 each $12.34
OMEGA-3 ACID ETHYL ESTERS 1 G ORAL CAP 60687-127-65 50 each each 2.164 each 1 each $14.31
OMEGA-3 FATTY ACIDS 1000 MG ORAL CAP 1093933733 60 each each 0.189 each 1 each $12.34
OMEPRAZOLE (PRILOSEC) PO 2MG/ML (NICU) UHCS-0000-14 50 mL Bottle 0.333 mL 50 mL $38.25
ONABOTULINUMTOXINA 100 UNITS INJ VIAL 0023-1145-01 1 each each 634 each 1 each "$1,275.93"
ONDANSETRON 4 MG ORAL RD TAB 65862-390-10 30 each each 0.185 each 1 each $12.34
ONDANSETRON HCL 4 MG ORAL TAB 68084-220-01 100 each each 0.693 each 1 each $12.84
ONDANSETRON HCL (PF) 4 MG/2 ML INJ SOLUTION 0409-4755-03 2 mL Vial 0.189 mL 2 mL $169.13
ONDANSETRON HCL 2 MG/ML IV SOLUTION 0143-9890-01 20 mL Vial 0.363 mL 20 mL $176.01
ORAL WOUND CARE PRODUCTS MM GEL PACK 8914145602 15 mL Packet 2.789 mL 15 mL $53.99
ORITAVANCIN 400 MG IV VIAL 70842-140-01 1 each each 1008.68 each 1 each "$2,029.97"
ORITAVANCIN 1200 MG IV VIAL 70842-225-01 1 each each 4640.23 each 1 each "$9,338.46"
ORPHENADRINE CITRATE 30 MG/ML INJ SOLUTION 17478-538-02 2 mL Vial 1.509 mL 2 mL $171.77
OSELTAMIVIR 6 MG/ML ORAL RECON. SUSP. 68180-678-01 60 mL Bottle 0.766 mL 60 mL $94.56
OSELTAMIVIR 30 MG ORAL CAP 72205-042-11 10 each each 1.524 each 1 each $13.67
OSELTAMIVIR 75 MG ORAL CAP 72205-044-11 10 each each 1.708 each 1 each $13.86
OSELTAMIVIR 75 MG ORAL CAP 16714-819-01 10 each each 8.837 each 1 each $20.99
OXACILLIN 1 G INJ VIAL 25021-146-10 1 each each 4.281 each 1 each $173.03
OXALIPLATIN 100 MG/20 ML IV SOLUTION 0781-9317-80 20 mL Vial 0.905 mL 20 mL $517.60
OXALIPLATIN 50 MG/10 ML (5 MG/ML) IV SOLUTION 71288-101-10 10 mL Vial 0.716 mL 10 mL $506.66
OXALIPLATIN 50 MG/10 ML (5 MG/ML) IV SOLUTION 0781-9315-70 10 mL Vial 0.905 mL 10 mL $508.55
OXAZEPAM 10 MG ORAL CAP 62584-812-01 100 each each 1.372 each 1 each $17.57
OXAZEPAM 15 MG ORAL CAP 62584-813-01 100 each each 1.572 each 1 each $16.42
OXCARBAZEPINE 150 MG ORAL TAB 68084-845-01 100 each each 0.288 each 1 each $12.44
OXCARBAZEPINE 300 MG ORAL TAB 68084-853-01 100 each each 0.816 each 1 each $12.97
OXCARBAZEPINE 300 MG ORAL TAB 68084-853-11 1 each each 0.816 each 1 each $12.97
OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION 0054-0199-59 250 mL Bottle 0.612 mL 250 mL $213.75
"OXIDIZED REGENERATED CELLULOSE 2 X 4"" MISC PAD (SURGICEL SNOW)" 63713-0020-82 10 each each 88.148 each 1 each $142.15
OXIDIZED REGENERATED CELLULOSE POWDER UHCS-0004-84 1 each KIT 166.174 each 1 each $334.43
OXYBUTYNIN CHLORIDE 5 MG ORAL 24HR. TAB 0904-6570-06 50 each each 1.836 each 1 each $13.99
OXYBUTYNIN CHLORIDE 5 MG ORAL TAB 68084-400-01 100 each each 0.422 each 1 each $12.57
OXYBUTYNIN CHLORIDE 10 MG ORAL 24HR. TAB 68084-610-21 30 each each 1.94 each 1 each $14.09
OXYCHLOROSENE SODIUM TP VIAL 0327-0001-10 2 g Jar 2.382 g 2 g $58.76
OXYCODONE 5 MG ORAL TAB 42858-001-10 100 each each 0.167 each 1 each $16.37
OXYCODONE 10 MG ORAL TR12 59011-410-20 20 each each 3.623 each 1 each $18.47
OXYCODONE 20 MG ORAL TR12 59011-420-20 20 each each 6.75 each 1 each $21.60
OXYCODONE 40 MG ORAL TR12 59011-440-20 20 each each 11.556 each 1 each $26.41
OXYCODONE 5 MG/5 ML ORAL SOLUTION UHCS-0004-15 5 mL Syringe 0.171 mL 5 mL $17.06
OXYCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB 0904-7095-61 100 each each 0.501 each 1 each $16.70
OXYCODONE-ACETAMINOPHEN 10-325 MG ORAL TAB 0904-6439-61 100 each each 1.014 each 1 each $17.21
OXYCODONE-ACETAMINOPHEN 5-325 MG ORAL TAB 0406-0512-62 100 each each 0.213 each 1 each $16.41
OXYCODONE-ACETAMINOPHEN 7.5-325 MG ORAL TAB 0406-0522-62 100 each each 0.848 each 1 each $17.05
OXYCODONE-ACETAMINOPHEN 7.5-325 MG ORAL TAB 0904-6438-61 100 each each 0.858 each 1 each $17.06
OXYMETAZOLINE 0.05 % NASL MIST 49348-130-27 30 mL SQUEEZ BTL 0.125 mL 30 mL $17.25
OXYMETAZOLINE 0.05 % NASL SPRAY 45802-410-59 30 mL SQUEEZ BTL 0.045 mL 30 mL $14.85
OXYMETAZOLINE 0.05 % NASL SPRAY 0904-6761-30 30 mL SQUEEZ BTL 0.063 mL 30 mL $15.39
OXYTOCIN 10 UNITS/ML INJ SOLUTION 63323-012-07 1 mL Vial 0.905 mL 1 mL $169.66
OXYTOCIN IN 0.9 % SOD CHLORIDE 20 UNIT/1000 ML IV SOLUTION UHCS-0004-31 1000 mL Bag 3.52 Bag 1000 mL $142.57
OXYTOCIN IN 0.9 % SOD CHLORIDE 20 UNIT/1000 ML IV SOLUTION 71285-6043-1 1000 mL Bag 13.45 Bag 1000 mL $152.50
OXYTOCIN IN 0.9 % SOD CHLORIDE 20 UNIT/1000 ML IV SOLUTION 70092-1067-08 1000 mL Bag 14.74 Bag 1000 mL $153.79
PACLITAXEL 6 MG/ML IV CONCENTRATE 70860-200-05 5 mL Vial 1.31 mL 5 mL $506.05
PACLITAXEL 6 MG/ML IV CONCENTRATE 61703-342-22 16.7 mL Vial 0.852 mL 16.7 mL $513.73
PACLITAXEL 6 MG/ML IV CONCENTRATE 61703-342-50 50 mL Vial 0.619 mL 50 mL $530.45
PACLITAXEL PROTEIN-BOUND 100 MG IV RECON. SUSP. 68817-134-50 1 each each 1532.66 each 1 each "$3,084.48"
PALIVIZUMAB 50 MG/0.5 ML IM SOLUTION 60574-4114-1 0.5 mL Vial 3256.56 mL .5 mL "$3,276.91"
PALIVIZUMAB 50 MG/0.5 ML IM SOLUTION 66658-230-01 0.5 mL Vial 3484.52 mL .5 mL "$3,506.30"
PAMIDRONATE 30 MG/10 ML (3 MG/ML) IV SOLUTION 67457-430-10 10 mL Vial 0.852 mL 10 mL $177.27
PANITUMUMAB 100 MG/5 ML (20 MG/ML) IV SOLUTION 55513-954-01 5 mL Vial 304.444 mL 5 mL "$3,063.47"
PANITUMUMAB 400 MG/20 ML (20 MG/ML) IV SOLUTION 55513-956-01 20 mL Vial 304.444 mL 20 mL "$12,253.87"
PANTOPRAZOLE 40 MG IV VIAL 55150-202-10 1 each each 2.061 each 1 each $170.81
PANTOPRAZOLE 40 MG IV VIAL 0143-9300-10 1 each each 2.563 each 1 each $171.31
PANTOPRAZOLE 40 MG ORAL EC TABLET 68084-813-09 80 each each 0.129 each 1 each $12.28
PANTOPRAZOLE 40 MG ORAL EC TABLET 35573-428-51 1 each each 0.209 each 1 each $12.36
PAPAIN 8.3 X 10'5 UNITS/UREA 10% TOPICAL UHCS-0002-96 30 g Jar 0.6 g 30 g $78.75
"PAPAIN POWDER,USP" UHCS-0003-34 100 g Jar 0.77 Jar 100 g $0.00
PAPAVERINE 30 MG/ML INJ SOLUTION 0517-4002-25 2 mL Vial 10.216 mL 2 mL $189.18
PAPAVERINE 30 MG/ML INJ SOLUTION 14789-121-05 2 mL Vial 12.47 mL 2 mL $193.69
"PARAB-CETYL,STEA ALC-P.GLY-SLS TP CLEANSER" 299392116 473 mL Bottle 0.019 mL 473 mL $62.99
PARENTERAL AMINO ACID 10% NO.1 10 % IV BAG 0990-7172-17 2000 mL Flex Cont 0.016 mL 2000 mL $160.25
PARENTERAL AMINO ACID 15% NO.5 15 % IV BAG 0338-0502-06 2000 mL Bag 0.044 mL 2000 mL $216.25
PARICALCITOL 5 MCG/ML HDPT SOLUTION 16729-311-08 1 mL Vial 5.847 mL 1 mL $174.60
PAROXETINE HCL 12.5 MG ORAL TB24 60505-1316-3 30 each each 0.833 each 1 each $12.98
PAROXETINE HCL 12.5 MG ORAL TB24 0378-2003-93 30 each each 1.855 each 1 each $14.01
PAROXETINE HCL 20 MG ORAL TAB 63739-963-10 100 each each 0.159 each 1 each $12.31
PAROXETINE HCL 25 MG ORAL TB24 0378-2004-93 30 each each 1.936 each 1 each $14.09
PATIENT MAY TAKE OWN MEDS UHCS-0002-98 1 each each Package 1 each $0.00
PATIROMER CALCIUM SORBITEX 8.4 G ORAL POWDER PACK 53436-084-30 30 each each 22.253 each 1 each $34.40
PEDI MV NO.189-FERROUS SULFATE 11 MG IRON/ML ORAL DROPS 87040501 50 mL DROP BTL 0.151 mL 50 mL $21.05
PEDIATRIC MULTIVITAMIN NO.17 ORAL CHEW TAB 904262160 100 each each 0.019 each 1 each $12.17
PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG- 10 MCG/ML ORAL DROPS 87040203 50 mL DROP BTL 0.151 mL 50 mL $56.15
PEG 3350-ELECTROLYTES 236-22.74-6.74 GRAM ORAL 52268-100-01 4000 mL Bottle 0.005 mL 4000 mL $32.15
PEG 400-HYPROMELLOSE-GLYCERIN 1-0.2-0.2 % OPHT DROPS 57896-181-05 15 mL DROP BTL 0.085 mL 15 mL $62.03
PEGFILGRASTIM-JMDB 6 MG/0.6 ML SUBQ SYRINGE 67457-833-06 0.6 mL Syringe 2771.1 mL .6 mL "$3,346.10"
PEMBROLIZUMAB 25 MG/ML IV SOLUTION 0006-3026-02 4 mL Vial 1335.44 mL 4 mL "$10,750.29"
PEMETREXED DISODIUM 100 MG IV VIAL 71288-166-10 1 each each 10.84 each 1 each $510.34
PEMETREXED DISODIUM 500 MG IV VIAL 71288-167-50 1 each each 46.74 each 1 each $546.24
PEMETREXED DISODIUM 500 MG IV VIAL 0002-7623-01 1 each each 3921.71 each 1 each "$7,892.44"
"PENICILLIN G BENZATHIN,PROCAIN 1,200,000 UNIT/ 2 ML(900K/300K) IM SYRINGE" 60793-602-10 2 mL Syringe 84.349 mL 2 mL $339.51
PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRINGE 60793-701-10 2 mL Syringe 105.818 mL 2 mL $425.92
PENICILLIN G BENZATHINE 600000 UNITS/ML IM SYRINGE 60793-700-10 1 mL Syringe 122.185 mL 1 mL $290.94
"PENICILLIN G POTASSIUM 10,000 UNITS/ML" UHCS-0004-63 0.2 mL Syringe 0.58 mL .2 mL $169.33
"PENICILLIN G POTASSIUM 10,000 UNITS/ML" UHCS-0004-56 10 mL Vial 0.58 mL 10 mL "$1,693.30"
PENICILLIN G POTASSIUM 5 MILLION UNIT INJ VIAL 0049-0520-22 1 each each 4.157 each 1 each $172.91
"PENICILLIN G POTASSIUM IM 100,000 UNITS/ML (NICU)" UHCS-0000-94 1 each each 4.157 each 1 each $189.54
"PENICILLIN G POTASSIUM IM 500,000 UNITS/ML (NICU)" UHCS-0000-96 1 each each 4.157 each 1 each $172.91
"PENICILLIN G POTASSIUM IV 100,000 UNITS/ML (NICU)" UHCS-0000-93 1 each each 4.157 each 1 each $189.54
"PENICILLIN G POTASSIUM IV 500,000 UNITS/ML (NICU)" UHCS-0000-95 1 each each 4.157 each 1 each $172.91
PENICILLIN V POTASSIUM 250 MG ORAL TAB 16714-234-01 100 each each 0.073 each 1 each $12.22
PENICILLIN V POTASSIUM 250 MG/5 ML ORAL VIAL 0093-4127-73 100 mL Bottle 0.054 mL 100 mL $54.00
PENTAMIDINE 300 MG INHL VIAL 13925-522-01 1 each Vial 80.06 each 1 each $154.31
PENTAMIDINE 300 MG INHL VIAL 63323-877-15 1 each Vial 99.42 each 1 each $173.67
PENTOBARBITAL SODIUM 50 MG/ML INJ SOLUTION 76478-501-20 20 mL Vial 33.253 mL 20 mL "$1,338.43"
PENTOBARBITAL SODIUM 50 MG/ML INJ SOLUTION 76478-501-50 50 mL Vial 19.398 mL 50 mL "$1,951.92"
PENTOXIFYLLINE 400 MG ORAL TBER 0904-5448-61 100 each each 0.158 each 1 each $12.31
PEPPERMINT SPIRIT ORAL SPIRIT 395224391 30 mL Bottle 0.225 mL 30 mL $60.75
PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) IV SOLUTION 61364-181-03 20 mL Vial 15.833 mL 20 mL $637.28
PERFLUORODECALIN (BULK) 100 % MISC LIQUID 5192748050 1 g Bottle 99 Bottle 1 g $123.30
PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSPENSION 11994-011-04 2 mL Vial 56.25 mL 2 mL $281.25
PERIT. DIALYSIS 3-4.25 % DEXTR CA 3.5 MEQ/L- MG 0.5 MEQ/L IP SOLUTION 0941-0429-52 2000 mL Bag 31.867 Bag 2000 mL $170.92
PERITONEAL DIALYSIS W/ 1.5 % DEXTROSE 0941-0426-52 2000 mL Bag 28.33 Bag 2000 mL $167.38
PERITONEAL DIALYSIS W/ 1.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0409-06 2000 mL Flex Cont 14.222 Flex Cont 2000 mL $153.27
PERITONEAL DIALYSIS W/ 1.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0409-01 6000 mL Flex Cont 31.26 Flex Cont 6000 mL $170.31
PERITONEAL DIALYSIS W/ 2.5 % DEXTROSE 0941-0427-52 2000 mL Bag 31.605 Bag 2000 mL $170.66
PERITONEAL DIALYSIS W/ 2.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0457-08 2000 mL Flex Cont 17.037 Flex Cont 2000 mL $156.09
PERITONEAL DIALYSIS W/ 2.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0457-01 6000 mL Flex Cont 31.95 Flex Cont 6000 mL $171.00
PERITONEAL DIALYSIS W/ 4.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0459-08 2000 mL Flex Cont 17.757 Flex Cont 2000 mL $156.81
PERITONEAL DIALYSIS W/ 4.5 % DEXTROSE AND LOW CA++ (CYLER) 0941-0459-01 6000 mL Flex Cont 32.83 Flex Cont 6000 mL $171.88

See Part 17