Medication Charges Part 17

PERITONEAL DIALYSIS W/1.5% DEXTROSE AND LOW CA++ 0941-0424-52 2000 mL Bag 28.414 Bag 2000 mL $167.46
PERITONEAL DIALYSIS W/1.5% DEXTROSE AND LOW CA++ 0941-0424-53 2500 mL Bag 31.532 Bag 2500 mL $170.58
PERITONEAL DIALYSIS W/2.5% DEXTROSE AND LOW CA++ 0941-0430-52 2000 mL Bag 31.699 Bag 2000 mL $170.75
PERITONEAL DIALYSIS W/2.5% DEXTROSE AND LOW CA++ 0941-0430-53 2500 mL Bag 32.422 Bag 2500 mL $171.47
PERITONEAL DIALYSIS W/4.25% DEXTROSE AND LOW CA++ 0941-0433-52 2000 mL Bag 31.992 Bag 2000 mL $171.04
PERITONEAL DIALYSIS W/4.25% DEXTROSE AND LOW CA++ 0941-0433-53 2500 mL Bag 33.132 Bag 2500 mL $172.18
PERMETHRIN 1 % TP LIQUID 6373612003 59 mL Bottle 0.112 mL 59 mL $60.61
PERMETHRIN 5 % TP CREAM 0472-0242-60 60 g Tube 0.32 g 60 g $73.20
PERPHENAZINE 2 MG ORAL TAB 0904-6599-61 100 each each 0.574 each 1 each $12.72
PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLUTION 50242-145-01 14 mL Vial 452.62 mL 14 mL "$12,752.57"
PH TEST 15 FEET MISC TEST 0003-0526-20 1 each each 54.981 each 1 each $108.98
PHENAZOPYRIDINE 100 MG ORAL TAB 42192-801-01 100 each each 0.222 each 1 each $12.37
PHENAZOPYRIDINE 100 MG ORAL TAB 10135-620-01 100 each each 0.588 each 1 each $12.74
PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2-0.1037 -0.0194 MG/5 ML ORAL ELIXIR UHCS-0001-47 60 mL Bottle 3.454 mL 60 mL $255.84
PHENOBARBITAL 32.4 MG ORAL TAB 63739-201-10 100 each each 0.656 each 1 each $15.51
PHENOBARBITAL 64.8 MG ORAL TAB 0603-5167-21 100 each each 0.624 each 1 each $16.82
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR UHCS-0003-18 5 mL Syringe 0.14 mL 5 mL $16.90
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR UHCS-0001-75 60 mL Bottle 0.14 mL 60 mL $75.90
PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR 0603-1508-58 473 mL Bottle 0.14 mL 473 mL $82.42
PHENOBARBITAL IV 10 MG/ML (NICU) UHCS-0000-13 13 mL Bottle 60.02 mL 13 mL $949.01
PHENOBARBITAL PO 4 MG/ML (NICU) UHCS-0001-76 60 mL Bottle 0.03 mL 60 mL $28.80
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLUTION 0641-0476-25 1 mL Vial 23.126 mL 1 mL $191.88
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLUTION 0641-0477-25 1 mL Vial 60.02 mL 1 mL $228.77
PHENOBARBITAL SODIUM 130 MG/ML INJ SOLUTION (ANESTHESIA) UHCS-ANES-08 1 mL mL Syringe 1 mL $0.00
PHENOBARBITAL SODIUM 65 MG/ML INJ SOLUTION (ANESTHESIA) UHCS-ANES-09 1 Syringe Syringe Syringe 1 Syringe $0.00
PHENOL 1.4 % MM AERO. SPRAY 1093945944 177 mL Bottle 1 Bottle 177 mL $14.50
PHENOL 1.4 % MM AERO. SPRAY 49348-991-36 177 mL Bottle 0.01 mL 177 mL $15.27
PHENOL-GLYCERIN 1.5-33 % MM SPRAY 7811200068 118 mL Bottle 0.032 mL 118 mL $17.28
PHENTOLAMINE 5 MG INJ VIAL 68094-101-20 1 each each 294.66 each 1 each $593.00
PHENYLEPH-MIN OIL-PETROLATUM 0.25-14-74.9 % RECT OINTMENT 573287194 57 g Tube 0.182 g 57 g $64.37
PHENYLEPHRINE (NEOSYNEPHRINE) DROPS 0.125% (NICU) UHCS-0004-07 30 mL Bottle 0.161 mL 30 mL $65.58
PHENYLEPHRINE BOLUS UHCS-ANES-32 1 mL Vial Vial 1 mL $0.00
PHENYLEPHRINE HCL 0.125 % NASL DROPS 5618412105 15 mL DROP BTL 0.197 mL 15 mL $77.21
PHENYLEPHRINE HCL 0.25 % NASL SPRAY 69536-025-15 15 mL SQUEEZ BTL 0.195 mL 15 mL $77.18
PHENYLEPHRINE HCL 0.25 % NASL SPRAY 0225-0800-47 15 mL SQUEEZ BTL 0.201 mL 15 mL $77.27
PHENYLEPHRINE HCL 0.5 % NASL SPRAY 0225-0805-47 15 mL SQUEEZ BTL 0.201 mL 15 mL $77.27
PHENYLEPHRINE HCL 2.5 % OPHT DROPS 17478-201-02 2 mL DROP BTL 14.25 mL 2 mL $52.80
PHENYLEPHRINE HCL 10 % OPHT DROPS 42702-103-05 5 mL DROP BTL 7.388 mL 5 mL $61.24
PHENYLEPHRINE HCL 10 MG/ML INJ SOLUTION 63323-751-01 1 mL Vial 1.145 mL 1 mL $169.90
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRINGE 70092-1046-46 10 mL Syringe 0.463 mL 10 mL $173.38
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRINGE 69374-957-10 10 mL Syringe 0.5 mL 10 mL $173.75
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRINGE 63037-173-25 10 mL Syringe 0.6 mL 10 mL $174.75
PHENYLEPHRINE-COCOA BUTTER 0.25-88.44 % RECT SUPPOSITORY 0536-1186-12 12 each each 0.119 each 1 each $24.42
PHENYLEPHRINE-DM-GUAIFENESIN 5-10-100 MG/5 ML ORAL LIQUID 49348-737-34 118 mL Bottle 0.017 mL 118 mL $50.61
PHENYTOIN (BULK) MISC POWDER 51552-0553-5 100 g Jar 0.39 g 100 g $99.75
PHENYTOIN (DILANTIN) PO 125 MG/5ML (NICU) UHCS-0000-56 60 mL Bottle 0.107 mL 60 mL $55.02
PHENYTOIN 100 MG/4 ML ORAL SUSPENSION 66689-036-50 4 mL Cup 0.886 mL 4 mL $15.69
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION UHCS-0001-48 60 mL Bottle 0.094 mL 60 mL $54.24
PHENYTOIN 125 MG/5 ML ORAL SUSPENSION 59762-0531-1 237 mL Bottle 0.094 mL 237 mL $70.88
PHENYTOIN 5% TOPICAL OINTMENT UHCS-0004-47 100 g Jar 0.22 g 100 g $82.75
PHENYTOIN 50 MG ORAL CHEW TAB 60687-156-25 30 each each 1.072 each 1 each $13.22
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP 68084-376-01 100 each each 0.341 each 1 each $12.49
PHYSOSTIGMINE SALICYLATE 1 MG/ML INJ SOLUTION 17478-510-02 2 mL AMPUL 36.149 mL 2 mL $241.05
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SOLUTION 0409-9157-01 0.5 mL AMPUL 7.482 mL .5 mL $172.49
PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJ SYRINGE 76329-1240-1 0.5 mL Syringe 44.208 mL .5 mL $190.85
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJ SOLUTION 43598-405-16 1 mL AMPUL 20.432 mL 1 mL $189.18
PHYTONADIONE (VITAMIN K1) 10 MG/ML INJ SOLUTION 0409-9158-01 1 mL AMPUL 24.016 mL 1 mL $192.77
PHYTONADIONE (VITAMIN K1) 5 MG ORAL TAB 16714-973-01 100 each each 18.505 each 1 each $30.66
PHYTONADIONE (VITAMIN K1) 5 MG ORAL TAB 60687-381-94 20 each each 46.611 each 1 each $58.76
PHYTONADIONE (VITAMIN K1) 5 MG ORAL TAB 60687-381-11 1 each each 46.611 each 1 each $58.76
PIFLUFOLASTAT F 18 296 MBQ TO 370 MBQ IV SYRINGE 71258-022-00 1 each each 6899 Syringe 1 each "$6,899.00"
PILOCARPINE HCL 1 % OPHT DROPS 70069-181-01 15 mL DROP BTL 4.569 mL 15 mL $129.29
PILOCARPINE HCL 2 % OPHT DROPS 70069-191-01 15 mL DROP BTL 4.673 mL 15 mL $130.85
PILOCARPINE HCL 4 % OPHT DROPS 17478-226-12 15 mL DROP BTL 3.039 mL 15 mL $106.34
PILOCARPINE HCL 5 MG ORAL TAB 68084-928-95 1 each each 2.101 each 1 each $12.90
PINDOLOL 5 MG ORAL TAB 57664-655-88 100 each each 0.812 each 1 each $12.96
PIOGLITAZONE 15 MG ORAL TAB 60687-391-01 100 each each 0.719 each 1 each $12.87
PIOGLITAZONE 30 MG ORAL TAB 33342-055-07 30 each each 0.169 each 1 each $12.32
PIOGLITAZONE 30 MG ORAL TAB 51079-514-20 100 each each 2.885 each 1 each $15.04
PIOGLITAZONE 45 MG ORAL TAB 65862-514-30 30 each each 0.138 each 1 each $12.29
PIOGLITAZONE 45 MG ORAL TAB 33342-056-07 30 each each 0.177 each 1 each $12.33
PIPERACILLIN/TAZOBACTAM (ZOSYN) IV 100MG/ML (NICU) UHCS-0000-11 1 each each 3.048 each 1 each $171.80
PIPERACILLIN-TAZOBACTAM 2.25 G IV VIAL 63323-309-20 1 each each 8.588 each 1 each $177.34
PIPERACILLIN-TAZOBACTAM 3.375 G IV VIAL 55150-120-30 1 each each 2.509 each 1 each $171.26
PIPERACILLIN-TAZOBACTAM 3.375 GRAM IV ADD-VANTAGE VIAL 0409-3378-13 1 each each 7.519 each 1 each $176.27
PIPERACILLIN-TAZOBACTAM 4.5 G IV VIAL 63323-320-50 1 each each 16.231 each 1 each $184.98
PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRINGE 0005-1971-02 0.5 mL Syringe 414.14 mL .5 mL $416.73
PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRINGE 0005-1971-01 0.5 mL Syringe 414.14 mL .5 mL $416.73
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRINGE 0005-2000-10 0.5 mL Syringe 453.936 mL .5 mL $456.77
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRINGE 0005-2000-02 0.5 mL Syringe 469.6 mL .5 mL $472.54
PNEUMOC 20-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRINGE 0005-2000-01 0.5 mL Syringe 469.6 mL .5 mL $472.54
PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML INJ SYRINGE 0006-4837-03 0.5 mL Syringe 209.808 mL .5 mL $273.65
PNV WITH CA NO.72-IRON-FA 27-1 MG ORAL TAB 3932810610 100 each each 0.099 each 1 each $12.25
POLIDOCANOL 0.5 % (10 MG/2 ML) IV SOLUTION 46783-121-52 2 mL AMPUL 9.85 mL 2 mL $188.45
POLIDOCANOL 1 % (20 MG/2 ML) IV SOLUTION 46783-221-52 2 mL AMPUL 11.3 mL 2 mL $191.35
POLYETHYLENE GLYCOL 3350 17 G ORAL POWDER PACK 11523-7268-8 24 each each 0.969 each 1 each $13.12
POLYETHYLENE GLYCOL 3350 17 G ORAL POWDER PACK 11523-7234-1 1 each each 1.063 each 1 each $13.21
POLYETHYLENE GLYCOL 3350 17 G ORAL POWDER PACK 0904-6422-13 30 each each 1.071 each 1 each $13.22
POLYETHYLENE GLYCOL 3350 17 G ORAL POWDER PACK 0904-6931-81 100 each each 1.114 each 1 each $13.26
POLYETHYLENE GLYCOL 3350 17 G ORAL POWDER PACK 0904-6931-86 1 each each 1.439 each 1 each $13.59
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER 1093978844 238 g Bottle 0.021 g 238 g $18.50
POLYETHYLENE GLYCOL 3350 17 GRAM/DOSE ORAL POWDER 49348-143-70 238 g Bottle 0.024 g 238 g $19.21
POLYMYXIN B SULFATE 500000 UNITS INJ VIAL 55150-234-10 1 each each 3.547 each 1 each $172.30
POLYMYXIN B SULFATE 500000 UNITS INJ VIAL 70860-103-10 1 each each 3.602 each 1 each $172.35
POLYMYXIN B SULFATE 500000 UNITS INJ VIAL 63323-321-01 1 each each 9.219 each 1 each $177.97
"POLYMYXIN B SULF-TRIMETHOPRIM 10,000 UNIT- 1 MG/ML OPHT DROPS" 61314-628-10 10 mL DROP BTL 0.72 mL 10 mL $67.95
POLYSACCHARIDE IRON COMPLEX 150 MG IRON ORAL CAP 904539561 100 each each 0.117 each 1 each $12.27
PORACTANT ALFA 120 MG INTR SUSPENSION 10122-510-01 1.5 mL Vial 334.513 mL 1.5 mL "$1,009.81"
PORACTANT ALFA 240 MG INTR SUSPENSION 10122-510-03 3 mL Vial 325.517 mL 3 mL "$1,965.31"
POSACONAZOLE 200 MG/5 ML (40 MG/ML) ORAL SUSPENSION 0085-1328-01 105 mL Bottle 12.664 mL 105 mL "$1,378.32"
POSACONAZOLE 300 MG/16.7 ML IV SOLUTION 0085-4331-01 16.7 mL Vial 29.337 mL 16.7 mL $985.98
POST BICARB DIALY SOLN W-O K NO.11 CA (2.5 MEQ/L) -MG (1.5 MEQ/L) HEMO SOLUTION 24571-108-05 5000 mL Bag 26.4 Bag 5000 mL $165.45
POST BICARBONATE DIALYSIS SOLN NO.2 K (2 MEQ/L) -CA (3.5)* 24571-103-05 5000 mL Bag 26.4 Bag 5000 mL $165.45
POST BICARBONATE DIALYSIS SOLN NO.9 K (4 MEQ/L)-CA (2.5)-* 24571-105-05 5000 mL Bag 26.4 Bag 5000 mL $165.45
POTASSIUM ACETATE 2 MEQ/ML IV SOLUTION 0409-8183-25 20 mL Vial 0.139 mL 20 mL $171.53
POTASSIUM ACETATE 2 MEQ/ML IV SOLUTION 0409-3294-51 50 mL Vial 0.172 mL 50 mL $177.35
POTASSIUM BICARB-CITRIC ACID 25 MEQ ORAL TBEF 51801-001-30 30 each each 0.331 each 1 each $12.48
POTASSIUM CHLORID-D5-0.45%NACL 10 MEQ/L IV BAG 0338-0669-04 1000 mL Bag 7.229 Bag 1000 mL $146.28
POTASSIUM CHLORID-D5-0.45%NACL 20 MEQ/L IV BAG 0338-0671-04 1000 mL Bag 4.352 Bag 1000 mL $143.40
POTASSIUM CHLORID-D5-0.45%NACL 30 MEQ/L IV BAG 0338-0673-04 1000 mL Bag 6.926 Bag 1000 mL $145.98
POTASSIUM CHLORID-D5-0.45%NACL 40 MEQ/L IV BAG 0338-0675-04 1000 mL Bag 0.007 mL 1000 mL $146.05
POTASSIUM CHLORIDE 8 MEQ ORAL TBER 0245-5315-01 100 each each 0.122 each 1 each $12.27
POTASSIUM CHLORIDE 10 MEQ ORAL CPER 0904-6930-61 100 each each 0.605 each 1 each $12.76
POTASSIUM CHLORIDE 10 MEQ ORAL CPER 0904-6068-61 100 each each 0.688 each 1 each $12.84
POTASSIUM CHLORIDE 2 MEQ/ML IV VIAL 63323-965-20 20 mL Vial 0.063 mL 20 mL $170.01
POTASSIUM CHLORIDE 2 MEQ/ML IV VIAL 0409-6651-06 10 mL Vial 0.286 mL 10 mL $171.61
POTASSIUM CHLORIDE 2 MEQ/ML IV VIAL 0264-1944-20 250 mL Flex Cont 0.082 mL 250 mL $189.25
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 0245-0360-89 1 each each 2.063 each 1 each $14.21
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 69543-379-01 1 each each 3.039 each 1 each $15.19
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 69543-379-10 100 each each 3.039 each 1 each $15.19
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 54288-125-01 1 each each 4.619 each 1 each $16.77
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 54288-125-10 100 each each 4.619 each 1 each $16.77
POTASSIUM CHLORIDE 20 MEQ ORAL PACKET 43386-194-31 100 each each 4.987 each 1 each $17.14
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ 0245-5319-01 100 each each 0.394 each 1 each $12.54
POTASSIUM CHLORIDE 20 MEQ ORAL TBTQ 66758-190-06 1 each each 0.503 each 1 each $12.65
POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV BAG 0338-0691-04 1000 mL Bag 7.345 Bag 1000 mL $146.40
POTASSIUM CHLORIDE IN 5 % DEX 20 MEQ/L IV BAG 0338-0683-04 1000 mL Bag 8.167 Bag 1000 mL $147.22
POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML IV IVPB 0338-0705-41 50 mL Bag 0.063 mL 50 mL $142.20
POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML IV IVPB 0338-0703-41 50 mL Bag 0.063 mL 50 mL $142.20
POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML IV IVPB 0409-7077-14 50 mL Bag 0.092 mL 50 mL $143.65
POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV IVPB 0338-0705-48 100 mL Bag 0.032 mL 100 mL $142.25
POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV IVPB 0338-0703-48 100 mL Bag 0.033 mL 100 mL $142.35
POTASSIUM CHLORIDE IV 0.2 MEQ/ML (NICU) UHCS-0002-67 100 mL Vial 0.214 mL 100 mL $190.15
POTASSIUM CHLORIDE PO 2 MEQ/ML (NICU) UHCS-0001-06 40 mL Bottle 0.286 mL 40 mL $180.19
POTASSIUM CHLORIDE-0.45 % NACL 20 MEQ/L IV BAG 0338-0704-34 1000 mL Bag 4.866 Bag 1000 mL $143.92
POTASSIUM CHLORIDE-D5-0.2%NACL 20 MEQ/L IV BAG 0338-0663-04 1000 mL Bag 6.665 Bag 1000 mL $145.72
POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV BAG 0338-0803-04 1000 mL Bag 7.345 Bag 1000 mL $146.40
POTASSIUM CITRATE 5 MEQ (540 MG) ORAL TBER 31722-129-01 100 each each 0.185 each 1 each $12.34
POTASSIUM CITRATE 5 MEQ (540 MG) ORAL TBER 68382-536-01 100 each each 0.491 each 1 each $12.64
POTASSIUM IODIDE 1 G/ML ORAL SOLUTION 71740-112-30 30 mL Bottle 13.237 mL 30 mL $445.71
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLUTION 0409-7295-01 15 mL Vial 0.852 mL 15 mL $181.53
POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLUTION 65219-052-29 5 mL Vial 4.044 mL 5 mL $188.97
POTASSIUM PHOSPHATE MONOBASIC 500 MG ORAL TABS 0486-1111-01 100 each each 0.49 each 1 each $12.64
"POTASSIUM, SODIUM PHOSPHATES 280-160-250 MG ORAL POWDER PACK" 6025800601 100 each each 0.297 each 1 each $12.45
POVIDONE-IODINE 0.3 % VAGL SOLUTION 0132-8743-02 274 mL Box 0.009 mL 274 mL $56.47
POVIDONE-IODINE 5 % MISC KIT 17518-060-04 1 each each 0 each 1 each $0.00
POVIDONE-IODINE 5 % MISC KIT UHCS-0005-01 1 each each 0 each 1 each $0.00
POVIDONE-IODINE 5 % OPHT SOLUTION 0065-0411-30 30 mL Bottle 0.292 mL 30 mL $33.06

See Part 18