Medication Charges Part 18

POVIDONE-IODINE 7.5 % TP SOLUTION 52380-1855-2 59 mL Box 0.012 mL 59 mL $54.71
POVIDONE-IODINE 10 % TP OINTMENT 52380-0126-2 1 g Packet 0.115 g 1 g $54.12
POVIDONE-IODINE 10 % TP OINTMENT 0536-1271-80 28.4 g Tube 0.034 g 28.4 g $54.97
POVIDONE-IODINE 10 % TP SOLUTION 67618-150-05 14.8 mL Bottle 0.076 mL 14.8 mL $55.87
POVIDONE-IODINE 10 % TP SOLUTION 0904-1103-09 236 mL Bottle 0.01 mL 236 mL $56.36
POVIDONE-IODINE 10 % TP SWAB 67618-153-01 1 each each 0.17 each 1 each $0.00
PRALIDOXIME 1 G INJ VIAL 60977-141-01 1 each each 80.067 each 1 each $248.82
PRAMIPEXOLE 0.25 MG ORAL TAB 0904-6704-61 100 each each 0.198 each 1 each $12.35
PRAMIPEXOLE 1 MG ORAL TAB 68462-333-90 90 each each 0.036 each 1 each $12.19
PRAMIPEXOLE 1 MG ORAL TAB 60687-592-21 30 each each 0.903 each 1 each $13.05
PRAMIPEXOLE 1 MG ORAL TAB 60687-592-11 1 each each 0.903 each 1 each $13.05
PRAMOXINE-CALAMINE 1-8 % TP LOTION 49348-337-36 177 mL Bottle 0.013 mL 177 mL $56.30
PRASUGREL 5 MG ORAL TAB 60505-4642-3 30 each each 0.387 each 1 each $12.54
PRASUGREL 10 MG ORAL TAB 16729-273-10 30 each each 0.246 each 1 each $12.40
PRAVASTATIN 20 MG ORAL TAB 0904-5892-61 100 each each 0.342 each 1 each $12.49
PRAVASTATIN 40 MG ORAL TAB 0904-5893-61 100 each each 0.447 each 1 each $12.60
PRAZOSIN 1 MG ORAL CAP 51079-630-20 100 each each 1.069 each 1 each $13.22
PRAZOSIN 1 MG ORAL CAP 68084-996-11 1 each each 1.076 each 1 each $13.23
PRE BICARB DIALY SOLN W-O K NO.11 CA (2.5 MEQ/L) -MG (1.5 MEQ/L) HEMO SOLUTION 24571-108-06 5000 mL Bag 28.685 Bag 5000 mL $167.74
PRE BICARBONATE DIALYSIS SOLN NO.2 K (2 MEQ/L) -CA (3.5)-MG(1) HEMO SOLUTION 24571-103-06 5000 mL Bag 28.685 Bag 5000 mL $167.74
PRE BICARBONATE DIALYSIS SOLN NO.9 K (4 MEQ/L)-CA (2.5)-MG (1.5) HEMO SOLUTION 24571-105-06 5000 mL Bag 28.685 Bag 5000 mL $167.74
PREDNISOLN SP-GATIFLOX-BROMFEN 1-0.5-0.075 % OPHT DROPS 71384-550-03 3.5 mL DROP BTL 1 DROP BTL 3.5 mL $61.75
PREDNISOLONE (ORAPRED) PO 15MG/5ML (NICU) UHCS-0002-75 5 mL Syringe 0.115 mL 5 mL $22.18
PREDNISOLONE ACETATE (PF) 1 % OPHT DROPS. 71384-501-05 5 mL DROP BTL 1 DROP BTL 5 mL $61.75
PREDNISOLONE ACETATE 1 % OPHT DROPS. 61314-637-05 5 mL DROP BTL 8.174 mL 5 mL $101.62
PREDNISOLONE SODIUM PHOSPHATE 1 % OPHT DROPS 24208-715-10 10 mL DROP BTL 3.708 mL 10 mL $97.83
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION UHCS-0003-43 5 mL Syringe 0.057 mL 5 mL $12.44
PREDNISOLONE SODIUM PHOSPHATE 15 MG/5 ML (3 MG/ML) ORAL SOLUTION 0121-0759-08 237 mL Bottle 0.125 mL 237 mL $42.30
PREDNISONE 1 MG ORAL TAB 0054-8739-25 100 each each 0.118 each 1 each $12.27
PREDNISONE 5 MG ORAL TAB 63739-518-10 100 each each 0.159 each 1 each $12.31
PREDNISONE 10 MG ORAL TAB 63739-519-10 100 each each 0.119 each 1 each $12.27
PREDNISONE 20 MG ORAL TAB 0054-0018-20 100 each each 0.115 each 1 each $12.27
PREDNISONE 5 MG/5 ML ORAL SOLUTION 0054-3722-50 120 mL Bottle 0.413 mL 120 mL $98.16
PREDNISONE 50 MG ORAL TAB 0054-0019-20 100 each each 0.214 each 1 each $12.36
PREGABALIN 25 MG ORAL CAP 60687-473-01 100 each each 0.374 each 1 each $16.57
PREGABALIN 50 MG ORAL CAP 0904-6992-61 100 each each 0.697 each 1 each $16.90
PREGABALIN 75 MG ORAL CAP 72205-013-90 90 each each 0.048 each 1 each $16.25
PREGABALIN 75 MG ORAL CAP 60687-495-01 100 each each 0.353 each 1 each $16.55
PREGABALIN 75 MG ORAL CAP 0904-7000-61 100 each each 0.709 each 1 each $16.91
PREGABALIN 100 MG ORAL CAP 0904-7001-61 100 each each 0.776 each 1 each $16.98
PRIMAQUINE 26.3 MG ORAL TAB 76385-102-01 100 each each 1.236 each 1 each $13.39
PRIMIDONE 50 MG ORAL TAB 68084-202-01 100 each each 0.487 each 1 each $12.64
PRIMIDONE 250 MG ORAL TAB 50268-687-15 50 each each 0.46 each 1 each $12.61
PRISMASATE 0/3.5 DIALYSIS SOLUTION UHCS-0001-15 5000 mL Bag 28.37 Bag 5000 mL $167.42
PRISMASATE 2/0 DIALYSIS SOLUTION UHCS-0001-16 5000 mL Bag 28.37 Bag 5000 mL $167.42
PRISMASATE 4/2.5 DIALYSIS SOLUTION UHCS-0001-17 5000 mL Bag 28.37 Bag 5000 mL $167.42
PROBENECID 500 MG ORAL TAB 0591-5347-01 100 each each 0.43 each 1 each $12.58
PROBENECID-COLCHICINE 500-0.5 MG ORAL TAB 0591-5325-01 100 each each 0.457 each 1 each $12.61
PROCAINAMIDE 500 MG/ML INJ SOLUTION 0409-1903-01 2 mL Vial 36.136 mL 2 mL $241.02
PROCEDURAL TRAY (MYELOGRAM TRAY) UHCS-0001-90 1 each each 15.63 each 1 each $336.93
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLUTION 23155-497-42 2 mL Vial 0.924 mL 2 mL $170.60
PROCHLORPERAZINE MALEATE 5 MG ORAL TAB 59746-113-06 100 each each 0.252 each 1 each $12.40
PROGESTERONE MICRONIZED 100 MG ORAL CAP 69543-374-10 100 each each 0.554 each 1 each $12.70
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP UHCS-0001-50 60 mL Bottle 0.037 mL 60 mL $50.82
PROMETHAZINE 6.25 MG/5 ML ORAL SYRUP 60432-608-16 473 mL Bottle 0.029 mL 473 mL $62.32
PROMETHAZINE 12.5 MG ORAL TAB 68084-154-01 100 each each 0.322 each 1 each $12.47
PROMETHAZINE 12.5 MG RECT SUPPOSITORY 45802-758-30 12 each each 5.386 each 1 each $29.69
PROMETHAZINE 25 MG ORAL TAB 0904-6461-61 100 each each 0.073 each 1 each $12.22
PROMETHAZINE 25 MG RECT SUPPOSITORY 45802-759-30 12 each each 4.109 each 1 each $28.41
PROMETHAZINE 25 MG/ML INJ FOR ANESTHESIA 0641-0955-25 1 mL Vial 1.533 mL 1 mL $170.28
PROMETHAZINE 25 MG/ML INJ FOR ANESTHESIA 0641-1495-31 1 mL AMPUL 1.533 mL 1 mL $340.57
PROMETHAZINE 25 MG/ML INJ SOLUTION 0641-0955-25 1 mL Vial 1.533 mL 1 mL $170.28
PROMETHAZINE 25 MG/ML INJ SOLUTION 0641-0928-25 1 mL Vial 1.533 mL 1 mL $170.28
PROMETHAZINE 25 MG/ML INJ SOLUTION 0641-0928-21 1 mL Vial 1.533 mL 1 mL $170.28
PROMETHAZINE-CODEINE 6.25-10 MG/5 ML ORAL SYRUP UHCS-0002-74 60 mL Bottle 0.333 mL 60 mL $36.18
PROPAFENONE 150 MG ORAL TAB 59651-256-01 100 each each 0.16 each 1 each $12.31
PROPARACAINE 0.5 % OPHT DROPS 61314-016-01 15 mL DROP BTL 2.161 mL 15 mL $93.17
PROPOFOL 10 MG/ML 20 ML IV EMULSION 0409-4699-30 20 mL Vial 0.074 mL 20 mL $170.23
PROPOFOL 10 MG/ML 20ML IV EMULSION (ANESTHESIA) UHCS-ANES-28 20 mL Vial Vial 20 mL $0.00
PROPOFOL 10 MG/ML IV EMULSION 43598-549-10 100 mL Vial 0.07 mL 100 mL $175.75
PROPOFOL 10 MG/ML IV EMULSION 0409-4699-24 100 mL Vial 0.074 mL 100 mL $176.15
PROPOFOL 10 MG/ML IV EMULSION (ANESTHESIA) UHCS-ANES-27 100 mL Vial Vial 100 mL $0.00
PROPRANOLOL 1 MG/ML IV SOLUTION 63323-604-01 1 mL Vial 1.459 mL 1 mL $170.21
PROPRANOLOL 10 MG ORAL TAB 0904-6550-61 100 each each 0.149 each 1 each $12.30
PROPRANOLOL 20 MG ORAL TAB 60687-306-01 100 each each 0.894 each 1 each $13.04
PROPRANOLOL 40 MG ORAL TAB 50268-702-15 50 each each 0.502 each 1 each $12.65
PROPRANOLOL 60 MG ORAL CS24 42291-522-01 100 each each 0.325 each 1 each $12.48
PROPRANOLOL 80 MG ORAL CS24 0527-4117-37 100 each each 0.163 each 1 each $12.31
PROPRANOLOL SUSPENSION (INDERAL) PO 1 MG/ML (NICU) UHCS-0004-68 30 mL Bottle 0.1 mL 30 mL $24.60
PROPYLTHIOURACIL 50 MG ORAL TAB 68084-964-25 30 each each 1.66 each 1 each $13.81
PROS-BENRALIZUMAB 30 MG/ML SUBQ SYRINGE PROS-0001-22 1 mL Syringe 4969.18 Syringe 1 mL $0.00
"PROS-OCTREOTIDE,MICROSPHERES 30 MG IM SERR" PROS-0001-14 1 each each 6255.26 each 1 each $0.00
PROTAMINE 10 MG/ML IV SOLUTION 63323-229-15 5 mL Vial 1.751 mL 5 mL $177.51
PROTAMINE 10 MG/ML IV SOLUTION 63323-229-35 25 mL Vial 1.052 mL 25 mL $195.05
PROTRIPTYLINE 5 MG ORAL TAB 0054-0210-25 100 each each 2.168 each 1 each $14.32
PRUCALOPRIDE 2 MG ORAL TAB 54092-547-01 30 each each 15.558 each 1 each $27.71
PSEUDOEPHEDRINE HCL 30 MG ORAL TAB 0904-6990-61 100 each each 0.028 each 1 each $12.18
PSEUDOEPHEDRINE-GUAIFENESIN 60-600 MG ORAL TB12 0536-1205-36 36 each each 0.352 each 1 each $12.50
PSEUDOEPHEDRINE-GUAIFENESIN 60-600 MG ORAL TB12 70677-0110-1 18 each each 0.359 each 1 each $12.51
PSEUDOEPHEDRINE-GUAIFENESIN 60-600 MG ORAL TB12 63824-057-36 36 each each 0.416 each 1 each $12.57
PSYLLIUM HUSK (ASPARTAME) 3.4 G ORAL POWDER PACK 37000-024-04 30 each each 0.388 each 1 each $12.54
PSYLLIUM SEED (SUGAR) ORAL POWDER 0536-4445-54 369 g Jar 0.011 g 369 g $17.56
PYRAZINAMIDE 500 MG ORAL TAB 61748-012-11 100 each each 4.799 each 1 each $16.95
PYRIDOSTIGMINE BROMIDE 60 MG ORAL TAB 68084-494-01 100 each each 1.142 each 1 each $13.29
PYRIDOXINE (VITAMIN B6) 50 MG ORAL TAB 5026885815 50 each each 0.13 each 1 each $12.28
PYRIDOXINE (VITAMIN B6) 50 MG ORAL TAB 5026885811 1 each each 0.13 each 1 each $12.28
PYRIDOXINE (VITAMIN B6) 100 MG/ML INJ SOLUTION 63323-180-01 1 mL Vial 7.112 mL 1 mL $175.86
PYRIMETHAMINE 25 MG ORAL TAB 52054-330-10 100 each each 12.629 each 1 each $24.78
QUETIAPINE 25 MG ORAL TAB 0904-6638-61 100 each each 0.189 each 1 each $12.34
QUETIAPINE 100 MG ORAL TAB 63739-665-10 100 each each 0.463 each 1 each $12.61
QUINAPRIL 10 MG ORAL TAB 68180-557-09 90 each each 0.154 each 1 each $12.30
QUINAPRIL 20 MG ORAL TAB 68084-899-25 30 each each 0.986 each 1 each $13.14
QUINIDINE GLUCONATE 324 MG ORAL TBER 53489-141-01 100 each each 4.078 each 1 each $16.23
QUININE SULFATE 324 MG ORAL CAP 50742-238-30 30 each each 0.482 each 1 each $12.63
RABEPRAZOLE 20 MG ORAL EC TABLET 62856-243-30 30 each each 17.088 each 1 each $29.24
RABIES IMMUNE GLOBULIN (PF) 150 UNITS/ML IM SOLUTION 76125-150-02 2 mL Vial 228.34 mL 2 mL $919.07
RABIES IMMUNE GLOBULIN (PF) 150 UNITS/ML IM SOLUTION 76125-150-10 10 mL Vial 228.34 mL 10 mL "$4,595.34"
RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLUTION 13533-318-01 1 mL Vial 624.02 mL 1 mL "$1,255.84"
RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLUTION 13533-318-10 1 mL Vial 624.02 mL 1 mL "$1,255.84"
RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLUTION 13533-318-05 5 mL Vial 633.384 mL 5 mL "$6,373.43"
"RABIES VACCINE, PCEC (PF) 2.5 UNITS IM RECON. SUSP." 58160-964-12 1 each Vial 285.03 each 1 each $573.62
RACEPINEPHRINE 2.25 % INHL NEBULIZER 0487-2784-01 1 each Vial 0.602 each 1 each $12.75
RACEPINEPHRINE 2.25 % INHL NEBULIZER 0487-5901-99 1 each Vial 1.085 each 1 each $13.24
RADIOPAQUE PVC MARKERS-BARIUM 24 MARKERS ORAL CAP 1085808107 10 each each 73.788 each 1 each $85.94
RALOXIFENE 60 MG ORAL TAB 60687-266-21 30 each each 3.9 each 1 each $16.05
RALTEGRAVIR 400 MG ORAL TAB 0006-0227-61 60 each each 30.885 each 1 each $43.04
RAMELTEON 8 MG ORAL TAB 52817-235-30 30 each each 1.025 each 1 each $15.88
RAMIPRIL 1.25 MG ORAL CAP 68382-144-06 30 each each 0.133 each 1 each $12.28
RAMIPRIL 2.5 MG ORAL CAP 57237-223-01 100 each each 0.102 each 1 each $12.25
RAMIPRIL 5 MG ORAL CAP 68382-146-01 100 each each 0.073 each 1 each $12.22
RAMIPRIL 10 MG ORAL CAP 60687-354-01 100 each each 0.451 each 1 each $12.60
RAMUCIRUMAB 10 MG/ML IV SOLUTION 50 ML 0002-7678-01 50 mL Vial 135.944 mL 50 mL "$13,679.37"
RAMUCIRUMAB 100 MG IV SOLUTION 0002-7669-01 10 mL Vial 135.944 mL 10 mL "$2,735.87"
RANIBIZUMAB 0.3 MG/0.05 ML IZ SYRINGE 50242-082-03 0.05 mL Syringe 23400 mL .05 mL "$2,354.63"
RANITIDINE (ZANTAC) IV 1MG/ML (NICU) UHCS-0000-10 25 mL Vial 1.188 mL 25 mL $198.45
RANITIDINE HCL 15 MG/ML ORAL SYRUP UHCS-0001-51 60 mL Bottle 0.147 mL 60 mL $57.42
RANITIDINE HCL 15 MG/ML ORAL SYRUP 54838-550-80 473 mL Bottle 0.147 mL 473 mL $118.13
RANITIDINE HCL 150 MG ORAL TAB 60687-322-01 100 each each 0.12 each 1 each $12.27
RANITIDINE HCL 150 MG ORAL TAB 60687-322-11 1 each each 0.12 each 1 each $12.27
RANITIDINE HCL 50 MG/2 ML (25 MG/ML) INJ SOLUTION 67457-397-99 2 mL Vial 5.719 mL 2 mL $180.19
RANITIDINE PO 2.5MG/ML SYRINGE (NICU) UHCS-0000-09 60 mL Bottle 0.147 mL 60 mL $30.42
RANOLAZINE 500 MG ORAL TB12 60687-549-21 30 each each 0.966 each 1 each $13.12
RASAGILINE 0.5 MG ORAL TAB 68546-142-56 30 each each 28.065 each 1 each $40.22
RASAGILINE 1 MG ORAL TAB 42571-221-30 30 each tablet 7.352 each 1 each $19.50
RASBURICASE 1.5 MG IV VIAL 0024-5150-10 1 each each 1011.727 each 1 each "$2,036.10"
RASBURICASE 7.5 MG IV VIAL 0024-5151-75 1 each each 5058.63 each 1 each "$10,180.49"
REGADENOSON 0.4 MG/5 ML IV SYRINGE 0469-6501-89 5 mL Syringe 44.286 mL 5 mL $445.63
REMDESIVIR 100 MG IV SOLUTION 61958-2901-1 1 each each 571.48 each 1 each "$1,150.10"
REMDESIVIR 100 MG IV SOLUTION 61958-2901-2 1 each each 571.48 each 1 each "$1,150.10"
REMDESIVIR 100 MG IV VIAL 61958-2901-1 1 each each 571.48 each 1 each "$1,150.10"
REMDESIVIR 100 MG IV VIAL 61958-2901-2 1 each each 571.48 each 1 each "$1,150.10"
REMIFENTANIL 1 MG IV VIAL 63323-723-03 1 each each 59.394 each 1 each $228.14
REMIFENTANIL 1 MG IV VIAL (ANESTHESIA) UHCS-ANES-16 1 vial vial Vial 1 vial $0.00
REPAGLINIDE 0.5 MG ORAL TAB 0574-0240-01 100 each each 0.185 each 1 each $12.34
REPAGLINIDE 1 MG ORAL TAB 0574-0241-01 100 each each 0.134 each 1 each $12.28
REVEFENACIN 175 MCG/3 ML INHL NEBULIZER 49502-806-93 3 mL Vial 3.171 mL 3 mL $20.31
"RHO(D) IMMUNE GLOBULIN-MALTOSE 5,000 UNIT(1000 MCG)/4.4 ML INJ SOLUTION" 70257-310-51 4.4 mL Vial 315.768 mL 4.4 mL "$2,796.13"
RIFABUTIN 150 MG ORAL CAP 59762-1350-1 100 each each 9.341 each 1 each $21.49
RIFAMPIN 10MG/ML PO SYRINGE (NICU) UHCS-0000-07 30 mL Bottle 3.23 Bottle 30 mL $24.83
RIFAMPIN 150 MG ORAL CAP 60687-575-11 1 each each 1.471 each 150 mg (1 each) $13.62 (1 each)

See Part 19