Medication Charges Part 19

RIFAMPIN 300 MG ORAL CAP 63739-415-10 100 each each 1.501 each 1 each $13.65
RIFAMPIN 600 MG IV VIAL 0068-0597-01 1 each each 68.35 each 1 each $237.10
RIFAMPIN 600 MG IV VIAL 67457-445-60 1 each each 70.74 each 1 each $239.49
RIFAMPIN 6MG/ML IV SYRINGE (NICU) UHCS-0000-08 1 each each 61.81 each 1 each $230.56
RIFAXIMIN 550 MG ORAL TAB 65649-303-03 60 each each 45.805 each 1 each $57.96
RIOCIGUAT 2.5 MG ORAL TAB 50419-254-01 90 each each 1 Bottle 1 each $12.16
RISEDRONATE 30 MG ORAL TAB 0093-3100-56 30 each each 45.779 each 1 each $57.93
RISEDRONATE 35 MG ORAL TAB 0430-0472-03 4 each each 78.725 each 1 each $90.88
RISPERIDONE 1 MG ORAL TAB 0904-6359-61 100 each each 0.094 each 1 each $12.24
RISPERIDONE 0.25 MG ORAL TAB 0904-6357-61 100 each each 0.108 each 1 each $12.26
RISPERIDONE 0.5 MG ORAL TAB 0904-6358-61 100 each each 0.112 each 1 each $12.26
RISPERIDONE 1 MG/ML ORAL SOLUTION 27808-002-01 30 mL Bottle 0.371 mL 30 mL $59.73
RISPERIDONE 1 MG/ML ORAL SOLUTION 50458-596-01 30 mL Bottle 3.749 mL 30 mL $161.07
RITONAVIR 100 MG ORAL TAB 0054-0407-13 30 each each 4.926 each 1 each $17.08
RITUXIMAB-PVVR 10 MG/ML IV SOLUTION 500 MG 0069-0249-01 50 mL Vial 55.172 mL 50 mL "$5,551.68"
RITUXIMAB-PVVR 100 MG IV SOLUTION 0069-0238-01 10 mL Vial 55.172 mL 10 mL "$1,110.34"
RIVAROXABAN 2.5 MG ORAL TAB 50458-577-10 100 each each 0.009 each 1 each $12.16
RIVAROXABAN 10 MG ORAL TAB 50458-580-10 100 each each 0.009 each 1 each $12.16
RIVAROXABAN 15 MG ORAL TAB 50458-578-10 100 each each 0.009 each 1 each $12.16
RIVAROXABAN 15 MG ORAL TAB 50458-578-01 1 each each 0.009 each 1 each $12.16
RIVAROXABAN 20 MG ORAL TAB 50458-579-10 100 each each 0.009 each 1 each $12.16
RIVAROXABAN 20 MG ORAL TAB 50458-579-01 1 each each 0.009 each 1 each $12.16
RIVASTIGMINE 4.6 MG/24 HOUR TD 24HR PATCH 0378-9070-16 1 each each 1.206 each 1 each $25.51
RIVASTIGMINE 4.6 MG/24 HOUR TD 24HR PATCH 16714-115-02 30 each each 3.873 each 1 each $28.17
RIVASTIGMINE 4.6 MG/24 HOUR TD 24HR PATCH 0781-7304-58 1 each each 12.486 each 1 each $36.79
RIVASTIGMINE 9.5 MG/24 HOUR TD 24HR PATCH 0378-9071-93 30 each each 1.54 each 1 each $25.84
RIVASTIGMINE 9.5 MG/24 HOUR TD 24HR PATCH 16714-116-02 30 each each 2.233 each 1 each $26.53
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAP 33342-089-09 60 each each 0.238 each 1 each $12.39
RIVASTIGMINE TARTRATE 1.5 MG ORAL CAP 63739-576-10 100 each each 2.361 each 1 each $14.51
RIVASTIGMINE TARTRATE 3 MG ORAL CAP 33342-090-09 60 each each 0.241 each 1 each $12.39
RIVASTIGMINE TARTRATE 3 MG ORAL CAP 63739-577-10 100 each each 2.361 each 1 each $14.51
RIZATRIPTAN 5 MG ORAL RD TAB 69452-156-73 18 each each 0.693 each 1 each $1.29
ROCURONIUM 10 MG/ML IV SOLUTION 43066-007-10 5 mL Vial 0.353 mL 5 mL $170.52
ROCURONIUM 10 MG/ML IV SOLUTION 72611-756-10 5 mL Vial 1.085 mL 5 mL $174.18
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRINGE UHCS-0004-91 5 mL Syringe 0.49 mL 5 mL $171.20
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRINGE 69374-924-05 5 mL Syringe 1.5 mL 5 mL $176.25
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRINGE 63037-155-25 5 mL Syringe 1.6 mL 5 mL $176.75
ROCURONIUM 50 MG/5 ML (10 MG/ML) IV SYRINGE 70092-1452-44 5 mL Syringe 2.23 mL 5 mL $179.90
ROFLUMILAST 500 MCG ORAL TAB 0310-0095-90 90 each each 12.737 each 1 each $24.89
ROMIPLOSTIM 250 MCG SUBQ VIAL 55513-221-01 1 each each 2384.73 each 1 each "$4,799.27"
ROMIPLOSTIM 500 MCG SUBQ VIAL 55513-222-01 1 each each 4769.45 each 1 each "$9,598.52"
ROPINIROLE 1 MG ORAL TAB 0904-6374-61 100 each each 0.282 each 1 each $12.43
ROPINIROLE 0.25 MG ORAL TAB 0904-6373-61 100 each each 0.276 each 1 each $12.43
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJ SOLUTION 55150-196-99 100 mL Bottle 0.17 mL 100 mL $185.75
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLUTION 55150-198-30 30 mL Vial 0.131 mL 30 mL $172.68
ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJ SOLUTION 63323-286-93 30 mL Vial 0.154 mL 30 mL $173.37
ROPIVACAINE (PF) 7.5 MG/ML (0.75 %) INJ SOLUTION 63323-287-21 20 mL Vial 0.231 mL 20 mL $173.37
ROSUVASTATIN 5 MG ORAL TAB 60687-234-01 100 each each 0.863 each 1 each $13.01
ROSUVASTATIN 10 MG ORAL TAB 60687-245-01 100 each each 0.932 each 1 each $13.08
ROSUVASTATIN 10 MG ORAL TAB 0904-6779-61 100 each each 0.971 each 1 each $13.12
ROSUVASTATIN 20 MG ORAL TAB 0904-6780-61 100 each each 0.867 each 1 each $13.02
ROSUVASTATIN 20 MG ORAL TAB 60687-256-01 100 each each 1.003 each 1 each $13.15
RUBIDIUM CHLORIDE RUBIDIUM-82 INJECTION 65174-021-10 1 each each 0 N/A 1 each $0.00
SACCHAROMYCES BOULARDII 250 MG ORAL CAP 7733380050 50 each each 0.694 each 1 each $12.84
SACITUZUMAB GOVITECAN-HZIY 180 MG IV VIAL 55135-132-01 1 each each 2288.03 each 1 each "$4,604.66"
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB 0078-0659-20 60 each each 10.181 each 1 each $22.33
SACUBITRIL-VALSARTAN 24-26 MG ORAL TAB 0078-0659-67 180 each each 10.181 each 1 each $22.33
SACUBITRIL-VALSARTAN 49-51 MG ORAL TAB 0078-0777-20 60 each each 10.181 each 1 each $22.33
SACUBITRIL-VALSARTAN 97-103 MG ORAL TAB 0078-0696-20 60 each each 10.181 each 1 each $22.33
SALIVA STIMULANT COMB. NO.2 MM LIQUID 4858251112 44.3 mL Bottle 0.101 mL 44.3 mL $53.08
SALIVA STIMULANT COMB. NO.2 MM LIQUID 04858-2001-55 44.3 mL Bottle 0.103 mL 44.3 mL $53.16
SALSALATE 500 MG ORAL TAB 65162-512-10 100 each each 0.217 each 1 each $12.37
SALSALATE 500 MG ORAL TAB 51293-803-01 100 each each 0.277 each 1 each $12.43
SAXAGLIPTIN 5 MG ORAL TAB 0310-6105-90 90 each each 13.442 each 1 each $25.59
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 0591-2258-79 10 each each 8.573 each 1 each $32.87
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 0591-2258-54 1 each each 8.875 each 1 each $33.18
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 50742-505-24 24 each each 9.141 each 1 each $33.44
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 10019-553-90 1 each each 11.759 each 1 each $36.06
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 10019-553-04 24 each each 11.759 each 1 each $36.06
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 0378-6470-44 24 each each 16.977 each 1 each $41.28
SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 45802-580-62 24 each each 17.704 each 1 each $42.00
SELENIUM 200 MCG ORAL TAB 7431203201 100 each tablet 0.049 each 1 each $12.20
SELENIUM 4MCG/ML IV NICU DILUTION UHCS-0004-35 10 mL Vial Vial 10 mL $0.00
SELENIUM 60 MCG/ML IV SOLUTION 0517-6560-25 10 mL Vial 18.856 mL 10 mL $379.48
SELENIUM SULFIDE 2.5 % TP LOTION 45802-040-64 120 mL Bottle 0.051 mL 120 mL $60.12
SENNOSIDES 8.6 MG ORAL TAB 0904-6522-61 100 each each 0.025 each 1 each $12.18
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB 63739-432-02 300 each each 0.036 each 1 each $12.19
SENNOSIDES-DOCUSATE SODIUM 8.6-50 MG ORAL TAB 63739-432-10 100 each each 0.06 each 1 each $12.21
SERTRALINE 50 MG ORAL TAB 60687-242-01 100 each each 0.225 each 1 each $12.38
SERTRALINE 50 MG ORAL TAB 60687-242-11 1 each each 0.225 each 1 each $12.38
SERTRALINE 100 MG ORAL TAB 60687-253-01 100 each each 0.306 each 1 each $12.46
SERTRALINE 100 MG ORAL TAB 60687-253-11 1 each each 0.306 each 1 each $12.46
SET-DEHP FREE GEMINI 2260 UHCS-0001-24 1 each each 5.12 each 1 each $98.27
SET-DEHP FREE SECONDARY SET UHCS-0003-39 1 each each 0.83 each 1 each $93.98
SET-GEMINI PUMP 10010454 DEHP-FREE W/FILTER UHCS-0001-25 1 each each 6.87 each 1 each $100.02
SET-GEMINI PUMP SET 2420 UHCS-0001-26 1 each each 3.21 N/A 1 each $96.36
SEVELAMER CARBONATE 0.8 G ORAL POWDER PACK 0115-1365-29 90 each each 1.349 each 1 each $13.50
SEVELAMER CARBONATE 0.8 G ORAL POWDER PACK 0955-1052-90 90 each each 6.105 each 1 each $18.26
SEVELAMER CARBONATE 2.4 G ORAL POWDER PACK 65862-931-90 90 each each 1.367 each 1 each $13.52
SEVELAMER CARBONATE 2.4 G ORAL POWDER PACK 0955-1054-90 90 each each 6.105 each 1 each $18.26
SEVELAMER CARBONATE 800 MG ORAL TAB 60687-328-65 50 each each 1.63 each 1 each $13.78
SEVELAMER CARBONATE 800 MG ORAL TAB 60687-328-33 1 each each 3.169 each 1 each $15.32
SEVELAMER CARBONATE 800 MG ORAL TAB 55111-789-11 100 each each 6.868 each 1 each $19.02
SEVELAMER HCL 800 MG ORAL TAB 52959-779-90 90 each each 5.54 each 1 each $17.69
SEVOFLURANE INHL LIQUID UHCS-0002-39 1 each Bottle 3.795 each 1 each $98.30
SEVOFLURANE INHL LIQUID 10019-651-64 250 mL Bottle 0.253 mL 250 mL "$23,688.25"
SILDENAFIL (PULM.HYPERTENSION) 20 MG ORAL TAB 0904-6671-04 30 each each 0.56 each 1 each $12.71
SILDENAFIL (REVATIO) PO 2MG/ML (NICU) UHCS-0000-06 10 mL Bottle 16.04 Bottle 10 mL $37.64
SILVER NITRATE APPLICATORS 75-25 % TP STICK 12870-0001-1 10 each Packet 0.605 each 1 each $60.05
SILVER SULFADIAZINE 1 % TP CREAM 43598-210-25 25 g Tube 0.096 g 25 g $56.40
SILVER SULFADIAZINE 1 % TP CREAM 43598-210-55 50 g Jar 0.084 g 50 g $58.20
SILVER SULFADIAZINE 1 % TP CREAM 59762-0131-2 25 g Tube 0.275 g 25 g $60.88
SILVER SULFADIAZINE 1 % TP CREAM 61570-131-40 400 g Jar 0.081 g 400 g $86.40
SIMETHICONE 80 MG ORAL CHEW TAB 63739-225-10 100 each each 0.076 each 1 each $12.23
SIMETHICONE 40 MG/0.6 ML ORAL DROPS. 1093960244 30 mL DROP BTL 1 DROP BTL 30 mL $49.60
SIMETHICONE 40 MG/0.6 ML ORAL DROPS. 0536-1303-75 30 mL DROP BTL 0.044 mL 30 mL $49.92
SIMETHICONE 40 MG/0.6 ML ORAL DROPS. 0904-5894-30 30 mL DROP BTL 0.057 mL 30 mL $50.31
SIMPLE SYRUP ORAL SYRUP 395266116 473 mL Bottle 0.029 mL 473 mL $63.24
SIMVASTATIN 5 MG ORAL TAB 63739-570-10 100 each each 0.079 each 1 each $12.23
SIMVASTATIN 10 MG ORAL TAB 16714-682-02 90 each each 0.037 each 1 each $12.19
SIMVASTATIN 10 MG ORAL TAB 63739-571-10 100 each each 0.079 each 1 each $12.23
SIMVASTATIN 20 MG ORAL TAB 68084-512-01 100 each each 0.222 each 1 each $12.37
SIMVASTATIN 40 MG ORAL TAB 51079-456-20 100 each each 0.111 each 1 each $12.26
SINCALIDE 5 MCG INJ VIAL 0270-0556-15 1 each each 116.973 each 1 each $285.72
SINCALIDE INJECTION SYRINGE 0270-0556-15 1 each each 116.973 each 1 each $285.72
SITAGLIPTIN PHOSPHATE 25 MG ORAL TAB 0006-0221-28 100 each each 15.164 each 1 each $27.31
SITAGLIPTIN PHOSPHATE 50 MG ORAL TAB 0006-0112-28 100 each each 15.164 each 1 each $27.31
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB 0006-0277-28 100 each each 15.164 each 1 each $27.31
SITAGLIPTIN PHOSPHATE 100 MG ORAL TAB 0006-0277-01 1 each each 15.164 each 1 each $27.31
SOD BORATE-BORIC AC-NACL-WATER OPHT IRSL 1011900252 118 mL Bottle 0.025 mL 118 mL $63.70
"SOD PHOS DI, MONO-K PHOS MONO 250 MG ORAL TAB" 6954326810 100 each tablet 0.313 each 1 each $12.46
SODIUM ACETATE 2 MEQ/ML IV SOLUTION 0409-7299-73 20 mL Vial 0.139 mL 20 mL $171.53
SODIUM ACETATE 2 MEQ/ML IV SOLUTION 0409-3299-06 100 mL Vial 0.055 mL 100 mL $174.25
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLUTION 51754-5001-1 50 mL Vial 0.106 mL 50 mL $174.05
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLUTION 51754-5001-5 50 mL Vial 0.106 mL 50 mL $174.05
SODIUM BICARBONATE 1 MEQ/ML (8.4 %) IV SOLUTION 51754-5001-4 50 mL Vial 0.106 mL 50 mL $174.05
SODIUM BICARBONATE 1 MEQ/ML (8.4 ) IV SOLN (RENAL REPLACEMENT) 51754-5001-1 50 mL Vial 0.106 mL 50 mL $174.05
SODIUM BICARBONATE 1 MEQ/ML (8.4 ) IV SOLN (RENAL REPLACEMENT) 51754-5001-5 50 mL Vial 0.106 mL 50 mL $174.05
SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRINGE 0409-5534-34 10 mL Syringe 0.999 mL 10 mL $178.74
SODIUM BICARBONATE 650 MG ORAL TAB 66553-008-01 500 each each 0.087 each 1 each $12.24
SODIUM BICARBONATE 650 MG ORAL TAB 7733383125 1 each each 0.108 each 1 each $12.26
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE 0409-6637-34 50 mL Syringe 0.2 mL 50 mL $178.75
SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRINGE 0409-6637-14 50 mL Syringe 0.223 mL 50 mL $179.90
SODIUM BICARBONATE IV 0.5MEQ/ML (NICU) UHCS-0000-54 10 mL Vial 0.999 mL 10 mL $178.74
SODIUM BICARBONATE PO 0.5 MEQ/ML (NICU) UHCS-0000-55 10 mL Bottle 0.999 mL 10 mL $178.74
SODIUM CHLOR 0.9% BACTERIOSTAT 0.9 % INJ SOLUTION 0409-1966-07 30 mL Vial 0.025 mL 30 mL $22.69
SODIUM CHLOR 0.9% BACTERIOSTAT 0.9 % INJ SOLUTION FOR PROTONIX OR FAMOTIDINE 0409-1966-07 30 mL Vial 0.025 mL 30 mL $22.69
SODIUM CHLORIDE 0.65 % NASL AERO. SPRAY 0904-3865-75 44 mL SQUEEZ BTL 0.013 mL 44 mL $74.82
SODIUM CHLORIDE 0.65 % NASL DROPS 225038280 50 mL DROP BTL 0.039 mL 50 mL $76.20
SODIUM CHLORIDE 0.9 % INHL NEBULIZER 0487-9301-33 3 mL Vial 0.03 mL 3 mL $10.89
SODIUM CHLORIDE 3 % INHL NEBULIZER 487900360 4 mL Vial 0.077 mL 4 mL $11.11
SODIUM CHLORIDE 3 % INHL NEBULIZER 378699789 15 mL Vial 0.036 mL 15 mL $11.34
SODIUM CHLORIDE 3 % INHL NEBULIZER 5019014263 4 mL Vial 0.146 mL 4 mL $11.38
SODIUM CHLORIDE 5 % OPHT DROPS 17478-623-12 15 mL DROP BTL 0.367 mL 15 mL $66.26
SODIUM CHLORIDE 5 % OPHT OINTMENT 24208-385-55 3.5 g Tube 4.203 g 3.5 g $75.46
SODIUM CHLORIDE 0.45 % 5 ML SYRINGE (NICU) UHCS-0001-79 5 mL Syringe 0.053 mL 5 mL $169.02
SODIUM CHLORIDE 0.45 % ADD-VANTAGE 0409-7132-67 100 mL Bag 0.013 mL 100 mL $0.00
SODIUM CHLORIDE 0.45 % ADD-VANTAGE 0409-7132-66 50 mL Bag 0.025 mL 50 mL $0.00
SODIUM CHLORIDE 0.45 % IV BAG 0338-0043-03 500 mL Bag 3.651 Bag 500 mL $142.70
SODIUM CHLORIDE 0.45 % IV BAG 0338-0043-04 1000 mL Bag 4.39 Bag 1000 mL $143.44

See Part 20