Medication Charges Part 20

SODIUM CHLORIDE 0.45 % IV BAG 0990-7985-02 250 mL Flex Cont 0.019 mL 250 mL $143.80
SODIUM CHLORIDE 0.45 % IV BOLUS 0409-7730-36 50 mL Bag 1.68 Bag 50 mL $0.00
SODIUM CHLORIDE 0.45 % IV BOLUS 0409-7985-09 1000 mL Flex Cont 0.005 mL 1000 mL $144.05
SODIUM CHLORIDE 0.45 % IV BOLUS 0409-7985-03 500 mL Flex Cont 0.011 mL 500 mL $144.55
SODIUM CHLORIDE 0.9 % 10 ML VIAL FOR BULK CHARGE UHCS-0002-35 10 mL Vial 0.053 mL 10 mL $22.47
SODIUM CHLORIDE 0.9 % 100 ML FOR BULK CHARGE UHCS-0002-14 100 mL Bag 0.017 mL 100 mL $125.90
SODIUM CHLORIDE 0.9 % 1000 ML FOR BULK CHARGE UHCS-0002-15 1000 mL Bag 3.444 Bag 1000 mL $142.49
SODIUM CHLORIDE 0.9 % 100ML SINGLE WRAP FOR BULK CHARGE UHCS-0002-17 100 mL Bag 0.019 mL 100 mL $126.10
SODIUM CHLORIDE 0.9 % 20 ML VIAL FOR BULK CHARGE UHCS-0002-36 20 mL Vial 0.058 mL 20 mL $23.10
SODIUM CHLORIDE 0.9 % 250 ML FOR BULK CHARGE UHCS-0002-12 250 mL Bag 0.01 mL 250 mL $141.55
SODIUM CHLORIDE 0.9 % 50 ML FOR BULK CHARGE UHCS-0002-16 50 mL Bag 0.025 mL 50 mL $125.45
SODIUM CHLORIDE 0.9 % 500 ML FOR BULK CHARGE UHCS-0002-13 500 mL Bag 0.01 mL 500 mL $144.05
SODIUM CHLORIDE 0.9 % INJ SOLUTION 0409-4888-20 20 mL Vial 0.058 mL 20 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SOLUTION 63323-186-10 10 mL Vial 0.055 mL 10 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SOLUTION USE WITH PROTONIX OR FAMOTIDINE 63323-186-10 10 mL Vial 0.055 mL 10 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SOLUTION USE WITH PROTONIX OR FAMOTIDINE 0409-4888-20 20 mL Vial 0.058 mL 20 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SYRINGE 8290306547 10 mL Syringe 0.026 mL 10 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SYRINGE 8290306546 10 mL Syringe 0.002 mL 10 mL $0.00
SODIUM CHLORIDE 0.9 % INJ SYRINGE 64253-202-30 10 mL Syringe 0.094 mL 10 mL $0.00
SODIUM CHLORIDE 0.9 % IR SOLN (BAG) 0264-2201-50 2000 mL Bottle 0.002 mL 2000 mL $75.55
SODIUM CHLORIDE 0.9 % IR SOLN (BAG) 0338-0047-44 1000 mL Bag 5.664 Bag 1000 mL $77.21
SODIUM CHLORIDE 0.9 % IR SOLN (BAG) 0338-0047-27 3000 mL Bag 11.888 Bag 3000 mL $83.44
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0338-0048-02 250 mL Bottle 3.11 Bottle 250 mL $74.66
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0338-0048-03 500 mL Bottle 3.325 Bottle 500 mL $74.88
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0338-0048-04 1000 mL Bottle 3.482 Bottle 1000 mL $75.03
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0338-0047-44 1000 mL Bag 5.664 Bag 1000 mL $77.21
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0338-0047-47 3000 mL Bag 10.345 Bag 3000 mL $81.90
SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION 0264-2201-70 4000 mL Bottle 12.263 Bottle 4000 mL $83.81
SODIUM CHLORIDE 0.9 % IV BAG 0264-7800-20 250 mL Bag 1.816 Bag 250 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-02 250 mL Flex Cont 2.533 Flex Cont 250 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-11 50 mL Flex Cont 1.8 Flex Cont 50 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-18 100 mL Bag 1.811 Bag 100 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-41 50 mL Flex Cont 2.032 Flex Cont 50 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-48 100 mL Flex Cont 1.95 Flex Cont 100 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0338-6304-02 250 mL Bag 3.456 Bag 250 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 0409-7983-61 150 mL Bag 0.032 Bag 150 mL $0.00
SODIUM CHLORIDE 0.9 % IV BAG 17271-701-07 1000 mL Bag 0.002 Bag 1000 mL $139.05
SODIUM CHLORIDE 0.9 % IV BAG 0990-7983-09 1000 mL Flex Cont 0.005 Flex Cont 1000 mL $139.44
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-03 500 mL Flex Cont 2.999 Flex Cont 500 mL $142.05
SODIUM CHLORIDE 0.9 % IV BAG 0338-0049-04 1000 mL Bag 3.444 Bag 1000 mL $142.49
SODIUM CHLORIDE 0.9 % IV BAG UHCS-0001-99 1000 mL Flex Cont 0.005 mL 1000 mL $144.05
SODIUM CHLORIDE 0.9 % IV BAG (PERFUSION) 0338-0049-04 1000 mL Bag 3.444 Bag 1000 mL $142.49
SODIUM CHLORIDE 0.9 % IV BAG FOR FLUSH 0409-7983-03 500 mL Flex Cont 0.01 mL 500 mL $144.05
SODIUM CHLORIDE 0.9 % IV BOLUS 0338-0049-02 250 mL Flex Cont 2.533 Flex Cont 250 mL $0.00
SODIUM CHLORIDE 0.9 % IV BOLUS 0338-9543-06 1000 mL Flex Cont 3.444 Flex Cont 1000 mL $142.49
SODIUM CHLORIDE 0.9 % IV BOLUS 0409-7983-03 500 mL Flex Cont 0.01 mL 500 mL $144.05
SODIUM CHLORIDE 0.9 % IV BOLUS 0409-7983-09 1000 mL Flex Cont 5 Flex Cont 1000 mL $144.05
SODIUM CHLORIDE 0.9 % IV BOLUS - FOR BLOOD ADMINISTRATION 0338-0049-02 250 mL Flex Cont 2.533 Flex Cont 250 mL $0.00
SODIUM CHLORIDE 0.9 % IV BOLUS - FOR BLOOD ADMINISTRATION 0409-7983-03 500 mL Flex Cont 0.01 mL 500 mL $144.05
SODIUM CHLORIDE 0.9 % IV BOLUS - FOR BLOOD ADMINISTRATION 0409-7983-09 1000 mL Flex Cont 5 Flex Cont 1000 mL $144.05
SODIUM CHLORIDE 0.9 % IV FLUSH 50 ML 0338-0049-11 50 mL Flex Cont 1.8 Flex Cont 50 mL $0.00
SODIUM CHLORIDE 0.9 % IV FOR STROKE INFUSION UHCS-0005-31 50 mL 1.448 50 mL $0.00
SODIUM CHLORIDE 0.9% ADD-VANTAGE 0409-7101-02 250 mL Bag 0.01 Bag 250 mL $0.00
SODIUM CHLORIDE 0.9% ADD-VANTAGE 0409-7101-67 100 mL Bag 0.015 Bag 100 mL $0.00
SODIUM CHLORIDE 0.9% ADD-VANTAGE 0409-7101-66 50 mL Bag 0.031 mL 50 mL $0.00
SODIUM CHLORIDE 0.9% INJ FOR PRE-PEN UHCS-0004-61 0.2 mL Syringe 0.037 mL .2 mL $21.95
SODIUM CHLORIDE 0.9% IRRIGATION BAG 3000 ML 0338-0047-27 3000 mL Bag 11.888 Bag 3000 mL $83.44
SODIUM CHLORIDE 0.9% IV BAG (COLD) 0338-0049-18 100 mL Bag 1.811 Bag 100 mL $0.00
SODIUM CHLORIDE 0.9% IV MINI-BAG PLUS 0338-0553-18 100 mL Bag 3.659 Bag 100 mL $0.00
SODIUM CHLORIDE 0.9% IV MINI-BAG PLUS 0338-0553-11 50 mL Bag 3.388 Bag 50 mL $0.00
SODIUM CHLORIDE 0.9% IV MINI-BAG PLUS 0338-9159-30 100 mL Bag 0.035 mL 100 mL $0.00
SODIUM CHLORIDE 1000 MG MISC TABS 0223-1760-01 100 each each 0.059 each 1 each $12.21
SODIUM CHLORIDE 3 % IV BAG 0338-0054-03 500 mL Bag 4.692 Bag 500 mL $143.74
SODIUM CHLORIDE 3% (0.513 MEQ/ML) (NICU) UHCS-0004-42 500 mL Bag 0.004 mL 500 mL $170.75
SODIUM CHLORIDE 4 MEQ/ML IV BAG 0409-1141-02 100 mL Vial 0.029 mL 100 mL $171.65
SODIUM CHLORIDE 4 MEQ/ML IV BAG 63323-187-30 30 mL Vial 0.138 mL 30 mL $172.89
SODIUM CHLORIDE PO 4 MEQ/ML (NICU) UHCS-0001-07 30 mL Bottle 0.056 mL 30 mL $170.43
SODIUM CHLORIDE-ALOE VERA NASL GEL 225052547 14.1 g Jar 0.174 g 14.1 g $76.70
SODIUM CITRATE 4 % (5 ML) CATH SYRINGE 69374-906-05 5 mL Syringe 5 mL 5 mL $193.75
SODIUM CITRATE 4 GRAM /100 ML (4 %) MISC SOLUTION 0942-9505-10 250 mL Bag 7.664 Bag 250 mL $146.71
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLUTION 121059500 15 mL Cup 0.205 mL 15 mL $15.23
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLUTION 121119000 30 mL Cup 0.111 mL 30 mL $15.48
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLUTION 5865731016 473 mL Bottle 0.011 mL 473 mL $17.35
SODIUM CITRATE-CITRIC ACID 500-334 MG/5 ML ORAL SOLUTION UHCS-0001-52 120 mL Bottle 0.07 mL 120 mL $57.00
SODIUM FERRIC GLUCONAT-SUCROSE 62.5 MG/5 ML IV SOLUTION 0143-9298-01 5 mL Vial 1.459 mL 5 mL $176.05
SODIUM FERRIC GLUCONAT-SUCROSE 62.5 MG/5 ML IV SOLUTION 0143-9298-10 5 mL Vial 1.459 mL 5 mL $176.05
SODIUM FLOURIDE F-18 UHCS-RAD-018 1 each each 606 each 1 each $606.00
SODIUM HYALURONATE 10 MG/ML IO SYRINGE 05047-4636-97 0.55 mL Syringe 26.8 Syringe .55 mL $51.10
SODIUM HYALURONATE 10 MG/ML IO SYRINGE 8544636971 0.55 mL Syringe 173.873 mL .55 mL $119.93
SODIUM HYALURONATE 23 MG/ML IO SYRINGE 8544508321 0.6 mL Syringe 198.267 mL .6 mL $143.26
SODIUM HYPOCHLORITE 0.25 % MISC SOLUTION 0436-0936-16 473 mL Bottle 0.025 mL 473 mL $65.83
SODIUM HYPOCHLORITE 0.5 % MISC SOLUTION 0436-0946-16 473 mL Bottle 0.025 mL 473 mL $65.83
SODIUM METABISULFITE (BULK) 100 % MISC GRANULES 5155200699 0.075 g Jar 70 g .075 g $59.25
SODIUM NITROPRUSSIDE 25 MG/ML IV SOLUTION 25021-310-02 2 mL Vial 60.08 mL 2 mL $288.91
SODIUM PHOSPHATE 3 MMOL/ML IV SOLUTION 63323-170-05 5 mL Vial 2.981 mL 5 mL $183.66
SODIUM PHOSPHATE 3 MMOL/ML IV SOLUTION 0409-7391-72 15 mL Vial 1.029 mL 15 mL $184.19
SODIUM PHOSPHATE 3 MMOL/ML IV SOLUTION 0409-7391-82 15 mL Vial 1.029 mL 15 mL $184.19
SODIUM PHOSPHATE 3 MMOL/ML IV SOLUTION 63323-170-15 15 mL Vial 1.309 mL 15 mL $188.39
SODIUM PHOSPHATES 19-7 GRAM/118 ML RECT ENEMA 0132-0201-40 133 mL SQUEEZ BTL 0.007 mL 133 mL $14.43
SODIUM POLYSTYRENE SULFONATE 15 G ORAL SUSPENSION 46287-006-60 60 mL Bottle 0.344 mL 60 mL $32.79
SODIUM POLYSTYRENE SULFONATE 15 G ORAL SUSPENSION UHCS-0002-52 120 mL Bottle 0.353 mL 120 mL $90.96
SODIUM POLYSTYRENE SULFONATE 15 G ORAL SUSPENSION 46287-006-01 473 mL Bottle 0.353 mL 473 mL $179.12
SODIUM POLYSTYRENE SULFONATE ORAL POWDER UHCS-0002-61 15 g Package 0.139 g 15 g $50.69
SODIUM POLYSTYRENE SULFONATE ORAL POWDER 10702-036-45 454 g Bottle 0.139 g 454 g $114.41
SODIUM POLYSTYRENE SULF-SORBTL 30-40 GRAM/120 ML RECT ENEMA 46287-006-04 120 mL SQUEEZ BTL 0.768 mL 120 mL $146.16
SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) IV SOLUTION 67457-163-02 2 mL Vial 22.169 mL 2 mL $213.09
SODIUM ZIRCONIUM CYCLOSILICATE 10 G ORAL POWDER PACK 0310-1110-30 30 each each 16.984 each 1 each $29.13
SORBITOL 3 % IRRIGATION SOLUTION 0338-0295-47 3000 mL Bottle 18.518 Bottle 3000 mL $157.57
SORBITOL 70 % MISC SOLUTION 4628750030 30 mL BLIST PACK 0.071 mL 30 mL $14.28
SORBITOL 70 % MISC SOLUTION 4628750001 473 mL Bottle 0.015 mL 473 mL $19.37
SORBITOL 70 % MISC SOLUTION UHCS-0001-53 60 mL Bottle 0.004 mL 60 mL $48.84
SORBITOL-MANNITOL-XANTHAN GUM ORAL LIQUID 1513702127 500 mL Bottle Bottle 500 mL $0.00
SOTALOL 80 MG ORAL TAB 68084-654-01 100 each each 0.758 each 1 each $12.91
SOTALOL 80 MG ORAL TAB 68084-654-11 1 each each 0.758 each 1 each $12.91
SOTALOL 150 MG/10 ML (15 MG/ML) IV SOLUTION 69724-112-10 10 mL Vial 299.9 mL 10 mL "$6,035.49"
SOTROVIMAB 500 MG/8 ML (62.5 MG/ML) IV SOLUTION 0173-0901-86 8 mL Vial 0 mL 8 mL $0.00
SPINAL NEEDLE TRAY PENCAN 24G REF 333868 UHCS-0005-36 1 each each 12.89 each 1 each $334.19
SPIRONOLACTONE 25 MG ORAL TAB 63739-544-10 100 each each 0.087 each 1 each $12.24
SPIRONOLACTONE (ALDACTONE) 1MG/ML PO SYRINGE (NICU) UHCS-0000-05 50 mL Bottle 2 Bottle 50 mL $62.75
SPY-MIS PACK (INDOCYANINE GREEN) 66259-936-15 1 each each 95 each 1 each $416.30
SPY-MIS PACK (INDOCYANINE GREEN) UHCS-0005-53 1 each each 125 each 1 each $446.30
STERILE TALC 4 GRAM RECON. SUSP. 62327-444-44 1 each each 170 each 1 each $342.13
STERILE TALC 5 G INPL RECON. SUSP. 63256-200-05 1 each each 113 Vial 1 each $281.75
STUDY DRUG UHCS-0003-32 1 each each N/A 1 each $0.00
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLUTION 43598-666-25 10 mL Vial 0.369 mL 10 mL $172.44
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLUTION 43598-666-11 10 mL Vial 0.369 mL 10 mL $172.44
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLUTION 0781-3411-70 10 mL Vial 0.462 mL 10 mL $173.37
SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJ SOLUTION 0781-3411-95 10 mL Vial 0.462 mL 10 mL $173.37
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRINGE UHCS-0004-90 8 mL Syringe 0.462 mL 8 mL $172.45
SUCCINYLCHOLINE CHLORIDE 200 MG/10 ML (20 MG/ML) IV SYRINGE 70092-1087-46 10 mL Syringe 2.904 mL 10 mL $197.79
SUCRALFATE 1 G ORAL TAB 63739-943-10 100 each each 0.187 each 1 each $12.34
SUCRALFATE 100 MG/ML ORAL SUSPENSION 50268-732-12 10 mL Cup 0.517 mL 10 mL $17.32
SUCRALFATE 100 MG/ML ORAL SUSPENSION 50268-732-11 10 mL Cup 0.517 mL 10 mL $17.32
SUCRALFATE 100 MG/ML ORAL SUSPENSION 66689-790-50 10 mL Cup 0.631 mL 10 mL $18.46
SUCRALFATE 100 MG/ML ORAL SUSPENSION 0121-0747-00 10 mL Cup 0.831 mL 10 mL $20.46
SUCRALFATE 100 MG/ML ORAL SUSPENSION UHCS-0001-54 120 mL Bottle 0.559 mL 120 mL $115.68
SUCRALFATE 100 MG/ML ORAL SUSPENSION 0254-1011-96 420 mL Bottle 0.387 mL 420 mL $174.69
SUGAMMADEX 100 MG/ML IV SOLUTION 0006-5423-12 2 mL Vial 57.036 mL 2 mL $282.82
SUGAMMADEX 100 MG/ML IV SOLUTION 0006-5425-15 5 mL Vial 41.787 mL 5 mL $420.48
SULFACETAMIDE SODIUM 10 % OPHT DROPS 24208-670-04 15 mL DROP BTL 2.271 mL 15 mL $94.82
SULFACETAMIDE SODIUM 10 % OPHT DROPS 61314-701-01 15 mL DROP BTL 2.743 mL 15 mL $101.90
SULFADIAZINE 500 MG ORAL TAB 0185-0757-01 100 each each 3.731 each 1 each $15.88
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSPENSION UHCS-0001-58 60 mL Bottle 0.135 mL 60 mL $20.25
SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML ORAL SUSPENSION 65862-496-47 473 mL Bottle 0.065 mL 473 mL $42.90
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG ORAL TAB 50268-728-15 50 each each 0.164 each 1 each $12.31
SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLUTION 0703-9514-93 10 mL Vial 0.731 mL 10 mL $176.06
SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG ORAL TAB 63739-228-10 100 each each 0.317 each 1 each $12.47
SULFASALAZINE 500 MG ORAL TAB 59762-5000-5 100 each each 0.134 each 1 each $12.28
SULFUR HEXAFLUORIDE MICROSPHR 25 MG IV RECON. SUSP. 0270-7099-73 1 each each 77.612 each 1 each $246.36
SULFUR HEXAFLUORIDE MICROSPHR 25 MG IV RECON. SUSP. 0270-7097-08 1 each each 77.613 each 1 each $246.36
SUMATRIPTAN SUCCINATE 25 MG ORAL TAB 16714-796-01 9 each each 0.803 each 1 each $12.95
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLUTION 55150-173-05 0.5 mL Vial 9.144 mL .5 mL $173.32
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLUTION 0143-9638-01 0.5 mL Vial 11.084 mL .5 mL $174.29
SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SUBQ SOLUTION 64679-728-08 0.5 mL Vial 44.336 mL .5 mL $190.92
SURGICEL ENDOSCOPIC APPLICATOR UHCS-0005-61 5 each each 19.602 each 1 each $27.70
TACROLIMUS 0.5 MG ORAL CAP 0904-6623-61 100 each each 0.661 each 1 each $12.81
TACROLIMUS 1 MG ORAL CAP 54288-135-01 100 each each 0.277 each 1 each $12.43
TACROLIMUS 1 MG ORAL CAP 51079-818-20 100 each each 0.83 each 1 each $12.98
TACROLIMUS 1 MG ORAL CAP 0904-7097-61 100 each each 0.84 each 1 each $12.99
TADALAFIL 20 MG ORAL TAB 0002-4464-30 30 each each 64.183 each 1 each $76.33

See Part 21