Medication Charges Part 21

TAMOXIFEN 10 MG ORAL TAB 63739-269-10 100 each each 0.334 each 1 each $12.48
TAMSULOSIN 0.4 MG ORAL CAP 63739-567-10 100 each each 0.225 each 1 each $12.38
TAPENTADOL 50 MG ORAL TAB 50458-820-02 100 each each 6.462 each 1 each $21.31
TBO-FILGRASTIM 300 MCG/0.5 ML SUBQ SYRINGE 63459-910-11 0.5 mL Syringe 184.2 mL .5 mL $260.85
TBO-FILGRASTIM 480 MCG/0.8 ML SUBQ SYRINGE 63459-912-15 0.8 mL Syringe 184.246 mL .8 mL $316.15
TC99M FILTERED SULFUR COLLOID UHCS-RAD-009 1 each each 240 each 1 each $240.00
TC99M MDP 65174-660-30 1 each each 240 each 1 each $240.00
TECHNETIUM TC 99M DTPA UHCS-RAD-026 1 each each 240 each 1 each $240.00
TECHNETIUM TC 99M MAG3 UHCS-RAD-008 1 each each 443 each 1 each $443.00
TECHNETIUM TC 99M MERTIATIDE UHCS-RAD-011 1 each each 240 each 1 each $240.00
TECHNETIUM TC 99M PYROPHOSPHATE UHCS-RAD-012 1 each each 240 each 1 each $240.00
TECHNETIUM TC 99M SESTAMIBI (CARDIOLITE) 11994-011-55 1 each each 367 each 1 each $367.00
TECHNETIUM TC 99M SESTAMIBI (MIRALUMA) UHCS-RAD-013 1 each each 367 each 1 each $367.00
TECHNETIUM TC 99M SODIUM PERTECHNETATE UHCS-RAD-006 1 each each 240 each 1 each $240.00
TECHNETIUM TC 99M TETROFOSMIN UHCS-RAD-022 1 each each 415 each 1 each $415.00
TECHNETIUM TC99M TILMANOCEPT UHCS-RAD-019 1 each each 1137 each 1 each "$1,137.00"
TEGASEROD HYDROGEN MALEATE 6 MG ORAL TAB 27505-090-60 60 each each 6.292 each 1 each $18.44
TELMISARTAN 40 MG ORAL TAB 68462-200-30 30 each each 0.344 each 1 each $12.49
TEMAZEPAM 7.5 MG ORAL CAP 0904-6436-04 30 each each 2.535 each 1 each $18.74
TEMAZEPAM 15 MG ORAL CAP 51079-418-20 100 each each 0.104 each 1 each $16.30
TEMOZOLOMIDE 20 MG ORAL CAP 0093-7600-57 5 each each 35.864 each 1 each $135.76
TEMOZOLOMIDE 140 MG ORAL CAP 43975-255-14 14 each each 20.844 each 1 each $56.52
TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST) IV VIAL 0008-1179-01 1 mL Vial 1883.8 mL 1 mL "$3,791.15"
TENECTEPLASE 50 MG IV VIAL 50242-120-47 1 each each 6813.82 each 1 each "$13,712.81"
TENECTEPLASE 50 MG IV VIAL FOR STROKE 50242-120-47 1 each each 6813.82 each 1 each "$13,712.81"
TENOFOVIR DISOPROXIL FUMARATE 300 MG ORAL TAB 0904-6821-04 30 each each 2.386 each 1 each $14.54
TERAZOSIN 1 MG ORAL CAP 51079-936-20 100 each each 0.218 each 1 each $12.37
TERAZOSIN 2 MG ORAL CAP 59746-384-06 100 each each 0.087 each 1 each $12.24
TERAZOSIN 5 MG ORAL CAP 59746-385-06 100 each each 0.09 each 1 each $12.24
TERAZOSIN 5 MG ORAL CAP 51079-938-20 100 each each 0.269 each 1 each $12.42
TERBINAFINE HCL 250 MG ORAL TAB 16714-795-01 30 each each 0.112 each 1 each $12.26
TERBUTALINE 1 MG/ML SUBQ SOLUTION 63323-665-01 1 mL Vial 1.46 mL 1 mL $170.21
TERCONAZOLE 0.4 % VAGL CREAM 51672-1304-6 45 g TUBE/KIT 0.456 g 45 g $74.52
TERCONAZOLE 0.8 % VAGL CREAM 51672-1302-0 20 g TUBE/KIT 0.893 g 20 g $71.86
TERCONAZOLE 80 MG VAGL SUPPOSITORY 45802-717-08 3 each each 15.8 each 1 each $101.40
TERIPARATIDE 20 MCG/DOSE (600MCG/2.4ML) SUBQ PEN 0002-8400-01 2.4 mL Syringe 1683.329 mL 2.4 mL "$8,130.48"
TESTOSTERONE CYPIONATE 200 MG/ML IM OIL 0009-0417-01 1 mL Vial 6.93 mL 1 mL $175.68
TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRINGE 49281-215-15 0.5 mL Syringe 65.392 mL .5 mL $201.45
TETANUS IMMUNE GLOBULIN (PF) 250 UNITS/ML IM SYRINGE 13533-634-02 1 mL mL 496.85 mL 1 mL $999.91
TETRACAINE HCL (BULK) MISC POWDER 51552-0269-9 0.5 g Jar 12.4 g .5 g $18.35
TETRACAINE HCL (PF) 0.5 % OPHT DROPS 0065-0741-14 4 mL DROP BTL 2.508 mL 4 mL $70.78
TETRACAINE HCL 0.5 % OPHT DROP. 54799-505-05 5 mL DROP BTL 4.668 mL 5 mL $47.64
TETRACYCLINE 500 MG ORAL CAP 23155-018-01 100 each each 4.665 each 1 each $16.82
TETRAHYDROZOLINE 0.05 % OPHT DROPS 49348-037-29 15 mL DROP BTL 0.109 mL 15 mL $62.39
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) IV SOLUTION 17156-299-18 1 each each 476 each 1 each "$1,904.00"
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) IV SOLUTION 69945-120-28 1 each each 476 each 1 each "$1,904.00"
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) IV SOLUTION 69945-120-56 1 each each 476 each 1 each "$1,904.00"
THALLOUS CHLORIDE TL-201 37 MBQ/ML (1 MCI/ML) IV SOLUTION 69945-120-99 1 each each 476 each 1 each "$1,904.00"
THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLUTION 11994-427-11 1 each each 0 each 1 each $0.00
THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLUTION 11994-427-19 1 each each 0 each 1 each $0.00
THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLUTION 11994-427-24 1 each each 0 each 1 each $0.00
THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLUTION 11994-427-26 1 each each 0 each 1 each $0.00
THEOPHYLLINE 300 MG ORAL TB12 62332-025-31 100 each each 2.487 each 1 each $14.64
THEOPHYLLINE 400 MG ORAL TB24 29033-001-01 100 each each 0.568 each 1 each $12.72
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR UHCS-0001-55 60 mL Bottle 0.616 mL 60 mL $85.56
THEOPHYLLINE 80 MG/15 ML ORAL ELIXIR 70408-644-34 473 mL Bottle 0.616 mL 473 mL $339.97
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLUTION 63323-013-21 2 mL Vial 2.171 mL 2 mL $173.09
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLUTION 63323-013-02 2 mL Vial 2.171 mL 2 mL $173.09
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLUTION 63323-013-09 2 mL Vial 2.171 mL 2 mL $173.09
THIAMINE HCL (VITAMIN B1) 100 MG/ML INJ SOLUTION 67457-196-02 2 mL Vial 3.942 mL 2 mL $176.63
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB 5164590599 100 each each 0.037 each 1 each $12.19
THIAMINE MONONITRATE (VIT B1) 100 MG ORAL TAB 7733393425 1 each each 0.151 each 1 each $12.30
THIORIDAZINE 10 MG ORAL TAB 51079-565-20 100 each each 0.349 each 1 each $12.50
"THROMB,HM-FIBRIN-APROTIN,S-CA 2 ML TP SYRINGE" 0338-9560-01 2 mL Syringe 48.54 mL 2 mL $265.83
"THROMB,HM-FIBRIN-APROTIN,S-CA 4 ML TP SYRINGE" 0338-9564-01 4 mL Syringe 40.683 mL 4 mL $331.48
"THROMB,HM-FIBRIN-APROTIN,S-CA 10 ML TP SYRINGE" 0338-9568-01 10 mL Syringe 39.931 mL 10 mL $803.61
"THROMB-CA-CME CEL-HEMOSTAT PAD 3 X 3 "" TP MED PAD" 60793-916-03 10 each each 44.767 each 1 each $98.77
THROMBIN (BOVINE) 5000 UNITS TP VIAL 60793-215-05 1 each each 39.98 each 1 each $208.73
THROMBIN (BOVINE) 20000 UNITS TP SPRAY 60793-217-21 1 each KIT 180.44 each 1 each $234.44
THROMBIN (BOVINE) 20000 UNITS TP VIAL 60793-217-20 1 each each 157.66 each 1 each $181.96
THROMBIN (RECOMBINANT) 5000 UNITS TP VIAL 0338-0322-01 1 each each 41.86 each 1 each $210.61
THROMBIN (RECOMBINANT) 20000 UNITS TP VIAL 0338-0326-01 1 each each 167.46 each 1 each $191.76
THROMBIN(HUMAN)-FIBRIN-CALCIUM 500 UNIT-80 MG /ML (2 ML) TP SYRINGE 61953-0011-1 2 mL Syringe 59.42 mL 2 mL $287.59
"THROMBIN-CAL-CMC-GEL-DRESS,HEM 10 CM2 TP MED PAD" 60793-907-01 10 each each 41.475 each 1 each $95.48
THYROID (PORK) 15 MG ORAL TAB 0456-0457-01 100 each each 0.721 each 1 each $12.87
THYROID (PORK) 30 MG ORAL TAB 42192-329-01 100 each each 0.605 each 1 each $12.76
TIAGABINE 4 MG ORAL TAB 0093-5031-56 30 each each 5.863 each 1 each $18.01
TICAGRELOR 60 MG ORAL TAB 0186-0776-60 60 each each 6.71 each 1 each $18.86
TICAGRELOR 90 MG ORAL TAB 0186-0777-39 100 each each 6.71 each 1 each $18.86
TIGECYCLINE 50 MG IV VIAL 63323-960-10 1 each each 26.325 each 1 each $195.08
TIGECYCLINE 50 MG IV VIAL 55150-228-10 1 each each 26.88 each 1 each $195.63
TIMOLOL MALEATE 0.25 % OPHT DROPS 61314-226-05 5 mL DROP BTL 0.954 mL 5 mL $65.52
TIMOLOL MALEATE 0.25 % OPHT GEL SOLUTION 24208-818-25 5 mL DROP BTL 30.514 mL 5 mL $213.32
TIMOLOL MALEATE 0.5 % OPHT DROPS 64980-514-05 5 mL DROP BTL 0.882 mL 5 mL $65.16
TIMOLOL MALEATE 0.5 % OPHT GEL SOLUTION 24208-819-05 5 mL DROP BTL 33.51 mL 5 mL $228.30
TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION INHL MIST 0597-0100-51 4 g AER W/ADAP 8.66 g 4 g $108.89
TIROFIBAN-0.9% SODIUM CHLORIDE 12.5 MG/250 ML (50 MCG/ML) IV SOLUTION 25208-002-02 250 mL Bag 0.854 mL 250 mL $429.67
TIZANIDINE 4 MG ORAL TAB 0904-6418-61 100 each each 0.331 each 1 each $12.48
TOBRAMYCIN (NEBCIN) FOR NEBULIZATION (NICU) UHCS-0001-82 2 mL Vial 0.647 mL 2 mL $170.04
TOBRAMYCIN (NEBCIN) IV 5 MG/ML (NICU) UHCS-0000-04 10 mL Vial 2.272 mL 10 mL $191.47
TOBRAMYCIN 0.3 % OPHT DROPS 61314-643-05 5 mL DROP BTL 2.862 mL 5 mL $75.06
TOBRAMYCIN 0.3 % OPHT OINTMENT 0065-0644-35 3.5 g Tube 56.571 g 3.5 g $258.75
TOBRAMYCIN FOR INHALATION UHCS-0001-81 7.5 mL Vial 0.384 mL 7.5 mL $183.07
TOBRAMYCIN PULSE DOSE MONITORING UHCS-CON0-03 1 each N/A N/A 1 each $0.00
TOBRAMYCIN SULFATE 1.2 G INJ VIAL 63323-303-55 1 each each 51.875 each 1 each $220.63
TOBRAMYCIN SULFATE 10 MG/ML INJ SOLUTION 63323-305-02 2 mL Vial 2.272 mL 2 mL $173.29
TOBRAMYCIN SULFATE 40 MG/ML INJ SOLUTION 67457-473-22 2 mL Vial 0.384 mL 2 mL $169.52
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT DROPS. 61314-647-25 2.5 mL DROP BTL 10.976 mL 2.5 mL $88.19
TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OPHT OINTMENT 0078-0876-01 3.5 g Tube 69.151 g 3.5 g $302.78
TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLUTION 50242-136-01 10 mL Vial 126.468 mL 10 mL "$2,545.17"
TOCILIZUMAB 400 MG/20 ML (20 MG/ML) IV SOLUTION 50242-137-01 20 mL Vial 126.468 mL 20 mL "$5,090.34"
TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLUTION 50242-135-01 4 mL Vial 126.468 mL 4 mL "$1,018.07"
TOLNAFTATE 1 % TP CREAM 49348-155-29 15 g Tube 0.133 g 15 g $56.00
TOLNAFTATE 1 % TP CREAM 1093956333 15 g Tube 0.133 g 15 g $56.00
TOLVAPTAN 15 MG ORAL TAB 49884-768-54 10 each each 43.421 each 1 each $55.57
TOLVAPTAN 15 MG ORAL TAB 49884-768-52 1 each each 43.421 each 1 each $55.57
TOLVAPTAN 15 MG ORAL TAB 60505-4704-0 10 each each 417.263 each 1 each $429.41
TOLVAPTAN 15 MG ORAL TAB 59148-020-50 10 each each 502.068 each 1 each $514.22
TOLVAPTAN 30 MG ORAL TAB 31722-869-03 10 each each 86.843 each 1 each $98.99
TOLVAPTAN 30 MG ORAL TAB 31722-869-01 1 each each 86.843 each 1 each $98.99
TOLVAPTAN 30 MG ORAL TAB 49884-770-52 1 each each 110.82 each 1 each $122.97
TOLVAPTAN 30 MG ORAL TAB 49884-770-54 10 each each 110.82 each 1 each $122.97
TOLVAPTAN 30 MG ORAL TAB 67877-636-02 10 each each 225.415 each 1 each $237.57
TOLVAPTAN 30 MG ORAL TAB 67877-636-33 10 each each 443.861 each 1 each $456.01
TOLVAPTAN 30 MG ORAL TAB 59148-021-50 10 each each 536.945 each 1 each $549.10
TOPIRAMATE 25 MG ORAL TAB 68084-342-01 100 each each 0.177 each 1 each $12.33
TOPIRAMATE 100 MG ORAL TAB 68084-344-01 100 each each 0.28 each 1 each $12.43
TOPOTECAN 4 MG IV VIAL 16729-151-31 1 each each 129.32 each 1 each $628.82
TORSEMIDE 10 MG ORAL TAB 50268-755-15 50 each each 0.185 each 1 each $12.34
TORSEMIDE 20 MG ORAL TAB 50268-756-15 50 each each 0.268 each 1 each $12.42
TORSEMIDE 20 MG ORAL TAB 50268-756-11 1 each each 0.268 each 1 each $12.42
TPN ADULT (CENTRAL) $510.00
TPN ADULT (PERIPHERAL) $510.00
TPN NEONATAL $510.00
TPN TAPER UHCS-0002-95 1 each each Bag 1 each $0.00
TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60MCG-5MG/ML IV SOLUTION UHCS-0003-16 10 mL Ampule 1.013 mL 10 mL $178.88
TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60MCG-5MG/ML IV SOLUTION 0517-8201-25 1 mL Vial 11.554 mL 1 mL $180.30
TRACE ELEMENTS CR-CU-MN-SE-ZN 10 MCG-1 MG-0.5 MG-60MCG-5MG/ML IV SOLUTION 0517-8210-25 10 mL Vial 2.057 mL 10 mL $189.32
TRACE ELEMENTS CR-CU-MN-ZN 0.85 MCG-0.1 MG -25MCG-1.5MG/ML IV SOLUTION 0517-6202-25 2 mL Vial 5.351 mL 2 mL $179.45
"TRACE ELEMENTS ZN-CU-MN-SE 1,000MCG-60MCG- 3 MCG-6 MCG/ML IV SOLUTION" 0517-9302-01 1 mL Vial 15.675 mL 1 mL $184.43
"TRACE ELEMENTS ZN-CU-MN-SE 1,000MCG-60MCG- 3 MCG-6 MCG/ML IV SOLUTION" 0517-9302-25 1 mL Vial 15.675 mL 1 mL $184.43
TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML IV SOLUTION 0517-9305-25 1 mL Vial 18.779 mL 1 mL $187.53
TRACE ELEMENTS ZN-CU-MN-SE 3 MG-0.3 MG-55 MCG-60 MCG/ML IV SOLUTION 0517-9305-01 1 mL Vial 18.779 mL 1 mL $187.53
TRAMADOL 50 MG ORAL TAB 51079-991-20 100 each each 0.071 each 1 each $12.22
TRANDOLAPRIL 1 MG ORAL TAB 68180-566-01 100 each each 0.208 each 1 each $12.36
TRANEXAMIC ACID 1000 MG/10 ML (100 MG/ML) IV SOLUTION 61990-0611-2 10 mL Vial 0.213 mL 10 mL $170.88
TRANEXAMIC ACID 1000 MG/10 ML (100 MG/ML) IV SOLUTION 55150-188-10 10 mL Vial 0.213 mL 10 mL $170.88
TRANEXAMIC ACID 1000 MG/10 ML (100 MG/ML) IV SOLUTION 67850-042-10 10 mL AMPUL 0.277 mL 10 mL $171.52
TRANEXAMIC ACID 1000 MG/10 ML (100 MG/ML) IV SOLUTION 43066-008-01 10 mL Vial 0.298 mL 10 mL $171.73
TRANEXAMIC ACID 1000 MG/10 ML (100 MG/ML) IV SOLUTION 43066-008-10 10 mL Vial 0.298 mL 10 mL $171.73
TRASTUZUMAB-DKST 150 MG IV VIAL 67457-991-15 7.14 mL Vial 111.646 mL 7.14 mL "$1,604.27"
TRAVOPROST 0.004 % OPHT DROPS 0065-0260-05 5 mL DROP BTL 71.714 mL 5 mL $419.32
TRAZODONE 50 MG ORAL TAB 0904-6868-61 100 each each 0.084 each 1 each $12.23
TRIAMCINOLONE ACETONIDE 0.025 % TP CREAM 45802-063-36 80 g Tube 0.095 g 80 g $61.60
TRIAMCINOLONE ACETONIDE 0.025 % TP CREAM 0168-0003-80 80 g Jar 0.107 g 80 g $62.56
TRIAMCINOLONE ACETONIDE 0.1 % DENT PASTE 51672-1267-5 5 g Tube 11.91 g 5 g $113.55
TRIAMCINOLONE ACETONIDE 0.1 % TP CREAM 45802-064-36 80 g Tube 0.071 g 80 g $59.68
TRIAMCINOLONE ACETONIDE 0.1 % TP LOTION 60432-561-61 60 mL Bottle 0.177 mL 60 mL $64.62
TRIAMCINOLONE ACETONIDE 0.1 % TP OINTMENT 45802-055-36 80 g Tube 0.04 g 80 g $57.20
TRIAMCINOLONE ACETONIDE 10 MG/ML INJ SUSPENSION 0003-0494-20 5 mL Vial 2.234 mL 5 mL $179.92
TRIAMCINOLONE ACETONIDE 40 MG/ML INJ SUSPENSION 70121-1651-5 1 mL Vial 3.191 mL 1 mL $171.94

See Part 22