Medication Charges Part 8

DIPYRIDAMOLE 25 MG ORAL TAB 64980-133-01 100 each each 1.094 each 1 each $13.24
DIVALPROEX 125 MG ORAL CDRS 68084-313-01 100 each each 0.528 each 1 each $12.68
DIVALPROEX 125 MG ORAL CDRS 68084-313-11 100 each each 0.528 each 1 each $12.68
DIVALPROEX 250 MG ORAL EC (DELAYED-RELEASE) TABLET 68084-776-01 100 each each 0.159 each 1 each $12.31
DIVALPROEX 500 MG ORAL TB24 68084-415-01 100 each each 1.044 each 1 each $13.19
DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV SOLUTION 0409-2344-88 20 mL Vial 0.224 mL 20 mL $173.23
DOBUTAMINE IN D5W 500 MG/250 ML (2000 MCG/ML) IV BAG 0409-2347-32 250 mL Bag 0.039 mL 250 mL $148.80
DOCETAXEL 20 MG/2 ML (10 MG/ML) IV SOLUTION 55150-378-01 2 mL Vial 5.635 mL 2 mL $510.77
DOCETAXEL 20 MG/2 ML (10 MG/ML) IV SOLUTION 66758-950-02 2 mL Vial 9.04 mL 2 mL $517.58
DOCETAXEL 80 MG/8 ML (10 MG/ML) IV SOLUTION 67457-532-08 8 mL Vial 7.245 mL 8 mL $557.46
DOCETAXEL 80 MG/8 ML (10 MG/ML) IV SOLUTION 66758-950-03 8 mL Vial 10.273 mL 8 mL $581.68
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID 50383-349-11 10 mL Cup 0.038 mL 10 mL $12.53
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID 50383-349-10 10 mL Cup 0.038 mL 10 mL $12.53
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID 0121-0544-10 10 mL BLIST PACK 0.102 mL 10 mL $13.17
DOCUSATE SODIUM 50 MG/5 ML ORAL LIQUID 0121-1870-10 10 mL Cup 0.102 mL 10 mL $13.17
DOCUSATE SODIUM 100 MG ORAL CAP 0904-6998-80 1000 each each 0.01 each 1 each $12.16
DOCUSATE SODIUM 100 MG ORAL CAP 0904-7183-61 100 each each 0.035 each 1 each $12.19
DOFETILIDE (TIKOSYN) 125 MCG FOR DISCHARGE 69452-131-17 60 each each 1.478 each 1 each $0.00
DOFETILIDE (TIKOSYN) 125 MCG FOR DISCHARGE 59762-0037-2 60 each each 3.851 each 1 each $0.00
DOFETILIDE (TIKOSYN) 250 MCG FOR DISCHARGE 16714-841-01 60 each each 2.552 each 1 each $0.00
DOFETILIDE (TIKOSYN) 250 MCG FOR DISCHARGE 69452-132-17 60 each each 1.478 each 1 each $0.00
DOFETILIDE 125 MCG ORAL CAP 42291-411-60 60 each each 0.266 each 1 each $12.42
DOFETILIDE 125 MCG ORAL CAP 69452-131-17 60 each each 1.478 each 1 each $13.63
DOFETILIDE 250 MCG ORAL CAP 42291-412-60 60 each each 0.287 each 1 each $12.44
DOFETILIDE 250 MCG ORAL CAP 69452-132-17 60 each each 1.478 each 1 each $13.63
DOFETILIDE 500 MCG ORAL CAP 42291-413-60 60 each each 0.272 each 1 each $12.42
DOLUTEGRAVIR 50 MG ORAL TAB 49702-228-13 30 each each 68.898 each 1 each $81.05
DONEPEZIL 5 MG ORAL TAB 60687-292-01 100 each each 0.077 each 1 each $12.23
DONEPEZIL 10 MG ORAL TAB 60687-303-01 100 each each 0.08 each 1 each $12.23
DOPAMINE 200 MG/5 ML (40 MG/ML) IV SOLUTION 0409-5820-01 5 mL Vial 0.512 mL 5 mL $171.31
"DOPAMINE IN 5 % DEXTROSE 800 MG/250 ML (3,200 MCG/ML) IV SOLUTION" 0409-7810-22 250 mL Bag 0.037 mL 250 mL $148.30
DOPAMINE IN D5W 400 MG/250 ML (1600 MCG/ML ) IV SOLN (NICU) 0338-1007-02 250 mL Bag 0.045 mL 250 mL $150.30
DOPAMINE IN D5W 400 MG/250 ML (1600 MCG/ML) IV SOLUTION 0338-1007-02 250 mL Bag 0.045 mL 250 mL $150.30
DOPAMINE IV 48 MG IN 30ML D5W INFUSION SYRINGE UHCS-0005-43 30 mL Syringe 0.045 mL 30 mL $170.10
DOPAMINE IV 96 MG IN 30ML D5W INFUSION SYRINGE UHCS-0005-46 30 mL Syringe 0.042 Syringe 30 mL $168.80
DORNASE ALFA 1 MG/ML INHL SOLUTION 50242-100-40 2.5 mL AMPUL 48.925 mL 2.5 mL $133.11
DORZOLAMIDE 2 % OPHT DROPS 42571-141-26 10 mL DROP BTL 0.831 mL 10 mL $69.06
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML OPHT DROPS 42571-147-26 10 mL DROP BTL 1.095 mL 10 mL $71.70
DORZOLAMIDE-TIMOLOL 22.3-6.8 MG/ML OPHT DROPS 50383-233-10 10 mL DROP BTL 4.619 mL 10 mL $106.94
DOXAZOSIN 1 MG ORAL TAB 68084-836-25 30 each each 0.591 each 1 each $12.74
DOXAZOSIN 2 MG ORAL TAB 68084-851-25 30 each each 0.597 each 1 each $12.75
DOXAZOSIN 4 MG ORAL TAB 0904-5524-61 100 each each 0.376 each 1 each $12.53
DOXEPIN 10 MG ORAL CAP 51079-436-20 100 each each 0.382 each 1 each $12.53
DOXEPIN 25 MG ORAL CAP 51079-437-20 100 each each 0.502 each 1 each $12.65
DOXEPIN 50 MG ORAL CAP 51079-438-20 100 each each 0.697 each 1 each $12.85
DOXERCALCIFEROL 0.5 MCG ORAL CAP 0955-1720-50 50 each each 5.545 each 1 each $17.70
DOXERCALCIFEROL 4 MCG/2 ML IV SOLUTION 0409-1330-01 2 mL Vial 0.854 mL 2 mL $170.46
DOXERCALCIFEROL 4 MCG/2 ML IV SOLUTION 71288-802-03 2 mL Vial 0.984 mL 2 mL $170.72
DOXORUBICIN 50 MG IV VIAL 0143-9277-01 1 each each 170.75 each 1 each $670.25
DOXORUBICIN 50 MG VIAL FOR CHEMOEMBOLIZATION 67457-436-50 1 each each 242.04 each 1 each $741.54
DOXORUBICIN 50 MG/25 ML IV SOLUTION 0143-9086-01 25 mL Vial 0.448 mL 25 mL $510.70
DOXORUBICIN 50 MG/25 ML IV SOLUTION 0143-9371-01 25 mL Vial 0.48 mL 25 mL $511.50
DOXORUBICIN 50 MG/25 ML IV SOLUTION 0069-4032-01 25 mL Vial 1.301 mL 25 mL $532.03
"DOXORUBICIN, PEG-LIPOSOMAL 2 MG/ML IV SUSPENSION" 43598-682-35 10 mL Vial 17.83 mL 10 mL $677.80
DOXYCYCLINE HYCLATE 50 MG ORAL CAP 50268-277-15 50 each each 1.129 each 1 each $13.28
DOXYCYCLINE HYCLATE 100 MG IV VIAL 67457-437-10 1 each each 15.399 each 1 each $184.15
DOXYCYCLINE HYCLATE 100 MG IV VIAL 68382-910-10 1 each each 22.317 each 1 each $191.07
DOXYCYCLINE HYCLATE 100 MG ORAL TAB 0904-0430-06 50 each each 1.389 each 1 each $13.54
DOXYLAMINE-PYRIDOXINE (VIT B6) 10-10 MG ORAL EC TABLET 70505-100-10 100 each each 2.896 each 1 each $15.05
DRONABINOL 2.5 MG ORAL CAP 17478-761-06 60 each each 1.496 each 1 each $17.70
DRONEDARONE 400 MG ORAL TAB 0024-4142-10 100 each each 10.143 each 1 each $22.29
DROPERIDOL 2.5 MG/ML INJ SOLUTION 0517-9702-25 2 mL Vial 3.598 mL 2 mL $175.95
DULAGLUTIDE 1.5 MG/0.5 ML SUBQ PEN 0002-1434-01 0.5 mL Syringe 429.835 mL .5 mL $432.52
DULOXETINE 20 MG ORAL EC CAP 50268-269-15 50 each each 0.694 each 1 each $12.84
DULOXETINE 20 MG ORAL EC CAP 50268-269-11 1 each each 0.694 each 1 each $12.84
DULOXETINE 20 MG ORAL EC CAP 0904-7043-04 30 each each 1.033 each 1 each $13.18
DULOXETINE 30 MG ORAL EC CAP 50268-270-13 30 each each 0.755 each 1 each $12.91
DULOXETINE 30 MG ORAL EC CAP 0904-7044-61 100 each each 1.037 each 1 each $13.19
DULOXETINE 60 MG ORAL EC CAP 68084-692-01 100 each each 0.648 each 1 each $12.80
DULOXETINE 60 MG ORAL EC CAP 68084-692-11 1 each each 0.648 each 1 each $12.80
DUOSOL 2/0 DIALYSIS SOLUTION UHCS-0005-59 5000 mL Bag 20 Bag 5000 mL $159.05
DUOSOL 4/0 DIALYSIS SOLUTION UHCS-0005-60 5000 mL Bag 20 Bag 5000 mL $159.05
DURVALUMAB 50 MG/ML IV SOLUTION 0310-4500-12 2.4 mL Vial 388.992 mL 2.4 mL "$1,878.83"
DURVALUMAB 50 MG/ML IV SOLUTION 10 ML 0310-4611-50 10 mL Vial 388.99 mL 10 mL "$7,828.42"
DUTASTERIDE 0.5 MG ORAL CAP 50268-282-13 30 each each 0.879 each 1 each $13.03
ECULIZUMAB 300 MG/30 ML IV SOLUTION 25682-001-01 30 mL Vial 217.433 mL 30 mL "$13,127.52"
EFAVIRENZ 600 MG ORAL TAB 65862-049-30 30 each each 1.93 each 1 each $14.08
ELECTROLYTE-A IV BAG 0338-0221-04 1000 mL Bag 5.217 Bag 1000 mL $144.27
ELECTROLYTE-A IV BAG (PERFUSION) 0338-0221-04 1000 mL Bag 5.217 Bag 1000 mL $144.27
ELOTUZUMAB 300 MG IV VIAL 0003-2291-11 1 each each 2102.35 each 1 each "$4,230.98"
ELOTUZUMAB 400 MG IV VIAL 0003-4522-11 1 each each 2803.12 each 1 each "$5,641.28"
ELTROMBOPAG 25 MG ORAL TAB 0078-0685-15 30 each each 223.662 each 1 each $450.12
EMOLLIENT COMBINATION NO.92 TP LOTION 5280048856 473 mL Bottle 0.011 mL 473 mL $59.20
EMPAGLIFLOZIN 10 MG ORAL TAB 0597-0152-37 30 each each 12.057 each 1 each $24.21
EMPAGLIFLOZIN 25 MG ORAL TAB 0597-0153-37 30 each each 12.057 each 1 each $24.21
EMPTY BAG 100 ML UHCS-0000-99 1 each each 3.511 each 1 each $44.01
EMPTY BAG 150 ML UHCS-0003-70 1 each each 3.439 Bag 1 each $43.94
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB 42385-953-30 30 each each 0.77 each 1 each $12.92
EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG ORAL TAB 0904-7172-07 30 each each 1.154 each 1 each $13.30
EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG ORAL TAB 61958-2002-1 30 each each 69.812 each 1 each $81.96
EMTRICITAB-RILPIVIR-TENOFO ALA 200-25-25 MG ORAL TAB 61958-2101-1 30 each each 111.678 each 1 each $123.83
ENALAPRIL MALEATE 2.5 MG ORAL TAB 0904-5609-61 100 each each 0.335 each 1 each $12.49
ENALAPRIL MALEATE 5 MG ORAL TAB 0904-5502-61 100 each each 0.345 each 1 each $12.50
ENALAPRIL MALEATE 10 MG ORAL TAB 0904-5610-61 100 each each 0.298 each 1 each $12.45
ENALAPRILAT 1.25 MG/ML IV SOLUTION 0143-9787-10 1 mL Vial 4.413 mL 1 mL $173.16
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 71288-410-87 0.8 mL Syringe 7.205 mL .8 mL $174.51
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 0781-3262-68 0.8 mL Syringe 7.393 mL .8 mL $174.67
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 63323-531-08 0.8 mL Syringe 8.255 mL .8 mL $175.35
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 63323-531-98 0.8 mL Syringe 8.255 mL .8 mL $175.35
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 63323-584-63 0.8 mL Syringe 8.255 mL .8 mL $175.35
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 63323-584-65 0.8 mL Syringe 8.255 mL .8 mL $175.35
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 63323-584-99 0.8 mL Syringe 8.255 mL .8 mL $175.35
ENOXAPARIN 80 MG/0.8 ML SUBQ SYRINGE 0703-8680-23 0.8 mL Syringe 18.359 mL .8 mL $183.44
ENOXAPARIN 100 MG/ML SUBQ SYRINGE 71288-410-89 1 mL Syringe 7.205 mL 1 mL $175.96
ENOXAPARIN 100 MG/ML SUBQ SYRINGE 63323-605-94 1 mL Syringe 8.517 mL 1 mL $177.27
ENOXAPARIN 100 MG/ML SUBQ SYRINGE 63323-605-84 1 mL Syringe 8.517 mL 1 mL $177.27
ENOXAPARIN 100 MG/ML SUBQ SYRINGE 0703-8580-23 1 mL Syringe 18.363 mL 1 mL $187.11
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRINGE 16714-056-10 0.8 mL Syringe 10.078 mL .8 mL $176.81
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRINGE 63323-609-90 0.8 mL Syringe 12.689 mL .8 mL $178.90
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRINGE 63323-655-99 0.8 mL Syringe 12.689 mL .8 mL $178.90
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRINGE 63323-655-21 0.8 mL Syringe 12.689 mL .8 mL $178.90
ENOXAPARIN 120 MG/0.8 ML SUBQ SYRINGE 0703-8610-23 0.8 mL Syringe 27.538 mL .8 mL $190.78
ENOXAPARIN 150 MG/ML SUBQ SYRINGE 63323-537-01 1 mL Syringe 12.802 mL 1 mL $181.55
ENOXAPARIN 150 MG/ML SUBQ SYRINGE 63323-537-84 1 mL Syringe 12.802 mL 1 mL $181.55
ENOXAPARIN 150 MG/ML SUBQ SYRINGE 63323-589-94 1 mL Syringe 12.802 mL 1 mL $181.55
ENOXAPARIN 150 MG/ML SUBQ SYRINGE 63323-589-21 1 mL Syringe 12.802 mL 1 mL $181.55
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE 0781-3238-01 0.3 mL Syringe 7.443 mL .3 mL $170.98
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE 0781-3238-63 0.3 mL Syringe 7.443 mL .3 mL $170.98
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE 63323-533-93 0.3 mL Syringe 8.22 mL .3 mL $171.22
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE 63323-559-65 0.3 mL Syringe 8.22 mL .3 mL $171.22
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE UHCS-0003-17 0.3 mL Syringe 14.763 mL .3 mL $173.18
ENOXAPARIN 30 MG/0.3 ML SUBQ SYRINGE 0703-8530-23 0.3 mL Syringe 18.38 mL .3 mL $174.26
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 0781-3246-02 0.4 mL Syringe 6.855 mL .4 mL $171.49
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 0781-3246-64 0.4 mL Syringe 6.855 mL .4 mL $171.49
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 63323-535-08 0.4 mL Syringe 8.383 mL .4 mL $172.10
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 63323-535-98 0.4 mL Syringe 8.383 mL .4 mL $172.10
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 71288-410-83 0.4 mL Syringe 13.855 mL .4 mL $174.29
ENOXAPARIN 40 MG/0.4 ML SUBQ SYRINGE 0703-8540-23 0.4 mL Syringe 18.335 mL .4 mL $176.08
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRINGE 63323-566-98 0.6 mL Syringe 8.113 mL .6 mL $173.62
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRINGE 63323-566-21 0.6 mL Syringe 8.113 mL .6 mL $173.62
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRINGE 63323-607-98 0.6 mL 8.116 mL .6 mL $173.62
ENOXAPARIN 60 MG/0.6 ML SUBQ SYRINGE 0703-8560-23 0.6 mL Syringe 9.328 mL .6 mL $174.35
ENSURE PRE-SURGERY CLEAR NUTRITION DRINK 7007465040 296 mL Bottle 0.007 mL 296 mL $2.07
ENSURE SURGERY IMMUNONUTRITION SHAKE 7007465046 12 Bottle Box 2 Bottle 12 Bottle $24.00
ENTACAPONE 200 MG ORAL TAB 60687-188-11 1 each each 2.98 each 1 each $15.13
ENTACAPONE 200 MG ORAL TAB 60687-188-21 30 each each 2.98 each 1 each $15.13
EPHEDRINE SULFATE 50 MG/ML INJ SOLUTION 14789-014-01 1 mL Vial 14.683 mL 1 mL $183.43
EPHEDRINE SULFATE 50 MG/ML INJECTION (WRAPPER) 55150-373-01 1 mL Vial 6.272 mL 1 mL $175.02
EPHEDRINE SULFATE 50 MG/ML INJECTION (WRAPPER) 16714-037-25 1 mL Vial 6.966 mL 1 mL $175.72
EPHEDRINE SULFATE 50 MG/ML INJECTION (WRAPPER) 0781-3269-95 1 mL Vial 7.694 mL 1 mL $176.44
EPHEDRINE SULFATE 50 MG/ML INJECTION (WRAPPER) 70121-1637-5 1 mL Vial 7.759 mL 1 mL $176.51
EPHEDRINE SULFATE-0.9%NACL(PF) 25 MG/5 ML (5 MG/ML) IV SYRINGE 61553-301-33 5 mL Syringe 1.228 mL 5 mL $174.89
EPHEDRINE SULFATE-0.9%NACL(PF) 25 MG/5 ML (5 MG/ML) IV SYRINGE UHCS-0004-98 5 mL Syringe 2.329 mL 5 mL $180.40
EPHEDRINE SULFATE-0.9%NACL(PF) 25 MG/5 ML (5 MG/ML) IV SYRINGE 70092-1478-44 5 mL Syringe 3.968 mL 5 mL $188.59
EPIDURAL ANESTHESIA TRAY REF 332209 UHCS-0005-34 1 each each 17.174 each 1 each $338.47
EPIDURAL DRUG RESERVOIR 100 ML UHCS-0001-30 1 each each 6.033 each 1 each $46.53
EPIDURAL DRUG RESERVOIR 250 ML UHCS-0001-31 1 each each 6.599 each 1 each $47.10
EPINEPHRINE 0.1 MG/ML JET NEB UHCS-0003-29 5 mL Syringe 0.798 mL 5 mL $172.74
EPINEPHRINE 0.15 MG/0.3 ML INJ ATIN 49502-101-02 2 each each 131.625 each 1 each $264.90

See Part 9