Medication Charges Part 10

FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ SOLUTION 70092-7108-36 100 mL Bag 0.338 mL 100 mL $256.55
FENTANYL-ROPIVACAINE-NACL (PF) 2-0.2 MCG/ML-% INJ SOLUTION 70092-1504-36 100 mL Bag 0.375 mL 100 mL $260.25
FERRIC CARBOXYMALTOSE 50 MG IRON/ML IV SOLUTION 0517-0650-01 15 mL Vial 58.959 mL 15 mL "$1,779.83"
FERRIC SUBSULFATE 259 MG/G TP SOLUTION 59365-6065-1 8 g Bottle 1.808 g 8 g $68.46
FERRIC SUBSULFATE 259 MG/G TP SOLUTION 59365-6065-0 8 g Bottle 10.843 g 8 g $140.74
FERROUS FUMARATE 200 MG (65 MG IRON) W/ VIT C (25 MG) ORAL TBER 3665226769 100 each each 0.132 each 1 each $12.28
FERROUS GLUCONATE 324 MG (37.5 MG IRON) ORAL TAB 2055501900 100 each each 0.023 each 1 each $12.17
FERROUS GLUCONATE 324 MG (38 MG IRON) ORAL TAB 574050811 100 each each 0.056 each 1 each $12.21
FERROUS SULFATE 140 MG (45 MG IRON) ORAL TBER 1000673014 60 each each 0.054 each 1 each $12.20
FERROUS SULFATE 142 MG (45 MG IRON) ORAL TBER 4098527343 60 each each 0.038 each 1 each $12.19
FERROUS SULFATE 15 MG IRON (75 MG)/ML ORAL DROPS 5483801150 50 mL DROP BTL 0.061 mL 50 mL $51.65
FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIXIR UHCS-0001-40 60 mL Bottle 0.014 mL 60 mL $49.44
FERROUS SULFATE 220 MG (44 MG IRON)/5 ML ORAL ELIXIR 5038377816 473 mL Bottle 0.014 mL 473 mL $55.22
FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID 121053005 5 mL Cup 0.378 mL 5 mL $14.04
FERROUS SULFATE 325 MG ORAL TAB 904759161 100 each each 0.018 each 1 each $12.17
FERROUS SULFATE DRIED 144 MG (45 MG IRON) ORAL TBER 4612208365 30 each each 0.078 each 1 each $12.23
FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLUTION 59338-775-01 17 mL Vial 18.746 mL 17 mL $641.35
FEXOFENADINE 180 MG ORAL TAB 51079-548-20 100 each each 0.759 each 1 each $12.91
FIDAXOMICIN 200 MG ORAL TAB 52015-080-01 20 each each 106.337 each 1 each $118.49
FIDAXOMICIN 200 MG ORAL TAB (ONE-TIME) 52015-080-01 20 each each 106.337 each 1 each $118.49
FINASTERIDE 5 MG ORAL TAB 0904-6830-06 50 each each 0.488 each 1 each $12.64
FINASTERIDE 5 MG ORAL TAB 0904-6830-61 100 each each 0.952 each 1 each $13.10
FLAVOXATE 100 MG ORAL TAB 50268-324-15 50 each each 1.17 each 1 each $13.32
FLECAINIDE 50 MG ORAL TAB 0054-0010-20 100 each each 0.36 each 1 each $12.51
FLECAINIDE 100 MG ORAL TAB 0054-0011-20 100 each each 0.539 each 1 each $12.69
FLU VAC QV 2022(18YR UP)RCM-PF 180 MCG (45 MCG X 4)/0.5 ML IM SYRINGE 49281-722-10 0.5 mL Syringe 122.844 mL .5 mL $230.17
FLU VAC QV 2022(18YR UP)RCM-PF 180 MCG (45 MCG X 4)/0.5 ML IM SYRINGE 49281-722-88 0.5 mL Syringe 122.844 mL .5 mL $230.17
FLU VACC QS2022-23 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE 58160-890-41 0.5 mL Syringe 31.542 mL .5 mL $184.52
FLU VACC QS2022-23 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRINGE 58160-890-52 0.5 mL Syringe 31.542 mL .5 mL $184.52
FLU VACC QS2022-23(65YR UP)-PF 240 MCG/0.7 ML IM SYRINGE 49281-122-65 0.7 mL Syringe 87.746 mL .7 mL $230.17
FLU VACC QS2022-23(65YR UP)-PF 240 MCG/0.7 ML IM SYRINGE 49281-122-88 0.7 mL Syringe 87.746 mL .7 mL $230.17
FLUCONAZOLE (DIFLUCAN) IV 2 MG/ML (NICU) UHCS-0000-48 100 mL Bag 0.046 mL 100 mL $173.35
FLUCONAZOLE (DIFLUCAN) PO 10 MG/ML (NICU) UHCS-0000-47 24 mL Bottle 0.427 mL 24 mL $31.85
FLUCONAZOLE 10 MG/ML ORAL RECON. SUSP. 16714-695-01 35 mL Bottle 0.22 mL 35 mL $56.30
FLUCONAZOLE 100 MG ORAL TAB 0904-6500-61 100 each each 0.962 each 1 each $13.11
FLUCONAZOLE IN DEXTROSE(ISO-O) 200 MG/100 ML IV IVPB 0143-9667-01 100 mL Flex Cont 0.058 mL 100 mL $174.55
FLUCONAZOLE IN NACL (ISO-OSM) 100 MG/50 ML IV IVPB 55390-194-01 50 mL Glass Cont 0.118 mL 50 mL $174.65
FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV IVPB 0409-4688-18 100 mL Flex Cont 0.042 mL 100 mL $172.95
FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV IVPB 25021-184-66 100 mL Flex Cont 0.37 mL 100 mL $205.75
FLUCONAZOLE IN NACL (ISO-OSM) 400 MG/200 ML IV IVPB 0409-4688-12 200 mL Flex Cont 0.024 mL 200 mL $173.55
FLUCONAZOLE IN NACL (ISO-OSM) 400 MG/200 ML IV IVPB 25021-184-67 200 mL Flex Cont 0.203 mL 200 mL $209.35
FLUCYTOSINE (ANCOBON) PO 10MG/ML (NICU) UHCS-0000-46 1 each each 117.856 each 1 each $139.46
FLUCYTOSINE 250 MG ORAL CAP 42794-009-08 30 each each 27.705 each 1 each $39.86
FLUDARABINE 50 MG/2 ML IV SOLUTION 63323-192-02 2 mL Vial 19.09 mL 2 mL $537.68
FLUDROCORTISONE 0.1 MG ORAL TAB 68084-288-01 100 each each 0.525 each 1 each $12.68
FLUDROCORTISONE 0.1 MG ORAL TAB 68084-288-11 100 each each 0.525 each 1 each $12.68
FLUMAZENIL 0.1 MG/ML IV SOLUTION 0143-9684-10 5 mL Vial 0.507 mL 5 mL $171.29
FLUMAZENIL 0.1 MG/ML IV SOLUTION 0143-9684-01 5 mL Vial 0.507 mL 5 mL $171.29
FLUOCINONIDE 0.05 % TP CREAM 0093-0262-30 30 g Tube 2.244 g 30 g $121.32
FLUOCINONIDE 0.05 % TP OINTMENT 51672-1264-2 30 g Tube 0.588 g 30 g $71.64
FLUORESCEIN 1 MG OPHT STRIP 17238-900-11 100 each each 0.166 each 1 each $24.47
FLUORESCEIN 500 MG/5 ML (10 %) IV SOLUTION 17478-253-10 5 mL Vial 12.902 mL 5 mL $233.26
FLUOROMETHOLONE 0.1 % OPHT DROPS. 60758-880-05 5 mL DROP BTL 13.122 mL 5 mL $126.36
FLUOROMETHOLONE 0.25 % OPHT DROPS. 11980-228-05 5 mL DROP BTL 31.108 mL 5 mL $216.29
FLUOROURACIL 5 G/100 ML IV SOLUTION 63323-117-69 100 mL Vial 0.144 mL 100 mL $513.90
FLUOROURACIL 500 MG/10 ML IV SOLUTION 63323-117-19 10 mL Vial 0.178 mL 10 mL $501.28
FLUOXETINE 10 MG ORAL CAP 0904-5784-61 100 each each 0.063 each 1 each $12.21
FLUOXETINE 20 MG ORAL CAP 0904-5785-61 100 each each 0.066 each 1 each $12.22
FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION 65862-306-12 120 mL Bottle 0.304 mL 120 mL $85.08
FLURBIPROFEN SODIUM 0.03 % OPHT DROPS 69292-722-25 2.5 mL DROP BTL 9.184 mL 2.5 mL $83.71
FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/DOSE INHL DISKUS 0173-0859-14 28 each BLIST PACK 3.216 each 1 each $164.30
FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE INHL DISKUS 0173-0882-14 28 each BLIST PACK 3.216 each 1 each $164.30
FLUTICASONE PROPIONATE 44 MCG/ACTUATION INHL HFA INHALER 0173-0718-20 10.6 g AER W/ADAP 16.087 g 10.6 g $244.77
FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASL SPRAY SUSP. 0054-3270-99 16 g AER W/ADAP 0.351 g 16 g $79.87
FLUTICASONE PROPIONATE 110 MCG/ACTUATION INHL HFA INHALER 0173-0719-20 12 g AER W/ADAP 19.023 g 12 g $302.53
FLUTICASONE PROPIONATE 220 MCG/ACTUATION INHL HFA INHALER 0173-0720-20 12 g AER W/ADAP 29.548 g 12 g $428.83
FLUTICASONE PROPION-SALMETEROL 100-50 MCG/DOSE INHL DISKUS 0173-0695-04 14 each BLIST PACK 9.911 each 1 each $213.00
FLUTICASONE PROPION-SALMETEROL 115-21 MCG/ACTUATION INHL HFA INHALER 0173-0716-22 8 g CANISTER 25.015 g 8 g $274.37
FLUTICASONE PROPION-SALMETEROL 230-21 MCG/ACTUATION INHL HFA INHALER 0173-0717-22 8 g CANISTER 37.099 g 8 g $371.04
FLUTICASONE PROPION-SALMETEROL 250-50 MCG/DOSE INHL DISKUS 0173-0696-04 14 each BLIST PACK 9.911 each 1 each $213.00
FLUTICASONE PROPION-SALMETEROL 500-50 MCG/DOSE INHL DISKUS 0173-0697-04 14 each BLIST PACK 16.154 each 1 each $300.41
FLUTICASONE-UMECLIDIN-VILANTER 100-62.5-25 MCG INHL DISKUS 0173-0887-14 28 each BLIST PACK 5.424 each 1 each $226.12
FLUTICASONE-UMECLIDIN-VILANTER 200-62.5-25 MCG INHL DISKUS 0173-0893-14 28 each each 5.424 each 1 each $226.12
FLUVASTATIN 80 MG ORAL TB24 0378-5121-93 30 each each 5.979 each 1 each $18.13
FLUVOXAMINE 50 MG ORAL TAB 51079-992-20 100 each each 0.412 each 1 each $12.56
FOLIC ACID 1 MG ORAL TAB 62584-897-01 100 each each 0.14 each 1 each $12.29
FOLIC ACID 1 MG ORAL TAB 62584-897-11 1 each each 0.14 each 1 each $12.29
FOLIC ACID 5 MG/ML INJ SOLUTION 63323-184-10 10 mL Vial 2.128 mL 10 mL "$2,518.78"
FOLIC ACID-VIT B6-VIT B12 2.5-25-2 MG ORAL TAB 6936722409 90 each each 0.113 each 1 each $12.26
FOLIC ACID-VIT B6-VIT B12 2.5-25-2 MG ORAL TAB 5199138490 90 each each 0.368 each 1 each $12.52
FOMEPIZOLE 1 G/ML IV SOLUTION 0517-0710-01 1.5 mL Vial 350.627 mL 1.5 mL "$1,058.46"
FONDAPARINUX 10 MG/0.8 ML SUBQ SYRINGE 55150-233-10 0.8 mL Syringe 12.853 mL .8 mL $179.03
FONDAPARINUX 2.5 MG/0.5 ML SUBQ SYRINGE 55150-230-10 0.5 mL Syringe 12.132 mL .5 mL $174.82
FONDAPARINUX 7.5 MG/0.6 ML SUBQ SYRINGE 55150-232-10 0.6 mL Syringe 17.102 mL .6 mL $179.01
FORMOTEROL FUMARATE 20 MCG/2 ML INHL NEBULIZER 49502-605-30 2 mL Vial 2.17 mL 2 mL $15.14
FOSAPREPITANT 150 MG IV VIAL 0143-9384-01 1 each each 21.67 each 1 each $190.42
FOSCARNET 24 MG/ML IV SOLUTION 25021-189-84 250 mL Bag 1.33 mL 250 mL $636.25
FOSCARNET 24 MG/ML IV SOLUTION 63323-875-50 250 mL Bottle 1.572 mL 250 mL $696.75
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACKET 0456-4300-01 1 each each 64.92 each 1 each $77.07
FOSFOMYCIN TROMETHAMINE 3 G ORAL PACKET 70700-268-94 1 each each 74.18 each 1 each $86.33
FOSINOPRIL 10 MG ORAL TAB 76282-200-90 90 each each 0.173 each 1 each $12.32
FOSINOPRIL 20 MG ORAL TAB 69097-857-05 90 each each 0.103 each 1 each $12.25
FOSPHENYTOIN (CEREBYX) IV 10 MG/ML (NICU) UHCS-0000-45 10 mL Vial 0.695 mL 10 mL $175.70
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLUTION 0069-6001-25 2 mL Vial 1.057 mL 2 mL $170.86
FOSPHENYTOIN 100 MG PE/2 ML INJ SOLUTION 67457-516-25 2 mL Vial 6.926 mL 2 mL $182.60
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLUTION 0069-6001-21 10 mL Vial 1.204 mL 10 mL $180.79
FOSPHENYTOIN 500 MG PE/10 ML INJ SOLUTION 0069-5474-02 10 mL Vial 1.204 mL 10 mL $180.79
FULVESTRANT 250 MG/5 ML IM SYRINGE 71288-555-86 5 mL Syringe 17.55 mL 5 mL $587.25
FULVESTRANT 250 MG/5 ML IM SYRINGE 0310-0720-10 5 mL Syringe 188.088 mL 5 mL "$1,892.64"
FUROSEMIDE (LASIX) PO 10 MG/ML (NICU) UHCS-0000-44 60 mL Bottle 0.07 mL 60 mL $25.80
FUROSEMIDE 10 MG/ML INJ SOLUTION 0409-6102-25 2 mL Vial 0.314 mL 2 mL $169.38
FUROSEMIDE 10 MG/ML INJ SOLUTION 0409-6102-26 4 mL Vial 0.166 mL 4 mL $169.41
FUROSEMIDE 10 MG/ML INJ SOLUTION 0409-6102-36 4 mL Vial 0.166 mL 4 mL $169.41
FUROSEMIDE 10 MG/ML INJ SOLUTION 0409-6102-27 10 mL Vial 0.094 mL 10 mL $169.69
FUROSEMIDE 10 MG/ML ORAL SOLUTION 0054-3294-46 60 mL Bottle 0.07 mL 60 mL $52.80
FUROSEMIDE 20 MG ORAL TAB 0054-8297-25 100 each each 0.074 each 1 each $12.22
FUROSEMIDE 40 MG ORAL TAB 0054-8299-25 100 each each 0.074 each 1 each $12.22
FUROSEMIDE 80 MG ORAL TAB 51079-527-20 100 each each 0.112 each 1 each $12.26
GABAPENTIN 100 MG ORAL CAP 63739-591-10 100 each each 0.083 each 1 each $12.23
GABAPENTIN 300 MG ORAL CAP 67877-223-10 1000 each each 0.034 each 1 each $12.18
GABAPENTIN 300 MG ORAL CAP 67877-223-01 100 each each 0.061 each 1 each $12.21
GABAPENTIN 300 MG ORAL CAP 63739-236-10 100 each each 0.15 each 1 each $12.30
GABAPENTIN 400 MG ORAL CAP 63739-984-10 100 each each 0.172 each 1 each $12.32
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLUTION 0270-5164-14 15 mL Vial 1.551 mL 15 mL $192.02
GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLUTION 0270-5164-15 20 mL Vial 1.551 mL 20 mL $199.77
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) IV SOLUTION 50419-325-12 10 mL Vial 2.679 mL 10 mL $195.54
GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) IV SYRINGE 50419-325-28 10 mL Syringe 3.034 mL 10 mL $199.09
GADOBUTROL 15 MMOL/15 ML (1 MMOL/ML) IV SOLUTION 50419-325-13 15 mL Vial 2.679 mL 15 mL $208.94
GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) IV SYRINGE 50419-325-27 7.5 mL Syringe 3.153 mL 7.5 mL $192.40
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML (469.01 MG/ML) IV SOLUTION 50419-188-84 20 mL Vial 3.836 mL 20 mL $245.47
GADOPENTETATE DIMEGLUMINE 10 MMOL/20 ML (469.01 MG/ML) IV SYRINGE 50419-188-38 20 mL Syringe 4.159 mL 20 mL $251.93
GADOPENTETATE DIMEGLUMINE 2.5 MMOL/5 ML (469.01 MG/ML) IV SOLUTION 50419-188-81 5 mL Vial 4.27 mL 5 mL $190.10
GADOPENTETATE DIMEGLUMINE 7.5 MMOL/15 ML (469.01 MG/ML) IV SOLUTION 50419-188-83 15 mL Vial 3.882 mL 15 mL $226.98
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLUTION 0407-2943-02 15 mL Vial 0.924 mL 15 mL $182.61
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLUTION 67684-2001-2 15 mL Vial 1.062 mL 15 mL $184.68
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLUTION 0407-2943-05 20 mL Vial 0.924 mL 20 mL $187.23
GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLUTION 67684-2001-3 20 mL Vial 1.062 mL 20 mL $189.99
GADOTERIDOL 279.3 MG/ML IV SOLUTION 0270-1111-02 15 mL Vial 1.302 mL 15 mL $188.28
GADOTERIDOL 279.3 MG/ML IV SOLUTION 0270-1111-03 20 mL Vial 1.302 mL 20 mL $194.79
GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) IV SOLUTION 50419-320-05 10 mL Vial 13.112 mL 10 mL $299.87
GALANTAMINE 4 MG ORAL TAB 68084-729-21 30 each each 2.234 each 1 each $14.38
GALANTAMINE 8 MG ORAL C24P 47335-835-83 30 each each 1.145 each 1 each $13.30
GANCICLOVIR SODIUM 500 MG IV VIAL 70436-089-55 1 each each 37.142 each 1 each $536.64
GANCICLOVIR SODIUM 500 MG IV VIAL 63323-315-10 1 each each 44.587 each 1 each $544.09
GELATIN ABSORBABLE MM POWDER 0009-0433-04 1 g Packet 50.315 g 1 g $104.32
GELATIN ABSORBABLE OPHT FILM 9029703 6 each each 207.7 each 1 each $232.00
"GELATIN SPONGE,ABSORB-PORCINE 100 TP SPONGE" 0009-0342-01 6 each each 17.605 each 1 each $71.61
"GELATIN SPONGE,ABSORB-PORCINE 100 TP SPONGE" 6371301974 6 each each 18.728 each 1 each $72.73
"GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TP SPONGE" 6371301972 12 each each 3.837 each 1 each $8.34
GELFOAM 12-7 MM SPONGE UHCS-0001-72 1 each each 3.853 each 1 each $57.85
GEMCITABINE 1 G IV VIAL 25021-235-50 1 each each 15.24 each 1 each $514.74
GEMCITABINE 200 MG IV VIAL 71288-113-10 1 each each 3.97 each 1 each $503.47
GEMCITABINE 200 MG IV VIAL 25021-234-10 1 each each 5.08 each 1 each $504.58
GEMFIBROZIL 600 MG ORAL TAB 60687-224-01 100 each each 0.241 each 1 each $12.39
GENTAMICIN (GARAMYCIN) IM 10 MG/ML (NICU) UHCS-0000-59 2 mL Vial 0.831 mL 2 mL $170.41
GENTAMICIN 0.1 % TP CREAM 45802-056-35 15 g Tube 1.843 g 15 g $81.65
GENTAMICIN 0.1 % TP OINTMENT 45802-046-35 15 g Tube 1.862 g 15 g $81.93
GENTAMICIN 0.3 % OPHT DROPS 60758-188-05 5 mL DROP BTL 0.61 mL 5 mL $63.80
GENTAMICIN 40 MG/ML INJ SOLUTION 0409-1207-25 2 mL Vial 0.412 mL 2 mL $169.57

See Part 11