Background In 2024 incidence of tuberculosis in England rose to 9.4 per 100,000, which is close to exceeding the low-incidence designation threshold. Addressing the rising incidence requires policy making to ensure sufficient staff, hospital resources and budgets are available to meet the increasing demand. However, costing of active pulmonary TB in the UK are limited and better clarity is needed on the clinical pathway of tuberculosis and the resources involved. Objective This study aims to estimate the costs of active pulmonary drug-sensitive tuberculosis care in England using a micro-costing approach. Method The analysis was performed from the perspective of the National Health Service (NHS), capturing direct medical costs only. The clinical pathway for different severities of tuberculosis care was defined through a review of the literature, clinical guidelines, and interviews with clinicians. Costs were mainly drawn from the British National Formulary and the eMIT national database for drug costs, and the National Cost Collection (2021-22) for diagnostics, monitoring, nursing and hospitalisation alongside a desk-based review. Results Per-patient costs in 2021 ranged from approximately GBP2,000 for community-managed cases to over GBP50,000 for the most complex patients. An estimated 70% of patients cost between GBP4,971 and GBP7,307. The weighted average cost of treatment across all complexities was GBP8,125 per patient reflective of the proportion of cases at each severity. For the 4,423 patients in 2021, it is estimated that the costs of direct treatment were at least GBP36 million, highlighting the significant financial implications of increasing tuberculosis. Conclusion The findings demonstrate that tuberculosis care imposes a substantial and highly variable cost burden on the NHS. Overall, this study provides cost estimates that can inform service planning, resource allocation, and future economic evaluations. Further research is needed on the costs of drug-resistant TB to support comprehensive TB control strategies.