AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR

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1 NDC Code HCPCS Code Medication Name & Amount Inpatient Fee J8499 ACETAMINOPHEN 80 MG CHEWABLE TABLET J3490 ACETAMINOPHEN 325 MG TABLET J3490 ACETAMINOPHEN 325 MG TABLET J3490 ACETAMINOPHEN 325 MG TABLET J8499 ACETAMINOPHEN 500 MG TABLET J8499 ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY J8499 ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY J8499 ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY J8499 ACETAZOLAMIDE 250 MG TABLET J1120 ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION 2, J3490 ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION J3490 ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION ACETYLCYSTEINE 200 MG/ML (20 %) SOLUTION J8499 TETRACYCLINE 250 MG CAPSULE P9047 ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION 2, P9047 ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION 2, P9045 ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION 1, P9045 ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION 3, P9045 ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION 4, P9045 ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION 1, J8499 ALBUTEROL SULFATE 2 MG/5 ML SYRUP 1, Outpatient Fee $ $ 1.00 $ $ 1.00 $ $ 1.00 $ $ 1.00 $ $ 1.00 $ $ $ $ $ $ $ $ 2.79 $ $ 2, $ $ $ $ $ $ $ $ $ $ 2, $ $ 2, $ $ 1, $ $ 3, $ $ 4, $ $ 1, $ $ 1, J3490 ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION $ 3, $ 3, J8499 ALLOPURINOL 100 MG TABLET $ 1.00 $ J8499 ALLOPURINOL 300 MG TABLET $ 1.00 $ J8499 ALPRAZOLAM 0.25 MG TABLET $ $ J8499 ALPRAZOLAM 0.5 MG TABLET $ $ ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL J8499 SUSPENSION $ $ ALUMINUM HYDROXIDE GEL 320 MG/5 ML ORAL SUSPENSION $ $ J8499 AMANTADINE HCL 100 MG CAPSULE $ 1.00 $ J0280 AMINOPHYLLINE 250 MG/10 ML INTRAVENOUS SOLUTION $ $ J8499 AMITRIPTYLINE 10 MG TABLET $ 1.00 $ J8499 AMITRIPTYLINE 25 MG TABLET $ 1.00 $ J8499 AMITRIPTYLINE 50 MG TABLET $ 1.00 $ AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR J3490 INHALATION $ $ J8499 AMOXICILLIN 250 MG CAPSULE $ $ J8499 AMOXICILLIN 500 MG CAPSULE $ 1.00 $ J8499 AMOXICILLIN 500 MG CAPSULE $ 1.00 $ J8499 AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION $ $ J8499 AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION $ $

2 J8499 AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION $ $ J0285 AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION $ 1, $ 1, J8499 AMPICILLIN 250 MG CAPSULE $ $ J8499 AMPICILLIN 500 MG CAPSULE $ $ J8499 AMPICILLIN 500 MG CAPSULE $ $ J0290 AMPICILLIN 1 GRAM SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 1 GRAM SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 1 GRAM SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 125 MG SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 2 GRAM SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 2 GRAM SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 250 MG SOLUTION FOR INJECTION $ $ J0290 AMPICILLIN 500 MG SOLUTION FOR INJECTION $ $ J8499 ASCORBIC ACID (VITAMIN C) 250 MG TABLET $ 1.00 $ J8499 ASCORBIC ACID (VITAMIN C) 500 MG TABLET $ 1.00 $ J8499 ASPIRIN 81 MG CHEWABLE TABLET $ $ J8499 ASPIRIN 81 MG CHEWABLE TABLET $ $ J8499 ASPIRIN 325 MG TABLET,DELAYED RELEASE $ 1.00 $ J8499 ASPIRIN 81 MG TABLET,DELAYED RELEASE $ 1.00 $ J8499 ATENOLOL 25 MG TABLET $ 1.00 $ J8499 ATENOLOL 50 MG TABLET $ $ J0461 ATROPINE 0.1 MG/ML INJECTION SYRINGE $ $ J0461 ATROPINE 0.1 MG/ML INJECTION SYRINGE $ $ J0461 ATROPINE 0.1 MG/ML INJECTION SYRINGE $ $ J0461 ATROPINE 0.4 MG/ML INJECTION SOLUTION $ $ J0461 ATROPINE 0.4 MG/ML INJECTION SOLUTION $ 1, $ 1, J3490 ATROPINE 1 % EYE DROPS $ 1, $ 1, J8499 B COMPLEX WITH VITAMIN C TABLET $ $ J3490 BACITRACIN 50,000 UNIT INTRAMUSCULAR SOLUTION $ $ J3490 BACITRACIN 500 UNIT/GRAM EYE OINTMENT $ 3, $ 3, NEOMYCIN BACITRACN ZN POLYMYX 3.5 MG 400 UNIT J3490 5,000 UNIT/GRAM TOP OINT $ $ BACITRACIN POLYMYXIN B 500 UNIT 10,000 UNIT/GRAM J3490 TOPICAL OINTMENT $ $ BACITRACIN POLYMYXIN B 500 UNIT 10,000 UNIT/GRAM J3490 EYE OINTMENT $ $ J8499 BACLOFEN 10 MG TABLET $ $ WATER FOR INJECTION, BACTERIOSTATIC INJECTION J3490 SOLUTION $ $ J8499 BENZONATATE 100 MG CAPSULE $ 1.00 $ J8499 BENZONATATE 100 MG CAPSULE $ 1.00 $ J8499 BENZTROPINE 1 MG TABLET $ $ J8499 BETHANECHOL CHLORIDE 25 MG TABLET $ 1.00 $ J8499 BISACODYL 10 MG RECTAL SUPPOSITORY $ $ J8499 BISACODYL 10 MG RECTAL SUPPOSITORY $ $ 59.00

3 BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION J3490 SOLUTION $ $ BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION J3490 SOLUTION $ $ BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION J3490 SOLUTION $ $ BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION J3490 SOLUTION $ $ J3490 BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION $ $ J3490 BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION $ $ J3490 BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION $ $ BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION J3490 SOLUTION $ $ J8499 CAFFEINE 200 MG TABLET $ $ CALCIUM CARBONATE 500 MG CALCIUM (1,250 MG) J8499 TABLET $ 1.00 $ CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS J3490 SYRINGE $ $ CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS J3490 SYRINGE $ $ CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS J0610 SOLUTION $ $ CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS J0610 SOLUTION $ $ CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS J0610 SOLUTION $ $ J8499 CARBAMAZEPINE 100 MG CHEWABLE TABLET $ $ J8499 CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION $ 2, $ 2, J8499 CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION $ $ J8499 CARBAMAZEPINE 200 MG TABLET $ 1.55 $ J3490 CARBAMIDE PEROXIDE 6.5 % EAR DROPS $ $ J8499 CARISOPRODOL 350 MG TABLET $ $ J0690 CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION $ $ J0690 CEFAZOLIN 10 GRAM SOLUTION FOR INJECTION $ $ J0690 CEFAZOLIN 500 MG SOLUTION FOR INJECTION $ $ J0697 CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION $ $ J0697 CEFUROXIME SODIUM 750 MG SOLUTION FOR INJECTION $ $ J8499 CEPHALEXIN 250 MG CAPSULE $ $ J8499 CEPHALEXIN 500 MG CAPSULE $ $ J8499 CHERRY FLAVOR (BULK) SYRUP $ $ CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION J2400 SOLUTION $ $

4 CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION J2400 SOLUTION $ $ CHLOROPROCAINE (PF) 30 MG/ML (3 %) INJECTION J2400 SOLUTION $ $ J3230 CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION $ 1, $ 1, J8499 CHLORPROMAZINE 25 MG TABLET $ 4.52 $ J8499 CHLORTHALIDONE 25 MG TABLET $ 2.39 $ J8499 CLINDAMYCIN HCL 150 MG CAPSULE $ $ J3490 CLINDAMYCIN 150 MG/ML INJECTION SOLUTION $ $ J3490 CLINDAMYCIN 150 MG/ML INJECTION SOLUTION $ $ J3490 CLINDAMYCIN 150 MG/ML INJECTION SOLUTION $ $ J3490 CLINDAMYCIN 150 MG/ML INJECTION SOLUTION $ $ J3490 CLINDAMYCIN 150 MG/ML INJECTION SOLUTION $ $ J8499 CLONIDINE HCL 0.1 MG TABLET $ $ J8499 CLONIDINE HCL 0.1 MG TABLET $ $ J8499 CLONIDINE HCL 0.2 MG TABLET $ $ J3490 CLOTRIMAZOLE 1 % TOPICAL CREAM $ $ J3490 CLOTRIMAZOLE 1 % VAGINAL CREAM $ $ J8499 ASPIRIN 325 MG TABLET $ 1.00 $ J3490 COCAINE 4 % TOPICAL SOLUTION $ 7, $ 7, J8499 CODEINE SULFATE 30 MG TABLET $ $ J8499 COLCHICINE 0.6 MG TABLET $ 8.90 $ CYANOCOBALAMIN (VIT B 12) 1,000 MCG/ML INJECTION J3420 SOLUTION $ $ CYANOCOBALAMIN (VIT B 12) 1,000 MCG/ML INJECTION J3420 SOLUTION $ $ J8499 CYCLOBENZAPRINE 10 MG TABLET $ $ J3490 CYCLOPENTOLATE 1 % EYE DROPS $ $ J8499 CYPROHEPTADINE 4 MG TABLET $ $ J8499 DOCUSATE SODIUM 100 MG CAPSULE $ $ J8499 DAPSONE 25 MG TABLET $ $ J8540 DEXAMETHASONE 0.5 MG TABLET $ $ J8540 DEXAMETHASONE 4 MG TABLET $ $ J1100 DEXAMETHASONE 10 MG/ML INJECTION SOLUTION $ $ J1100 DEXAMETHASONE 10 MG/ML INJECTION SOLUTION $ $ J1100 DEXAMETHASONE 4 MG/ML INJECTION SOLUTION $ $ DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS J3490 SOLUTION $ $ DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS J3490 SOLUTION $ $ J3490 DEXTROSE 25 % IN WATER (D25W) INTRAVENOUS SYRINGE $ $ J7060 DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $

5 J7070 DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ J7060 DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ J7060 DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION $ $ DEXTROSE 70 % IN WATER (D70W) INTRAVENOUS J3490 SOLUTION $ $ J8499 DIAZEPAM 2 MG TABLET $ 1.00 $ J8499 DIAZEPAM 5 MG TABLET $ 1.00 $ J3490 DIBUCAINE 1 % TOPICAL OINTMENT $ $ J8499 DICYCLOMINE 10 MG CAPSULE $ $ J3490 DIGOXIN 50 MCG/ML ORAL SOLUTION $ $ J3490 DIGOXIN 50 MCG/ML ORAL SOLUTION $ 4.24 $ J8499 DIGOXIN 250 MCG TABLET $ 2.23 $ J8499 DILTIAZEM 30 MG TABLET $ 1.00 $ J8499 DILTIAZEM 60 MG TABLET $ 1.00 $ J8499 DILTIAZEM 90 MG TABLET $ 1.00 $ J1200 DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION $ $ J1200 DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION $ $ J1200 DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION $ $ J8499 DIPHENHYDRAMINE 25 MG CAPSULE $ 1.00 $ J8499 DIPHENHYDRAMINE 50 MG CAPSULE $ $ J8499 DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR $ $ DIPHENOXYLATE ATROPINE 2.5 MG MG/5 ML ORAL J8499 LIQUID $ 2, $ 2, DIPHENOXYLATE ATROPINE 2.5 MG MG/5 ML ORAL J8499 LIQUID $ $ J8499 DIPHENOXYLATE ATROPINE 2.5 MG MG TABLET $ $ J3490 DOCUSATE CALCIUM 240 MG CAPSULE $ $ J8499 DOXEPIN 25 MG CAPSULE $ 1.00 $ J9000 DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION $ $ J9000 DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION $ $ DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER J3490 FOR SOLUTION $ 1, $ 1, BUPRENORPHINE 4 MG NALOXONE 1 MG SUBLINGUAL J3490 FILM $ $ J8499 DOXYLAMINE SUCCINATE 25 MG TABLET $ $ J8499 DOXYLAMINE SUCCINATE 25 MG TABLET $ $ 59.00

6 J3490 EPHEDRINE SULFATE 50 MG/ML INJECTION SOLUTION $ 1, $ 1, J0171 EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE $ $ J0171 EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE $ $ J3490 ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT $ $ J3490 ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT $ $ J3490 ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT $ $ ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML ORAL J8499 POWDER FOR SUSPENSION $ 9, $ 9, ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS J1364 SOLUTION $ 2, $ 2, J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ J3010 FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION $ $ FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL J8499 LIQUID $ 2.01 $ FERROUS SULFATE 325 MG (65 MG IRON) TABLET,DELAYED J3490 RELEASE $ 1.00 $ J3490 FLUOCINONIDE 0.05 % TOPICAL CREAM $ 1, $ 1, J8499 FLUPHENAZINE 5 MG TABLET $ $ J3490 FOLIC ACID 5 MG/ML INJECTION SOLUTION $ 1, $ 1, J8499 FOLIC ACID 1 MG TABLET $ 1.00 $ J8499 FOLIC ACID 400 MCG TABLET $ 1.00 $ J1940 FUROSEMIDE 10 MG/ML INJECTION SOLUTION $ $ J1940 FUROSEMIDE 10 MG/ML INJECTION SOLUTION $ $ J1940 FUROSEMIDE 10 MG/ML INJECTION SOLUTION $ $ J8499 FUROSEMIDE 20 MG TABLET $ 1.00 $ J8499 FUROSEMIDE 40 MG TABLET $ $ J8499 FUROSEMIDE 80 MG TABLET $ 1.00 $ J8499 FUROSEMIDE 80 MG TABLET $ 1.00 $ J1580 GENTAMICIN 40 MG/ML INJECTION SOLUTION $ $ J1580 GENTAMICIN 40 MG/ML INJECTION SOLUTION $ $ J8499 GLYBURIDE 5 MG TABLET $ 1.00 $ J8499 GLYCERIN (CHILD) RECTAL SUPPOSITORY $ $ J8499 GLYCERIN (CHILD) RECTAL SUPPOSITORY $ $ J3490 GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION $ $ J8499 HALOPERIDOL 1 MG TABLET $ $ J8499 HALOPERIDOL 5 MG TABLET $ $ J1630 HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION $ $ J1630 HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION $ $ J3490 HOMATROPINE 5 % EYE DROPS $ $ J0360 HYDRALAZINE 20 MG/ML INJECTION SOLUTION $ $

7 J0360 HYDRALAZINE 20 MG/ML INJECTION SOLUTION $ $ J0360 HYDRALAZINE 20 MG/ML INJECTION SOLUTION $ $ J8499 HYDRALAZINE 10 MG TABLET $ 1.00 $ J8499 HYDRALAZINE 25 MG TABLET $ 1.00 $ J8499 HYDRALAZINE 50 MG TABLET $ 1.00 $ J8499 HYDROCHLOROTHIAZIDE 25 MG TABLET $ 1.00 $ J8499 HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY $ $ J8499 HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY $ $ J1170 HYDROMORPHONE 1 MG/ML INJECTION SYRINGE $ $ J1170 HYDROMORPHONE 2 MG/ML INJECTION SYRINGE $ $ J8499 HYDROMORPHONE 2 MG TABLET $ $ J8499 HYDROMORPHONE 2 MG TABLET $ $ J3410 HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION $ $ J8499 HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION $ $ J8499 HYDROXYZINE HCL 10 MG TABLET $ 1.00 $ J8499 HYDROXYZINE HCL 25 MG TABLET $ $ J8499 HYOSCYAMINE MG SUBLINGUAL TABLET $ $ J8499 IBUPROFEN 400 MG TABLET $ $ J8499 IBUPROFEN 600 MG TABLET $ $ J8499 IBUPROFEN 800 MG TABLET $ $ J8499 IBUPROFEN 200 MG TABLET $ 1.00 $ J8499 IMIPRAMINE 10 MG TABLET $ $ J8499 IMIPRAMINE 25 MG TABLET $ 1.00 $ J8499 INDAPAMIDE 2.5 MG TABLET $ 1.00 $ J8499 INDOMETHACIN 25 MG CAPSULE $ $ J8499 ISONIAZID 300 MG TABLET $ $ J8499 ISOSORBIDE DINITRATE 10 MG TABLET $ $ J8499 ISOSORBIDE DINITRATE 20 MG TABLET $ $ J8499 ISOSORBIDE DINITRATE 5 MG TABLET $ $ J3490 KETAMINE 10 MG/ML INJECTION SOLUTION $ $ J3490 KETAMINE 100 MG/ML INJECTION SOLUTION $ $ J3490 LYSINE 500 MG TABLET $ 1.00 $ J8499 LEVOTHYROXINE 100 MCG TABLET $ 1.60 $ J8499 LEVOTHYROXINE 150 MCG TABLET $ 1.58 $ J7120 LACTATED RINGERS INTRAVENOUS SOLUTION $ $ J0640 LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION $ $ J0640 LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION $ $ J8499 LEUCOVORIN CALCIUM 5 MG TABLET $ $ J8499 LEVOTHYROXINE 25 MCG TABLET $ 1.55 $ J8499 LEVOTHYROXINE 50 MCG TABLET $ 1.58 $ J8499 LEVOTHYROXINE 75 MCG TABLET $ 1.58 $ J3490 LIDOCAINE 4 % (40 MG/ML) MUCOSAL SOLUTION $ 1, $ 1,285.43

8 J3490 LIDOCAINE 5 MG/ML (0.5 %) INJECTION SOLUTION $ $ J3490 LIDOCAINE 5 MG/ML (0.5 %) INJECTION SOLUTION $ $ J3490 LIDOCAINE 10 MG/ML (1 %) INJECTION SOLUTION $ $ J3490 LIDOCAINE 10 MG/ML (1 %) INJECTION SOLUTION $ $ J3490 LIDOCAINE 20 MG/ML (2 %) INJECTION SOLUTION $ $ J3490 LIDOCAINE 20 MG/ML (2 %) INJECTION SOLUTION $ $ J8499 LISINOPRIL 20 MG TABLET $ 1.00 $ J8499 LITHIUM CARBONATE 150 MG CAPSULE $ $ J8499 LITHIUM CARBONATE 300 MG CAPSULE $ 1.00 $ J8499 LITHIUM CITRATE 8 MEQ/5 ML ORAL SOLUTION $ $ J8499 LOPERAMIDE 2 MG CAPSULE $ $ J8499 LOPERAMIDE 1 MG/5 ML ORAL LIQUID $ $ J8499 LORAZEPAM 0.5 MG TABLET $ $ J8499 LORAZEPAM 1 MG TABLET $ 1.00 $ J8499 MAGNESIUM CITRATE ORAL SOLUTION $ $ MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION J3475 SOLUTION $ $ MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION J3475 SOLUTION $ $ J3490 MANNITOL 20 % INTRAVENOUS SOLUTION $ $ J2150 MANNITOL 25 % INTRAVENOUS SOLUTION $ $ J8499 MEDROXYPROGESTERONE 10 MG TABLET $ 1.00 $ J8499 MEDROXYPROGESTERONE 2.5 MG TABLET $ 1.00 $ J8499 MEGESTROL 20 MG TABLET $ 1.00 $ J8499 METHADONE 5 MG/5 ML ORAL SOLUTION $ $ J8499 METHADONE 5 MG/5 ML ORAL SOLUTION $ 1.00 $ J8499 METHADONE 10 MG TABLET $ 1.00 $ J8499 METHADONE 5 MG TABLET $ 1.00 $ J2800 METHOCARBAMOL 100 MG/ML INJECTION SOLUTION $ 1, $ 1, J8499 METHOCARBAMOL 500 MG TABLET $ 1.00 $ METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION J9260 SOLUTION $ $ METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION J9260 SOLUTION $ $ J8499 METHYLDOPA 250 MG TABLET $ 1.00 $ METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) C9399 INTRAVENOUS SOLUTION $ 6, $ 6, J8499 METHYLPHENIDATE 5 MG TABLET $ $ J7509 METHYLPREDNISOLONE 4 MG TABLET $ $ METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION J1040 FOR INJECTION $ $ J2765 METOCLOPRAMIDE 5 MG/ML INJECTION SOLUTION $ $ J8499 METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION $ 1, $ 1, J8499 METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION $ $ J8499 METOCLOPRAMIDE 10 MG TABLET $ $ J8499 METOCLOPRAMIDE 5 MG TABLET $ 1.00 $ 1.00

9 METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS J3490 SOLUTION $ $ J8499 METOPROLOL TARTRATE 50 MG TABLET $ $ J8499 METRONIDAZOLE 250 MG TABLET $ $ J8499 METRONIDAZOLE 500 MG TABLET $ $ J8499 METRONIDAZOLE 500 MG TABLET $ $ J8499 METRONIDAZOLE 500 MG TABLET $ $ J8499 METRONIDAZOLE 500 MG TABLET $ $ METRONIDAZOLE 500 MG/100 ML SODIUM CHLORIDE(ISO) J3490 INTRAVENOUS PIGGYBACK $ $ J3490 MICONAZOLE NITRATE 2 % TOPICAL CREAM $ $ J3490 MICONAZOLE NITRATE 2 % VAGINAL CREAM $ $ J3490 MINERAL OIL ORAL $ $ J3490 MINERAL OIL ENEMA $ $ J8499 MINOXIDIL 2.5 MG TABLET $ 1.00 $ J2270 MORPHINE 15 MG/ML INJECTION SOLUTION $ $ J3490 NAFCILLIN 1 GRAM SOLUTION FOR INJECTION $ $ J3490 NAFCILLIN 1 GRAM SOLUTION FOR INJECTION $ $ J3490 NAFCILLIN 10 GRAM SOLUTION FOR INJECTION $ 2, $ 2, J2300 NALBUPHINE 20 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ 3, $ 3, J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J2310 NALOXONE 0.4 MG/ML INJECTION SOLUTION $ $ J8499 NAPROXEN 250 MG TABLET $ $ J8499 NAPROXEN 375 MG TABLET $ $ J8499 NEOMYCIN 500 MG TABLET $ $ J8499 NIACIN 50 MG TABLET $ $ J8499 NIACIN 500 MG TABLET $ $ J8499 NIFEDIPINE 10 MG CAPSULE $ 1.00 $ J8499 NITROFURANTOIN MACROCRYSTAL 50 MG CAPSULE $ 2.88 $ J8499 NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET $ 1.64 $ J3490 NITROGLYCERIN 2 % TRANSDERMAL OINTMENT $ $ J8499 NORTRIPTYLINE 10 MG CAPSULE $ 1.00 $ J8499 NORTRIPTYLINE 25 MG CAPSULE $ 1.00 $ J3490 NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM $ $ J3490 NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM $ 1, $ 1, J3490 NYSTATIN 100,000 UNIT/GRAM TOPICAL CREAM $ $ J3490 NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION $ $ J3490 NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION $ $ NYSTATIN TRIAMCINOLONE 100,000 UNIT/G 0.1 % J3490 TOPICAL CREAM $ 3, $ 3, J8499 OXYBUTYNIN CHLORIDE 5 MG TABLET $ 1.00 $ 1.00

10 J8499 OXYCODONE ACETAMINOPHEN 5 MG 325 MG TABLET $ $ J8499 OXYCODONE ACETAMINOPHEN 5 MG 325 MG TABLET $ $ J3490 OXYMETAZOLINE 0.05 % NASAL SPRAY $ $ J2590 OXYTOCIN 10 UNIT/ML INJECTION SOLUTION $ $ J2590 OXYTOCIN 10 UNIT/ML INJECTION SOLUTION $ $ J2590 OXYTOCIN 10 UNIT/ML INJECTION SOLUTION $ $ PENICILLIN G POTASSIUM 20 MILLION UNIT SOLUTION FOR J2540 INJECTION $ 1, $ 1, PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR J2540 INJECTION $ $ J8499 PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION $ $ J8499 PENICILLIN V POTASSIUM 250 MG TABLET $ $ J8499 PENICILLIN V POTASSIUM 500 MG TABLET $ $ J8499 PHENAZOPYRIDINE 100 MG TABLET $ $ J8499 PHENAZOPYRIDINE 200 MG TABLET $ $ J8499 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR $ 2, $ 2, J8499 PHENOBARBITAL 32.4 MG TABLET $ 1.00 $ J8499 PHENOBARBITAL 97.2 MG TABLET $ 1.25 $ PHENOBARBITAL SODIUM 130 MG/ML INJECTION J2560 SOLUTION $ 2, $ 2, PHENOBARB HYOSCY ATROPINE SCOP 16.2 MG MG J MG/5 ML ELIXIR $ 15, $ 15, PHENOBARB HYOSCY ATROPINE SCOP 16.2 MG MG J MG/5 ML ELIXIR $ $ J3490 PHENYLEPHRINE 10 % EYE DROPS $ 1, $ 1, J3490 PHENYLEPHRINE 2.5 % EYE DROPS $ 1, $ 1, J1165 PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION $ $ J1165 PHENYTOIN SODIUM 50 MG/ML INTRAVENOUS SOLUTION $ $ J8499 PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE $ 1.79 $ J3490 PHYSOSTIGMINE 1 MG/ML INJECTION SOLUTION $ 1, $ 1, PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML INJECTION J3430 SYRINGE $ $ J3490 PILOCARPINE 1 % EYE DROPS $ 2, $ 2, J3490 POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION $ $ POTASSIUM BICARBONATE CITRIC ACID 25 MEQ J8499 EFFERVESCENT TABLET $ $ POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS J3480 SOLUTION $ $ POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS J3480 SOLUTION $ $

11 POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS J3480 SOLUTION $ $ POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS J3480 SOLUTION $ $ POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS J3480 SOLUTION $ $ POTASSIUM CHLORIDE ER 10 MEQ CAPSULE,EXTENDED J8499 RELEASE $ 1.05 $ J8499 POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID $ $ J8499 POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID $ $ POTASSIUM PHOSPHATES MBASIC AND DIBASIC 3 J3490 MMOL/ML INTRAVENOUS SOLUTION $ $ J8499 PRAZOSIN 1 MG CAPSULE $ 1.58 $ J8499 PRAZOSIN 2 MG CAPSULE $ 2.18 $ J3490 PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION $ 1, $ 1, J7512 PREDNISONE 1 MG TABLET $ $ J7512 PREDNISONE 10 MG TABLET $ $ J7512 PREDNISONE 20 MG TABLET $ 1.00 $ J7512 PREDNISONE 5 MG TABLET $ $ J2690 PROCAINAMIDE 500 MG/ML INJECTION SOLUTION $ 2, $ 2, J8597 PROCHLORPERAZINE MALEATE 10 MG TABLET $ $ J8597 PROCHLORPERAZINE MALEATE 5 MG TABLET $ $ J8597 PROCHLORPERAZINE MALEATE 5 MG TABLET $ $ J2550 PROMETHAZINE 25 MG/ML INJECTION SOLUTION $ $ J2550 PROMETHAZINE 50 MG/ML INJECTION SOLUTION $ $ J2550 PROMETHAZINE 50 MG/ML INJECTION SOLUTION $ $ J8597 PROMETHAZINE 12.5 MG TABLET $ $ J8597 PROMETHAZINE 25 MG TABLET $ $ J8499 PROMETHAZINE 6.25 MG CODEINE 10 MG/5 ML SYRUP $ $ J8499 PROMETHAZINE 6.25 MG CODEINE 10 MG/5 ML SYRUP $ $ J3490 PROPARACAINE 0.5 % EYE DROPS $ $ J8499 PROPRANOLOL 10 MG TABLET $ 1.00 $ J8499 PROPRANOLOL 20 MG TABLET $ 1.00 $ J8499 PROPRANOLOL 40 MG TABLET $ 1.00 $ J8499 PROPYLTHIOURACIL 50 MG TABLET $ 1.00 $ J2720 PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION $ $ PYRIDOXINE (VITAMIN B6) 100 MG/ML INJECTION J3415 SOLUTION $ $ J8499 PYRIDOXINE (VITAMIN B6) 25 MG TABLET $ 1.00 $ J8499 PYRIDOXINE (VITAMIN B6) 50 MG TABLET $ 1.00 $ J3490 SILVER SULFADIAZINE 1 % TOPICAL CREAM $ 1, $ 1, J3490 SILVER SULFADIAZINE 1 % TOPICAL CREAM $ $ J3490 SIMETHICONE 125 MG CHEWABLE TABLET $ $ 59.00

12 J8499 SIMETHICONE 40 MG/0.6 ML ORAL DROPS,SUSPENSION $ $ J8499 SIMPLE SYRUP $ $ J3490 SODIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION $ $ SODIUM BICARBONATE 8.4 % (1 MEQ/ML) INTRAVENOUS J3490 SYRINGE $ $ J8499 SODIUM BICARBONATE 650 MG TABLET $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SYRINGE $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SYRINGE $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SYRINGE $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SYRINGE $ $ J3490 SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SOLUTION $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SOLUTION $ $ A4216 SODIUM CHLORIDE 0.9 % INJECTION SOLUTION $ $ J7131 SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION $ $ J7131 SODIUM CHLORIDE 4 MEQ/ML INTRAVENOUS SOLUTION $ $ J3490 SODIUM CHLORIDE 0.9 % FOR NEBULIZATION $ $ J8499 SODIUM CHLORIDE 1 GRAM TABLET $ 1.00 $ J3490 SODIUM CHLORIDE 5 % EYE DROPS $ $ SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS J3490 SOLUTION $ $ SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS J3490 SOLUTION $ $ SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) J3490 INTRAVENOUS SOLUTION $ $ J8499 SORBITOL 70 % SOLUTION $ $ J3490 SORBITOL 3 % IRRIGATION SOLUTION $ $ J8499 SPIRONOLACTONE 25 MG TABLET $ 1.00 $ J8499 SPIRONOLACTONE 25 MG TABLET $ 1.00 $ A4217 WATER FOR IRRIGATION, STERILE SOLUTION $ $ A4217 WATER FOR IRRIGATION, STERILE SOLUTION $ $ A4217 WATER FOR IRRIGATION, STERILE SOLUTION $ $ J3000 STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION $ 3, $ 3, SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION J0330 SOLUTION $ $ SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION J0330 SOLUTION $ 1, $ 1, SULFAMETHOXAZOLE 400 MG TRIMETHOPRIM 80 MG/5 J3490 ML INTRAVENOUS SOLUTION $ $ SULFAMETHOXAZOLE 400 MG TRIMETHOPRIM 80 MG/5 J3490 ML INTRAVENOUS SOLUTION $ 1, $ 1, SULFAMETHOXAZOLE 400 MG TRIMETHOPRIM 80 MG J8499 TABLET $ $ 59.00

13 J8499 SULFASALAZINE 500 MG TABLET $ 1.00 $ J8499 TAMOXIFEN 10 MG TABLET $ 1.00 $ J8499 TEMAZEPAM 15 MG CAPSULE $ 1.00 $ TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR J1071 OIL $ $ J8499 TETRACYCLINE 500 MG CAPSULE $ $ J3490 SODIUM CHLORIDE ALOE VERA NASAL GEL $ $ J3490 THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION $ 2, $ 2, THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION J3411 SOLUTION $ $ FLU VACCINE QS (6 MOS UP)(PF)60 MCG( MCGX4)/0.5 ML IM SYRINGE $ $ J3260 TOBRAMYCIN 40 MG/ML INJECTION SOLUTION $ $ J3260 TOBRAMYCIN 40 MG/ML INJECTION SOLUTION $ 1, $ 1, J3260 TOBRAMYCIN 40 MG/ML INJECTION SOLUTION $ $ J3260 TOBRAMYCIN 40 MG/ML INJECTION SOLUTION $ 1, $ 1, J3490 TOBRAMYCIN 0.3 % EYE DROPS $ $ J8499 TRAZODONE 100 MG TABLET $ $ J8499 TRAZODONE 50 MG TABLET $ 1.00 $ J3490 TRIAMCINOLONE ACETONIDE % TOPICAL CREAM $ $ J3490 TRIAMCINOLONE ACETONIDE % TOPICAL CREAM $ $ J3490 TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM $ $ J3490 TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM $ $ TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR J3301 INJECTION $ $ TRIAMTERENE 37.5 MG HYDROCHLOROTHIAZIDE 25 MG J8499 TABLET $ 1.00 $ J8499 TRIAZOLAM 0.25 MG TABLET $ $ J8499 TRIFLUOPERAZINE 5 MG TABLET $ $ J8499 TRIHEXYPHENIDYL 2 MG TABLET $ 1.00 $ TRIMETHOBENZAMIDE 100 MG/ML INTRAMUSCULAR J3250 SOLUTION $ 1, $ 1, J3370 VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION $ $ J3370 VANCOMYCIN 500 MG INTRAVENOUS SOLUTION $ $ J3370 VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION $ 4, $ 4, J3370 VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION $ $ J3490 VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION $ 1, $ 1, J8499 VERAPAMIL 40 MG TABLET $ 1.00 $ J8499 VERAPAMIL 80 MG TABLET $ 1.00 $ J9360 VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION $ $ J9370 VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION $ $ J8499 VITAMIN A 10,000 UNIT CAPSULE $ 1.00 $ J8499 VITAMIN E 400 UNIT CAPSULE $ 1.00 $ 1.00

14 J8499 WARFARIN 2 MG TABLET $ 1.00 $ J8499 WARFARIN 2.5 MG TABLET $ 1.00 $ J8499 WARFARIN 5 MG TABLET $ $ J8499 WARFARIN 7.5 MG TABLET $ 1.00 $ J8499 ACETAMINOPHEN 300 MG CODEINE 30 MG TABLET $ $ J8499 ACYCLOVIR 200 MG CAPSULE $ $ J8499 ACYCLOVIR 400 MG TABLET $ $ J0270 ALPROSTADIL 500 MCG/ML INJECTION SOLUTION $ 4, $ 4, J0270 ALPROSTADIL 500 MCG/ML INJECTION SOLUTION $ 4, $ 4, J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION $ $ J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION $ $ J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION $ $ J0282 AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION $ $ J7500 AZATHIOPRINE 50 MG TABLET $ 1.00 $ J9040 BLEOMYCIN 15 UNIT SOLUTION FOR INJECTION $ 1, $ 1, J3490 BUMETANIDE 0.25 MG/ML INJECTION SOLUTION $ $ J3490 BUMETANIDE 0.25 MG/ML INJECTION SOLUTION $ $ J3490 BUMETANIDE 0.25 MG/ML INJECTION SOLUTION $ $ J8499 BUMETANIDE 0.5 MG TABLET $ 1.22 $ J8499 BUMETANIDE 1 MG TABLET $ 1.00 $ BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % J3490 DEXTROSE INJECTION $ $ J8499 BUPROPION HCL 75 MG TABLET $ 1.00 $ J8499 BUSPIRONE 10 MG TABLET $ 1.00 $ J8499 BUSPIRONE 5 MG TABLET $ 1.00 $ J0595 BUTORPHANOL TARTRATE 2 MG/ML INJECTION SOLUTION $ $ J8499 CALCITRIOL 0.25 MCG CAPSULE $ 1.00 $ J8499 CAPTOPRIL 12.5 MG TABLET $ $ J8499 CAPTOPRIL 25 MG TABLET $ 1.62 $ J8499 CARBIDOPA 10 MG LEVODOPA 100 MG TABLET $ $ J8499 CARBIDOPA 25 MG LEVODOPA 100 MG TABLET $ 1.00 $ J8499 CEFADROXIL 500 MG CAPSULE $ $ J0698 CEFOTAXIME 1 GRAM SOLUTION FOR INJECTION $ $ J0698 CEFOTAXIME 10 GRAM SOLUTION FOR INJECTION $ 1, $ 1, J0698 CEFOTAXIME 500 MG SOLUTION FOR INJECTION $ $ J0694 CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION $ $ J0694 CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION $ $ J0694 CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION $ $ CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR J8499 SUSP IN A PACKET $ $ J9060 CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION $ $ CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE J3490 INTRAVENOUS PIGGYBACK $ $ CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE J3490 INTRAVENOUS PIGGYBACK $ $ J8499 CLONAZEPAM 0.5 MG TABLET $ $ 59.00

15 J8499 CLONAZEPAM 1 MG TABLET $ 1.00 $ J7502 CYCLOSPORINE 100 MG CAPSULE $ $ J7515 CYCLOSPORINE 25 MG CAPSULE $ $ J2597 DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION $ 6, $ 6, J2597 DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION $ 1, $ 1, J3490 DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION $ $ J8499 DOXAZOSIN 2 MG TABLET $ $ J3490 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE $ $ J3490 DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE $ $ J8499 ENALAPRIL MALEATE 5 MG TABLET $ 1.00 $ J8499 ENALAPRIL MALEATE 20 MG TABLET $ 1.00 $ J3490 ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION $ $ J8499 ESTRADIOL 1 MG TABLET $ 1.00 $ J8499 ETHAMBUTOL 400 MG TABLET $ $ J9181 ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION $ $ J9181 ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION $ $ J8499 FAMOTIDINE 20 MG TABLET $ 1.00 $ J8499 FAMOTIDINE 20 MG TABLET $ 1.00 $ J8499 FLECAINIDE 100 MG TABLET $ 1.00 $ J8499 FLECAINIDE 50 MG TABLET $ 1.00 $ J8499 FLUDROCORTISONE 0.1 MG TABLET $ $ J8499 FLUOXETINE 10 MG CAPSULE $ 1.00 $ J8499 FLUOXETINE 20 MG CAPSULE $ 1.00 $ J8499 FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION $ 5.76 $ J3490 FLURBIPROFEN 0.03 % EYE DROPS $ $ J8499 GLIPIZIDE 5 MG TABLET $ 1.00 $ J3490 GUAIFENESIN 200 MG TABLET $ $ J8499 GUANFACINE 1 MG TABLET $ $ J1644 HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION $ $ J1644 HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION $ $ J1644 HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION $ $ J1644 HEPARIN (PORCINE) 10,000 UNIT/ML INJECTION SOLUTION $ $ J8499 HYDROCORTISONE 100 MG/60 ML ENEMA $ $ J3490 HYDROMORPHONE 8 MG TABLET $ $ J8499 HYDROXYCHLOROQUINE 200 MG TABLET $ 1.97 $ J8499 HYDROXYUREA 500 MG CAPSULE $ 1.00 $ J3490 IBUPROFEN 100 MG/5 ML ORAL SUSPENSION $ $ J3490 KETOCONAZOLE 2 % TOPICAL CREAM $ 1, $ 1, J1885 KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION $ $

16 J1885 KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION $ $ J8499 KETOROLAC 10 MG TABLET $ $ J3490 LABETALOL 5 MG/ML INTRAVENOUS SOLUTION $ $ J3490 LABETALOL 5 MG/ML INTRAVENOUS SOLUTION $ $ J8499 LABETALOL 100 MG TABLET $ 1.00 $ J3490 LEVOBUNOLOL 0.5 % EYE DROPS $ $ J8499 LEVOTHYROXINE 88 MCG TABLET $ 1.55 $ J8499 LEVOTHYROXINE 112 MCG TABLET $ $ J8499 LISINOPRIL 10 MG TABLET $ 1.00 $ J8499 LISINOPRIL 5 MG TABLET $ 1.00 $ J8499 LORATADINE 10 MG TABLET $ $ J8499 LORATADINE 10 MG TABLET $ $ J2060 LORAZEPAM 2 MG/ML INJECTION SOLUTION $ $ J2060 LORAZEPAM 2 MG/ML INJECTION SOLUTION $ $ J2060 LORAZEPAM 2 MG/ML INJECTION SOLUTION $ $ MAGNESIUM OXIDE 400 MG (241.3 MG MAGNESIUM) J8499 TABLET $ $ J9209 MESNA 100 MG/ML INTRAVENOUS SOLUTION $ $ J8499 METFORMIN 500 MG TABLET $ 1.00 $ J8499 METHIMAZOLE 10 MG TABLET $ 1.00 $ J8499 METHIMAZOLE 5 MG TABLET $ 1.00 $ J2250 MIDAZOLAM 1 MG/ML INJECTION SOLUTION $ $ J2250 MIDAZOLAM 1 MG/ML INJECTION SOLUTION $ $ J2250 MIDAZOLAM 1 MG/ML INJECTION SOLUTION $ $ J2250 MIDAZOLAM 1 MG/ML INJECTION SOLUTION $ $ J8499 MISOPROSTOL 100 MCG TABLET $ 1.00 $ J9280 MITOMYCIN 40 MG INTRAVENOUS SOLUTION $ 42, $ 42, MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) J8499 ORAL SOLUTION $ $ J8499 NABUMETONE 500 MG TABLET $ $ J3490 TETRAHYDROZOLINE 0.05 % EYE DROPS $ $ NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS J3490 SOLUTION $ $ J8499 OXYCODONE 20 MG/ML ORAL CONCENTRATE $ 9, $ 9, J8499 OXYCODONE 5 MG TABLET $ $ J8499 OXYCODONE 5 MG TABLET $ $ J2430 PAMIDRONATE 30 MG INTRAVENOUS SOLUTION $ $ J3490 PERMETHRIN 5 % TOPICAL CREAM $ 1, $ 1, J3490 PERMETHRIN 1 % TOPICAL LIQUID $ $ POTASSIUM CHLORIDE 10 MEQ/50 ML IN STERILE WATER J3480 INTRAVENOUS PIGGYBACK $ $ POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER J3480 INTRAVENOUS PIGGYBACK $ $ POTASSIUM CHLORIDE ER 20 MEQ TABLET,EXTENDED J8499 RELEASE(PART/CRYST) $ 1.00 $ J7510 PREDNISOLONE 15 MG/5 ML ORAL SOLUTION $ $

17 J7510 PREDNISOLONE 15 MG/5 ML ORAL SOLUTION $ $ PREDNISOLONE SODIUM PHOSPHATE 5 MG BASE/5 ML (6.7 J7510 MG/5 ML) ORAL SOLN $ 2, $ 2, J8499 PRIMIDONE 50 MG TABLET $ 1.00 $ J8499 PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY $ $ J8499 PROMETHAZINE 25 MG RECTAL SUPPOSITORY $ $ J2704 PROPOFOL 10 MG/ML INTRAVENOUS EMULSION $ $ J2704 PROPOFOL 10 MG/ML INTRAVENOUS EMULSION $ $ J2704 PROPOFOL 10 MG/ML INTRAVENOUS EMULSION $ $ J8499 PYRIDOSTIGMINE BROMIDE 60 MG TABLET $ 1.31 $ J8499 RIFAMPIN 150 MG CAPSULE $ $ J3490 SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION $ $ J3490 SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION $ $ J3490 SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION $ $ J3490 SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION $ $ J3490 SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION $ $ J8499 SOTALOL 80 MG TABLET $ 1.00 $ J8499 SPIRONOLACTONE 100 MG TABLET $ 1.00 $ J8499 SUCRALFATE 1 GRAM TABLET $ 1.00 $ J3490 TIMOLOL MALEATE 0.5 % EYE DROPS $ $ J3260 TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION $ 2, $ 2, J3490 TRIFLURIDINE 1 % EYE DROPS $ 6, $ 6, POLYMYXIN B SULFATE 10,000 UNIT TRIMETHOPRIM 1 J3490 MG/ML EYE DROPS $ $ J8499 URSODIOL 300 MG CAPSULE $ 6.48 $ J8499 WARFARIN 1 MG TABLET $ 1.00 $ SULFAMETHOXAZOLE 800 MG TRIMETHOPRIM 160 MG J8499 TABLET $ $ SULFAMETHOXAZOLE 800 MG TRIMETHOPRIM 160 MG J8499 TABLET $ $ J3490 POVIDONE IODINE 10 % TOPICAL OINTMENT $ $ J8499 MECLIZINE 12.5 MG TABLET $ $ J8499 MECLIZINE 25 MG TABLET $ 1.00 $ J8499 MECLIZINE 25 MG TABLET $ 1.00 $ POTASSIUM CHLORIDE ER 8 MEQ TABLET,EXTENDED J3490 RELEASE $ 1.00 $ J8499 ESTRADIOL 0.5 MG TABLET $ 1.00 $ J8499 DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID $ $ J8499 DIPHENHYDRAMINE 12.5 MG/5 ML ORAL LIQUID $ $ IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR J3490 INHALATION $ $ IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR J3490 INHALATION $ $ J8499 LISINOPRIL 2.5 MG TABLET $ 1.00 $ J8499 VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE $ 2.02 $ J8499 SENNOSIDES 8.6 MG TABLET $ $ 59.00

18 J8499 SENNOSIDES 8.6 MG TABLET $ $ ALUMINUM MAG HYDROXIDE SIMETHICONE 200 MG 200 J3490 MG 20 MG/5 ML ORAL SUSP $ $ ALUMINUM MAG HYDROXIDE SIMETHICONE 200 MG 200 J3490 MG 20 MG/5 ML ORAL SUSP $ $ ISOSORBIDE DINITRATE ER 40 MG TABLET,EXTENDED J8499 RELEASE $ $ PROPRANOLOL ER 60 MG CAPSULE,24 HR,EXTENDED J8499 RELEASE $ 2.78 $ PROPRANOLOL ER 80 MG CAPSULE,24 HR,EXTENDED J8499 RELEASE $ 1.47 $ J8610 METHOTREXATE SODIUM 2.5 MG TABLET $ 2.82 $ J8499 BISACODYL 5 MG TABLET,DELAYED RELEASE $ $ J8499 ERYTHROMYCIN 250 MG TABLET $ $ THEOPHYLLINE ER 100 MG TABLET,EXTENDED RELEASE,12 J8499 HR $ $ THEOPHYLLINE ER 100 MG TABLET,EXTENDED RELEASE,12 J8499 HR $ $ J8499 GUAIFENESIN 100 MG/5 ML ORAL LIQUID $ $ J8499 GUAIFENESIN 100 MG/5 ML ORAL LIQUID $ $ J8499 GUAIFENESIN 100 MG/5 ML ORAL LIQUID $ $ J3490 BACITRACIN ZINC 500 UNIT/GRAM TOPICAL PACKET $ 1.00 $ J3490 HYDROCORTISONE 1 % TOPICAL CREAM $ $ J3490 SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL $ $ J8499 CYANOCOBALAMIN (VIT B 12) 500 MCG TABLET $ 1.00 $ J8499 TERAZOSIN 1 MG CAPSULE $ 1.00 $ J8499 TERAZOSIN 2 MG CAPSULE $ 1.00 $ J8499 TERAZOSIN 5 MG CAPSULE $ 1.00 $ J8499 VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE $ 2.17 $ J8499 TRAMADOL 50 MG TABLET $ $ J8499 METFORMIN 850 MG TABLET $ 1.00 $ J8499 METFORMIN 850 MG TABLET $ 1.00 $ J8499 TIZANIDINE 4 MG TABLET $ $ POTASSIUM CHLORIDE 20 MEQ/L IN D5 0.9 % SODIUM J3490 CHLORIDE INTRAVENOUS $ $ POTASSIUM CHLORIDE 40 MEQ/L IN D5 0.9 % SODIUM J3490 CHLORIDE INTRAVENOUS $ $ POTASSIUM CHLORIDE 10 MEQ/L IN DEXTROSE 5 % 0.45 % J3490 SODIUM CHLORIDE IV $ $ POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 % 0.2 % J3490 SODIUM CHLORIDE IV $ $ POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 % 0.2 % SODIUM CHLORIDE IV $ $ J3490 D5 / 0.45% NACL W KCL 20 MEQ/L IV SOLUTION $ $ J3490 D5 / 0.45% NACL W KCL 20 MEQ/L IV SOLUTION $ $

19 POTASSIUM CHLORIDE 30 MEQ/L IN DEXTROSE 5 % 0.45 % J3490 SODIUM CHLORIDE IV $ $ POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 % 0.45 % J3490 SODIUM CHLORIDE IV $ $ LIDOCAINE EPINEPHRINE 0.5 % 1:200,000 INJECTION J3490 SOLUTION $ $ POTASSIUM CHLORIDE 20 MEQ/L IN 5 % DEXTROSE J3490 INTRAVENOUS SOLUTION $ $ SODIUM CITRATE CITRIC ACID 500 MG 334 MG/5 ML ORAL J8499 SOLUTION $ 1.34 $ J2274 MORPHINE (PF) 1 MG/ML INJECTION SOLUTION $ $ NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % J3490 DEXTROSE INTRAVENOUS $ $ DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE J3490 INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE J3490 INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE J3490 INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE J7042 INTRAVENOUS SOLUTION $ $ DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE J7042 INTRAVENOUS SOLUTION $ $ LIDOCAINE 20 MG/ML (2 %) EPINEPHRINE 1:100,000 J3490 INJECTION SOLUTION $ $ LIDOCAINE 1 % EPINEPHRINE 1:100,000 INJECTION J3490 SOLUTION $ $ LIDOCAINE EPINEPHRINE (PF) 1.5 % 1:200,000 INJECTION J3490 SOLUTION $ $ DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % J1250 DEXTROSE IV $ 1, $ 1, LIDOCAINE EPINEPHRINE (PF) 2 % 1:200,000 INJECTION J3490 SOLUTION $ $ J8499 METHADONE 10 MG/ML ORAL CONCENTRATE $ 1, $ 1, J8499 METHADONE 10 MG/ML ORAL CONCENTRATE $ $ DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS J3490 SOLUTION $ $ J3490 GLUCOSE 4 GRAM CHEWABLE TABLET $ $ POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM J3480 CHLORIDE INTRAVENOUS $ $ POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM J3490 CHLORIDE INTRAVENOUS $ $ CALCIUM CARBONATE 200 MG CALCIUM (500 MG) J8499 CHEWABLE TABLET $ 1.00 $ J9040 BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION $ 3, $ 3,550.65