Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02600001 HB IV INFUS HYDRATION 31-60 MIN 96360 $2,049.01 $2,665.08 02600002 HB IV INFUSION HYDRATION ADDL HR 96361 $502.12 $649.97 02600003 HB IV INFUSION THERAPY 1ST HR 96365 $2,294.89 $2,984.91 02600004 HB IV THERAPY ADDL SEQ UP TO 1 HR 96367 $502.12 $649.97 02600005 HB IV THERAPY-CONCURRENT 96368 $700.35 $907.85 02600007 HB INFUSION SC INITIAL FIRST HR 96369 $942.60 $1,225.38 02600008 HB SC INFUSION ADD'L HOURS 96370 $468.23 $608.70 02600012 HB IV INFUSION THERAPY EA ADDL HR 96366 $502.12 $649.97 02600013 HB IV PUSH INITIAL 96374 $1,253.71 $1,629.84 02600014 HB IV PUSH ADDL SEQ NEW DRUG 96375 $893.88 $1,162.05 02600015 HB IVP ADDL SEQ SAME DRUG 96376 $940.84 $1,223.10 02600017 HB APPL ON-BODY INJECTOR SUBQ INJ 96377 $468.23 02700005 HB CYTOTOXIC SPILL KIT $252.20 02700007 HB 24 HR PH PROBE $3,194.60 02700008 HB FEMSTOP $762.42 02700009 HB PC IPPB KIT $348.08 02700016 HB PEFR-EQUIPMENT $913.64 02700018 HB PC AERO KIT $1,868.84 02700020 HB PC O/P USN EQUIPMENT $1,054.19 02700021 HB PC MICRO-SPIROMETER $11,489.64 02700022 HB PC O/P HHN EQUIPMENT $667.65 02700033 HB STOCKINETTE,2"X25YD/BOX $301.10 02700034 HB DILATOR, RDS $2,968.15 02700035 HB NEEDLE, BIOPSY/ASP/LOC/INJ $428.94 02700036 HB POWER MODULE BACK BATTERY Q0496 $1,971.27 02700042 HB HMGG, TRAVEL CASE Q0508 $758.94 02700044 HB METANEB RT DEVICE KIT $2,315.11 02700045 HB PC METANEB KIT $348.08 02700046 HB HM MODULAR CABLE Q0509 $27,908.70 02710001 HB SUPPORTER, SCROTAL $878.47 02710002 HB SPLINT FOREARM - SMALL $506.19 02710003 HB SPLINT, SUGARTONG $2,785.66 02710005 HB SPICA - HIP (SINGLE OR DOUBLE) $5,502.06 02710006 HB COLLAR, CERVICAL $683.29 02710009 HB CAST, SHORT ARM CAST $1,779.83 02710012 HB PADS R2 EP STUDY $777.89 02710013 HB SPLINT FINGER 2 INCHES $361.24 02710014 HB MUCUS CLEARING DEVICE $363.13 02710018 HB BILE BAG REG $636.70 02710019 HB FECAL INCONTINENCE COLLECTOR $519.25 02710022 HB PC PEP VALVE $411.14 02710023 HB SPLINT WRIST - LARGE $433.48

Ancillary FY22 1 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02710024 HB SPLINT WRIST - MEDIUM $433.48 02710027 HB PENTAMIDINE KIT $515.14 02710029 HB SPLINT, WRIST $1,215.76 02710032 HB SUPPORT LUMBO-SACRAL $1,329.46 02710033 HB KNEE IMMOBILIZER $1,372.86 02710035 HB AEROSOL INHAL, PENTAM ADD'L 10 $1,478.41 02710036 HB SPICA - THUMB OR FINGER $1,661.25 02710037 HB BI-VALVE OR DC CAST $400.08 02710038 HB KIT, OSTOMY 5PK (1 PIECE) $1,692.37 02710039 HB SPLINT, MOLDED $1,712.51 02710041 HB EAR LAVAGE $482.73 02710044 HB 02 CONNECTION TUBING MASK $485.54 02710045 HB HEADSET NAVIGATION DEVICE $501.06 02710047 HB SPLINT FOREARM - MEDIUM $613.49 02710050 HB SPICA CAST - INFANT $181.61 02710053 HB PC HELIOX ADMIN. PER HOUR $228.21 02710054 HB PC NITROGEN ADMIN. PER HOUR $228.21 02710055 HB ILEOSTOMY POUCH $848.98 02710056 HB UNIVALVE CAST OR SPLINT $264.08 02710057 HB PC H.H.N. KIT $435.35 02710058 HB SPLINT FOREARM - LARGE $728.90 02710059 HB SPLINT,THUMB $763.16 02710060 HB PAG-HEART NEB EQUIP $780.86 02710061 HB PASSY MUIR SPEAKING VALVE $803.67 02710063 HB STOMAHESIVE WAFER $821.54 02710064 HB SPLINT, ARM $979.70 02710067 HB PENTAMIDINE EQUIPMENT OP * $1,183.05 02710070 HB SPLINT, KNEE VELCRO $4,898.34 02710073 HB CAST, SHORT LEG WALKING $2,233.99 02710074 HB CAST, CYLINDER THIGH TO ANKLE $2,536.68 02710077 HB CAST, PATELLAR TENDON BEARING $3,161.24 02710078 HB CAST, LONG LEG $3,680.96 02710080 HB KIT, WOUND CLEASING $308.72 02710081 HB SPLINT, SHORT/LONG LEG $2,990.49 02710083 HB PUMP DISCONNECT KIT $137.29 02710085 HB SPLINT WRIST - SMALL $361.24 02710087 HB CAST, SHOE $740.63 02710089 HB CAST SHORT LEG $9,285.31 02710090 HB CAST, LONG ARM $4,478.11 02710091 HB CAST, LONG LEG WALKING $2,233.99 02710101 HB SPLINT, IMMOBILIZER KNEE $1,372.86 02710104 HB SPLINT,IMMOBILIZER SHOULDER $220.06

Ancillary FY22 2 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720001 HB BASKET GEMINI 3FR $1,923.83 02720003 HB CRYOCATH, FROSTBYTE CLAMP $14,214.18 02720008 HB MEDIA FOR IUI $226.08 02720009 HB WIRE, MICRO EXCHANGE $2,646.13 02720010 HB CATH PERIPHERAL DILITATION C1725 $2,729.50 02720016 HB LASER FIBER, 3 $4,212.23 02720017 HB NEUROPEN WITH NEUROENDOSCOPES $4,406.60 02720018 HB VALVE, DRAINAGE/FARRELL $305.78 02720021 HB CATH DELIVERY SYSTEM $6,746.55 02720023 HB LASER FIBER, 9 $8,693.09 02720025 HB CATH INTRA-AORTC BALLOON $15,893.93 02720034 HB CLIP SURGICAL SPRING CLIP $216.90 02720035 HB KIT, OSTOMY (2 PIECE) $1,150.21 02720036 HB LEVEL I TUBING D-50 $1,169.85 02720037 HB DRAIN 1 $370.43 02720039 HB ENDOSCOPIC VERSATEP $1,002.86 02720040 HB ENDO LLETZ BALL ELCTRODE $318.49 02720044 HB ENDOSCOPE SHEATH DISPOSABLE $584.69 02720045 HB COLOSTOMY BAG $585.72 02720046 HB KYPHON BONE FILLER DEVICE OR $1,213.38 02720047 HB CATHETER, EPISTAXIS BALLOON $597.74 02720048 HB ENDO ELECTRODE CUTTING LOOP $976.36 02720049 HB SHEATH, PERITONEAL/AMPLATZ $606.67 02720050 HB PC NASAL MASKS BIPAP $1,236.22 02720051 HB ENDO IRRIG ENDO-FLO 0037970 $616.13 02720053 HB BIOPSY BRUSH COOK 040310 $619.28 02720054 HB NEEDLE, SCLEROSING $1,265.85 02720055 HB CATH FOLEY W/THERMISTER $529.21 02720056 HB CANNULA, CORONARY PERFUSION DL $621.78 02720058 HB ELECTRODE, ACRIM/MENIS/PEN $622.94 02720059 HB CATHETER, UMBILICAL VES $623.04 02720064 HB CANNULA AVR CABG KIT $641.27 02720068 HB TRACH TUBE #14 $1,301.48 02720072 HB CLAMP, DISPOSABLE $417.20 02720073 HB FILTER, BLOOD TRANSFUSION * $678.92 02720074 HB PACING WIRE, TEMPORARY $828.77 02720075 HB LEADWIRE, EKG $157.17 02720077 HB FRAZIER SUCTION TIPS $333.38 02720080 HB HANDLE, ENDOSCOPIC GIA $1,015.79 02720081 HB TROCAR, ENDOSCOPIC 1 $572.82 02720082 HB CLIP GUN MAGAZINE $333.20 02720084 HB NEEDLE, SPINAL/DISC $723.71

Ancillary FY22 3 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720086 HB KIT, PACEMAKER 1 $728.70 02720088 HB INTRODUCER, OSTEO ONE STEP $8,207.28 02720089 HB CATHETER, THORACIC MM $745.40 02720090 HB CATHETER PASSER $963.06 02720093 HB PIN, DISTRACTION 1 $563.60 02720096 HB ENDO TIP CAUTERY PEDS RT ANGLE $754.44 02720098 HB LACRIMAL INTUBATION SET $760.76 02720099 HB ROD, OSTOMY $228.63 02720101 HB PEN, HEATING LACTOSORB PLATE $840.17 02720104 HB ENDO BIPOLAR EBF01 $785.02 02720107 HB GRASPER, ENDOSCOPIC 1 $1,164.25 02720108 HB PIN SKULL PINS MAYFIELD- OMI $226.37 02720110 HB PREP DURA $211.66 02720111 HB BLADE, TREPHINE $811.05 02720112 HB LTA KIT $357.08 02720114 HB TUBING, INSUFFLATION $439.25 02720115 HB KYPHON BONE ACCESS NEEDLE 11 G $348.92 02720116 HB ANTENNA,EXTRNL NEUROSTIMALUTOR $1,123.06 02720121 HB SPLINT DENVER SERIES $264.47 02720123 HB ADHESIVE, SKIN 1 $391.28 02720124 HB 23G BIPOLAR TAPERED FINE POINT $493.53 02720125 HB SYRINGE MEDRAD POWER INJECTOR $180.46 02720126 HB ARTHRO, MENISCAL SYSTEM $1,383.12 02720132 HB FILTER MILEX $87.34 02720133 HB SONOHYSTOGRAM CATHETER $257.16 02720135 HB NET, RETRIEVAL ROTH $1,321.32 02720137 HB OSTENE BONE HEMOSTASIS 2.5GRMS $874.45 02720139 HB TUBE, JEJUN FEED/SGL LUMEN $1,403.05 02720140 HB FORCEPS, BIOPSY 1 $537.00 02720144 HB TUBE,TRACH DCT/DFEN W/DISP CAN $1,547.28 02720145 HB KIT, NEUROSTIMULATOR 1 $1,048.05 02720148 HB MEDTRONIC REFILL KIT $1,548.79 02720153 HB TUNNELING ROD, CATH PASSER $1,325.98 02720154 HB TUBE, MIC (FEEDING) $2,318.28 02720159 HB TOOL, DISSECTING 2 $1,540.32 02720161 HB KIT, TRANFIX/BIO-TENODESIS $1,600.03 02720162 HB NEEDLE, ELECT/BEVEL/TROCAR $1,644.04 02720165 HB HEMOSTAT, SOF-GRIP $817.31 02720166 HB BAG DRAINAGE URINARY $269.93 02720168 HB CUTTER, LOCKING LEAD $1,065.94 02720169 HB PERF QUICK PRIME LINE $277.65 02720170 HB ENDO PROBE HANDPIECE $830.59

Ancillary FY22 4 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720171 HB PC MICRO BRUSH $2,020.50 02720172 HB STRIPPER VEIN DISPOSABLE $841.62 02720174 HB PLEUR-EVAC $2,373.68 02720175 HB SPENCER DEPTH ELECTRODES 8 CON $2,465.79 02720176 HB NEEDLE, OSTYCUT $850.28 02720177 HB T-TUBE, 2 $851.92 02720178 HB ENDO TROCAR 10MM BLNT OMST10BT $861.35 02720183 HB ILIUMINATOR, LIGHTMAT SURGICAL $871.58 02720184 HB PC BROCH OCC CATH C2628 $1,899.64 02720185 HB PERF HEMOCONCENTRATOR PEDS $899.03 02720187 HB TWIST DRILL SURGICAL 1 $905.31 02720189 HB KIT, KYPHOPLASTY INTRO SYSTEM $18,248.13 02720190 HB TRACH PERCUTANEOUS SET $735.97 02720191 HB ENDO SUCTION/IRRIG/PROBE $917.91 02720193 HB CATHETER, MULTI LUMEN $919.68 02720195 HB CANNULA, RETROGRADE CARDIOPLEG $930.89 02720198 HB CANNULA, RETROGRADE 1 $943.04 02720199 HB IV PUMP SET, NITROGLYCERIN $748.31 02720201 HB ARTHRO WAND 1 $1,895.51 02720202 HB BLADE, ACROM/BLASTER/MIONIZER $891.71 02720208 HB IRRIGATION SET, CYSTO $775.50 02720213 HB PERF RESERVOIR CARDIOTOMY $987.03 02720215 HB RESERVOIR, DRAIN 1 $281.65 02720216 HB DRAIN LUMBAR DRAINAGE SET $995.30 02720218 HB PACK, AFFINITY VAVD ACCESSORY $525.82 02720225 HB SHOULDER SUSPENSION KIT 2 $1,023.07 02720228 HB LP DRAINAGE KIT $1,037.33 02720229 HB TUBE, RECTAL $588.79 02720230 HB RADIAL ARTERY KIT $600.40 02720231 HB ENDO POLY LOOP $1,381.78 02720232 HB TUBING, PCA $607.94 02720233 HB TUBE, GASTROSTOMY 1 $620.13 02720235 HB CABLE, LEAD EKG WIRE $1,054.48 02720236 HB RESUSCITATION BAG $284.10 02720243 HB ANESTHESIA BREATHING TRACT $1,035.84 02720246 HB NEEDLE SET, BX/ASPIR, ECHO TIP $672.67 02720247 HB TROCAR, ENDOSCOPIC 2 $1,078.19 02720248 HB INFLATION DEVICE ENDO $1,081.33 02720251 HB BLADE, INCISOR/ABRADER $1,087.61 02720253 HB INTRODUCER ACCUSTICK $694.71 02720254 HB CANNULA ANTERIOR CHAMBER $435.31 02720257 HB MARKER, SPOT TATOO $364.80

Ancillary FY22 5 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720259 HB MICRO PUNCTURE SET $369.99 02720262 HB CAPSULE, WIRELESS AGILE $1,442.24 02720263 HB STAPLER, ENDOSCOPIC 5 $3,032.00 02720264 HB TAP, DISPOSABLE 1 $1,114.53 02720265 HB TUBING PENUMBRA STERILE $3,146.34 02720266 HB PC PNEUMOTHORAX SET $3,402.80 02720267 HB BASKET, RETRIEVAL II $2,788.91 02720269 HB BASKET RETRIEVABLE INSERTABLE C1889 $1,134.78 02720271 HB ELECTRODE, ESU 1 $1,137.95 02720272 HB CATH EPID TUN-L XL 16GA X 3.5 $1,140.05 02720276 HB KIT, IRRIGATION OSTOMY $944.19 02720279 HB SECONDARY PIGGY BACK $873.18 02720280 HB UNIVER MICROINTRODUCER KIT 7FR $960.28 02720283 HB ENDO SWITCH BLADE TIPS $552.83 02720285 HB COLLAGEN, HEMOSTAT INSTAT 1 $829.31 02720286 HB PICC SELDING CONVERSION SET $540.37 02720287 HB PROBE ESPOHAGEAL RECTAL DISP $552.69 02720288 HB DRAIN, VENTRICULAR $1,221.86 02720289 HB CATHETER, VENTRICULAR 2 $1,231.66 02720290 HB NEEDLE, KYPHON $1,236.22 02720294 HB 8-CONTACT STRIP ELECTRODE $3,079.21 02720296 HB KYPHX SYRINGE A08A $1,257.40 02720297 HB PC YAG LASER FIBER $6,702.66 02720298 HB INFUSION SET, BUTTERFLY $216.79 02720299 HB NEEDLE, SCALP VEIN $216.79 02720303 HB TUBING SET $1,292.68 02720306 HB SMART NEEDLE $1,936.21 02720308 HB NEEDLE, FNA $1,961.24 02720311 HB ORAL APPLIANCE $2,041.84 02720312 HB GUIDE, DRILL 1 $1,276.45 02720315 HB CEMENT CART.SYS 540198000 $1,351.71 02720318 HB CATHETER, THORACIC $289.28 02720321 HB ENDO DISSECT, LONG/SHORT $3,175.23 02720322 HB RETRACTOR, ABDOMINAL MOBIUS $1,376.82 02720324 HB TUBING CUSA MANIFOLD $1,376.82 02720325 HB TUBE HARVESTER WITH PINS $3,857.90 02720326 HB LACRICATH 1 $4,587.48 02720329 HB CANNULA, HYDRODISSECTOR $153.69 02720331 HB ADHESIVE, INDERMIL $385.76 02720334 HB APPLICATOR TIP 1 $760.16 02720335 HB BLADE, GENERAL 2 $1,394.54 02720337 HB CATH CHIOU SP 075920 $1,395.68

Ancillary FY22 6 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720338 HB NEEDLE, BIOPSY/ASP/LOC/INJ MRI $845.85 02720339 HB PERF RESEVOIR CARDIO 90300018 $1,405.14 02720340 HB ELECTRODES $1,406.62 02720342 HB GASTROSTOMY GIAS-100 $1,411.13 02720343 HB NEURO BECKER EDMS $1,417.71 02720345 HB INTRODUCER, NEEDLE $848.98 02720346 HB ABC DISPOSABLE TIP (NOZZLE) $1,424.23 02720353 HB POUCH, EAKINS $266.47 02720355 HB BLOOD CONSERVATION SYSTEM $1,463.16 02720356 HB INFLATION APPARATUS $1,477.40 02720357 HB TWIST DRILL, SURGICAL 2 $1,477.40 02720362 HB SEALANT HEMOSTATIC 1 $2,037.24 02720363 HB PERF CDI 500 SHUNT SENSOR $1,508.88 02720365 HB ENDO SHEARS, LONG/SHORT $2,402.58 02720366 HB CATHETER, PENUMBRA NEURON GUIDE $1,528.87 02720367 HB MONITORING KIT, VENTRICULAR $7,025.07 02720368 HB REAMER, MODULAR SHAFT 1 $1,536.06 02720369 HB CANNULA, CORONARY PERF $1,540.06 02720374 HB MONITORING KIT, INTRACRANIAL P $8,971.43 02720378 HB PROBE, SOMN/ULTRSND/ARTHRO $1,580.29 02720379 HB NAV-X EP MAP ELECTRODE $9,643.82 02720380 HB PROBE, ABLATION $12,666.58 02720381 HB KIT, ENDO MUCOSAL RESECTION $2,489.71 02720382 HB TUBE, GASTROSTOMY 2 $1,606.35 02720384 HB BONE MILL BM200 $1,612.60 02720387 HB CATHETER, BILIARY DILAT C1726 $1,651.89 02720388 HB SEPARATOR PENUMBRA $14,310.91 02720389 HB IMPEDANCE PROBE $1,659.75 02720390 HB CANNULA, ERCP BALL/CONTOUR $839.58 02720391 HB RETRACTOR, FAN ENDOSCOPIC $1,662.89 02720392 HB NEEDLE, ENTRY $147.97 02720394 HB KIT, PENUMBRA $23,077.97 02720395 HB SPHINCTERTOME DBL LUMEN $1,534.12 02720398 HB BRUSH, FEMORAL/CYTO $330.08 02720400 HB IV BAG-O-JET $308.28 02720401 HB CATHETER, UMBILICAL $337.19 02720402 HB POSITION COLLAR CERVICAL SOFT $340.80 02720403 HB CANNULA, ARTHRO/ENDO $345.77 02720404 HB TUBING TO EVACUATOR MACHINE $345.77 02720406 HB NEEDLE, ENDO VERESS 1 $348.92 02720407 HB URODYNAMIC PUMP TUBING $348.92 02720411 HB ENDO CLOSURE PROC/KIT CTI-512N $1,423.54

Ancillary FY22 7 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720412 HB ENDO VERSASTEP NEEDLE 14G $358.34 02720415 HB CLIP, HEMOLOK $367.79 02720420 HB DRAIN ABRAMSON TRIPLE LUMEN $374.05 02720422 HB MICROPUNCTURE SET C1894 $613.61 02720423 HB WIRE, TOUHY-BORST Y-VALVE CONN $380.23 02720425 HB TUBING, IRRIGATION 1 $635.05 02720426 HB COLOSTOMY CLAMP $381.50 02720428 HB PRESSURE TUBING $467.41 02720429 HB TUBING, STACKHOUSE/EVACUATOR $389.79 02720430 HB DRAINAGE SET, CHEST SNGL LINE $391.23 02720432 HB BALLOON, KYPHON $6,373.90 02720433 HB CANNULA 8.25MM X 7 CM AR 6530 $392.96 02720435 HB BIOPSY KIT $393.30 02720438 HB RETAINER, VISCERA SURGIFISH $400.08 02720442 HB CANNULA, ARTHRO 1 $405.48 02720446 HB DRAIN, PENROSE $343.97 02720453 HB ENDO TIP COVER INTUI 400180-0 $430.67 02720454 HB CANNULA, VENOUS 2 STAGE OVAL $431.48 02720455 HB PERF ARTERIAL FILTER (351) $436.94 02720459 HB CATHETER, ROBINSON $438.19 02720461 HB BIOPSY DEVICE KYPHON $439.82 02720462 HB SCALPEL, SURGICAL 2 $444.74 02720464 HB TUBING ARTERIAL LINE M/F $435.11 02720465 HB SET MINI TRIFUSE $138.66 02720466 HB KNIFE, HANDLE BEV/LARYN $451.51 02720468 HB STATLOCK $311.98 02720469 HB BLADE, SAW 1 $492.93 02720472 HB PROBE, FLOW PUMP $471.53 02720473 HB SURGIFOAM, ABSORBABLE SPONGE 2 $471.53 02720475 HB ENDO PROBE ELECTRODE $475.95 02720478 HB CANNULA, OPS VALVE $488.05 02720480 HB BALLOON, EXTRACT/BASKET $1,283.37 02720483 HB CANNULA, INNER DISP $496.22 02720484 HB BLADE, AORTIC PUNCH $497.25 02720485 HB KIT, REFILL NEUROSTIMULATION $502.95 02720486 HB NEEDLE, JAM/INF/CAR/MNS/DURA $502.95 02720493 HB INSEMI-CATHETER $174.47 02720496 HB ENDO IRRIGATOR HYDRO-SURG PLUS $807.04 02720497 HB TUBING, PENROSE DRAIN $171.18 02720501 HB TUBE, GASTROSTOMY 2 $1,343.94 02720503 HB ABDOMINAL BINDER $1,274.16 02720508 HB CANNULA , VENOUS RETURN $559.51

Ancillary FY22 8 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720509 HB DILATOR $568.94 02720510 HB PERICARDIOCENTESIS KIT $1,406.90 02720512 HB SNARE, POLYPECTOMY $828.82 02720513 HB CONTAINER, PLEURX EVAC $580.63 02720514 HB BLADE, LARYNGOSCOPE $581.53 02720515 HB CATHETER, CHOLANGIOGRAM $581.53 02720522 HB MONITORING TRANSDUCER VENOUS $1,713.11 02720523 HB MONITORING TRANSDUCER ARTERY $1,511.15 02720525 HB CATHETER, COUNCIL C1729 $1,728.66 02720526 HB CANNULA, IRRIGATING 2 $1,728.91 02720531 HB BALLOON, PRESSURE DEVICE $1,778.06 02720532 HB ENDO CLIP APPLIER 5MM $1,779.23 02720533 HB BLADE, HARMONIC $1,785.49 02720536 HB PROBE, COAGULATING BEAM $1,339.13 02720537 HB INJECTOR $1,564.69 02720538 HB TUBE, BRONCHCATH, RT/LT $843.01 02720541 HB ANORECTAL CATHETER $1,093.69 02720545 HB TUBE, ET $385.42 02720546 HB URINARY DRAIN BAG $399.40 02720549 HB INFUSION US LYSIS SYSTEM $11,285.53 02720556 HB SHEATH, BANNANA PEEL $1,498.72 02720557 HB CATHETER, COUNCIL STIFFNERS $379.79 02720558 HB GASTROSTOMY PLV-24-.38 $677.12 02720559 HB HEMOSTASIS PATCH $850.28 02720560 HB INFLATION DEVICE KYPHON $994.49 02720562 HB KIT, TIPS $3,735.20 02720563 HB 2 CONTACT STRIP ELECTRODE $1,396.44 02720567 HB CATHETER, ARGON COAG PROBE $1,840.43 02720568 HB NASOGASTRIC TUBE IRRIGATION $570.07 02720570 HB CATHETER, BILIARY MANOMETRY $1,947.33 02720572 HB BLADE, DISSECTING DIEGO $1,273.10 02720575 HB BLADE, PIVOTAL/FIXED HEAD $91.44 02720582 HB CANNULA SEAL $454.86 02720583 HB CANNULA AORTIC $1,348.84 02720586 HB CANNULA, ARTERIAL 2 $2,097.52 02720588 HB CANNULA, IMA $321.13 02720589 HB CANNULA, OPHTHALMIC $512.37 02720591 HB CANNULA, VENOUS 5 $4,586.34 02720599 HB CATHETER, VENTRICULAR 1 $430.67 02720600 HB CLIP CORONARY ARTERY RETRACTON $235.78 02720601 HB CLIP OMNI CLIP GUN $773.28 02720602 HB CLIP SURGICLIP PREMIUM $2,524.73

Ancillary FY22 9 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720604 HB CUTTER, ENDOSCOPIC 4 $3,102.59 02720606 HB DISSECTOR, BLUNT CHERRY $386.64 02720609 HB ENDO ENDOPOUCH PRO RETRIEVAL $775.31 02720611 HB ENDO LAP DISC HAND DVICE LD111 $5,032.68 02720612 HB SCISSORS, ENDOSCOPIC 1 $1,310.84 02720613 HB ENDO SURESEAL II $231.39 02720615 HB HANDPIECE, ENDOSCOPIC 1 $1,024.21 02720619 HB EXTRACTOR, STONE TIPLESS 2 $2,612.23 02720621 HB GELPORT, SEAL CAP $3,967.03 02720622 HB HEMOCLIP $423.38 02720623 HB CATHETER, HYDRAGLIDE 1 $354.34 02720624 HB ISOLATOR, ENDO XCL / XCR $13,696.94 02720627 HB IV MICRODRIP SET $70.28 02720631 HB KIT, WIRE STYLET $651.56 02720632 HB KIT, NEEDLE EYE SNARE WRKSTN $5,402.40 02720633 HB KIT, PROCEDURAL CARDIOVASCULAR $280.05 02720634 HB KIT, REPAIR CATHETER $1,291.68 02720636 HB KYPHON OSTEO INTRODUCER SYSTEM $11,410.80 02720637 HB LEAD EXTENDER, BULLDOG $1,551.30 02720638 HB MIDAS REX LUBRICANT/DIFFU $392.96 02720639 HB NEEDLE KEITH $103.72 02720645 HB TUBE, GASTROSTOMY $570.07 02720646 HB PACK, PHACO $1,436.58 02720649 HB PERFUSION HEMOCONCENTRATOR $1,244.62 02720652 HB PERF SUCTION CELL SAVER $302.17 02720654 HB PERFUSION ASSIST PACK $3,215.75 02720655 HB RASP MICRO RECIPROCATING $796.45 02720656 HB REAMER, CORING/HEAD $2,150.13 02720658 HB RELOAD, GIA ENDO 1 $1,393.73 02720659 HB SET SPINAL TRIGEMINAL GANGLION $2,552.48 02720660 HB SHUNT, CARDIOVASCULAR 1 $1,226.65 02720661 HB KIT, CATHETER $571.20 02720662 HB ENDO TACKER SYSTEM 5MM $2,715.95 02720669 HB T-TUBE, 1 $330.08 02720671 HB TUBING LEVEL 1 IR 600 $188.63 02720672 HB TUBING TUR 2 LEAD $286.16 02720673 HB TUBING, TEFLON $1,820.36 02720678 HB BASKET RETRIEVABLE INSERTABLE C1889 $2,033.83 02720681 HB BIOGLUE, SKNCLSR SYRINGE 3 $5,442.85 02720682 HB BLADE, GENERAL 1 $602.97 02720683 HB CABLE, MICROTARGETING $1,240.22 02720685 HB CANNULA, ENDO/ERCP/IRRIG $542.98

Ancillary FY22 10 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720687 HB CATH THORACIC 36FR $569.37 02720690 HB CATHETER, DELIVERY SPY SCOPE $5,308.55 02720692 HB CATHETER, FOLEY 3WAY 5CC/30CC $671.00 02720693 HB CATHETER, BAKRI TAMPONADE $1,848.79 02720694 HB CATHETER, PICC DBL LUMEN C1751 $1,002.29 02720695 HB CATHETER, TEXAS EXTERNAL $171.18 02720696 HB CATHETER, TROCAR MM $1,519.95 02720697 HB CATHETER, PENUMBRA DELIVERY 6F $4,189.36 02720698 HB COLOSTOMY BAG 45MM $531.89 02720699 HB CORE BIOPSY NEEDLE-EUS $2,347.97 02720700 HB CANNULA, J HOOK $152.12 02720702 HB CANNULA, VENOUS 1 $820.48 02720703 HB CANNULA, VENOUS 2 $1,515.94 02720706 HB COOK NEEDLE $678.23 02720708 HB DRAIN PLEUR-EVAC ADULT/PEDS $543.82 02720712 HB EYE RETRACTOR FLEXIBLE $1,181.92 02720714 HB GUN, BIOGLUE APPLICATOR 1 $2,249.03 02720716 HB INTRO BLUE-ON-BLUE 8FR 260-120 $568.96 02720717 HB IV BLOOD PUMP Y-TYPE OR $182.71 02720718 HB KIT, DEEP BRAIN STIMULATION $368.66 02720721 HB LIGACLIP $269.86 02720723 HB BACKGROUND MATERIAL $204.31 02720726 HB NO COST SUPPLY $1.00 02720727 HB PERI PATCH REPAIR KIT $494.41 02720736 HB CATHETER, CONNECTOR CTU $204.02 02720737 HB CVC INSERTION KIT $695.99 02720738 HB BRUSH, CYTOLOGY RX $1,465.32 02720739 HB DEPT ELECTRODE PASSING NEEDLE $1,052.34 02720742 HB DRAIN, URINARY $399.40 02720744 HB PROBE, EHL $3,366.06 02720745 HB ELECTRODE, FETAL SCALP $459.81 02720747 HB ENDO ARTICULATIN LIN CUT ATW35 $1,716.69 02720748 HB EP MAP REFERENCE PATCH $7,885.63 02720750 HB NEEDLE, GUN SEMI-AUTO DISP $691.57 02720754 HB INDEFLATOR PTCA $1,017.56 02720760 HB CAST PLASTER SPLINT $162.66 02720763 HB ELC URINARY DRAIN BAG 154002 $140.83 02720765 HB TUBE, TRACHEOSOFT $937.32 02720766 HB CATHETER, FASTNER PERCU-STAY $145.25 02720767 HB FLOW CONTRL DEVICE 44-201 $157.17 02720768 HB DISSECTOR, SPONGE PEANUTS $105.83 02720769 HB BLADE, BEAVER $162.89

Ancillary FY22 11 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720770 HB PIN GUIDE $993.34 02720771 HB IV PCA TUBING $169.75 02720772 HB STAPLER, ENDOSCOPIC 1 $1,304.53 02720773 HB MERIT MEDICAL RESPONSE KIT $1,412.25 02720777 HB CANNULA, BISHOP HARMON $124.39 02720778 HB TUBE, REPLACMNT Y-PORT $217.30 02720779 HB LENS GLIDE $182.30 02720781 HB DILATOR, VESSEL $201.69 02720783 HB DECUBICARE PAD $291.47 02720784 HB ADAPTER TUOHY-BORST TBA-6 $348.92 02720787 HB TUNNELER, SURGICAL 1 $545.84 02720789 HB TUBING HOTLINE $652.48 02720790 HB POUCH/WAFER PEDS $766.79 02720791 HB NEEDLE, VERTEBROPLASTY $840.23 02720794 HB MONITORING KIT, INTRAUTERINE P $1,101.07 02720795 HB ELECTRODE TEMP PACING 6F $1,209.94 02720799 HB ELECTRODE, ESU 3 $1,719.49 02720800 HB BLADE, OPTHALMOLOGIC 1 $434.53 02720806 HB INTRODUCER SHEATH $248.93 02720807 HB CLIP, DISPOSABLE 1 $1,047.81 02720808 HB ENDO ANTI FOG $174.66 02720809 HB NEEDLE, OSTYCUT BIOPSY $1,037.33 02720811 HB PC ENDOTRACHEAL TUBE # $1,054.19 02720813 HB ESU INSULATED COATED BLADE $130.39 02720814 HB SMOKE HOUSE FILTER $198.03 02720817 HB CATHETER, AIRWAY $205.40 02720818 HB BAG, DRAINAGE 600ML TRU-CLOSE $207.47 02720819 HB NEEDLE, CHIBA $207.47 02720823 HB ADHESIVE REPAIR SUPPLY $214.37 02720825 HB BUTTERFLY, IV INFUSION $215.74 02720829 HB CHROMOVISION LIGHT HANDLE $216.90 02720835 HB TUBE STOMACH EVACUATOR 32FR $232.63 02720842 HB NEEDLE CYSTOME $224.92 02720843 HB CANNULA, INTRACARDIAC SUMP $264.33 02720845 HB NEEDLE, LONG, AMNIO, ECHOTIP $459.82 02720846 HB OT STRAPPING MATERIAL $64.08 02720847 HB RELOAD, ENDOSTITCH 1 $324.42 02720849 HB THEMOCOOL TUBING SET $330.08 02720850 HB TUBING, PRESSURE 1 $267.18 02720854 HB TUBING SMOKE EVACUATOR $222.24 02720858 HB CLIP APPLIER LIGACLIP $898.01 02720859 HB SCALPEL, SURGICAL 1 $39.46

Ancillary FY22 12 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720860 HB MASTISOL LIQUID ADHESIVE $78.59 02720863 HB SUCTION, RESEVOIR J-P $999.59 02720864 HB CATHETER, URINARY EXTERNAL $84.90 02720865 HB OPTHALMIC SURG KIT $84.90 02720871 HB NEEDLE, INTRODUCER MANAN $186.71 02720876 HB BAG, DRAINAGE URINARY $111.06 02720880 HB KIT, UROSTOMY $208.64 02720883 HB SNARE 1 $271.48 02720884 HB TIP,PULSEVAC FLEX / IRRIGATION $288.62 02720889 HB NEEDLE, RADIOFREQUENCY $466.76 02720896 HB CORD, DISPOSABLE 1 $308.65 02720899 HB PERF PMP PCK MEMBRANE 62003-01 $1,829.53 02720902 HB CATHETER, RENAL DILATOR $1,866.83 02720904 HB SPLINT 1 $669.43 02720905 HB ENDOVASCULAR/RENAL DILATOR SET $1,895.51 02720911 HB TRANSDUCER, NEONATE $701.69 02720912 HB BLADE, MYRINGOTOMY $291.05 02720913 HB CANNULA, ARTERIAL FEMORAL 4 $1,945.17 02720914 HB CATH ROBINSON $667.60 02720915 HB BLADE, SAW 2 $1,058.40 02720916 HB NEEDLE, BIOPSY 3 $1,989.53 02720919 HB KYPHON BONE BIOSPY DEVICE $1,433.44 02720921 HB PC CYTOLOGY BRUSH $1,444.65 02720922 HB PC TOTAL FACE MASK $2,726.21 02720926 HB PC BRONCHOSCOPY FORCEPS $3,549.15 02720928 HB CATH PACK -CATH LAB * $1,075.52 02720929 HB NERVE STIMULATOR 1 $2,050.90 02720931 HB EXTRACTOR, STONE $2,057.44 02720932 HB PC WANG NEEDLE $2,326.41 02720933 HB CATHETER, SWAN-GANZ W/THROMBO $2,088.19 02720934 HB BASKET, LITHOCATCH/PARACHUTE $2,102.99 02720935 HB FORCEPS, ENDOSCOPIC 3 $2,134.42 02720936 HB ENDO CLIP $2,170.57 02720937 HB TAP, DISPOSABLE 3 $2,191.82 02720943 HB FORCEPS, BIOPSY I $454.73 02720944 HB KIT, CRANIAL ACCESS $2,289.03 02720949 HB TUBING, IVAC PUMP NICU $1,068.73 02720950 HB CATH SIZING BALLOON $2,417.52 02720954 HB TWIST DRILL, SURGICAL 3 $1,936.39 02720957 HB SNARE, GOOSE NECK $3,985.89 02720958 HB CATHETER, DRAINAGE APDL $1,244.84 02720962 HB CATHETER, ACHALASIA DILATOR $2,842.36

Ancillary FY22 13 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02720965 HB BLADE, HARMONIC SCALPEL $1,751.31 02720966 HB KIT, LEAD ACCSRY INTR/REV $2,693.95 02720968 HB NEEDLE, SPINAL $320.66 02720969 HB PERF RESERVOIR OXGYENATOR $2,751.95 02720972 HB SET LEVEL I DISP $813.32 02720980 HB INTRODUCER/SHEATH, CV 1 $2,786.24 02720981 HB TIP, CATHETER INTRODUCER $2,786.24 02720983 HB FORCEPS, ENDOSCOPIC 4 $2,810.26 02720984 HB TUBE, REAMER/IRRIG/ASPIRATOR $2,814.85 02720986 HB ELECTRODE, VERSA/LOW IMPEDENCE $2,849.14 02720987 HB PIN, GUARD $381.03 02720990 HB CATH ARTHERECTOMY C1714 $25,633.36 02720991 HB CATHETER, ATHERECTOMY BALLOON C1714 $17,289.04 02720992 HB ARTHRO WAND 2 $2,976.86 02720994 HB CATHETER, BALLOON PTA C1725 $2,933.24 02720996 HB CATH DUOSTAT PTCA C1725 $1,071.66 02720999 HB CATH DILITATION PTA C1725 $2,994.11 02721000 HB FORCEPS, SPYBITE BIOPSY $3,205.57 02721001 HB SHEARS, HARMONIC 2 $3,247.20 02721004 HB CAPSULE, ENDOSCOPE DEL SYS $3,388.63 02721005 HB LIGASURE, ESU 2 $3,397.79 02721008 HB CATH INFUSION PTCA C1725 $3,058.79 02721011 HB FORCEP BX PIRANHA 505-160 $3,523.82 02721014 HB CATHETER, BALLOON SMALL VSL DEV. C1725 $6,645.85 02721015 HB TAP, DISPOSABLE 4 $3,649.26 02721016 HB TIB TUNNEL CANN AR-1802D $402.35 02721019 HB TUBE, TRACHEOSTOMY 1 $635.05 02721020 HB TUBE, TRACHEOSTOMY 2 $1,657.45 02721021 HB CATH DILITATION PTCA C1725 $2,974.00 02721022 HB HEMORRHOID STAPLER $3,718.69 02721027 HB CANNULA, VENOUS FEMORAL 2 $3,866.45 02721031 HB CATHETER, BALLOON MICROSYS STEALTH C1726 $7,479.60 02721032 HB CATH DILATION VALVULOPLASTY C1726 $13,012.03 02721039 HB CATHETER,BALLOON BIL DILAT C1726 $3,452.46 02721042 HB BLADE, SHAVER 3 $4,303.39 02721044 HB CATH DILATION SEPTOSTOMY C1726 $2,416.28 02721045 HB CATHETER, ABLA ESOPHAGUS C1888 $5,602.85 02721047 HB BONE CEMENT REMOVAL SYSTEM $4,443.73 02721049 HB CATHETER,DISCYPHOR SYS W/GUIDE $4,652.83 02721050 HB NEEDLE, TRANSJUGULAR LIVER $4,659.10 02721051 HB CATHETER, CRE BAL DILAT C1726 $2,300.82 02721052 HB ANCHOR, AMPLATZ C1713 $1,282.17

Ancillary FY22 14 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721053 HB CATHETER, DRAINAGE NEPHROSTOMY C1729 $1,116.58 02721056 HB NEURO MICROTARGETING DEVICE $5,237.01 02721059 HB PROBE, NIM 2 $5,506.78 02721060 HB CATHETER, DRAINAGE 2 C1729 $1,057.00 02721061 HB CATHETER, DRAINAGE C1729 $1,257.80 02721062 HB CATHETER, DRAINAGE BILIARY C1729 $1,109.85 02721064 HB CATHETER, NASO BIL DRAINAGE C1729 $883.30 02721065 HB CATHETER, EP,19 OR FEW ELEC C1730 $6,749.04 02721067 HB CATHETER, BICAP PROBE $6,557.62 02721068 HB LASER FIBER, 6 $6,935.39 02721069 HB CATH EP <19 ELECTRODES C1730 $8,359.32 02721073 HB KIT, ENDOVESSEL HARVEST $6,981.64 02721074 HB CATH EP ABLATION 3D C1732 $11,281.14 02721075 HB CATH EP DIAG/ABLAT 3D MAP C1732 $13,751.01 02721076 HB CATH EP ABLATION NON 3D C1733 $11,082.03 02721079 HB CATHETER, HEMO, LONG TERM C1750 $1,192.51 02721080 HB 64-CONTACT STRIP ELECTRODE $7,767.49 02721081 HB CATHETER, PENUMBRA REPERFUSION $7,770.11 02721083 HB CATHETER, MICROSYS INFUSION C1751 $4,106.21 02721084 HB CATHETER, CENTRAL VEN TPL LMN C1751 $1,594.16 02721085 HB CATHETER, CENTRAL VEN SNGL LMN C1751 $328.62 02721088 HB UK INFUSION CATHETER $1,354.41 02721091 HB CATHETER, SINUS 1 $12,553.84 02721092 HB MICROSYS CATHETER 2-TIP $3,256.77 02721094 HB MICROSYS CATHETER 1-TIP C2628 $3,101.69 02721095 HB CATHETER, CENTRAL VEN DBL LMN C1751 $1,236.38 02721098 HB CATHETER PERM-A-CATH C1751 $2,967.11 02721099 HB CATH ENDOPROSTHESIS DELVRY C1874 $14,933.99 02721101 HB CATHETER, PORT-A-CATH C1751 $159.42 02721105 HB BIOPTOME $3,653.56 02721107 HB BLADE, SHAVER 1 $1,740.33 02721109 HB BLOOD ADMIN SET Y TYPE $251.42 02721110 HB BLOOD PUMP SET W/FILT 7' * $462.28 02721111 HB BRAVO CAPSULE $3,024.91 02721112 HB CANISTER, V.A.C. $622.50 02721113 HB CATH FOLEY $923.00 02721114 HB CATH ROBINSON 2-EYE 26FR $351.04 02721115 HB CATH ULTRASOUND INTRAVASC C1753 $6,591.63 02721116 HB CATHETER, EPIDURAL ARROW 19 GA C1754 $7,548.82 02721117 HB CATHETER, THROMBCT/EMBOLECT-120CM C1757 $8,342.31 02721118 HB CATH THROMBCT/EMBOLECT-50CM C1757 $6,027.90 02721119 HB CATHETER, DIAGNOSTIC $682.78

Ancillary FY22 15 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721121 HB CATHETER, FOGARTY C1757 $4,670.59 02721122 HB CATHETER, THROMBCT/EMBOLECT-50CM C1757 $5,928.97 02721124 HB CATH ULTRASOUND ACUNAV C1759 $23,962.19 02721125 HB CATHETER, TRANS/LU,NONLRS 3 C1725 $3,829.32 02721128 HB INTRO/SHEATH EP FIXED NON-PEEL C1766 $1,101.50 02721129 HB CATHETER, BALLOON DILATION2 C1726 $4,467.93 02721131 HB CATHETER, BALLOON DILATION4 C1726 $2,323.04 02721132 HB GUIDEWIRE, 0.18/GOLD C1769 $1,290.27 02721135 HB GUIDE WIRE PTCA C1769 $1,391.20 02721137 HB CATHETER, BALLOON DILATION7 C1726 $4,938.35 02721138 HB GUIDEWIRE C1769 $412.25 02721139 HB GUIDEWIRE, TERUMO AMPLATZ C1769 $613.61 02721140 HB GUIDE WIRE ACCESSORY KIT C1769 $1,613.51 02721141 HB CATHETER, BALLOON DILATION3 C1726 $1,901.81 02721143 HB GUIDEWIRE, MM C1769 $232.39 02721144 HB CATHETER, DRAINAGE 3 C1729 $2,700.21 02721145 HB GUIDEWIRE, LONG .018-.015 C1769 $613.61 02721146 HB GUIDEWIRE EXCHANGE PTCA C1769 $2,826.25 02721147 HB CATHETER, DRAINAGE 1 C1729 $289.23 02721149 HB CATHETER FLOWIRE C1769 $2,722.09 02721150 HB GUIDE WIRE CATH LAB C1769 $2,080.55 02721151 HB GLIDEWIRE/GUIDEWIRE C1769 $1,605.66 02721152 HB GUIDEWIRE, INTERVENTIONAL COON C1769 $228.21 02721154 HB GUIDE WIRE EP C1769 $268.62 02721155 HB GLIDE WIRE TERUMO C1769 $537.48 02721156 HB GUIDEWIRE J BENTSON COONS C1769 $613.61 02721157 HB GUIDEWIRE, TERUMO C1769 $613.61 02721158 HB STENT, OASIS NON-COAT/COV W/DEL C1876 $526.29 02721159 HB GUIDEWIRE, US 1408/1809/2500 C1769 $613.61 02721160 HB GUIDEWIRE, AMPLATZ SS C1769 $613.61 02721161 HB JAGWIRE I C1769 $1,442.24 02721163 HB COIL, PUSHER $1,710.32 02721164 HB CATHETER, INFUSION 1 C1751 $860.64 02721166 HB GUIDEWIRE, MICROSYS MICROWIRE C1769 $2,828.64 02721170 HB GUIDE WIRE CATH EP LAB C1769 $939.25 02721171 HB GUIDEWIRE, PLATINUM .018 TIPPED C1769 $2,381.57 02721174 HB CATHETER, GUIDING MICROSYS C1887 $3,557.34 02721175 HB GUIDEWIRE, PMG NITREZ 18-60 C1769 $298.80 02721176 HB GUIDE WIRE-J BENTSON COONS C1769 $615.95 02721177 HB MRI ENDORECTAL INSERTABLE COIL C1770 $1,328.46 02721179 HB RTRVL DVC, COIL C1773 $4,106.21 02721180 HB SNARE RETRIEVER DEVICE C1773 $2,119.94

Ancillary FY22 16 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721181 HB RTRVL DVC, FILTER IVC C1773 $1,224.07 02721182 HB RTRVL DVC, SNARE GNC C1773 $3,303.69 02721185 HB PT/PRGMR, NEUROSTIMULATOR 4 C1787 $7,675.77 02721187 HB EMBOLIC PROTECTION SYSTEM * C1884 $13,176.59 02721190 HB CATHETER, URETERAL 1 C1758 $524.98 02721191 HB EMBOLIC PROTECTION SYSTEM* C1884 $18,635.19 02721192 HB EMBOLIZATION PROTECTIVE SYSTEM C1884 $10,276.77 02721193 HB CATH ANGIOPLASTY LASER C1885 $20,069.82 02721194 HB CATH THERMODILUTION C1887 $2,429.82 02721196 HB CATH DIAGNOSTIC ANGIO C1887 $247.16 02721197 HB CATHETER, GUIDING C1887 $1,346.90 02721200 HB CATHETER, GUIDING 1 C1887 $812.48 02721201 HB CATH GUIDING PEDS C1887 $1,402.00 02721202 HB CATH GUIDING RAPIDO DEL SYS C1887 $7,618.52 02721203 HB GUIDEWIRE 6 C1769 $3,354.92 02721204 HB THROMBOLITIC INFUSION WIRE C1887 $2,137.92 02721205 HB CATHETER, GUIDING 4 C1887 $2,427.38 02721206 HB CATH BERMAN C1887 $2,018.79 02721207 HB CATH DIAGNOSTC ANGIO MULTIPACK C1887 $1,876.01 02721208 HB INTRO/SHEATH, GUIDING C1892 $676.31 02721209 HB INTRO/SHEATH, GUIDING 1 C1892 $746.17 02721211 HB EP INTRO/SHEATH, GUIDING 1 C1892 $639.67 02721212 HB INTRO/SHEATH GUIDE EP TRNSPTL C1893 $1,630.31 02721213 HB INTRO/SHEATH FIXED NON PEEL C1893 $1,799.11 02721215 HB NEEDLE, TRANSEPTAL $2,216.79 02721216 HB INTRODUCER SHEATH, NON GUIDING C1894 $325.29 02721220 HB INTRO/SHEATH, CONTRALATERA C1894 $520.20 02721222 HB INTRO/SHEATH, BLKN LONG C1894 $801.57 02721224 HB INTRO/SHEATH C1894 $404.84 02721225 HB CATHETER, OCCLUSION BALLOON C2628 $1,679.29 02721230 HB GUIDEWIRE 3 C1769 $1,686.02 02721232 HB EP CATHETER-EZ STEER NAV BI-D C2630 $27,623.35 02721237 HB K-WIRE, SUPPLY 2 $1,066.35 02721238 HB ENDOSCOPIC STRYKEFLOW II $672.06 02721239 HB TOOL, DISSECTING 1 $1,008.40 02721241 HB K-WIRE, SUPPLY 3 $1,635.24 02721244 HB PERFUSION BIO PUMP 1 $1,734.71 02721246 HB FILTER, BUFFALO KTP $642.96 02721248 HB PT/PRGMR, NEUROSTIMULATOR 5 C1787 $8,275.77 02721252 HB CUTTER, ENDOSCOPIC 2 $2,034.78 02721254 HB K-WIRE, SUPPLY 1 $413.70 02721255 HB RELOAD, ENDOSCOPIC 2 $1,545.10

Ancillary FY22 17 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721256 HB EXTENSION, SINUS GUIDE $841.45 02721258 HB ARTHRO FLOOR SUCTION MAT OR $485.28 02721259 HB PRESSURIZER, FEMORAL CEMENT $748.81 02721260 HB CATHETER, GUIDING PERF/INFUS 3 C1887 $2,877.70 02721262 HB SUCTION MINI POINT WAND $423.38 02721264 HB BLADE, FULL RADIUS $1,026.70 02721270 HB INTRO/SHEATH, GUIDING 2 C1892 $1,100.52 02721271 HB SPRAY SET, BIO TISSEEL $754.13 02721272 HB CATHETER, EP COOL-TIP C2630 $6,197.67 02721276 HB INTRODUCER/SHEATH,NONGDNG 3 C1894 $2,734.81 02721284 HB INTRODUCER/SHEATH,NONGDNG 2 C1894 $763.39 02721287 HB PROBE, CRYOABLATION 3 C2618 $14,214.18 02721288 HB CATHETER, SUPRAPUBIC 1 C2627 $677.28 02721291 HB CATHETER, STAMEY SUPRAPUBIC C2627 $678.96 02721293 HB CATHETER, OCCLUSION 1 C2628 $3,232.06 02721294 HB INTRODUCER/SHEATH, LASER 2 C2629 $15,680.12 02721297 HB SLEEVE, INFUSION 1 $637.69 02721298 HB CATHETER,ANORECTAL MANOSHLD AR $609.19 02721300 HB PINS, HEADLESS DISPOSABLE $1,349.49 02721301 HB KIT, CATHETER STEER NAVIGATION $7,480.28 02721303 HB CATHETER, CENTESIS $693.89 02721304 HB KIT, BONOPTY BONE SYSTEM $803.40 02721305 HB NEEDLE, TROCAR $368.27 02721307 HB CATHETER, TROCAR $368.27 02721309 HB QUADRANT ILLUMINATION $2,352.27 02721313 HB PROBE, ABLATION RITAS $6,197.67 02721314 HB PROBE, ABLATION VALLEY LAB $4,488.46 02721315 HB CATHETER, ESOPHAGEAL MANOSHLD $496.23 02721316 HB KYPHON BONE FILLER DEVICE $883.53 02721317 HB NEEDLE, BONOPTY BIOPSY $987.60 02721320 HB RETRACTOR, WOUND $829.46 02721321 HB NEEDLE, MAXI-CELL $430.00 02721322 HB DILATOR $223.49 02721323 HB KIT, BARD BIOPSY SYSTEM $721.00 02721324 HB KIT, EASY CORE BIOPSY SYSTEM $700.58 02721325 HB PROBE, NIM 1 $965.79 02721327 HB VACTHERAPY, CANISTER 300/500ML $627.08 02721328 HB TUBE, VINYL CONNECTOR $368.27 02721329 HB WIRE, LOCALIZATION 20G $270.71 02721330 HB DILATOR, DISPOSABLE 1 $1,031.95 02721332 HB PUMP, PAIN ON-Q A4306 $1,709.34 02721334 HB CATHETER, INFUSION 2 C1751 $1,571.75

Ancillary FY22 18 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721339 HB CATHETER, PLEURX WITH KIT C1729 $3,564.40 02721341 HB G030064/S41 CVRS STEERBL GUIDE C1769 $19,327.37 02721342 HB CATHETER, DRAINAGE 4 C1729 $4,635.19 02721344 HB CATHETER, HEMO, LONG TERM 1 C1750 $1,598.60 02721345 HB CATHETER, INFUSION/NON-HEMO 2 C1751 $3,489.24 02721347 HB CATHETER, GUIDING PERF/INFUS 2 C1887 $2,259.14 02721350 HB CATHETER, BALLOON RADIOELEMENT C1728 $13,995.50 02721351 HB TUBE, FEEDING 2 $1,558.49 02721353 HB PROBE, MONOPOLAR 3 $7,480.28 02721354 HB BLADE, REAMER 1 $1,696.11 02721355 HB BLADE, TRICUT 2 $3,061.43 02721357 HB NEURO MONITORING KIT 4 $5,331.71 02721360 HB SPRAY SET, CSL/TSSL/BIOCUE $754.13 02721362 HB SIZER, BREAST ALL SIZES $674.73 02721363 HB PIN, PERCUTANEOUS $2,061.26 02721364 HB PROBE, MONOPOLAR / ENDO OTO $6,361.02 02721365 HB ANESTHESIA TUBE 2 $1,574.78 02721366 HB TISSUE LOC/EXCSN DEV (IMPL WIRE) C1819 $527.81 02721368 HB TAP, DISPOSABLE 2 $1,844.26 02721369 HB CUTTER, ENDOSCOPIC 5 $3,635.63 02721381 HB TIP, RUMI $603.33 02721383 HB TUBING, CUSA / MWA $2,079.77 02721385 HB PERFUSION, PACK ADAPTER 1 $1,127.18 02721388 HB KIT, INTERNAL TRAJECTORY GUIDE $7,183.90 02721392 HB CATHETER, HEMO, LONG TERM 4 C1750 $2,593.38 02721395 HB LASER FIBER, 4 $5,256.55 02721396 HB LASER FIBER, 1 $1,682.87 02721397 HB CATH BALLOON WEDGE C1887 $884.53 02721399 HB CANNULA, ARTERIAL 1* $698.51 02721401 HB REAMER, MODULAR SHAFT 3 $4,572.33 02721402 HB NEEDLE, MICRODISSECTION $844.06 02721403 HB CATHETER, SEEKING/EMBOL 1* $502.75 02721405 HB BLADE, SAW 5 $4,969.21 02721406 HB BALLOON, OCCLUSION NON-NEURO $2,283.90 02721408 HB BALLOON, OCCLUSION NEURO $7,927.44 02721409 HB IMMOBILIZER, ALUMI - HAND $439.25 02721410 HB PUNCH, BIOPSY DISPOSABLE $66.17 02721412 HB CATHETER,TRANS/LUM,NONLSR 2 C1725 $6,329.39 02721415 HB CATHETER, GUIDING PERF/INFUS C1887 $4,287.09 02721416 HB SPATULA, BRAIN SILICONE DISP $672.06 02721417 HB LASER FIBER, 2* $1,014.28 02721418 HB STRAP, FOOT/ANKLE DISTRACTOR $576.83

Ancillary FY22 19 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721422 HB RETRACTOR, WOUND 1 $828.21 02721425 HB PIN, GUIDE 2 $1,635.24 02721427 HB GUIDEWIRE 1 C1769 $501.19 02721428 HB GUIDEWIRE 2 C1769 $1,972.57 02721454 HB BLADE, SAW 3 $1,786.66 02721455 HB CANNULA, ARTERIAL FEMORAL 2 $791.08 02721458 HB DRAIN, EXTERNAL 1 $1,260.89 02721465 HB TUBE NASO-ENTRO FED NG/J OR $2,716.64 02721467 HB RETRACTOR LP/CHK, ADLT/CHLD $407.83 02721469 HB PADS, ARCTIC SUN ADDL PAD $2,161.32 02721470 HB PADS, ARCTIC SUN MULTI-PK $5,679.89 02721471 HB CATHETER-PERIPHERAL CTO 14 $10,083.93 02721475 HB STYLET, PACEMAKR ACCSS LEAD $672.06 02721478 HB CAGE MAX TITANIUM $11,634.54 02721479 HB KIT, NAVIGATED PEDCLS ACCSS $4,553.80 02721481 HB CATHETER, JETSTREAM G2 PV C1724 $18,713.55 02721482 HB CATHETER, RELIANT BALLOON $3,513.74 02721486 HB SEALANT HEMOSTATIC MM $1,764.82 02721487 HB COLLAGEN,HEMOSTAT INSTAT MM $778.60 02721489 HB PLATELET SEPARATION SYSTEM $4,178.14 02721490 HB T-TUBE 4 $1,672.59 02721491 HB SMALL JOINT CANNULA SET $1,019.57 02721496 HB KIT, FRACTURE 4 $18,869.24 02721497 HB KIT, FRACTURE 5 $19,160.54 02721498 HB GUIDEWIRE 4 * $2,082.83 02721502 HB TUBE, TRACHEOSTOMY 3 $1,910.48 02721503 HB RELOAD, ENDOSCOPIC 1 $673.05 02721507 HB NEEDLE, ELECTRODE MICRO TIP $677.28 02721508 HB TOOL, TUNNELING LONG $2,121.67 02721509 HB SPACE PASSING ELEVATOR $781.68 02721514 HB PROBE, ENDOSCOPIC 2 $1,946.88 02721515 HB ENDOSCOPIC STRYKEFLOW W/TIP $1,371.55 02721516 HB GUIDEWIRE, .35 X 135CM $1,880.37 02721519 HB IMPELLA MONITOR SET TUBING $698.53 02721522 HB PROBE, CHOLANGIOFLEX UHD $6,788.50 02721527 HB SYSTEM, TITANIUM KNOT $1,502.66 02721533 HB MANIPULATOR, UTERINE $995.30 02721535 HB TUBING, DOLPHIN 1 $1,114.23 02721536 HB ESU SEALER DISSECTING $6,855.37 02721538 HB CATH, IVUS GUIDED CTO/PERI C1887 $18,808.46 02721539 HB CATHETER, PACING BALLOON $897.13 02721540 HB BIOPSY FORCEP 7F $1,495.45

Ancillary FY22 20 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721542 HB ELECTRODE, TEMPORARY PACING $5,695.88 02721543 HB CATHETER, EXPORT ASPIRATION $4,025.25 02721544 HB PADS, UNIVERSAL ARCTIC GEL $2,354.61 02721545 HB PADS, ARCTIC GEL (S,M,L) $7,769.50 02721546 HB KIT, CRYOABLATION C2618 $22,201.47 02721547 HB STAPLER, ENDOSCOPIC 2 $1,607.04 02721548 HB STAPLER, ENDOSCOPIC 3 $2,162.95 02721549 HB STAPLER, ENDOSCOPIC 4 $2,636.30 02721551 HB BLADE, TRUNCATED 2 $6,114.98 02721554 HB TIP, PHACOEMULSIFICATION 1 $839.93 02721555 HB PUNCH DISPOSABLE 1 $575.34 02721556 HB CATHETER, BALLOON-IN-BALLOON C1726 $5,209.49 02721557 HB CATHETER, MULTI-TRACK $686.94 02721558 HB PERF CELL SAVER BRAT KIT $1,495.35 02721559 HB PERF UNIV 3 SPIKE $1,405.56 02721560 HB BASKET RETRIEVABLE INSERTABLE C1889 $1,616.73 02721562 HB KIT LEAD LOCKING DEVICE $3,995.74 02721563 HB RETRACTOR, SCROTAL/TISSUE $2,553.78 02721564 HB RETRACTOR, VAGINAL $1,577.90 02721569 HB KIT, ASPIRATION VIZISHOT $1,563.32 02721570 HB COLLAGEN, HEMOSTAT INSTAT 2 $1,699.87 02721573 HB NEEDLE, BIOPSY 1 $660.29 02721575 HB BIOGLUE, SKNCLSR SYRINGE 2 $4,294.68 02721576 HB NEEDLE, ASPIRATION 1 $1,131.24 02721577 HB CATHETER, ANORECTAL DISP. $750.39 02721578 HB INTRODUCER/SHEATH,NONGDNG 1 C1894 $688.07 02721580 HB SUCTION VALVE 1 $305.88 02721582 HB CANNULA BLOWER MISTER $784.09 02721583 HB KIT, TRI/QUAD LPRSCPC SYS $3,252.91 02721585 HB PERFUSION LINE SPIKE $240.33 02721586 HB ESU FILTER SMOKE EVACUATOR $1,286.61 02721587 HB PROBE, PRASS MONOPOLAR STIM $2,785.74 02721588 HB PROBE, BALL TIP PEDICL STIM $2,785.74 02721590 HB PACK, PERFUSION PUMP TABLE1 $1,264.74 02721591 HB KIT, OPTIVAC TRIPLE MIX $1,505.07 02721592 HB REAMER, MODULAR SHAFT 2 $3,095.11 02721593 HB KIT, VITRECTOMY INNOVAT PAK $3,180.06 02721597 HB KIT, PATIENT SPINAL CORD $1,148.22 02721598 HB ELECTRODE, ESU 2 $1,320.59 02721602 HB HANDPIECE, ENDOSCOPIC 3 $2,575.62 02721604 HB CATHETER, EP<19 ELECTRODES 2 C1730 $3,146.10 02721605 HB CANNULA, VENOUS 4 $2,930.04

Ancillary FY22 21 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721606 HB PERFUSION, MANOMETER LINE $451.51 02721607 HB TUBE, ENDOTRACHEAL 3 $2,306.16 02721609 HB CATHETER,TRANS/LUM,NONLSR 1 C1725 $4,467.93 02721610 HB CANNULA, ARTERIAL FEMORAL 6 $2,930.04 02721611 HB TUBING, PERFUSION 1 $402.98 02721613 HB PROBE, MONOPOLAR 1 $1,145.79 02721614 HB SPATULA, PLASMA DISPOSABLE $2,570.78 02721615 HB K-WIRE, SUPPLY 4 $2,233.34 02721616 HB CATHETER, BALLOON DILATION6 C1726 $4,422.99 02721617 HB STAPLER, ENDOSCOPIC 6 $3,634.01 02721618 HB CATHETER, GUIDING PERF/INFUS C1887 $3,820.93 02721619 HB CATHETER, BALLOON DILATION5 C1726 $3,116.96 02721621 HB CANNULA, ARTERIAL FEMORAL 5 $2,354.71 02721622 HB EXTENSION, STAPLER 1 $1,233.18 02721624 HB PROBE, MONOPOLAR 2 $1,670.14 02721629 HB MONITORING CATH W LICOX BLT $4,708.40 02721632 HB VAC THERAPY SYSTEM 1 $701.57 02721634 HB HEAT EXCHANGER 1 $2,281.89 02721636 HB FLANGE, ACETABULAR 1 $1,492.93 02721637 HB CLAMP, BULLDOG 1 $208.77 02721638 HB CANNULA, INTRODUCTION $776.82 02721639 HB DISPOSABLE PULLBACK SLED $609.32 02721640 HB DILATOR,VSSL,PERI,HYDRO CTD $241.29 02721641 HB DILATOR,VSSL, PERIPHERAL IR $166.89 02721642 HB SHEATH, PINNACLE II RDPAQUE C1894 $546.21 02721643 HB CATHETER, INDWLL SILICONE 1 A4344 $179.63 02721644 HB PROBE, CRYOABLATION 2 C2618 $8,027.87 02721645 HB SLEEVE, TRACTION ARM $920.06 02721646 HB FILTER, BLOOD 1 $368.98 02721649 HB REAMER SWANSON 1 $335.00 02721650 HB REAMER CRTCLSCRW RMVR DISP2 $3,468.94 02721652 HB ADAPTOR, CELL SAVER $308.29 02721653 HB CATHETER,BALLOON DILATION9 C1726 $6,360.15 02721654 HB CATHETER, DIAGNOSTIC 1 $264.59 02721655 HB NEEDLE, SPINAL 1 $155.36 02721657 HB EXTRACTOR, STONE TIPLESS 1 $1,027.74 02721660 HB CATHETER,THRMBCTMYEMBLCTMY1 C1757 $249.55 02721661 HB KIT, MINI STICK DILATOR $687.42 02721663 HB ELECTRODE, ESU 4 $2,334.51 02721665 HB PT/PRGMR, NEUROSTIMULATOR 6 C1787 $8,584.84 02721666 HB BOLT EXTRACTION SCREW RMVL 1 $1,261.41 02721670 HB HEMOSTAT ABSORBABLE SURGICE $747.71

Ancillary FY22 22 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721673 HB CABLE, PACEMAKER ACCESSORY $907.50 02721678 HB SHEARS, HARMONIC 2 $3,614.10 02721679 HB PLEDGET, CARDIOVASCULAR 1 $208.73 02721680 HB SNARE, W/HOOKS $3,468.87 02721681 HB SHEATH, CARDIOVASCULAR 1 $1,290.89 02721683 HB ASPIRATOR, ENT 2 $1,023.19 02721684 HB CATHETER, GLIDECATH HYDRA 1 $716.91 02721685 HB CATHETER,THRMBCTMYEMBLCTMY2 C1757 $1,036.81 02721686 HB SCISSORS, ENDOSCOPIC 2 $2,427.54 02721687 HB CATHETER, GUIDING 2 C1887 $2,376.30 02721688 HB CATHETER, GUIDING 3 C1887 $4,215.05 02721689 HB CATHETER, GUIDING 5 C1887 $5,033.89 02721690 HB CATHETER, GUIDING 6 C1887 $6,823.46 02721691 HB EP INTRO/SHEATH, GUIDING 2 C1892 $4,216.50 02721692 HB EP INTRO/SHEATH, GUIDING 3 C1892 $2,067.05 02721693 HB EP INTRO/SHEATH, GUIDING 4 C1892 $5,053.59 02721695 HB BP CUFF HF LATITUDE KIT $6,845.70 02721699 HB CANNULA LONG TERM SET 1 $1,383.92 02721703 HB CANNULA, CATH VENT SUMP 1 $435.59 02721704 HB CANNULA AORTIC $424.23 02721706 HB ATRIAL CATH MONITORING SET $539.96 02721708 HB SUCTION COAGULATOR 1 $238.21 02721709 HB PRESSURE MONITORING SET 1 $1,077.65 02721710 HB SEALANT, HEMOSTATIC 3 $5,934.99 02721711 HB CATHETER, INTRAVAS ULTRSND1 C1753 $6,692.76 02721713 HB CANNULA, GRAFT 1 $4,553.34 02721716 HB PERFUSION OXYGENATOR 5 $6,111.93 02721717 HB PERFUSION OXYGENATOR 6 $7,350.67 02721718 HB PERFUSION OXYGENATOR 1 $2,593.14 02721719 HB PERFUSION OXYGENATOR 2 $3,101.35 02721720 HB PERFUSION OXYGENATOR 3 $4,167.65 02721721 HB CATHETER, BALLOON DILATION8 C1726 $5,678.64 02721724 HB PERF FILTER SET 1 $1,104.87 02721725 HB CATHETER, HEMO, LONG TERM 5 C1750 $3,455.74 02721727 HB CATHETER, CARDIOPLEGIA 1 $1,193.36 02721728 HB PACK, ACCESSORY VNS $4,243.60 02721731 HB BAG,DRAINAGE URN MTR 2000ML $187.03 02721732 HB CATHETER, FOLEY 2 WAY SEC $110.80 02721740 HB KIT, PICC SELDING $908.38 02721741 HB RELOAD, ENDOSCOPIC 3 $2,067.03 02721742 HB RELOAD, ENDOSCOPIC 4 $2,663.47 02721743 HB TUBING, SUCTION 1 $447.96

Ancillary FY22 23 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721745 HB CANNULA, VENOUS 3 $2,345.85 02721746 HB CATHETER, EP<19 ELECTRODES 1 C1730 $1,177.46 02721747 HB DRAIN, HEMOVAC 1 $235.97 02721749 HB BLADE, DERMACARRIER 1 $505.93 02721751 HB PERFUSION EXTENTION LINE $555.84 02721753 HB RET DEV, INSERTABLE 1 C1773 $2,166.63 02721754 HB RET DEV, INSERTABLE 3 C1773 $8,705.10 02721755 HB BLADE, SAW 4 $2,692.97 02721760 HB GUIDE WIRE 2 C1769 $1,381.18 02721761 HB GUIDE WIRE 3 C1769 $1,936.89 02721763 HB CATHETER, ATHERECT ROTATION 2 C1724 $8,797.23 02721764 HB CATH EP 20+ ELECTRODES 1 C1731 $7,349.79 02721765 HB CATH EP 20+ ELECTRODES 2 C1731 $9,574.27 02721766 HB CATH EP 20+ ELECTRODES 3 C1731 $11,119.27 02721767 HB CATH EP 20+ ELECTRODES 4 C1731 $12,149.27 02721768 HB CATHETER, DIAG/ABLATION 1 C1732 $13,179.26 02721769 HB CATHETER, DIAG/ABLATION 2 C1732 $14,724.29 02721771 HB CANNULA ARTERIAL FEMORAL $2,210.89 02721773 HB SCREW POWER DRIVER $1,088.99 02721774 HB PLATE, TEMPLATE 1 $646.60 02721776 HB VEIN HOLDER $549.03 02721777 HB SUCTION KAMVAC CVD MINI 1 $490.07 02721778 HB ADAPTER, LUER 1 $79.39 02721779 HB CANNULA, VENOUS 6 $14,467.66 02721781 HB RETRIEVER, ROTH NET 1 $1,177.46 02721782 HB REAMER CRTCLSCRW RMVR DISP1 $2,493.32 02721783 HB DISSECTOR, BALLOON ENDO 1 $1,674.33 02721784 HB DISSECTOR, BALLOON ENDO 2 $2,497.89 02721785 HB CATHETER, GUIDING PERF/INFUS C1887 $805.38 02721786 HB CATHETER, INTRVSC OCT LIGHT $7,481.38 02721787 HB AMBULATORY CARDIAC ZIO PATCH $1,882.41 02721789 HB PROBE, ESU 1 $3,943.04 02721790 HB PROBE, ESU 2 $4,258.39 02721791 HB SUCTION IRRIGATION SYSTEM 1 $1,728.77 02721792 HB CATHETER, BALLOON DILATION1 C1726 $703.30 02721793 HB DILATOR, DISPOSABLE 1 $2,016.88 02721794 HB DILATOR, DISPOSABLE 2 $3,496.01 02721798 HB BLADE, BANANA 1 $260.90 02721799 HB BLADE, BANANA 2 $1,792.30 02721801 HB FASTENER CARTRIDGE ESOPHYX $3,505.17 02721802 HB ADJUSTABLE BAND $2,570.46 02721803 HB CHISEL, ESU LIGAMENT $3,757.03

Ancillary FY22 24 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721805 HB CANNULA, RADIO FREQUENCY 1 $524.08 02721806 HB TUNNELER, SURGICAL 2 $3,418.98 02721807 HB KIT, PLASMA EXCH-SPECTRA/OPTIA $2,354.73 02721808 HB ANTICOAGULANT $130.07 02721809 HB TUBING, BLOOD WARMER $225.29 02721810 HB TUBING, EXTENSION PHERESIS $81.04 02721812 HB KIT,RED BLOOD CELL EXCHANGE $2,044.26 02721813 HB TUBING LDL REDUCTION $782.95 02721814 HB LDL COLUMNS $8,544.26 02721815 HB LDL BLOOD CELL SEPARATOR $1,347.87 02721816 HB KIT, PHOTOPHERESIS $9,574.27 02721817 HB UVADEX $1,291.37 02721818 HB KIT, STEM CELL COLLECTION $1,853.69 02721819 HB KIT, WHITE CELL DEPLETION $1,853.69 02721820 HB TRICITRSOL 50CC $895.49 02721821 HB KIT, PLATELET DEPLETION $7,053.32 02721822 HB BASKET, RETRIEVAL I $1,969.01 02721823 HB BASKET, RETRIEVAL III $4,724.49 02721825 HB BASKET, LITHO MECHANICAL $5,785.15 02721826 HB CATHETER, ERCP $1,528.12 02721827 HB CANNULA, ERCP SWING TIP $2,065.54 02721828 HB SPHINCTERTOME/PAPILLOTOME I $1,926.11 02721829 HB SPHINCTERTOME/PAPILLOTOMEII $2,516.87 02721830 HB BALLOON,RX EXTRACT/MULTI 3V $1,777.58 02721831 HB STENT, RETRIEVER $1,556.11 02721834 HB OVERTUBE, DOUBLE BALLOON I $2,392.60 02721836 HB OVERTUBE, GASTRIC GARDIS $1,891.09 02721837 HB TUBE, JEJUN GW(FEEDING) $2,788.91 02721838 HB CAPSULE, WIRELESS PILLCAM $4,135.54 02721839 HB CATHETER, BALLOON BIL RX C1726 $2,456.07 02721840 HB CATHETER,CRE BAL DILAT ROTH C1726 $1,140.01 02721841 HB CATHETER, HALO GUIDE WIRE C1887 $1,442.24 02721842 HB CATHETER,ENDOSCOPY,ABLATION C1888 $10,079.13 02721843 HB GUIDEWIRE PATHFINDER/ACCESS C1769 $1,519.18 02721844 HB GUIDEWIRE/GLIDEWIR/VISIGLID C1769 $2,088.24 02721845 HB JAGWIRE II C1769 $2,015.54 02721846 HB FORCEPS, RESCUE $5,220.84 02721847 HB FORCEPS, BIOPSY II $3,142.88 02721849 HB BALLOON, ENDOSCOPY EXTRACTN $2,288.71 02721850 HB RAPID REFILL CONT. INJ SYS $494.43 02721851 HB NEEDLE, EUS ECHO-HD $3,058.00 02721852 HB NEEDLE, HD U/S ACCESS $3,496.89

Ancillary FY22 25 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721854 HB SUCTION, ENDO BROVAC $2,981.28 02721855 HB OTSC SYSTEM SET 100.10 $3,666.18 02721856 HB OTSC TRIPOD ANCHOR ST200.10 $3,512.25 02721858 HB OTSC TWIN GRASPER 200.45 $4,654.08 02721864 HB LASER FIBER, 7 $7,720.47 02721866 HB ELECTRODE, ESU 5 $3,947.59 02721867 HB CAPSULE, ENDOSCOPE DEL SYS $1,674.33 02721868 HB KIT, ENDO MUCUS RESECTION $2,123.53 02721872 HB BLADE, TRUNCATED 1 $5,079.68 02721873 HB ENDO CATCH 1 $609.32 02721875 HB COBLATOR, ENT 1 $2,212.00 02721878 HB PT/PRGMR, NEUROSTIMULATOR 1 * C1787 $4,718.94 02721879 HB SHEARS, HARMONIC 1 * $2,084.95 02721882 HB LASER FIBER, 8 * $8,287.66 02721883 HB DRIVER AMPLATZER TORQUE 1 $4,750.69 02721885 HB KIT, STANDARD PEG $839.45 02721887 HB CATHETER,CRYOABLATION ARCTIC C1733 $22,282.71 02721888 HB INTRO/SHEATH EP FLEXCATH C1766 $7,982.65 02721891 HB KIT,TUBE GASTROSTOMY FEEDING $1,313.98 02721892 HB OTSC SYSTEM SET 100.12 $4,078.14 02721893 HB KIT, TUBE JEJUNAL FEEDING $1,599.57 02721894 HB NEEDLE,ECHOTIP CELIAC PLEXUS $2,285.83 02721896 HB CATHETER, URETERAL 2 C1758 $1,672.05 02721897 HB CATHETER,ENSMBL DS BLN18-22 C1887 $35,839.29 02721900 HB TUBE, NASAOGASTRIC $2,174.21 02721901 HB KIT, COAXIAL TEMNO BX SYSTEM $862.04 02721903 HB FORCEP,COLON MAXUM RATTOOTH $3,064.29 02721905 HB OTSC SYSTEM SET 100.27 $4,283.82 02721906 HB OTSC SYSTEM SET 100.14 $4,612.81 02721909 HB DISSECTOR, BALLOON ENDO 3 $3,536.95 02721915 HB CONNECTOR SMARTSTITCH $1,420.22 02721917 HB PROBE, RADIO FREQUENCY 1 $3,820.89 02721919 HB DRAIN 2 $1,912.55 02721921 HB GUIDE, DRILL 2 $2,139.41 02721925 HB BLADE, OSTEOTOME 1 $1,626.67 02721928 HB EXTRACTOR, CONICAL 2 $3,155.00 02721929 HB HEAD REAMER 1 $2,765.56 02721930 HB DRILL BIT, DISPOSABLE 1 $748.68 02721931 HB DRILL BIT, DISPOSABLE 2 $1,288.39 02721932 HB DRILL BIT, DISPOSABLE 3 $1,676.97 02721933 HB DRILL BIT, DISPOSABLE 4 $2,146.22 02721934 HB DRILL BIT, DISPOSABLE 5 $2,543.25

Ancillary FY22 26 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02721935 HB DRILL BIT, DISPOSABLE 6 $3,083.18 02721936 HB DRILL BIT, DISPOSABLE 7 $3,750.21 02721937 HB DRILL BIT, DISPOSABLE 8 $4,351.42 02721938 HB DRILL BIT, DISPOSABLE 9 $5,104.63 02721940 HB TUBING, PCA $124.66 02721942 HB PREVALON BOOT $854.14 02721943 HB CATH, CNTRL VENOUS, SINGLE $566.94 02721944 HB KNIFE, BAYONET 1 $1,957.91 02721946 HB NO COST ITEM SUPPLY-CL $1.00 02721948 HB KNIFE, TRIANGLE TIP $5,112.82 02721953 HB SCALPEL, SURGICAL 10 STER $64.08 02721958 HB HEMOCLIP MEDIUM $148.27 02721959 HB LIGACLIP SMALL $91.80 02721961 HB MASTISOL LIQUID ADHESIVE $64.08 02721964 HB PACK, PERFUSION PUMP TABLE $1,199.98 02721966 HB COLLAGEN, HEMOSTAT INSTAT $986.66 02721969 HB BLADE, PIVOTAL/FIXED $93.61 02721972 HB DRAIN ,BLAKE $422.23 02721973 HB DRAIN, RESERVOIR $134.96 02721974 HB DRAIN, PLEUR ADULT/PEDS $529.11 02721975 HB FLOSEAL HEMOSTAT 5ML $1,684.44 02721979 HB CATHETER,BRACHYTHSEEDADMIN1 C1728 $1,119.00 02721980 HB CATHETER, CUTTING BALLOON C1725 $8,285.38 02721981 HB PRP INJECTION KIT $1,826.99 02721982 HB CATHETER, SOLITARE DEVICE C1757 $29,858.55 02721983 HB KIT, SPINAL CORD STIM 2 $11,960.49 02721984 HB BOLT EXTRACTION SCREW RMVL2 $2,764.94 02721985 HB NEEDLE, MAX FORCE INJECTOR $608.06 02721987 HB GRASPER, MONOPOLAR HEMOST $2,127.11 02721988 HB GRASPER, MONOPOLAR 230 CM $2,750.43 02721989 HB CLIP, QUICK $1,299.09 02721990 HB ATTACHMENT DISTANT DISPOSBL $876.62 02721991 HB BLADE, DERMATOME 1 $366.56 02721992 HB GUIDEWIRE 5 C1769 $2,849.93 02721993 HB HEARTMATE, CENTRIMAG PUMP $44,923.99 02721995 HB KIT, SPARES TAH $12,174.10 02722000 HB ATHERECTOMY DEVICE $22,732.52 02722001 HB PROBE, MICROWAVE $10,424.02 02722009 HB BALLOON, ULTRASOUND LIN/RAD $437.90 02722012 HB MOUTHPIECE, QFIX $157.55 02722013 HB CLIP, QFIX NOSE $104.81 02722014 HB FILTER, QFIX BACTERIAL $249.02

Ancillary FY22 27 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722016 HB NANODOTS-SCREENED $288.04 02722018 HB MICROCATH SUREFIRE INF SYS $16,525.38 02722020 HB TUBE, FEEDING 1 $558.12 02722022 HB PIN, STEINMAN 1 $308.56 02722023 HB PIN, STEINMAN 2 $1,159.34 02722026 HB FIBER LASER R-1 $812.22 02722027 HB FIBER LASER R-2 $950.60 02722028 HB FIBER LASER R-3 $1,508.70 02722030 HB CATHETER, INTRAVAS ULTRSND 1 C1753 $5,376.88 02722031 HB OCCLUDERS, COLPO-PNEUMO $961.95 02722032 HB TROCAR SITE CLOSURE SYS $521.81 02722034 HB PERF ANTICOAGULANT LINE $397.02 02722035 HB INFINITY SAMPLING SYSTEM $443.82 02722036 HB FORCEPS,RESCUE RAT-T/ALIGTR $1,223.58 02722037 HB INFLATION SYSTEM BIG60 $669.96 02722038 HB CYSTOTOME $3,229.40 02722042 HB BASKET BILIARY STONE REMOVAL $2,373.82 02722043 HB ENDOCATH OCCLUSION BALLOON C2628 $5,211.51 02722045 HB GUIDEWIRE, FINDRWIRZ SYSTEM $8,029.27 02722047 HB CANNULA, SOFT TIP GUIDE $2,786.24 02722053 HB NEEDLE, BIOPSY SYSTEM $521.88 02722056 HB MIC-KEY MEASURING STOMA $171.40 02722062 HB TISSUE HELIX $1,808.17 02722063 HB CATHETER, RADIO ENDO $8,603.37 02722065 HB BIOGLUE, SKNCLSR SYRINGE CL $5,442.85 02722069 HB PATCH, TACHOSIL $4,966.23 02722072 HB AEROSIZER STENT SYSTEM C1874 $1,887.26 02722074 HB SEALER, BIPOLAR 1 $4,081.43 02722075 HB CLIP, OCCLUSION 1 $8,287.66 02722076 HB CLIP, OCCLUSION 2 $17,814.03 02722077 HB LIGASURE, ESU 3* $4,035.59 02722078 HB STAPLER, ENDOSCOPIC 7 $4,224.37 02722079 HB VAC THERAPY SYSTEM 2 $1,442.92 02722080 HB ROD, REAMING 1 $1,402.05 02722082 HB SEALANT, HEMOSTATIC 2 $4,966.23 02722083 HB TUBE, HOLLOW REAMER* $2,445.69 02722084 HB SEAL SYSTEM PROXIMAL AORTIC $4,045.14 02722085 HB TUBING HTA PROCEDURE SET 1 $8,176.49 02722088 HB KIT, MENISCAL REPAIR $1,157.43 02722090 HB TRACKER FUSION ENT $1,563.15 02722091 HB CATHETER, GUIDING PERF/INFUS C1887 $8,004.07 02722092 HB REAMER, ORTHO 1 $4,108.67

Ancillary FY22 28 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722094 HB CUP, VACCUUM EXTRACTION $576.79 02722095 HB SURGICEL $922.02 02722097 HB CATHETER, ENDO BIL DRAIN $1,261.63 02722101 HB SURGICAL ELECTR KNIFE DISP $4,759.02 02722102 HB TUBE, MIC-KEY JEJUNAL STOMA $2,968.10 02722104 HB TOOL, ULTRA DISK DRIVE* $3,835.69 02722105 HB INSERTION KIT ART/VEN $732.53 02722106 HB FORCEPS, ENDOSCOPIC 1* $382.61 02722107 HB GENERATOR, RADIO FREQUENCY* $4,224.05 02722109 HB EXTRACTION BALLOON 1 $1,777.58 02722110 HB KIT, LIPIVAGE W/CANNULA $1,649.61 02722111 HB KNOT PUSHER 1 $1,580.42 02722117 HB CATHETER, FAST CLOSURE 1 $6,164.00 02722119 HB HELIFX APPLIER $32,863.74 02722120 HB CATHETER, HELIFX GUIDE C1887 $13,639.02 02722127 HB FORCEPS, ENDOSCOPIC 2* $1,478.52 02722128 HB PT/PRGMR, NEUROSTIMULATOR 3* C1787 $6,564.78 02722129 HB PACK, ACL DISPOSABLE $1,491.99 02722131 HB BONE COLLECTOR $1,145.91 02722132 HB PREP CATHETER $1,599.63 02722134 HB SPECIMEN COLLECTION SYSTEM1 $613.33 02722135 HB ESU SUPRALOOP 1 $1,263.18 02722136 HB DISSECTOR, ARTICULATING 1 $8,542.34 02722137 HB PUSHER COIL NEURO $1,836.70 02722138 HB EUS BALLOON $671.50 02722139 HB PROBE COLOFLEX UHD $3,785.40 02722140 HB STEERABLE GUIDE CATHETER $21,776.31 02722141 HB CATHETER,OCELOT ATHERECTOMY $26,062.18 02722142 HB PROBE, PEN 1 $11,891.60 02722143 HB PROBE, PEN 2 $12,664.48 02722144 HB PROBE, PEN 3 $15,756.09 02722145 HB CATHETER, GUIDING PERF/INFUS C1887 $9,313.31 02722148 HB LUMBAR CATHETER 1 $1,590.04 02722149 HB TOOL, DISSECTING 3 $2,660.94 02722150 HB TUBING HTA PROCEDURE SET 2 $9,057.60 02722151 HB PERICARDIAL SUMP 1 $421.06 02722153 HB DISPOSABLE INSTRUMENTS 1 $5,967.91 02722156 HB INTRODUCER/SHEATH, LASER 3 C2629 $16,580.92 02722157 HB HANDPIECE, NEURO 1 $15,690.75 02722158 HB HANDPIECE BENDING TOOL $613.33 02722159 HB GUIDE, OUTER TUBE W/STYLET $1,618.88 02722160 HB DRAINAGE SYSTEM 1 $636.41

Ancillary FY22 29 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722162 HB SCREW, STEREOTACTIC 1 $905.56 02722163 HB SPACER, TIBIAL/FEMORAL 1 $5,450.72 02722164 HB NEURO MONITORING KIT 5 $5,883.32 02722165 HB HAND DRILL DISPOSABLE 1 $953.63 02722166 HB CATHETER PICC LUMEN 3CG $2,013.12 02722167 HB NEEDLE, BREAST VACUUM ATEC $3,067.03 02722168 HB URODYNAMIC PUMP TUBING* $1,636.07 02722169 HB CATHETER, SINGLE LUMEN CAT895 $3,347.46 02722170 HB CATHETER, DUAL LUMEN CAT880 $4,080.92 02722171 HB CATHETER, RECTAL ABD CAT875 $2,951.97 02722172 HB R.I.A. SYSTEM 1 $2,816.68 02722173 HB R.I.A. SEAL 1 $442.22 02722174 HB TOOL, SIZING 1 $1,626.02 02722178 HB INTRODUCER/SHEATH, GDNG 1 C1893 $1,513.12 02722183 HB GELFILM $3,862.91 02722184 HB NOZZLE, DISPOSABLE 1 $520.72 02722185 HB FOREIGN BODY HOOD $334.61 02722186 HB PUSH CATHETER 4/5 FR $331.37 02722187 HB RX LOCKING/BIOPSY CAP $166.25 02722189 HB NERVE STIMULATOR 2 $3,305.35 02722192 HB ENDO ANTI-FOG 1 $568.79 02722194 HB PIN, STEINMAN 3 $2,079.68 02722197 HB GRASPER, ENDOSCOPIC 3 $4,191.37 02722198 HB COREVALVE DELIVERY SYSTEM $13,237.76 02722199 HB COREVALVE LOADING SYSTEM $3,435.29 02722203 HB CANNULA AND STYLET 1 $1,997.95 02722204 HB SOLOPATH INTRODUCER/BALLOON $4,949.22 02722205 HB STINGRAY CTO BALLOON $8,285.01 02722206 HB CROSS BOSS CTO CATHETER $6,690.01 02722207 HB DRY SEAL SHEATH $2,988.37 02722208 HB CATHETER, HYSTERO DIAG 5-7F $715.61 02722209 HB RAPTOR MINI $1,292.50 02722210 HB OVERTUBE ENDO ACCESS SYSTEM $1,809.48 02722213 HB BLADE, QUADCUT 1 $1,349.06 02722214 HB BLADE, QUADCUT 2 $1,946.67 02722216 HB CTO NEEDLE HOLDER $1,528.92 02722217 HB LOCKING BIOPSY CAP $233.81 02722218 HB CATHETER, ENDO STENT PUSH $1,145.46 02722219 HB CATHETER, SPRAY $2,018.10 02722220 HB CATHETER, ABLATION HALO 90 & 60 $7,774.27 02722221 HB PROBE, NEURO SHIELDED 1 $1,756.03 02722222 HB CANNULA, ARTERIAL 2* $1,688.74

Ancillary FY22 30 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722223 HB STERNAL CABLE SYSTEM $1,179.23 02722224 HB SUCTION WATER SEAL $735.40 02722225 HB SHUNT, CAROTID 1 $4,180.59 02722229 HB OBTURATOR 1 $501.49 02722230 HB GUIDEWIRE 7 C1769 $5,146.28 02722233 HB BLADE, ROTATING 1 $1,341.04 02722234 HB ANES PRESSURE BAG DISP $555.96 02722235 HB CATHETER, ENDOVASCULAR $15,739.93 02722236 HB CATHETER, TRANS/LU,NONLRS 4 C1725 $5,441.09 02722239 HB SPACER, TIBIAL/FEMORAL 3 $9,731.81 02722241 HB RETRACTOR HOOK $1,123.16 02722245 HB NAVIGATIONAL BRUSH $1,421.84 02722246 HB BALLOON CATHETER C1726 $2,464.12 02722247 HB INFLATION DEVICE $670.36 02722248 HB IMPELLA PURGE CASSETTE $2,068.45 02722255 HB KNIFE, OPHTHALMIC 1 $272.38 02722256 HB BONE CUTTER 1 $658.50 02722257 HB KIT, PORTAL ENTRY 1 $2,049.21 02722258 HB CANNULA W/OBTURATOR $2,334.41 02722259 HB TAMPONADE BALLOON KIT $2,212.65 02722260 HB SHEARS, HARMONIC 4 $5,232.81 02722261 HB BAG, RETRIEVAL 1 $1,483.63 02722266 HB BALLOON DRUG COATED 3 C2623 $11,380.48 02722267 HB WATCHMAN ACCESS SYSTEM $6,078.05 02722270 HB TRANSANAL ACCESS PLATFORM $5,123.96 02722271 HB BALLOON DRUG COATED 1 C2623 $9,746.72 02722272 HB BALLOON DRUG COATED 2 C2623 $10,496.79 02722273 HB CATHETER PH IMPEDANCE $1,428.48 02722276 HB SPACER, TIBIAL/FEMORAL 2 $7,505.49 02722277 HB KIT, THERAPEUTIC DOUBLE PHLEBOTOMY $998.66 02722278 HB CANNULA, ANGIOVAC STAND ALONE $40,570.66 02722279 HB NEEDLE, BIOPSY 2* $1,199.68 02722280 HB NEEDLE, BIOPSY 4* $2,966.07 02722281 HB NEEDLE, BIOPSY 5 $3,828.45 02722282 HB NEEDLE, BIOPSY 6 $4,692.86 02722285 HB BARRIER PROTECTIVE LIQUID $71.77 02722286 HB BARRIER RING $144.20 02722287 HB TAH MANAGEMENT SYSTEM Q0508 $346.13 02722288 HB BALLOON, ENDOSCOPY PULM BIOPSY $3,356.14 02722289 HB ADAPTER, ENDOSCOPY BIOPSY $986.18 02722290 HB POSITIONER, DISPOSABLE 1 $583.33 02722291 HB POSITIONER, DISPOSABLE 2 $1,658.20

Ancillary FY22 31 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722295 HB DELIVERY SYSTEM EVOLUTR $15,820.59 02722296 HB LOADING SYSTEM EVOLUTR $3,433.17 02722299 HB EP CABLE UMBILICAL $6,061.73 02722300 HB SENSOR, ANAL/EMG STIMULATION $895.04 02722303 HB KIT, CATHETER EDGE NAVIGATION BR $8,455.95 02722304 HB BREEZA DRINK /CAN $184.73 02722305 HB DUCTOGRAM CANNULA $537.68 02722306 HB KIT, COOLED RADIOFREQUENCY $5,864.82 02722307 HB MAT, COOLED RADIOFREQUENCY $5,864.82 02722308 HB PAD, GROUNDING $215.85 02722309 HB KIT, COOLED RADIOFREQUENCY ACTIVE TIP $10,088.12 02722310 HB PROBE, COOLED RADIOFREQUENCY $3,505.06 02722311 HB FLOW RETRIEVER CATHETER $13,186.75 02722312 HB ASPIRATION GUIDE CATHETER $6,849.48 02722313 HB RETRACTION ASPIRATOR $2,786.41 02722314 HB MICRA INTRODUCER SHEATH C1894 $4,880.15 02722316 HB BRAINPATH SHEATH $7,475.32 02722317 HB BRAINPATH HOOKS $1,123.77 02722318 HB SCALPEL, BONE $3,539.95 02722319 HB SCISSOR, ENDOSCOPIC $2,785.44 02722320 HB PERFUSION CANNULA BLUNT $2,699.68 02722321 HB INTRODUCER/SHEATH,NONGDNG C1894 $2,247.55 02722322 HB KIT, ANGIO TOUCH $481.20 02722323 HB PERFUSION SWITCH $622.22 02722324 HB DV FORCEPS BIPOLAR REPOSABLE $2,528.16 02722325 HB DV FORCEPS PROGRASP REPOSABLE $2,211.20 02722326 HB DV DRIVER NEEDLE REPOSABLE $2,211.20 02722327 HB DV SCISSORS MONO REPOSABLE $2,922.97 02722329 HB DV DRIVER NEEDLE MEGA REPOSABLE $1,923.34 02722331 HB PROBE, ABLATION $10,893.15 02722332 HB INFLOW TUBING SET $867.90 02722333 HB TISSUE REMOVAL STANDARD $6,116.04 02722334 HB TISSUE REMOVAL XL $6,818.22 02722335 HB SEAL SCOPE SET $268.96 02722336 HB CATHETER, GUIDING PERF/INFUS C1887 $5,207.42 02722337 HB SCALPEL BONE $3,539.95 02722338 HB BALLOON APPLICATOR $10,087.76 02722339 HB CLIP, LIGATING $601.86 02722340 HB KNEE BLOCK $10,087.76 02722341 HB CATHETER, STRETTA TRANSORAL $8,668.86 02722342 HB KIT BMAC ANGEL $7,376.45 02722343 HB SHEARS, HARMONIC $6,101.50

Ancillary FY22 32 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722344 HB KIT, ENDOMETRIAL ABLATION $6,521.64 02722345 HB PLEURX DRAINAGE $885.53 02722346 HB FOLEY TIP CATHETER PUNCH $910.41 02722347 HB CARNATION PATCH 2-DAY $1,196.76 02722348 HB MAX CANISTER $530.65 02722349 HB MAX PUMP $13,810.88 02722350 HB CATHETER 5, STRAIGHT TIP $1,690.74 02722351 HB CATHETER 6, STRAIGHT TIP $2,747.64 02722352 HB CATHETER 8, XTORQ TIP $4,201.42 02722353 HB SEPARATOR 5 $1,039.46 02722354 HB SEPARATOR 6 $1,570.07 02722355 HB SEPARATOR 8 $2,733.10 02722356 HB INDIGO ASPIRATION TUBING $636.76 02722357 HB CATHETER SELECT NERUON BER, 5 FR $181.72 02722358 HB BLADELESS OBTURATOR $520.45 02722359 HB DV VESSEL SEALER $4,904.78 02722360 HB LITHOTRIPTOR CABLE $1,529.37 02722361 HB DV GRASPER REPOSABLE $2,163.22 02722362 HB CATHETER INDWELLING FOLEY 3 WAY A4346 $279.13 02722363 HB CATHETER, CORONARY DIAGNOSTIC $4,287.09 02722364 HB PROBE, PEN $16,796.92 02722365 HB CATHETER, URINARY STRAIGHT A4351 $439.05 02722366 HB NEEDLE, DEFLUX $923.15 02722369 HB KIT, VESSEL HARVESTING $7,178.76 02722370 HB DV CANNULA SEAL $670.19 02722372 HB FAT GRAFTING HARVEST SYSTEM $2,139.96 02722373 HB DV SCISSORS REPOSABLE $2,049.83 02722497 HB DV CANNULA REDUCER $501.56 02722498 HB DV CLIP APPLIER REPOSABLE $388.15 02722499 HB CATHETER, BALLOON DILATION C1726 $11,682.55 02722500 HB KIT, CAPTIVATOR $2,769.45 02722501 HB ANOSCOPE, DISPOSABLE $59.61 02722502 HB EXTERNAL FIXATOR HOLDER $4,092.39 02722503 HB GELPORT PLATFORM $2,606.61 02722504 HB ARTHRO WAND $4,432.56 02722505 HB SERRATED KNIFE $6,553.63 02722506 HB UNIVERSAL DRIVER $817.03 02722507 HB CATHETER SPYGLASS $14,991.33 02722508 HB PROBE, MEASUREMENT $1,916.08 02722509 HB FORCEP, ENDOSCOPIC $3,981.89 02722510 HB INJECTION NEEDLE $1,349.10 02722511 HB POWERPICK $1,356.37

Ancillary FY22 33 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722512 HB PROBE, COAGULATING $2,153.05 02722513 HB ADJUSTABLE ENDOSCOPIC VALVE $670.19 02722514 HB PERFUSION CARDIOPLEGIA SET $571.34 02722515 HB CATHETER, INTUBATION $846.10 02722516 HB NAIL INSERTION SLEEVE $1,754.71 02722517 HB KIT, DRILL AND WRENCH $4,021.15 02722518 HB KIT, DRILL AND WRENCH $6,456.22 02722519 HB TRUFREEZE ACTIVE VENTING SPRAY KIT $11,093.76 02722520 HB CARPAL TUNNEL RELEASE SYSTEM $5,860.18 02722521 HB BALLOON RUMI $1,113.60 02722522 HB PERFUSION PIGTAIL LINE $299.48 02722523 HB CARDIOHELP HLS SET $29,296.50 02722524 HB STAPLER, ENDOSCOPIC $5,535.98 02722525 HB TITANIUM FASTENERS $5,733.69 02722526 HB TANDEM HEART PUMP KIT $33,657.83 02722527 HB TISSUE REMOVAL REACH $6,809.79 02722528 HB TISSUE REMOVAL LITE $4,550.31 02722533 HB STENT GRAFT BALOON CATHETER $590.14 02722534 HB DRYSEAL INTRODUCER SHEATH $3,947.17 02722535 HB DRYSEAL INTRODUCER SHEATH $5,478.51 02722536 HB CHARGER, NEUROSTIMULATOR $9,079.89 02722538 HB INTRODUCER, OSTEO TOOL $2,792.40 02722539 HB PULMONARY BALLOON DILATOR $2,747.91 02722540 HB DV REPOSABLE DISSECTOR $2,567.33 02722541 HB BLADE, CAPSULOTOMY $2,029.53 02722542 HB BONE GRAFTING KIT $6,762.48 02722543 HB HANDPIECE, NEURO $13,562.91 02722544 HB HANDPIECE, NEURO $14,728.81 02722545 HB ENDOSCOPIC SEAL $221.14 02722546 HB OBTURATOR PORT $1,176.37 02722547 HB FILTERED TUBE SET $1,205.16 02722548 HB BLADE, SHAVER $1,859.42 02722549 HB CUSA STANDARD TIP $4,301.14 02722550 HB DV REPOSABLE HOOKS $1,490.41 02722551 HB DV REPOSABLE RETRACTOR $2,747.91 02722552 HB PROTECTION SLEEVE $914.66 02722553 HB CATHETER, GUIDING PERF/INFUS C1887 $11,899.78 02722554 HB SLEEVE, OUTER PROTECTION $1,385.73 02722555 HB PROBE EXTENSION CABLE $1,222.17 02722556 HB KIT, LARYNGECTOMY PULMONARY $3,034.48 02722557 HB PROBE, BIPOLAR $4,841.56 02722558 HB TIP, INSERTER $1,007.57

Ancillary FY22 34 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722560 HB ELECTRODE, HIGH FREQUENCY $1,797.93 02722561 HB CARTRIDGE CRRT $1,911.41 02722562 HB EPI-SENSE ABLATION KIT $31,115.52 02722564 HB CATHETER ABLATION $15,083.42 02722565 HB GUIDEWIRE C1769 $20,935.17 02722566 HB KIT, DISPOSABLE INSTRUMENTS $1,885.59 02722567 HB STAPLER, ENDOSCOPIC $4,527.52 02722568 HB TUBING C02 $486.78 02722569 HB PROBE, DOPPLER $2,919.34 02722570 HB BRONCHOSCOPE ADAPTOR $1,006.26 02722571 HB PROLACT +4 10ML $922.49 02722572 HB PROLACT +4 20ML $1,525.81 02722573 HB PROLACT +6 30ML $1,974.44 02722574 HB PROLACT +8 40ML $2,423.09 02722575 HB PROLACT +10 50ML $2,871.72 02722576 HB GELPOINT ACCESS PLATFORM $3,896.80 02722577 HB KIT, BIOPSY TRANSPORT $4,184.68 02722578 HB FIBER LASER $3,729.31 02722580 HB AIRFLOW PAD $531.27 02722581 HB PROBE, ABLATION $13,297.27 02722582 HB CAROTID SHUNT $5,238.04 02722583 HB TOOL, LOOPING $2,208.80 02722584 HB GUIDEWIRE C1769 $4,220.00 02722585 HB ULTRASONIC TIP $3,722.78 02722586 HB CAROTID SHUNT $4,476.49 02722604 HB CABLE OR 1MM X 16 61CM IN EXTENSION $45.79 02722605 HB DRIVER, DISPOSABLE $813.78 02722608 HB AIMING GUIDES $333.98 02722619 HB TIP, ASPIRATION $4,204.31 02722620 HB KIT, CEMENT MIXING $1,634.36 02722621 HB THREAD LOCKING SLEEVE $2,594.81 02722622 HB MANIPULATOR, UTERINE $1,525.74 02722623 HB BLADE, DERMATOME $666.05 02722624 HB KIT, AUTOMATED MANIFOLD $1,784.84 02722627 HB KIT, ZOLL START-UP $1,934.40 02722628 HB ADJUSTABLE ENDOSCOPIC VALVE $668.66 02722629 HB DISPOSABLES KIT $1,885.59 02722630 HB SPINAL CORD CABLE $45.79 02722632 HB BAG, TISSUE RETRIEVAL $1,114.87 02722633 HB DV BLADELESS OBTURATOR $527.33 02722634 HB BALLOON DILATOR $1,706.32 02722635 HB ADAPTOR SPLITTER KIT $24,517.98

Ancillary FY22 35 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722636 HB INTRODUCER/SHEATH, GUIDING C1893 $3,608.92 02722637 HB ERCP SAMPLING SYSTEM $1,346.48 02722638 HB INJECTABLE SUBMUCOSAL COMPOSITION $1,131.88 02722639 HB PROTEK DUO KIT $36,349.65 02722642 HB TRANSFILTRATION TUBING HK $364.76 02722643 HB PROCEDURE PACK FAST CLOSURE $6,276.45 02722644 HB BAG, TISSUE RETRIEVAL $1,114.87 02722645 HB DV BLADELESS OBTURATOR $527.33 02722646 HB BALLOON DILATOR $1,706.32 02722647 HB CATHETER, FOLEY 22/24 FR $223.70 02722648 HB KANGAROO BAG $115.73 02722649 HB BINDER, PELVIC $1,921.25 02722650 HB ANGI ASSIST C02 KIT $1,290.01 02722651 HB BALLOON, TRUEPATH CTO DEVICE C1769 $12,402.31 02722653 HB CATHETER, MICROSYS NAVIEN SUPPORT C1887 $10,520.52 02722654 HB CATHETER, TRAILBLAZER 014X150 C1887 $1,720.10 02722655 HB DETACHER SMART COIL $2,337.91 02722656 HB NEEDLE, BIOPSY IVAS 11G $3,983.01 02722657 HB BALLOON, CURVED C1726 $14,722.33 02722659 HB DELIVERY GUN $4,040.47 02722660 HB DETACHER, AZUR $1,827.85 02722661 HB DETACHER, BARRICADE HANDHELD CABLE $4,844.11 02722662 HB BALLOON DRUG COATED 5 C2623 $10,804.07 02722663 HB BALLOON DRUG COATED 4 C2623 $10,030.73 02722664 HB RTRVL DVC, SNARE GNC 1 $3,789.04 02722665 HB TUBING, ASPIRATION $3,214.33 02722666 HB MAX CANISTER 1 $3,214.33 02722667 HB CATHETER, GUIDING 7 C1887 $7,471.64 02722668 HB VALVE, ROTATING HEMOSTATIC $345.23 02722669 HB COMPRESSION WRAP $2,136.77 02722676 HB REAMER, METATARSALPHALANGEAL $2,869.61 02722677 HB SUCTION TOOL REMOVABLE SHEATH $39.26 02722678 HB AUDITORY OSSEO, INTERNAL/EXTERNAL COMPONENTS L8690 $645.11 02722679 HB CORD, BIPOLAR HIGH FREQUENCY $2,282.08 02722680 HB COMPRESSION APPARATUS $588.84 02722681 HB CANNULA, EXTRACTION $834.84 02722682 HB UNIVERSAL FILL KIT $266.94 02722683 HB HANDPIECE, SURGICAL GUIDE $2,424.71 02722684 HB CATHETER, DRAINAGE C1729 $5,770.61 02722685 HB CATHETER, RESTORATION $13,175.59 02722686 HB FLIPCUTTER $2,962.51 02722687 HB TISSUE HARVESTING SYSTEM $4,026.35

Ancillary FY22 36 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722688 HB SAFETY PEG KIT $1,230.02 02722689 HB PROBE, PNEUMATIC $2,275.53 02722690 HB TRACTION ROPE $70.67 02722691 HB SEALANT HEMOSTATIC $1,346.48 02722698 HB TITANIUM FASTENERS $3,143.08 02722699 HB DV REPOSABLE RETRACTOR $2,352.74 02722700 HB DV SCISSORS REPOSABLE $4,515.74 02722701 HB PROBE, ULTRASOUND $4,412.36 02722702 HB CARTRIDGE NEEDLE INJECTOR $2,217.96 02722703 HB INTRODUCER/SHEATH,NONGDNG C1894 $4,011.95 02722704 HB ENDOSCOPY BRAVO CAPSULE $2,410.31 02722707 HB CAP, DISTAL ATTACHMENT $380.10 02722708 HB DV CAUTERY SPATULA $2,063.74 02722709 HB PRECISION INFLATION INJECTOR $1,418.13 02722710 HB SPINE BALLOON $14,724.51 02722711 HB BONEWAX $135.84 02722713 HB FIDUCIAL ECHO TIP NEEDLE $4,320.65 02722714 HB PRESSURE MONITOR SET $1,358.37 02722715 HB VOCAL INFUSION NEEDLE $2,063.74 02722716 HB RET DEV, INSERTABLE C1773 $10,653.93 02722717 HB ABLATION CATHETER $15,085.49 02722718 HB INTRODUCER/SHEATH,NONGDNG C1894 $4,009.09 02722726 HB CHEST TUBE SILICONE CATHETER $250.13 02722727 HB SILICONE BREAST DELIVERY SLEEVE $1,140.17 02722728 HB RELOAD, ENDOSCOPIC $4,088.07 02722729 HB KIT, INSERTION PACK $14,724.51 02722730 HB KIT, DECOMPRESSION $15,627.39 02722731 HB BOOT LINER DISPOSABLE $324.15 02722734 HB PENILE ASSEMBLY SYSTEM $3,356.07 02722736 HB CATHETER, ABLATION, NON-CARDIAC C1888 $9,178.41 02722737 HB FORCEPS, BIPOLAR $4,196.02 02722738 HB CATHETER, ELECTROPHYSIOLOGY OTHR THAN COOL-TIP C1733 $12,144.41 02722739 HB VIRTUAL SURGICAL PLANNING SPLINT $7,337.74 02722740 HB MANIFOLD FOUR PORT $380.10 02722741 HB INTRODUCER/SHEATH,NONGDNG C1894 $1,524.13 02722743 HB CANNULA, LACRIMAL $220.87 02722745 HB EXTERNAL NEUROSTIMULATOR $3,499.39 02722746 HB WIRE GUIDE LOCKING TOOL $248.00 02722747 HB ENDOSCOPIC DOUBLE BALLOON PUMP $494.75 02722748 HB CATHETER, ESOPHAGEAL $3,105.57 02722749 HB TISSUE EXTACTION SYSTEM $1,704.83 02722753 HB REZUM DEVICE KIT $7,585.15

Ancillary FY22 37 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722754 HB KIT, ANGEL SYSTEM PRP $2,961.02 02722755 HB KIT, INTRAPERITONEAL HYPERTHERMIA $20,399.36 02722756 HB PERFUSION OXYGENATOR $4,795.46 02722758 HB CLIP, DISPOSABLE $2,622.05 02722759 HB NEEDLE, INJECTION $781.39 02722760 HB ASPIRATION TIP $4,016.57 02722761 HB ILLUMINATOR $2,602.11 02722762 HB FILTER GRAFT $2,892.48 02722764 HB KIT, HAND CONTROLLER $476.06 02722765 HB ZEPHYR DELIVERY CATHETER $4,217.64 02722766 HB CHARTIS CATHETER $7,173.04 02722767 HB WOUND INCISION SYSTEM $4,180.59 02722769 HB FORCEP BIPOLAR TIPS $4,196.10 02722770 HB PLATELET RECOVERY SYSTEM $2,961.45 02722771 HB FORCEP BIOPSY INSERTABLE C1889 $214.03 02722772 HB LEAD EXTENDER $2,537.93 02722773 HB INTRODUCER/SHEATH, LASER C2629 $18,026.49 02722774 HB INTRODUCER SHEATH PERITONEAL $1,811.71 02722775 HB SEALANT, HEMOSTATIC $2,601.03 02722776 HB HEMOSTAT DELIVERY SYSTEM INSERTABLE C1889 $9,900.52 02722777 HB COIL COMPRESSION INSERTABLE C1889 $2,064.17 02722778 HB CANNULA, DRIVE SHAFT $1,086.38 02722779 HB ADAPTER, CARIOPLEGIA CANNULAE $481.20 02722780 HB CATHETER, PERITONEAL $4,322.40 02722781 HB CANNULA, TRANSSEPTAL TANDEMHEART $24,105.62 02722782 HB OXYGENATOR, TANDEMLUNG $20,399.79 02722783 HB TUBING, ASPIRATION $1,810.58 02722784 HB KNIFE, ELECTROSURGICAL $4,340.78 02722785 HB SHEARS, THERMAL LIGATING $3,320.36 02722786 HB KIT, TOTAL KNEE SURGICAL $4,181.74 02722787 HB TOOL, DISSECTING $3,442.39 02722788 HB CATHETER, VENTRICULAR $3,887.44 02722789 HB CATHETER, GUIDING PERF/INFUS C1887 $17,768.52 02722790 HB PROBE, ENDOSCOPIC $4,136.09 02722791 HB DRILL PIN HEADLESS $2,960.73 02722792 HB STYLET, NAVIGATION $2,423.09 02722793 HB RELOAD, ENDOSCOPIC $5,531.15 02722794 HB CABLES, ELECTRODE STERILE $3,689.32 02722795 HB ASPIRATOR, UTERINE $622.94 02722796 HB ENDOSCOPE SHEATH DISPOSABLE A4270 $532.52 02722797 HB TUBE, TRACHEAL LASER $724.68 02722798 HB INTRODUCER/SHEATH,NONGDNG C1894 $10,081.10

Ancillary FY22 38 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722799 HB CATHETER,THRMBCTMYEMBLCTMY C1757 $30,718.49 02722800 HB CARNATION PATCH 7-DAY $2,064.17 02722802 HB DISPOSABLE TISSUE RESECTOR $4,207.86 02722803 HB PACEMAKER SPLITTER KIT $23,502.08 02722804 HB KIT, ARM SUPPORT $1,061.28 02722805 HB CATHETER ERCP $643.22 02722806 HB CABLE, MULTILEAD $3,497.22 02722807 HB PROSTATE TEMPLATE $1,179.92 02722808 HB BRACHYTHERAPY NEEDLE C1715 $661.29 02722809 HB TUBING SET $2,960.72 02722810 HB KIT, CEMENT MIXING $2,312.59 02722811 HB VIRTUAL SURGICAL PLANNING SPLINT $7,335.30 02722812 HB TUBING, IRRIGATION $2,319.79 02722813 HB STONE CATCHER $1,144.89 02722814 HB CATHETER, EP<19 ELECTRODES C1730 $5,036.17 02722815 HB WOUND RETRACTION SYSTEM SMALL $2,492.27 02722816 HB WOUND RETRACTION SYSTEM MEDIUM $3,461.34 02722817 HB BUTTON, TRACHEOSTOMY $109.07 02722818 HB ADAPTER DRAPE SLEEVE $1,523.21 02722819 HB EXTENSION CABLE $2,963.73 02722820 HB PT/PRGMR, NEUROSTIMULATOR C1787 $11,360.79 02722821 HB CARTRIDGE, PUMP $1,421.01 02722822 HB COLLECTION SYSTEM FMS $1,349.15 02722823 HB CATHWORKS FFR SYSTEM $5,364.61 02722824 HB KNIFE, COLD WAVEFORM $1,738.07 02722825 HB CABLE, NEUROSTIMULATOR $869.20 02722826 HB NEEDLE, ASPIRATION $2,477.92 02722827 HB DISSECTOR, ARTICULATING $10,596.79 02722828 HB SEALANT HEMOSTATIC $1,195.07 02722829 HB WIRE REUNION $609.99 02722830 HB RETRACTOR, WOUND $2,025.69 02722831 HB CAUTERY PENCIL $92.63 02722832 HB RET DEV, INSERTABLE C1773 $2,922.97 02722833 HB CATHETER BILIARY DILATION $914.39 02722834 HB CONNECTOR KIT $217.65 02722835 HB KNIFE, COLD WAVEFORM $1,738.07 02722836 HB CABLE, NEUROSTIMULATOR $869.20 02722837 HB NEEDLE, ASPIRATION $2,477.92 02722838 HB DISSECTOR, ARTICULATING $10,596.79 02722839 HB PROBE, CRYOABLATION C2618 $24,018.29 02722840 HB CATHETER, INFUSION MIDLINE C1751 $1,571.75 02722841 HB PROLACTA READY TO FEED $2,361.63

Ancillary FY22 39 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722842 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $13,947.00 02722843 HB TUBE MEDULLARY $942.64 02722844 HB DUODENOSCOPE STERILE SINGLE USE C1748 $20,138.65 02722845 HB PIN, FIXATION $1,451.43 02722846 HB KNEE TRACKING SYSTEM $3,497.22 02722847 HB CATHETER,THRMBCTMYEMBLCTMY C1757 $24,722.76 02722848 HB CATHETER, GUIDING PERF/INFUS C1887 $13,977.98 02722849 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $15,087.83 02722850 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $13,947.00 02722852 HB ANGIOVAC COMPLETE KIT $29,159.31 02722853 HB LASER FIBER $9,512.75 02722854 HB MANTA CLOSURE DEVICE $5,200.39 02722855 HB TRAPPER EXCHANGE DEVICE $2,420.49 02722856 HB RF WIRE GUIDE NYKANEN $6,514.18 02722858 HB CARDIOHELP HLS SET $29,380.86 02722859 HB COAGULATION GUIDED DEVICE $28,605.43 02722860 HB BONE PLANER $1,896.48 02722861 HB DV SUCTION IRRIGATOR $2,528.16 02722862 HB PULMONARY EMBOLISM REMOVAL SYSTEM $25,836.06 02722863 HB SCALPEL BONE $4,722.83 02722864 HB PROTEK DUO KIT $25,282.18 02722865 HB FAT TRANSFER SYSTEM $3,913.56 02722866 HB CAUTERY PENCIL $92.63 02722868 HB ACCESS DISPOSABLE INSTRUMENTS $11,629.21 02722869 HB PROBE, CRYOABLATION C2618 $24,018.29 02722870 HB 4 CONTACT STRIP ELECTRODES $4,021.23 02722871 HB 9 CONTACT STRIP ELECTRODES $4,543.50 02722872 HB 6 CONTACT STRIP ELECTRODES $4,121.72 02722873 HB 2 CONTACT DISPOSABLE CONNECTOR BLOCK $598.02 02722874 HB 4 CONTACT DISPOSABLE CONNECTOR BLOCK $778.81 02722875 HB 6 CONTACT DISPOSABLE CONNECTOR BLOCK $744.90 02722876 HB 8 CONTACT DISPOSABLE CONNECTOR BLOCK $631.91 02722877 HB 10 CONTACT DISPOSABLE CONNECTOR BLOCK $790.10 02722878 HB 12 CONTACT DISPOSABLE CONNECTOR BLOCK $688.41 02722879 HB 16 CONTACT DISPOSABLE CONNECTOR BLOCK $790.10 02722880 HB PLACEMENT WRENCH BOLTS $7,556.30 02722882 HB NEUROPROTECTION TRANSCAROTID SYSTEM $19,630.50 02722883 HB LIGHT CABLE DISPOSABLE $2,054.40 02722884 HB DELIVERY GRAFT TOOL $1,397.59 02722885 HB TIP, STRAIGHT UNIVERSAL $4,488.97 02722886 HB FLUID CONTROL SYSTEM $3,138.31 02722887 HB PROBE, BIPOLAR $3,705.39

Ancillary FY22 40 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722888 HB KNIFE, DUAL ELECTROSURGICAL $4,338.21 02722889 HB KNIFE, DUAL ELECTROSURGICAL $6,008.37 02722890 HB RET DEV, INSERTABLE C1773 $4,707.72 02722891 HB SHOCKWAVE CATHETER $16,533.23 02722892 HB DESTINO TWIST GUIDING SHEATH $4,306.63 02722894 HB CATHETER, BALLOON DILATION C1726 $16,543.50 02722895 HB CATHETER, GUIDING PERF/INFUS C1887 $7,325.52 02722896 HB CATHETER, GUIDING PERF/INFUS C1887 $19,152.33 02722897 HB CANNULA, DIRECTIONAL $4,873.80 02722898 HB CATHETER,TRANS/LUM,NONLSR C1725 $2,385.09 02722899 HB KIT, IMAGING DRUG PACK $3,133.53 02722900 HB PERFUSION OXYGENATOR $9,755.37 02722901 HB PERFUSION OXYGENATOR $8,613.69 02722902 HB DRILL TROCAR PIN $496.35 02722903 HB KIT, REMOTE MONITOR $16,801.80 02722904 HB BONE SCREW REMOVER $1,602.25 02722905 HB INDIGO CATH 12 W/ASP TUBING $21,927.69 02722906 HB INDIGO SEPARATOR 12 $12,384.87 02722907 HB SIZING KIT, AIRWAY W/ BALLOON CATH $2,780.10 02722908 HB CATHETER, DEPLOYMENT AND LOADER $7,503.00 02722909 HB VERSA CROSS TRNSPTL KIT $7,415.37 02722910 HB DESTINO TWIST GUIDING SHEATH $6,812.83 02722911 HB AZUR DETACHMENT CONTROLLER $6,430.61 02722912 HB EBUS PROBE $481.99 02722913 HB RAT TOOTH ALLIGATOR FORCEPS $3,637.20 02722914 HB AMB CARDIAC TELEMETRY - ZIO AT $6,181.82 02722915 HB ALBATION PROBE KIT $26,542.29 02722916 HB PAIN PUMP PCA SYSTEM $2,528.73 02722917 HB PAIN PUMP PCA SYSTEM $362.52 02722918 HB SUBMUCOSAL LIFTING AGENT $1,287.21 02722919 HB BLADE AND TUBING SET $4,578.67 02722920 HB REAMER HEAD $5,465.37 02722921 HB KIT, BONE HARVESTING $16,905.12 02722922 HB TUBING SET W/TIP $6,076.98 02722923 HB NEEDLE MODULE EMG $4,873.80 02722924 HB DV CAMERA SHEATH SP $891.78 02722925 HB HEADED SCREW $1,027.35 02722926 HB OLIVE WIRE $1,264.61 02722927 HB MORCELLATOR LAPAROSCOPIC $5,616.54 02722928 HB DV STAPLER CANNULA $8,923.65 02722929 HB DV KIT, ENTRY GUIDE $1,918.26 02722930 HB SUCTION IRRIGATION SYSTEM $1,551.97

Ancillary FY22 41 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722931 HB HANDPIECE, ENDOSCOPIC $5,261.60 02722932 HB RETRACTOR ATTACHMENT $3,139.20 02722933 HB KIT, HIGH INTENSITY FOCUSED ULTRASOUND $11,635.80 02722934 HB DIRECT CURRENT CUTTER SET $3,491.11 02722935 HB BLUEPRINT GUIDE $5,442.99 02722936 HB CATHETER, SEROMA 14G X 3.5IN $711.01 02722937 HB BRONCHIAL BALLOON $1,430.74 02722938 HB FULLY ARTICULATING CATHETER,IF1000 $7,503.00 02722939 HB PERIPHERAL VISION PROBE,IF1000 $3,354.66 02722940 HB CATHETER GUIDE $665.82 02722942 HB BIOPSY NEEDLE,23G,IF1000,5-PACK $2,421.00 02722943 HB BIOPSY NEEDLE,21G,IF1000,5-PACK $2,421.00 02722944 HB BIOPSY NEEDLE,19G,IF1000,5-PACK $2,421.00 02722945 HB SWIVEL CONNECTOR $1,559.16 02722946 HB ASSEMBLY,VISION PROBE ADAPTER AND SUCTIO $778.80 02722947 HB VISION PROBE BAG,IF1000 $462.45 02722948 HB PACEMAKER ACCSSRY, ACUITY LEAD DLVRY SYSTM $4,216.50 02722949 HB IOVERA SMART TIP $4,870.51 02722950 HB IOVERA CARTRIDGE $424.39 02722951 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $11,584.14 02722952 HB BIOPSY CORE SYSTEM $3,397.75 02722953 HB ELECTROMAGNETIC PATIENT TRACKER $1,990.08 02722954 HB APPLICATOR, ULTRAMIST $778.83 02722955 HB MINIONE FEED SET W/ ADAPTER $258.97 02722956 HB PLATE HOLDING PIN $264.87 02722962 HB DEPLOYMENT CATHETER AND LOADER $7,503.00 02722963 HB DV CAUTERY SPATULA $1,174.23 02722964 HB DV FORCEPS REPOSABLE $1,702.80 02722965 HB KIT SMARTHCATH $891.78 02722966 HB DV DISPOSABLE INSTRUMENT SHEATH $552.84 02722967 HB INTRODUCER/SHEATH,NONGDNG C1894 $4,906.66 02722968 HB GUIDE WIRE, ROTAWIRE $2,467.32 02722969 HB CONTROLLER MAGNET $1,117.74 02722970 HB PERFUSION CARDIOPLEGIA SET $1,681.25 02722971 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $15,097.02 02722972 HB FORCEP, BIOPSY INSERTABLE C1889 $4,959.24 02722973 HB INTRODUCER/SHEATH, GUIDING C1893 $1,774.62 02722974 HB CATHETER, TRANSLUMINAL DRUG-COATED C2623 $15,097.02 02722975 HB G-TUBE $1,361.22 02722976 HB SHOCKWAVE C2 IVL CATHETER $25,349.71 02722977 HB HARMONY DELIVERY SYSTEM $14,073.51 02722978 HB SEPARATOR PENUMBRA $12,050.44

Ancillary FY22 42 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02722979 HB NAV-X EP MAP ELECTRODE $2,779.84 02740003 HB FLEX THERMOPLASTIC COLLAR MOLD L0130 $1,333.01 02740004 HB CERV COLLAR THERMOPL FOAM 2PC L0172 $1,257.39 02740005 HB CERV COLLAR SEMIRIG THERMO2PC L0174 $2,150.13 02740006 HB TLSO RIGID FRAME HYPEREX PRE L0472 $2,895.29 02740007 HB TLSO RIGID PLASTIC CUSTOM FAB L0484 $8,553.15 02740008 HB TLSO RIGIDLINED CUST FAB TWO L0486 $9,085.71 02740010 HB LO SAGITT RIGID PANEL PREFAB L0627 $2,420.89 02740011 HB SLO POST RIGID PANEL PREFAB L0630 $1,299.92 02740013 HB LSO FLEXION CONTROL PREFAB L0633 $1,861.56 02740015 HB SLO SAGIT RIGID PANEL PREFAB L0635 $5,298.32 02740016 HB LSO SAGITTAL RIGID PANEL CUST. L0636 $7,975.80 02740018 HB CTLSO A-P-L CONTROL MOLDED L0700 $10,466.99 02740019 HB HALO CERVICAL INTO JACKET VEST L0810 $12,764.58 02740021 HB MRI COMPATIBLE SYSTEM L0859 $5,651.90 02740023 HB TENSION BASED SCOLIOSIS ORTHO L1005 $12,460.98 02740026 HB POST-OP HIP ABDUCT CUSTOM FAB L1685 $7,038.50 02740028 HB KO ELAS W CONDYLE PADS & JNTS L1820 $1,253.09 02740029 HB KO W ADJ FLEX/EXT ROTAT CUST L1845 $4,072.05 02740030 HB KO W ADJ FLEX/EXT ROTAT MOLD L1846 $6,720.95 02740031 HB AFT ANKLE GAUNTLET L1902 $818.43 02740032 HB AFO SNGL UPRIGHT W/ADJUST STOP L1920 $2,142.81 02740034 HB AFO POS SOLID ANK PLASTIC CUST L1960 $3,757.14 02740035 HB AFT DOUBLE SOLID STIRRUP CALF L1990 $3,133.24 02740036 HB KAFO FEMORAL FX CAST CUSTOM L2128 $8,787.00 02740037 HB VARUS/VALGUS STRAP PADDED L2270 $683.97 02740038 HB PRE-TIBIAL SHELL MOLDED L2340 $3,140.12 02740039 HB KNEE JOINT DROP LOCK EA JOINT L2405 $815.24 02740040 HB ADJ FLEX EXT HIP JNT CNTRL EA L2624 $2,474.54 02740041 HB SOFT INTERFACE ABOVE KNEE MOLD L2830 $1,047.33 02740042 HB TIB LENGTH SOCK, FX/EQUAL, EA L2840 $494.91 02740044 HB ABDUCT RESTRAINER CANVAS & WEB L3660 $1,005.17 02740045 HB EO MOTIONDOUBLE UPRIGHT CUSTOM L3720 $4,214.10 02740051 HB WHFO NONTORSION JOINT PREFAB L3931 $1,553.19 02740052 HB UPPER EXT FX ORTHOSIS HUMERAL L3980 $2,310.08 02740053 HB ANKLE CONTROL ORTHOSIS PREFAB L4350 $1,006.06 02740062 HB HM SYS CONTROLLER BTY Q0508 $2,490.29 02740066 HB STABILIZATION BELT Q0508 $498.07 02740070 HB HEARTMATE, SYS CONTROLLER HM11 Q0481 $23,359.60 02740072 HB HEARTMATE, POCKETPAK POUCH Q0508 $1,095.14 02740077 HB HMGG,UNVRSL BTTRY CHARGR Q0495 $29,228.84 02740078 HB HM GG SHOWER BAG Q0501 $2,241.27

Ancillary FY22 43 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02740079 HB HMGG HOLSTER VEST LARGE Q0498 $1,873.64 02740080 HB HMGG MODULAR BELT Q0499 $1,718.30 02740081 HB HMGG, CONSOLIDATED BAG Q0499 $1,618.69 02740082 HB HMGG,POWER MOD DC INPUT CBL Q0478 $1,944.81 02740084 HB HMGG, DISPLAY MODULE CABLE Q0486 $1,992.22 02740085 HB HMGG, POWER MODULE CABLE Q0477 $4,731.54 02740087 HB HMGG, SYSTEM DRIVER Q0481 $23,359.60 02740088 HB HM POWER MODULE Q0479 $125,826.12 02740089 HB HM, BATTERY CLIP SET Q0497 $5,478.64 02740090 HB HM, UNVRSL BATTERY CHARGER Q0495 $35,860.14 02740111 HB BATTERY, LITHIUM-ION 14VL Q0506 $12,451.45 02740113 HB DRIVELINE MANAGEMENT SYSTEM Q0508 $314.27 02740114 HB HW, ADAPTER CONTROLLER DC Q0508 $10,548.20 02740115 HB HW, PATIENT PACK Q0498 $3,340.53 02740116 HB HW, BATTERY CHARGER Q0495 $25,930.25 02740117 HB HW, LITHIUM BATTERIES Q0506 $5,321.41 02740118 HB HW, KIT, PUMP IMPLANT Q0508 $26,890.87 02740119 HB HW, CONTROLLER KIT Q0508 $26,547.36 02740120 HB HW, SHOWER BAG Q0501 $2,140.66 02740122 HB HW, ADAPTER CONTROLLER DC* Q0508 $10,548.20 02740126 HB HW, CONTROLLER KIT* Q0508 $22,497.76 02740129 HB HM POCKET CONTROLLER BATTERY Q0506 $2,490.29 02740130 HB HM POCKET CONTROLLER Q0481 $27,393.17 02740131 HB HM PC WEAR ACCESSORY KIT Q0508 $846.70 02740132 HB HW CONTROLLER, AC ADAPTER Q0508 $6,811.29 02740133 HB HW PATIENT PACK Q0499 $3,341.46 02740134 HB HW BATTERY CHARGER Q0495 $24,016.08 02740135 HB HW BATTERY Q0506 $5,321.73 02740136 HB HW SHOWER BAG Q0501 $2,526.51 02740137 HB HW WAIST PACK Q0499 $3,341.46 02740138 HB HW SHOULDER PACK Q0508 $3,504.45 02740140 HB HEARTMATE, PCKT CONT HMII Q0481 $27,833.68 02740143 HB HEARTMATE II MPU Q0479 $44,917.01 02740144 HB HW, CONTROLLER KIT Q0508 $20,527.09 02740145 HB HM MOBILE POWER UNIT Q0479 $21,535.53 02740146 HB HM II BACKUP BATTERY Q0506 $3,445.30 02740147 HB HEARTMATE 3 LVAD MODULAR CABLE Q0508 $53,469.36 02750003 HB PACEMAKER DUAL CHMBR C1785 $88,547.76 02750009 HB PACEMAKER SINGLE CHMBR C1786 $75,427.67 02750011 HB PCMKR OTHER THAN SINGLE/DUAL C2621 $67,077.42 02750013 HB PACEMAKER, SINGLE CHAMBER 1 C1786 $35,831.72 02750014 HB PACEMAKER, DUAL CHAMBER 2 C1785 $43,579.14

Ancillary FY22 44 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02750022 HB PACEMAKER, OTHER THAN SINGLE / DUAL CHAMBER C2621 $42,631.47 02750025 HB PACEMAKER, DUAL CHAMBER C1785 $44,282.31 02760003 HB LENS INTRAOCULAR 2 C1780 $1,251.36 02760004 HB LENS INTRAOCULAR 1 C1780 $748.15 02760005 HB LENS INTRAOCULAR 4 C1780 $4,445.96 02760006 HB LENS INTRAOCULAR 5 C1780 $8,100.40 02780004 HB CARDIAC VALVE HUMAN TISSUE 15 $81,926.81 02780005 HB CARDIAC VALVE HUMAN TISSUE 18 $88,134.67 02780007 HB CARDIO VASCULAR ASSIST PUMP $374,737.49 02780009 HB IMPLANT, CARDIAC PLEDGET $75.15 02780013 HB ANCHOR BOLTS $322.47 02780014 HB ORTHO CEMENTRALIZER $349.13 02780016 HB KIT FRACTURE $379.06 02780017 HB KIT, VARICEAL BANDING $1,694.73 02780018 HB VESSEL GUARD 1 $4,259.58 02780025 HB CONNECTOR, CEREBRAL 1 $616.99 02780026 HB EXTERNAL FIXATION 8 C1713 $5,143.09 02780032 HB PEG, ORTHO 1 $698.27 02780033 HB FELT, SURGICAL 1 $748.15 02780036 HB EXTERNAL FIXATION 27 C1713 $24,738.65 02780037 HB EMBOLIC LIQUID SYSTEM GLUE $25,468.78 02780039 HB MANDIBLE 4 $25,935.66 02780054 HB GRAFT 9 $32,788.69 02780055 HB LAP BAND SYSTEM 3 $33,667.92 02780056 HB CAGE, SPINE 20 $34,025.63 02780057 HB ANCHOR /SCREW 28 C1713 $19,587.78 02780065 HB CARDIAC VALVE HUMAN TISSUE 4 $48,591.73 02780066 HB CARDIAC VALVE HUMAN TISSUE 11 $63,572.11 02780069 HB CARDIAC GRAFT AORTIC VALVED CO $53,447.44 02780075 HB CARDIAC BAND $11,970.32 02780078 HB SPACER, SPINE 14 $35,511.92 02780080 HB BMP SMALL 3 $39,908.07 02780081 HB CAGE, SPINE 19 $36,379.78 02780084 HB CAGE, SPINE 26 $55,286.26 02780086 HB CARDIAC VALVE HUMAN TISSUE 3 $42,823.03 02780087 HB DISC, CERVICAL SPINE 2 $48,062.50 02780090 HB CARDIAC VALVE HUMAN TISSUE 7 $49,876.31 02780092 HB SPACER, SPINE 20 $52,320.24 02780099 HB SUPPORT BAR PECTUS $8,488.95 02780100 HB PLATE 5 $8,533.84 02780107 HB GRAFT 2 $8,967.74 02780117 HB BONE GRAFT 2 $9,695.95

Ancillary FY22 45 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780118 HB GRIP CABLE 2 $9,795.69 02780121 HB COIL, EMBOLIZATION 1 $15,963.23 02780134 HB CONNECTOR, SPINE 7 $12,381.09 02780135 HB NAIL, ORTHO 2 $12,409.25 02780138 HB CARDIAC RING ANNULOPLASTY 2 $13,336.94 02780140 HB COIL, EMBOLIZATION 2 $12,695.80 02780147 HB CONNECTOR, SPINE 8 $15,960.42 02780150 HB EXTERNAL FIXATION 22 C1713 $17,343.98 02780154 HB SPACER, SPINE 8 $19,551.50 02780155 HB STRUT, SPINE PSR 2 $19,559.28 02780157 HB VALVE, NEURO 1 $21,535.20 02780160 HB LEAD 4 $21,945.57 02780161 HB VALVE 3 $22,183.32 02780163 HB WASHER, SPINE 1 $1,217.00 02780164 HB EMBOLIC SPHERES $1,849.70 02780168 HB SHEET, MEDPOR 4 $5,974.79 02780170 HB SHUNT 3 $4,984.48 02780171 HB BAND $4,369.17 02780172 HB CROSSLINK, SPINE 1 $3,179.12 02780173 HB SHUNT 4 $8,169.76 02780175 HB VALVE 2 $8,660.05 02780180 HB COIL, EMBOLIZATION 3 $13,602.65 02780183 HB LINER, ORTHO 5 $21,945.57 02780189 HB SEALANT 3 $4,423.32 02780193 HB GRAFT, DURAGEN 3 $4,744.73 02780203 HB SPHERE EYE PLASTIC 2 $5,985.13 02780205 HB BONE FILLER 2 $6,238.72 02780208 HB PLATE 4 $5,561.69 02780215 HB LINER, ORTHO 2 $7,869.97 02780216 HB BLOCK CARVING TESTICULAR IMP $7,930.31 02780217 HB TESTICULAR PROSTHESIS 1 $7,930.31 02780224 HB CONNECTOR, SPINE 5 $8,288.83 02780227 HB COIL, HILAL .018 $884.51 02780228 HB EXTERNAL FIXATION 2 C1713 $911.12 02780233 HB CLIP, LIGATION-RESOLUTION $1,549.46 02780234 HB PLATE 1 $1,006.59 02780235 HB SHUNT 1 $1,037.40 02780237 HB EMOBOLIZATION COIL IMPLNT $1,113.40 02780238 HB BLOCKER $1,127.23 02780241 HB CEMENT RESTRICTOR $1,246.92 02780244 HB PLUG, SPINE 1 $1,286.80 02780249 HB RESERVOIR, NEURO 1 $1,396.55

Ancillary FY22 46 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780253 HB EXTERNAL FIXATION 13 C1713 $8,793.79 02780254 HB SEAMGUARD BIOAB $1,625.97 02780255 HB ISOTOPE, MICROSPHERES LC BEADS $15,914.14 02780256 HB CEMENT, SPINE $1,736.01 02780263 HB CONNECTOR, SPINE 2 $2,224.49 02780265 HB GASTROSTOMY G-J TUBE $2,562.93 02780266 HB NEEDLE, FIX SYSTEM 1 $2,595.40 02780267 HB KIT, NEPHROSTOMY 23-510-11 $2,849.01 02780269 HB CLIP, LIGATION-QUICK $784.42 02780270 HB ORTHO CABLE 2 $3,009.16 02780273 HB BONE FILLER 1 $3,192.79 02780275 HB GRIP CABLE 1 $3,301.82 02780276 HB FIBRIN GLUE INJ KIT C9250 $3,434.52 02780278 HB SHEET, MEDPOR 2 $3,670.55 02780279 HB ORTHO BONE GRAFT SUBSTITUTE 1 $3,491.37 02780282 HB PATCH 1 $3,685.90 02780287 HB CONNECTOR, SPINE 3 $4,035.51 02780293 HB NEURO CATH KIT $3,938.22 02780294 HB NO COST IMPLANT $1.00 02780296 HB ORTHO BONE GRAFT SUBSTITUTE 2 $4,862.95 02780297 HB ORTHO BONE GRAFT SUBSTITUTE 4 $18,805.33 02780303 HB VENA CAVA FILTER 1 C1880 $9,498.10 02780304 HB VENA CAVA FILTER IMPLANT C1880 $10,788.49 02780310 HB SPACER 3 $1,568.64 02780317 HB HOOK, SPINE 3 $7,139.99 02780322 HB AUDITORY IMPLANT 2 $2,860.42 02780323 HB IMPLANT, ELASTOMERIC TUBING $694.37 02780326 HB PLATE 2 $3,174.98 02780330 HB PROSTHESIS ENT $2,942.70 02780335 HB NEURO BAR $239.40 02780338 HB SPACER 8 $9,744.68 02780339 HB SPACER, SPINE 12 $26,443.52 02780347 HB SPINE SET SCREW $1,222.98 02780350 HB PC BRONCHIAL STENT C1874 $6,554.93 02780352 HB BEARING, KNEE 1 $6,089.66 02780356 HB IMPLANT, POUCH PAIN PUMP $831.69 02780357 HB CONNECTOR, SPINE 1 $219.45 02780359 HB CLIP, ANEURYSM 1 $2,411.90 02780363 HB SPACER, SPINE 5 $8,967.74 02780366 HB SPINE PEEK 4 $26,933.19 02780370 HB CAP FIXATION PROTECTION PIN $279.29 02780372 HB SHEET, MEDPOR 1 $2,888.47

Ancillary FY22 47 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780375 HB LINER, ORTHO 3 $9,591.11 02780380 HB COIL, MWCE 0.35 $469.49 02780381 HB CEMENT, BONE KYPHON $2,256.17 02780382 HB SPACER , SPINE 1 $4,678.39 02780391 HB TUBE,EAR PRESSURE EQUALIZING 1 $111.17 02780400 HB ROD 1 $1,064.73 02780402 HB CONNECTOR, SPINE 4 $5,949.71 02780404 HB COVER, BUR HOLE 1 $1,057.40 02780405 HB CROSSCONNECTOR, 1 $4,956.53 02780409 HB PROSTHESIS, EYELID 1 $588.53 02780415 HB GRAFT, DURAGEN 1 $1,310.64 02780416 HB GRAFT, DURAGEN 2 $2,611.13 02780417 HB GRAFT, DURAGEN 4 $8,453.12 02780430 HB ANCHOR /SCREW 21 C1713 $14,464.13 02780434 HB ANCHOR /SCREW 4 C1713 $2,484.13 02780437 HB ANCHOR /SCREW 20 C1713 $14,332.34 02780440 HB ANCHOR /SCREW 12 C1713 $8,240.83 02780443 HB ANCHOR /SCREW 18 C1713 $11,092.49 02780449 HB ANCHOR /SCREW 22 C1713 $16,848.88 02780454 HB ROD 2 $2,404.05 02780457 HB ANCHOR /SCREW 2 C1713 $1,123.26 02780464 HB ROD, SPINE 2 $2,889.96 02780466 HB ANCHOR /SCREW 9 C1713 $6,102.32 02780473 HB ANCHOR /SCREW 34 C1713 $26,976.47 02780475 HB ANCHOR /SCREW 15 C1713 $10,552.15 02780476 HB ANCHOR /SCREW 29 C1713 $20,948.04 02780477 HB ANCHOR /SCREW 41 C1713 $34,205.16 02780480 HB ANCHOR /SCREW 37 C1713 $29,539.07 02780482 HB ANCHOR /SCREW 25 C1713 $15,960.42 02780494 HB CATHETER, INFUSION/NON-HEMO 2 C1751 $1,515.87 02780498 HB COIL, NESTOR $1,549.17 02780500 HB ANCHOR /SCREW 33 C1713 $23,839.60 02780501 HB ANCHOR /SCREW 30 C1713 $21,391.09 02780505 HB CATHETER, INTRASPINAL 1 C1755 $958.66 02780510 HB CLOSURE DEVICE, VASC PLUG C1760 $2,774.92 02780511 HB HUMAN TISSUE 1 C1762 $1,346.66 02780513 HB HUMAN TISSUE 43 C1762 $96,266.55 02780514 HB HUMAN TISSUE 5 C1762 $9,871.71 02780515 HB HUMAN TISSUE 6 C1762 $10,469.06 02780516 HB HUMAN TISSUE 15 C1762 $25,167.59 02780517 HB HUMAN TISSUE 11 C1762 $17,456.73 02780519 HB HUMAN TISSUE 13 C1762 $21,082.70

Ancillary FY22 48 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780520 HB HUMAN TISSUE 2 C1762 $2,801.39 02780521 HB HUMAN TISSUE 3 C1762 $5,077.40 02780522 HB HUMAN TISSUE 26 C1762 $45,158.00 02780523 HB BONE CEMENT 4 $5,207.10 02780525 HB ROD 3 $5,276.91 02780527 HB HUMAN TISSUE 20 C1762 $36,728.91 02780529 HB HUMAN TISSUE 4 C1762 $7,506.39 02780530 HB HUMAN TISSUE 18 C1762 $31,102.87 02780532 HB HUMAN TISSUE 7 C1762 $12,527.81 02780533 HB HUMAN TISSUE 14 C1762 $30,198.38 02780535 HB HUMAN TISSUE 14 C1762 $20,372.81 02780536 HB ROD, SPINE 4 $6,284.41 02780538 HB GRAFT SYNTHETIC TISSUE 3 C1763 $6,064.96 02780540 HB GRAFT SYNTHETIC TISSUE 5 C1763 $7,780.69 02780541 HB GRAFT SYNTHETIC TISSUE 1 C1763 $3,192.07 02780542 HB GRAFT SYNTHETIC TISSUE 11 C1763 $14,983.62 02780543 HB GRAFT SYNTHETIC TISSUE 9 C1763 $12,339.44 02780544 HB CATHETER, MAHURKAR C1752 $968.37 02780548 HB GENERATOR, NEUROSTIMULATOR 3 C1767 $89,466.44 02780550 HB GENERATOR, NEUROSTIMULATOR 5 C1767 $107,506.00 02780551 HB GENERATOR, NEUROSTIMULATOR 9 C1767 $102,642.75 02780552 HB GENERATOR, NEUROSTIMULATOR13 C1767 $180,810.00 02780554 HB GRAFT VASCULAR 8 C1768 $14,813.24 02780555 HB GRAFT VASCULAR 15 C1768 $26,005.54 02780556 HB GRAFT VASCULAR 18 C1768 $34,504.42 02780558 HB GRAFT VASCULAR 2 C1768 $3,182.13 02780559 HB ROD, SPINE 5 $7,990.21 02780560 HB GRAFT VASCULAR 7 C1768 $12,953.38 02780562 HB GRAFT VASCULAR 4 C1768 $6,533.07 02780565 HB GRAFT VASCULAR 5 C1768 $9,389.58 02780567 HB GRAFT VASCULAR 6 C1768 $10,636.14 02780568 HB GRAFT VASCULAR 3 C1768 $4,694.63 02780569 HB GRAFT VASCULAR 13 C1768 $21,746.08 02780570 HB GRAFT VASCULAR 1 C1768 $1,356.65 02780572 HB REP DEV URINARY W/SLING 3 C1771 $8,977.75 02780573 HB REP DEV URINARY W/SLING 2 C1771 $6,848.03 02780576 HB PUMP INFUSION 1 C1772 $89,777.35 02780581 HB JOINT DEVICE 23 C1776 $19,289.80 02780582 HB JOINT DEVICE 14 C1776 $11,578.20 02780584 HB JOINT DEVICE 40 C1776 $35,047.82 02780585 HB JOINT DEVICE 21 C1776 $17,626.52 02780587 HB JOINT DEVICE 5 C1776 $3,700.73

Ancillary FY22 49 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780588 HB JOINT DEVICE 8 C1776 $6,944.76 02780589 HB JOINT DEVICE 25 C1776 $21,374.31 02780590 HB JOINT DEVICE 30 C1776 $23,192.48 02780594 HB JOINT DEVICE 9 C1776 $7,456.24 02780595 HB JOINT DEVICE 27 C1776 $22,702.79 02780598 HB INSERT, ORTHO 4 C1776 $10,499.49 02780599 HB SPINE ASSEMBLY 1 C1776 $2,394.06 02780600 HB JOINT DEVICE 18 C1776 $14,483.55 02780602 HB JOINT DEVICE 6 C1776 $4,806.25 02780603 HB BONE CEMENT 6 $9,661.77 02780604 HB JOINT DEVICE 16 C1776 $13,327.89 02780606 HB JOINT DEVICE 48 C1776 $37,756.36 02780607 HB JOINT DEVICE 32 C1776 $27,811.44 02780608 HB JOINT DEVICE 74 C1776 $67,860.29 02780609 HB JOINT DEVICE 73 C1776 $65,834.11 02780611 HB JOINT DEVICE 19 C1776 $13,961.40 02780612 HB JOINT DEVICE 80 C1776 $77,308.28 02780615 HB JOINT DEVICE 11 C1776 $9,482.90 02780616 HB JOINT DEVICE 13 C1776 $10,184.93 02780618 HB JOINT DEVICE 22 C1776 $15,567.75 02780620 HB JOINT DEVICE 29 C1776 $24,322.87 02780621 HB JOINT DEVICE 31 C1776 $24,359.62 02780622 HB JOINT DEVICE 7 C1776 $5,234.02 02780623 HB ORTHO FEMORAL 3 C1776 $16,908.07 02780624 HB JOINT DEVICE 1 C1776 $989.87 02780627 HB JOINT DEVICE 81 C1776 $80,450.46 02780628 HB INSERT, ORTHO 2 C1776 $6,633.56 02780629 HB JOINT DEVICE 76 C1776 $69,977.12 02780632 HB CATHETER, DIALYSIS, SHORT TERM C1752 $964.53 02780634 HB CATHETER, MAHURKAR C1752 $982.21 02780635 HB LEAD, NEUROSTIMULATOR 15 C1778 $35,555.19 02780636 HB LEAD, NEUROSTIMULATOR 20 C1778 $57,079.22 02780637 HB LEAD, NEUROSTIMULATOR 6 C1778 $17,706.72 02780638 HB LEAD, NEUROSTIMULATOR 9 C1778 $25,127.71 02780642 HB D STAT FLOWABLE HEMOSTAT C1760 $2,471.26 02780643 HB CLOSURE HEMOSTASIS DEVICE C1760 $2,001.83 02780644 HB CLOSURE DEVICE VASCULAR C1760 $3,434.37 02780647 HB MESH 7 C1781 $8,345.96 02780648 HB MESH 13 C1781 $16,925.51 02780649 HB MESH 9 C1781 $11,194.23 02780653 HB MESH 10 C1781 $12,690.17 02780654 HB MESH 14 C1781 $18,344.50

Ancillary FY22 50 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780657 HB MESH 4 C1781 $2,722.62 02780658 HB MESH 5 C1781 $4,645.63 02780660 HB MESH 15 C1781 $20,145.08 02780661 HB MESH 1 C1781 $870.06 02780662 HB MESH 6 C1781 $6,804.79 02780673 HB GRAFT SYNTHETIC TISSUE 15 C1763 $21,613.92 02780675 HB PROSTHESIS BREAST IMP 8 C1789 $10,894.05 02780676 HB PROSTHESIS BREAST IMP 7 C1789 $9,666.50 02780678 HB PROSTHESIS BREAST IMP 4 C1789 $5,224.72 02780679 HB PROSTHESIS BREAST IMP 6 C1789 $6,798.76 02780680 HB PROSTHESIS BREAST IMP 9 C1789 $12,917.98 02780686 HB PROSTHESIS, PENILE INFLATABLE 2 C1813 $12,692.87 02780687 HB BONE CEMENT 10 $24,189.36 02780688 HB PROSTHESIS, URINARY SPHINCTER 2 C1815 $29,283.23 02780689 HB LOOP RECRDR CARDIAC IMPLANT C1764 $26,362.00 02780690 HB NEUROSTIMULATOR, RECHARGEABLE 7 C1820 $179,340.00 02780691 HB NEUROSTIMULATOR, RECHARGEABLE 2 C1820 $117,324.84 02780696 HB JOINT DEVICE 86 C1776 $89,860.28 02780697 HB STENT, COATED/COV W/DEL SYSTEM 14 C1874 $34,278.65 02780698 HB JOINT DEVICE 83 C1776 $78,324.28 02780702 HB LEAD, NEUROSTIMULATOR 4 C1778 $12,125.77 02780703 HB STENT, COATED/COV W/DEL SYSTEM 9 C1874 $25,436.91 02780704 HB STENT, COATED/COV W/DEL SYS 15 C1874 $52,210.79 02780706 HB STENT, COATED/COV W/DEL SYSTEM 12 C1874 $30,873.44 02780707 HB STENT, COATED/COV W/DEL SYSTEM 11 C1874 $27,236.37 02780709 HB BONE CEMENT 11 $28,720.99 02780710 HB LEAD PCMKR TRANSVN SNGL PASS C1779 $10,033.08 02780712 HB PORT, INDWELLING (IMPLANTABLE) C1788 $2,159.28 02780713 HB STENT, COATED/COV W/DEL SYSTEM 8 C1874 $26,277.77 02780714 HB PORT, INDWELLING 2 C1788 $2,838.08 02780715 HB SEPTAL DEFECT CLOSE IMPLANT C1817 $62,719.20 02780716 HB IMPLANT, INTRASPINOUS X-STOP C1821 $43,093.11 02780717 HB STENT, COATED/COV W DEL SYS 3 C1874 $18,136.84 02780718 HB STENT, NON/COATED W/DEL SYS 2 C1876 $16,227.29 02780719 HB STENT, WINGSPAN C1874 $28,915.31 02780723 HB STENT COATED W/ DELIVERY C1874 $33,498.71 02780724 HB STENT, COATED/COV W DEL SYS 2 C1874 $22,852.41 02780726 HB STENT, NON/COATED W/DEL SYS 1 C1876 $10,305.88 02780727 HB STENT, NEUROFORM C1876 $24,101.70 02780728 HB STENT, NON/COATED W/O DEL SYS C1877 $16,909.49 02780729 HB STENT, COATED/COV W DEL SYS 4 C1874 $21,764.21 02780730 HB STENT, COATED/COV W DEL SYS 1 C1874 $5,441.07

Ancillary FY22 51 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780735 HB ADAPTER/LEAD IMPLANTABLE 6 C1883 $8,327.41 02780736 HB ADAPTER/LEAD IMPLANTABLE 3 C1883 $4,831.56 02780742 HB LEAD, AICD, NON SNGL/DUAL 1 C1896 $9,304.19 02780744 HB LEAD, NEUROSTIM KIT 2 C1778 $4,702.62 02780750 HB LEAD, PACEMAKER 1 C1898 $5,876.33 02780753 HB LEAD, PACEMAKER 2 C1898 $10,673.54 02780755 HB CAROTID STENT SYSTEM C1876 $19,238.00 02780757 HB STENT, NON-COR, TEM, W/O DEL 4 C2617 $3,192.07 02780758 HB STENT, NON-COA/NON-COV W/DEL C1876 $22,274.70 02780763 HB STENT, NON-COR, TEM, W/O DEL 2 C2617 $658.38 02780765 HB STENT, NON-COR,TEM, W/DEL 1 C2625 $8,617.61 02780767 HB STENT, NON-COATED W DEL SYS 3 C1876 $17,230.01 02780771 HB STENT,ENT DUOD CLN WALLFLX I C1876 $24,162.20 02780772 HB STENT, NON-COATED W DEL SYS 4 C1876 $17,992.91 02780773 HB STENT, NON-COATED W DEL SYS 2 C1876 $13,602.65 02780774 HB STENT, NON-COATED W DEL SYS 1 C1876 $11,788.95 02780775 HB STENT, BIL/PAN NON-METAL C1877 $788.27 02780778 HB VENA CAVA FILTER, IVC C1880 $6,811.26 02780779 HB LEAD ICD ENDOCARD COIL C1895 $74,400.01 02780781 HB LEAD PCMKR OTHER THAN VDD C1898 $6,293.27 02780783 HB LEAD BI-V LEFT VENTRCULAR C1900 $39,981.64 02780784 HB STENT, URETERAL C2617 $1,469.02 02780785 HB STENT, URETERAL 90-3390-91 C2617 $2,374.22 02780788 HB NERVE GUIDE 1 C9352 $9,476.50 02780792 HB CHIN IMPLANT 1 $2,593.88 02780795 HB JOINT DEVICE 60 C1776 $47,717.18 02780796 HB JOINT DEVICE 70 C1776 $61,498.85 02780800 HB AUDITORY, OSSEO DEVICE 1 L8690 $29,021.84 02780805 HB VALVE 4 $23,539.51 02780807 HB HEARTMATE II, IMPLANT KIT $631,400.00 02780809 HB HEARTMATE, RING APICAL SEWING $6,117.59 02780813 HB CARDIAC VALVE HUMAN TISSUE 6 $45,025.42 02780818 HB GRAFT VASCULAR 14 C1768 $24,635.87 02780819 HB JOINT DEVICE 89 C1776 $92,255.45 02780825 HB CATHETER, IMPELLA $233,500.00 02780846 HB CONTRALATERAL LIMB 2 $39,349.29 02780847 HB PROSTHESIS, EYELID 2 $2,300.69 02780848 HB STENT, GRAFT BIFURCATED 25 $86,341.91 02780850 HB CEMENT,HYDROSET INJECTABLE 5CC $7,341.13 02780852 HB EXTNSN, AORTIC/ILIAC/THORACIC3 $39,788.31 02780855 HB CEMENT,HYDROSETINJECTABLE 10CC $13,693.80 02780856 HB VALVE, NEURO 4 $35,330.05

Ancillary FY22 52 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780858 HB EXTNSN, AORTIC/ILIAC/THORACIC1 $29,119.71 02780861 HB EXTNSN, AORTIC/ILIAC/THORACIC4 $42,499.22 02780866 HB CATHETER, DIALYSIS, LONG-TERM C1750 $4,355.73 02780869 HB HUMAN TISSUE 8 C1762 $13,512.78 02780874 HB NERVE GUIDE 2 C9352 $10,140.80 02780875 HB RT BRACYTX SOURCE, HDR IR-192 C1717 $1,814.15 02780876 HB ICD DUAL CHAMBER C1721 $300,384.68 02780877 HB ICD SINGLE CHAMBER C1722 $255,481.50 02780878 HB ICD OTHER THAN SINGLE/DUAL C1882 $321,375.36 02780885 HB SPINE COUGAR $23,750.61 02780886 HB DISC, CERVICAL SPINE 1 C1889 $45,437.96 02780896 HB JOINT DEVICE 72 C1776 $64,620.90 02780900 HB COIL, MICRO DETACHABLE $3,244.33 02780902 HB BONE CEMENT 1 $864.05 02780905 HB STENT, COATED/COV W/DEL SYS 17 C1874 $56,370.89 02780906 HB TUBE, JONES 1 $460.61 02780911 HB CARDIAC VALVE HUMAN TISSUE 19 $89,619.00 02780916 HB HUMAN TISSUE 9 C1762 $15,241.18 02780917 HB LEAD, NEUROSTIMULATOR 7 C1778 $19,420.34 02780918 HB LEAD, NEUROSTIMULATOR 18 C1778 $50,329.73 02780920 HB VENA CAVA FILTER 2 C1880 $6,486.91 02780924 HB ANCHOR LEAD 1 $410.84 02780925 HB CARDIAC VALVE HUMAN TISSUE 9 $48,940.67 02780926 HB CARDIAC VALVE HUMAN TISSUE 21 $100,277.64 02780929 HB EXTERNAL FIXATION 6 C1713 $3,539.16 02780930 HB GRAFT SYNTHETIC TISSUE 17 C1763 $26,983.85 02780931 HB GRAFT SYNTHETIC TISSUE 8 C1763 $10,012.19 02780933 HB KIT, PUMP INFUSION $1,346.98 02780934 HB ORTHO BONE GRAFT SUBSTITUTE 3 $6,915.45 02780935 HB SHEET, MEDPOR 3 $4,670.45 02780936 HB SUBDURAL ELECTRODE 2 $3,743.85 02780940 HB EYE SPHERE W/CONFORMER $620.69 02780941 HB VALVE, ENDOBRACHIAL 1 $24,694.82 02780942 HB ANCHOR /SCREW 44 C1713 $46,459.35 02780943 HB COVER, BUR HOLE 2 $3,142.99 02780944 HB JOINT DEVICE 75 C1776 $63,649.74 02780945 HB COUPLER 1 $1,795.99 02780948 HB BMP SMALL 3 $30,989.61 02780949 HB BMP MEDIUM 4 $43,937.88 02780950 HB BMP LARGE 5 $48,564.31 02780951 HB BMP X-LARGE 6 $48,564.31 02780959 HB GRAFT VASCULAR 27 C1768 $113,714.85

Ancillary FY22 53 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02780960 HB LEAD, AICD ENDO SINGLE COIL 2 C1777 $48,421.24 02780962 HB CARDIAC VALVE HUMAN TISSUE 16 $82,751.91 02780974 HB GRAFT SYNTHETIC TISSUE 7 C1763 $9,442.14 02780975 HB SPACER, SPINE 13 $26,939.81 02780977 HB STENT, COATED/COV W/DEL SYSTEM 5 C1874 $18,274.62 02780978 HB STENT, COATED/COV W/DEL SYSTEM 7 C1874 $21,499.04 02780986 HB INTRAUTERINE DEVICE (IUD) 1 $3,796.68 02780987 HB PORT, INDWELLING 5 C1788 $6,285.98 02780994 HB LEAD, NEUROSTIMULATOR 5 C1778 $13,751.61 02780996 HB CARDIAC RING ANNULOPLASTY 3 $14,962.14 02780999 HB JOINT DEVICE 69 C1776 $63,582.91 02781000 HB EXTERNAL FIXATION 18 C1713 $12,347.42 02781001 HB GRAFT SYNTHETIC TISSUE 2 C1763 $4,608.83 02781002 HB GRAFT SYNTHETIC TISSUE 4 C1763 $6,895.64 02781003 HB CATHETER,IMPLNTBLTOTALACCSS A4301 $2,526.70 02781004 HB NASAL SEPTAL PROSTHESIS D5922 $1,529.68 02781005 HB BONE CEMENT 3 $3,213.42 02781006 HB BONE CEMENT 5 $8,163.38 02781007 HB BONE CEMENT 8 $15,688.48 02781008 HB SHUNT 5 $12,880.05 02781012 HB DEFLUX INJECTION 1ML L8604 $17,519.70 02781014 HB SYNTHETIC IMPLANT URINARY 1 L8606 $1,917.03 02781016 HB SPHERE EYE PLASTIC 1 $165.08 02781020 HB SUBDURAL ELECTRODE 3 $6,605.09 02781021 HB CAGE, SPINE 27 $55,693.24 02781026 HB LEAD, CORONARY VENOUS 4 C1900 $18,259.61 02781028 HB CARDIAC VALVE HUMAN TISSUE 1 $33,894.89 02781031 HB SPACER, SPINE 2 $5,326.35 02781032 HB CATHETER, MAHURKAR (CL) C1752 $1,246.80 02781033 HB SHEET, SILASTIC 1 $250.91 02781034 HB SHEET, SILASTIC 2 $1,142.32 02781036 HB STENT, SELF RETAINING $638.27 02781043 HB EXTERNAL FIXATION 23 C1713 $18,069.93 02781044 HB CATHETER,HMDYLS,SHRT TERM C1752 $746.11 02781045 HB LAP BAND, PORT ONLY 2 $8,280.04 02781046 HB REP DEV URINARY W/SLING 6 C1771 $38,910.88 02781047 HB PROSTHESIS, PENILE INFLATABLE 12 C1813 $68,225.54 02781059 HB CANNULA, ATRIAL PVAD $19,368.49 02781060 HB CANNULA, VENTRICULAR PVAD 1 $13,557.94 02781061 HB CARD DEFIB SINGLE CHAMBER 1 C1722 $104,288.77 02781064 HB LEAD, NEUROSTIMULATOR 3 C1778 $9,684.28 02781066 HB CROSSLINK, SPINE 2 $4,525.35

Ancillary FY22 54 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781067 HB PALATE, SOFT TISSUE 1 C9727 $5,444.96 02781068 HB EXTERNAL FIXATION 10 C1713 $6,181.21 02781069 HB ANCHOR LEAD 2 $1,357.62 02781079 HB PROSTHESIS BREAST IMP 1 C1789 $240.98 02781080 HB PROSTHESIS BREAST IMP 2 C1789 $2,262.68 02781082 HB PROSTHESIS, PENILE INFLATABLE 10 C1813 $58,693.79 02781083 HB CATHETER, BRACHY SEED ADMIN 2 C1728 $22,626.75 02781088 HB ANCHOR /SCREW 42 C1713 $36,202.81 02781089 HB JOINT DEVICE 41 C1776 $30,138.84 02781090 HB JOINT DEVICE 42 C1776 $30,945.17 02781091 HB JOINT DEVICE 43 C1776 $31,759.74 02781092 HB JOINT DEVICE 44 C1776 $32,673.01 02781093 HB JOINT DEVICE 45 C1776 $33,397.10 02781095 HB SEALANT 5 $7,855.60 02781096 HB IMPLANT TISS MARKER CALYPSO BEACON A4648 $10,860.82 02781097 HB MEMBRANE, COLLAGEN 1 $905.07 02781098 HB PROSTHESIS, URINARY SPHINCTER 1 C1815 $15,684.45 02781100 HB PROSTHESIS, PENILE INFLATABLE 11 C1813 $59,825.14 02781102 HB PROSTHESIS, PENILE NONINFLATABLE 3 C2622 $46,792.14 02781106 HB FELT, SURGICAL 2 $1,022.31 02781108 HB GRAFT SYNTHETIC TISSUE 13 C1763 $16,464.04 02781110 HB SPACER, SPINE 19 $46,899.08 02781112 HB HUMAN TISSUE ALLODERM 16X20 Q4116 $263.31 02781122 HB HUMAN TISSUE ALLODERM 6 X16 Q4116 $265.39 02781126 HB CANNULA, ARTERIAL PVAD 1 $21,721.70 02781127 HB STENT,NON/COATED W/DELSYS 3 C1876 $19,459.02 02781131 HB JOINT DEVICE 46 C1776 $34,057.36 02781132 HB JOINT DEVICE 47 C1776 $34,898.69 02781133 HB JOINT DEVICE 50 C1776 $37,198.38 02781135 HB SPACER 1 $606.81 02781136 HB SPACER, SPINE 4 $6,335.50 02781137 HB JOINT DEVICE 52 C1776 $38,021.18 02781138 HB JOINT DEVICE 53 C1776 $38,564.22 02781140 HB GRAFT SYNTHETIC TISSUE 14 C1763 $18,056.15 02781143 HB SPACER, SPINE 11 $23,206.82 02781144 HB SPINE PEEK 5 $27,152.12 02781145 HB GRAFT VASCULAR C1768 $21,482.32 02781146 HB TRANSCONNETOR, SPINE 2 $4,525.35 02781148 HB PLUG, VASCULAR 2 $7,240.57 02781149 HB JOINT DEVICE 87 C1776 $86,569.95 02781150 HB CAGE, SPINE 1 $2,896.24 02781151 HB CAGE, SPINE 3 $7,503.87

Ancillary FY22 55 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781152 HB CAGE, SPINE 4 $8,127.13 02781154 HB CAGE, SPINE 6 $13,783.81 02781155 HB CAGE, SPINE 7 $15,766.74 02781156 HB CAGE, SPINE 8 $17,739.37 02781157 HB CAGE, SPINE 9 $18,998.27 02781158 HB CAGE, SPINE 11 $19,997.74 02781159 HB CAGE, SPINE 12 $22,653.50 02781160 HB CAGE, SPINE 13 $24,418.39 02781161 HB CAGE, SPINE 15 $27,152.12 02781162 HB CAGE, SPINE 16 $29,750.07 02781163 HB CAGE, SPINE 17 $30,881.41 02781164 HB CAGE, SPINE 18 $32,473.50 02781165 HB CAGE, SPINE 21 $37,225.13 02781166 HB CAGE, SPINE 22 $41,633.22 02781167 HB CAGE, SPINE 23 $54,002.81 02781168 HB CAGE, SPINE 24 $55,751.22 02781169 HB CAGE, SPINE 25 $57,739.80 02781170 HB CAGE, SPINE 28 $53,598.66 02781172 HB CAGE, SPINE 30 $61,915.02 02781176 HB KIT, PENILE PROSTHESIS 1 $4,054.31 02781179 HB STENT,NON-COR,TEM,W/O DEL3 C2617 $1,049.06 02781180 HB GRAFT SYNTHETIC TISSUE 6 C1763 $8,028.38 02781181 HB PROSTHESIS, PENILE INFLATABLE 13 C1813 $73,355.92 02781182 HB JOINT DEVICE 34 C1776 $24,889.44 02781183 HB JOINT DEVICE 35 C1776 $25,586.75 02781184 HB JOINT DEVICE 36 C1776 $26,672.84 02781185 HB JOINT DEVICE 37 C1776 $27,016.34 02781186 HB JOINT DEVICE 38 C1776 $28,057.18 02781190 HB HUMAN TISSUE GRFT JCKT 4X7 Q4107 $804.87 02781192 HB HUMAN TISSUE GRFT JCKT 5X10 Q4107 $359.86 02781195 HB SEALANT 1 $2,036.41 02781196 HB SEALANT 2 $3,114.25 02781197 HB SEALANT 4 $4,977.88 02781199 HB GRAFT VASCULAR 17 C1768 $28,943.73 02781201 HB MESH 11 C1781 $12,833.47 02781202 HB STENT, NON-COA/COV W/O DEL C1877 $12,218.45 02781203 HB LEAD ICD ENDOCARD DUAL COIL C1777 $62,014.55 02781207 HB LEAD, NEUROSTIMULATOR 1 C1778 $1,040.84 02781211 HB JOINT DEVICE 55 C1776 $40,211.85 02781212 HB JOINT DEVICE 40 C1776 $40,872.14 02781213 HB JOINT DEVICE 57 C1776 $42,149.53 02781215 HB JOINT DEVICE 58 C1776 $43,134.82

Ancillary FY22 56 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781216 HB JOINT DEVICE 61 C1776 $45,615.55 02781217 HB JOINT DEVICE 62 C1776 $46,376.61 02781218 HB JOINT DEVICE 63 C1776 $57,102.57 02781219 HB JOINT DEVICE 64 C1776 $48,873.77 02781220 HB JOINT DEVICE 65 C1776 $49,634.88 02781222 HB VALVE, NEURO 4 $25,658.75 02781223 HB VALVE, NEURO 7 $35,063.25 02781224 HB CLIP, ANEURYSM 2 $3,340.53 02781225 HB SPACER, SPINE 7 $16,254.23 02781228 HB RESERVOIR, NEURO 2 $2,488.94 02781232 HB GENERATOR, NEUROSTIMULATOR1 C1767 $72,664.20 02781233 HB JOINT DEVICE 66 C1776 $50,313.66 02781234 HB JOINT DEVICE 68 C1776 $51,996.29 02781236 HB SPACER, SPINE 10 $20,164.54 02781240 HB GRAFT VASCULAR 12 C1768 $18,553.94 02781241 HB MESH 20 C1781 $51,136.47 02781243 HB ADAPTER/LEAD IMPLANTABLE 5 C1883 $6,806.55 02781245 HB GRAFT 13 $90,461.76 02781246 HB GRAFT 15 $96,869.24 02781247 HB HUMAN TISSUE 23 C1762 $37,107.88 02781250 HB COLLAGEN IMPLANT 2 $5,520.93 02781255 HB STENT, ESOPH COV/ W/DEL C1874 $19,223.23 02781256 HB STENT,ENT DUOD CLNWALLFLXII C1876 $23,193.79 02781257 HB STENT,BIL WALLFLEX COVERED C1874 $23,726.42 02781258 HB STENT, WALLFLEX N-COV W/DEL C1876 $15,979.02 02781259 HB STENT,WALLFLEX PT/COV W/DEL C1874 $23,037.51 02781260 HB STENT, ENTERAL NG C1876 $16,560.05 02781261 HB STENT, SOLUS C1877 $1,439.47 02781262 HB STENT,BILIARY MTL HLS W/DEL C1874 $39,563.33 02781263 HB OTSC FISTULA CLOSURE 200.40 $4,445.06 02781264 HB KIT, CAGE INTERLOCK 1 $22,618.52 02781265 HB KIT, CAGE INTERLOCK 2 $34,374.14 02781266 HB KIT, CAGE INTERLOCK 3 $46,131.82 02781267 HB KIT, CAGE INTERLOCK 4 $57,887.46 02781271 HB GENERATOR, NEUROSTIMULATOR4 C1767 $82,268.81 02781277 HB PROSTHESIS, PENILE INFLATABLE 3 $13,312.75 02781278 HB STENT, GRAFT CONVERTER 1 $78,514.83 02781279 HB STENT, GRAFT THORACIC 10 $169,941.80 02781280 HB JOINT DEVICE 71 C1776 $58,776.06 02781282 HB REP DEV URINARY W/SLING 4 C1771 $9,005.45 02781283 HB CONNECTOR, CEREBRAL 2 $1,954.13 02781285 HB CARDIAC VALVE HUMAN TISSUE 5 $41,723.73

Ancillary FY22 57 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781287 HB STENT, GRAFT THORACIC 7 $144,315.29 02781289 HB GENERATOR,NEUROSTIMULATOR12 C1767 $176,400.00 02781290 HB EMBOLIZATION DEVICE, PIPELINE $96,266.55 02781292 HB JOINT DEVICE 78 C1776 $67,254.94 02781293 HB STENT,NON/COATED W/DELSYS 2 C1876 $12,788.23 02781294 HB MESH 12 C1781 $13,847.57 02781297 HB STENT, COATED/COV W/DEL SYSTEM 2 C1874 $14,209.60 02781298 HB STENT, COATED/COV W/DEL SYSTEM 3 C1874 $15,476.69 02781299 HB STENT, COATED/COV W/DEL SYSTEM 4 C1874 $16,291.25 02781300 HB STENT, COATED/COV W/DEL SYSTEM 6 C1874 $18,029.41 02781301 HB STENT, COATED/COV W/DEL SYSTEM 10 C1874 $26,319.04 02781302 HB STENT, COATED/COV W/DEL SYSTEM 13 C1874 $31,677.44 02781304 HB STENT,COATED/COV W/DELSYS21 C1874 $72,160.84 02781305 HB TRANSCATHETER, PULMONIC VLV $236,760.00 02781308 HB EXTERNAL FIXATION 4 C1713 $2,289.42 02781310 HB CATHETER, BRACHY SEED ADMIN 1 C1728 $1,119.00 02781319 HB STENT, GRAFT BIFURCATED 11 $38,473.72 02781320 HB STENT, GRAFT BIFURCATED 12 $42,565.04 02781327 HB STENT, GRAFT BIFURCATED 21 $82,587.65 02781329 HB STENT, GRAFT BIFURCATED 24 $85,763.62 02781331 HB ANCHOR /SCREW 35 C1713 $25,341.95 02781332 HB PORT, INDWELLING 1 C1788 $2,073.44 02781333 HB PORT, INDWELLING 3 C1788 $3,330.25 02781334 HB ANCHOR /SCREW 38 C1713 $36,973.00 02781335 HB ANCHOR /SCREW 39 C1713 $32,393.29 02781336 HB ANCHOR /SCREW 40 C1713 $33,722.08 02781337 HB ANCHOR /SCREW 43 C1713 $44,714.33 02781338 HB CAGE, SPINE 2 $6,109.25 02781341 HB WIRE, SUR TISSUE LOC DEVICE C1819 $190.07 02781342 HB TISSUE MARKER, CLIP/WIRE A4648 $678.80 02781352 HB VASCULAR PLUG AMPLATZ $7,240.57 02781353 HB SAPIEN AORTIC VALVE 23/26MM $300,000.00 02781358 HB EXTERNAL FIXATION 5 C1713 $2,778.99 02781359 HB EXTERNAL FIXATION 7 C1713 $4,181.84 02781360 HB EXTERNAL FIXATION 9 C1713 $5,648.46 02781362 HB NO COST ITEM IMPLANT-CL $1.00 02781363 HB MARKER, VISICOIL / NITINOL FIDUCIAL $1,176.60 02781364 HB ADHESION BARRIER 1 C1765 $2,425.17 02781365 HB ADHESION BARRIER 2 C1765 $5,701.92 02781367 HB TOTAL ARTIFICIAL HEART $866,504.00 02781368 HB NEEDLE, FIX SYSTEM 2 $4,261.07 02781376 HB MARKER, FIDUCIAL GOLD IZI $174.31

Ancillary FY22 58 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781380 HB ALLOGRAFT FLEXHD 4X12CM 0.8 Q4128 $237.59 02781382 HB ALLOGRAFT FLEXHD 4X7CM Q4128 $242.12 02781383 HB ALLOGRAFT FLEXHD 6X12CM Q4128 $218.31 02781385 HB ALLOGRAFT FLEXHD 6X16CM Q4128 $218.39 02781388 HB ALLOGRAFT FLEXHD 8X12CM 0.8 Q4128 $247.17 02781389 HB ALLOGRAFT FLEXHD 8X16CM Q4128 $218.39 02781390 HB ALLOGRAFT FLEXHD 8X16CM* Q4128 $249.99 02781391 HB ALLOGRAFT FLEXHD 8X20CM Q4128 $227.72 02781394 HB ALLOGRAFT FLEXHD 2X4CM Q4128 $192.60 02781395 HB ALLOGRAFT FLEXHD 4X12CM 0.4 Q4128 $132.39 02781396 HB ALLOGRAFT FLEXHD 4X7CM 0.4 Q4128 $154.30 02781397 HB ALLOGRAFT FLEXHD 4X16CM Q4128 $212.68 02781400 HB STENT, ESOPHAGEAL COVERED C1874 $19,911.56 02781403 HB CATHETER, IMPELLA 5.0 $233,500.00 02781404 HB FLOSEAL MM $1,469.06 02781407 HB CLIP, HEMOSTASIS $1,458.07 02781409 HB CARD/DEFI,OTHR THNSIN/DUAL1 C1882 $142,100.00 02781419 HB STENT, GRAFT THORACIC 9 $151,187.83 02781420 HB STENT, GRAFT THORACIC 10 $155,026.20 02781421 HB STENT, GRAFT THORACIC 11 $161,543.20 02781422 HB STENT, GRAFT THORACIC 11 $166,046.30 02781423 HB STENT, GRAFT THORACIC 12 $172,244.80 02781427 HB FIDUCIAL MARKERS CIVCO $1,352.48 02781429 HB SPACER, SPINE 9 $21,721.70 02781433 HB COIL, EMBOLIZATION $1,475.40 02781435 HB STENT, DUODENAL EVOLUTION C1876 $18,405.56 02781436 HB LEAD, AICD ENDO SINGLECOIL 1 C1777 $36,258.59 02781437 HB NASAL/FACIAL PROSTHESIS 1 L8048 $8,838.03 02781439 HB CAGE, SPINE 10 $19,035.75 02781440 HB GENERATOR, NEUROSTIMULATOR14 C1767 $185,420.90 02781441 HB ELECTRODE, NEUROSTIM IMPL1 C1778 $26,332.81 02781442 HB ELECTRODE, NEUROSTIM IMPL2 C1778 $27,193.94 02781443 HB KIT, XLIF 1 $29,161.52 02781444 HB KIT, XLIF 2 $47,136.16 02781445 HB KIT, XLIF 3 $68,891.32 02781446 HB KIT, XLIF 4 $90,646.47 02781451 HB CARDIAC RING ANNULOPLASTY 5 $24,111.95 02781453 HB LEAD, CORONARY VENOUS 2 C1900 $17,222.82 02781455 HB CARDIO DEFIB DUAL CHAMBER 1 C1721 $113,141.00 02781457 HB LEAD, AICD ENDO COIL 1 C1895 $36,169.35 02781458 HB LEAD, AICD ENDO COIL 2 C1895 $36,258.59 02781461 HB LEAD, NEUROSTIMULATOR 10 C1778 $23,681.39

Ancillary FY22 59 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781462 HB LEAD, NEUROSTIMULATOR 12 C1778 $25,424.16 02781463 HB LEAD, NEUROSTIMULATOR 13 C1778 $28,100.39 02781464 HB LEAD, NEUROSTIMULATOR 14 C1778 $28,870.89 02781465 HB KIT, NEURX DIAPHRAGM 1 $209,050.00 02781466 HB G-TUBE REPLACEMNT ENDOVIVE $551.22 02781467 HB CLIP, ENDO CLOSURE DEVICE $4,341.97 02781469 HB STENT, COLONIC WALLSTENT C1874 $21,709.83 02781470 HB MITRAL CLIP IMPLANT $266,100.00 02781473 HB CLIP, LAPAROSCOPIC 1 $725.18 02781476 HB KIT, ALIF LEVEL 2* $72,426.51 02781477 HB KIT, ALIF LEVEL 3* $88,125.79 02781482 HB CATHETER, HEMO, LONG TERM 2 C1750 $19,715.60 02781485 HB HUMAN TISSUE 17 C1762 $27,193.94 02781486 HB HUMAN TISSUE 19 C1762 $29,460.11 02781487 HB HUMAN TISSUE 21 C1762 $34,499.71 02781488 HB HUMAN TISSUE 24 C1762 $38,071.53 02781490 HB HUMAN TISSUE 30 C1762 $49,937.49 02781491 HB LAP BAND SYSTEM 1* $22,407.11 02781493 HB SPACER, SPINE 3 $6,073.32 02781494 HB SPACER, SPINE 6 $14,214.05 02781496 HB HUMAN TISSUE 35 C1762 $66,851.77 02781498 HB VALVE 3* $9,979.83 02781499 HB BONE CEMENT 2* $2,148.72 02781501 HB CATHETER, INTRASPINAL 4 C1755 $8,974.01 02781502 HB VALVE, NEURO 5 $27,601.85 02781503 HB BONE FILLER 3 $11,058.86 02781504 HB SHEET, MEDPOR 6 $7,886.24 02781505 HB ANCHOR /SCREW 24 C1713 $17,928.94 02781506 HB ANCHOR /SCREW 26 C1713 $16,016.54 02781508 HB MESH 8 C1781 $7,017.84 02781510 HB GENERATOR,NEUROSTIMULATOR15 C1767 $191,629.20 02781511 HB PORT, INDWELLING 4 C1788 $3,701.39 02781513 HB BONE CEMENT 7 $10,530.39 02781514 HB MESH 2* C1781 $936.96 02781515 HB MESH 3* C1781 $1,321.92 02781517 HB OCCLUDER, ABDOMINAL 3 $20,206.60 02781518 HB ANCHOR /SCREW 23 C1713 $11,866.84 02781521 HB COREVALVE AORTIC VALVE $209,184.16 02781522 HB CARDIAC MONITOR (LOOP RECORDER) C1764 $55,547.26 02781523 HB IMPLANT TISSUE MARKER I125 SDS A4648 $2,039.55 02781524 HB BONE FILLER 4 $25,126.79 02781525 HB JOINT DEVICE 2* C1776 $1,387.31

Ancillary FY22 60 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781526 HB JOINT DEVICE 3* C1776 $2,176.10 02781527 HB KIT, ALIF LEVEL 1 $34,445.66 02781529 HB JOINT DEVICE 26 C1776 $18,419.82 02781530 HB JOINT DEVICE 28 C1776 $20,014.86 02781531 HB TESTICULAR PROSTHESIS 3 $16,760.89 02781532 HB JOINT DEVICE 10 C1776 $7,033.82 02781533 HB JOINT DEVICE 12 C1776 $9,590.90 02781534 HB JOINT DEVICE 15 C1776 $10,388.03 02781535 HB JOINT DEVICE 17 C1776 $11,702.69 02781536 HB JOINT DEVICE 24 C1776 $20,035.04 02781537 HB GRAFT SYNTHETIC TISSUE 1* C1763 $1,776.61 02781539 HB GRAFT SYNTHETIC TISSUE 12* C1763 $11,965.63 02781540 HB ANCHOR / SCREW 1* C1713 $410.42 02781541 HB ANCHOR / SCREW 3* C1713 $1,814.49 02781542 HB HEARTWARE, SINGLE PUMP KIT $463,004.43 02781543 HB JOINT DEVICE 39 C1776 $29,107.10 02781544 HB SPACER 7 $7,396.98 02781545 HB ADAPTER/LEAD IMPLANTABLE 2* C1883 $3,072.37 02781547 HB ALLOGRAFT FLEXHD 8X16CM** Q4128 $203.96 02781548 HB ALLOGRAFT FLEXHD 8X20CM** Q4128 $442.71 02781549 HB JOINT DEVICE 33 C1776 $23,894.93 02781550 HB JOINT DEVICE 54 C1776 $39,621.52 02781552 HB ANCHOR /SCREW 5 C1713 $2,764.43 02781553 HB ANCHOR /SCREW 6 C1713 $3,290.29 02781555 HB JOINT DEVICE 59 C1776 $43,574.21 02781556 HB ICD GENERATOR, SUBCUTANEOUS C1722 $191,100.00 02781557 HB ICD ELECTRODE, SUBCUTANEOUS C1896 $31,726.24 02781558 HB EXTERNAL FIXATION 1* C1713 $498.27 02781559 HB EXTERNAL FIXATION 3* C1713 $1,459.93 02781560 HB JOINT DEVICE 4* C1776 $2,710.68 02781561 HB ANCHOR /SCREW 8 C1713 $5,411.08 02781562 HB ANCHOR /SCREW 10 C1713 $6,717.95 02781563 HB ANCHOR /SCREW 11 C1713 $7,646.80 02781565 HB LAMINARIA $103.99 02781566 HB DILAPAN (AQUACRYL) $179.88 02781567 HB ANCHOR /SCREW 7 C1713 $3,978.86 02781568 HB ANCHOR /SCREW 13 C1713 $9,148.07 02781569 HB STENT,COATED/COV W/DEL SYS1 C1874 $6,300.23 02781570 HB ANCHOR /SCREW 14 C1713 $8,248.25 02781571 HB ANCHOR /SCREW 16 C1713 $9,391.50 02781572 HB SENSOR/CARDIO MEMS PULM ART C2624 $220,460.00 02781574 HB WATCHMAN LAA DEVICE C1884 $225,439.25

Ancillary FY22 61 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781575 HB VALVE AORTIC EVOLUTR $349,610.99 02781576 HB IMPLANT TISSUE MARKER A4648 $10,429.59 02781577 HB PESSARY (SILICONE) A4562 $444.79 02781578 HB STENT, GRAFT THORACIC 17 $177,095.31 02781579 HB HUMAN TISSUE 9 C1762 $14,999.15 02781580 HB HUMAN TISSUE 11 C1762 $17,193.68 02781581 HB HUMAN TISSUE 27 C1762 $40,688.12 02781583 HB BMP XX-SMALL 1 $8,143.40 02781584 HB BMP X-SMALL 2 $55,568.90 02781585 HB BMP MEDIUM 4 $55,568.90 02781586 HB BMP LARGE / XLARGE 5 $63,831.33 02781587 HB MESH 17 C1781 $31,740.08 02781588 HB ANCHOR /SCREW 17 C1713 $10,012.12 02781589 HB ANCHOR /SCREW 19 C1713 $11,289.92 02781590 HB ANCHOR /SCREW 27 C1713 $16,939.80 02781591 HB ANCHOR /SCREW 31 C1713 $21,211.77 02781592 HB ANCHOR /SCREW 32 C1713 $22,172.21 02781593 HB ANCHOR /SCREW 36 C1713 $27,160.65 02781594 HB JOINT DEVICE 20 C1776 $13,983.68 02781595 HB JOINT DEVICE 49 C1776 $36,501.45 02781596 HB CAGE, SPINE 14 $25,392.08 02781601 HB EXTERNAL FIXATION 26 C1713 $21,410.63 02781602 HB GRAFT SYNTHETIC TISSUE 20 C1763 $24,032.48 02781603 HB PROSTHESIS BREAST IMP 3 C1789 $3,672.57 02781604 HB PROSTHESIS BREAST IMP 5 C1789 $5,840.30 02781606 HB MICRA LEADLESS PACEMAKER C1786 $161,256.81 02781609 HB LAP BAND SYSTEM $19,971.70 02781610 HB SPACER, SPINE $25,908.39 02781611 HB GRAFT VASCULAR C1768 $14,923.42 02781612 HB CARDIAC VALVE HUMAN TISSUE $43,072.56 02781613 HB CATHETER VENTRICULAR BIOGLIDE $1,457.81 02781614 HB UROLIFT SYSTEM L8699 $9,176.55 02781615 HB SHEET, MEDPOR $13,505.16 02781616 HB ALLOGRAFT FLEXHD 6X16CM Q4128 $486.38 02781617 HB COCHLEAR DEVICE L8614 $34,490.54 02781618 HB COCHLEAR DEVICE L8614 $16,732.51 02781619 HB HUMAN TISSUE C1762 $1,834.79 02781620 HB KIT XLIF $61,316.25 02781621 HB SPACER, SPINE $44,930.34 02781622 HB HUMAN TISSUE C1762 $26,933.87 02781623 HB JOINT DEVICE C1776 $104,800.07 02781624 HB EXTERNAL FIXATION C1713 $32,385.49

Ancillary FY22 62 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781625 HB EXTERNAL FIXATION C1713 $28,499.23 02781626 HB IMPLANT TISSUE MARKER MAGSEED MAGNET A4648 $1.00 02781627 HB IMPLANT TISSUE MARKER SAVI SCOUT RADAR A4648 $8,401.22 02781628 HB SPACER, SPINE $47,317.26 02781629 HB HEARTWARE, IMPLANT KIT $633,764.36 02781630 HB STENT, NON/COATED W/DEL SYS C1876 $9,682.70 02781631 HB CATHETER, VENTRICULAR $1,457.81 02781632 HB PROSTHESIS, URINARY SPHINCTER C1815 $20,597.80 02781633 HB PROSTHESIS, URINARY SPHINCTER C1815 $43,180.65 02781684 HB KIT BRIGADE ANTERIOR LUMBAR 1 LEVEL $53,867.73 02781685 HB GRAFT SYNTHETIC TISSUE C1763 $58,564.09 02781686 HB STENT, NON-COR,TEM, W/DEL C2625 $1,252.18 02781687 HB GENERATOR, NEUROSTIMULATOR C1767 $205,355.77 02781688 HB REP DEV URINARY W/SLING C1771 $8,355.39 02781689 HB PROSTHETIC IMPLANT BONE MATRIX L8699 $17,191.86 02781690 HB AAA EXCLUDER ENDOPROSTHESIS $105,301.00 02781691 HB AAA EXCLUDER ENDOPROSTHESIS $44,930.34 02781692 HB EXCLUDER ENDOPROSTHESIS $31,321.64 02781693 HB SPACE OAR IMPLANT SYSTEM $30,769.29 02781694 HB LEAD, NEUROSTIMULATOR C1778 $74,288.82 02781695 HB GENERATOR, NEUROSTIMULATOR C1767 $220,600.44 02781696 HB GENERATOR, NEUROSTIMULATOR C1767 $244,470.82 02781697 HB GRAFT ARTHROFLEX 4X4 Q4125 $1,501.32 02781698 HB GRAFT ARTHROFLEX 4X4 Q4125 $1,824.89 02781699 HB GRAFT ARTHROFLEX 4X7 Q4125 $857.86 02781700 HB GRAFT SYNTHETIC TISSUE C1763 $45,074.90 02781701 HB LEAD, NEUROSTIMULATOR C1778 $52,901.58 02781702 HB GENERATOR, NEUROSTIMULATOR C1767 $181,077.90 02781703 HB NEUROSTIMULATOR, RECHARGEABLE C1820 $186,200.00 02781704 HB EXCLUDER ENDOPROSTHESIS $44,914.26 02781705 HB AUDITORY, OSSEO DEVICE L8690 $37,829.57 02781706 HB AUDITORY, OSSEO DEVICE L8690 $35,627.60 02781707 HB VALVE, NEURO $34,407.98 02781708 HB VALVE, NEURO $35,609.81 02781709 HB GENERATOR, NEUROSTIMULATOR C1767 $247,846.61 02781710 HB GENERATOR, NEUROSTIMULATOR C1767 $251,673.46 02781711 HB LEAD, NEUROSTIMULATOR C1778 $44,264.60 02781712 HB CARDIOVERTER- DEFIBRILLATOR DUAL CHAMBER C1721 $153,273.41 02781717 HB VALVE, ENDOBRONCHIAL $26,450.80 02781718 HB CARDIOVERTER - DEFIBRILLATOR DUAL CHAMBER C1721 $156,877.71 02781719 HB PROSTHETIC IMPLANT NASAL L8699 $10,742.87 02781720 HB STENT, NON/COATED W/O DEL SYS C1877 $11,336.06

Ancillary FY22 63 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781732 HB PERMATEMP PPI GENERATOR C1722 $7,557.36 02781744 HB ESSURE COIL IMPLANT A4264 $15,114.74 02781746 HB ENDOPROSTHESIS EXCLUDER $105,014.94 02781747 HB HUMAN GRAFT TISSUE $10,731.00 02781748 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $25,857.59 02781749 HB HUMAN TISSUE ALLODERM 8X16 Q4116 $316.60 02781750 HB IMPLANT, BONE VOID FILLER-STRIP C9362 $11,200.80 02781752 HB STENT, ESOPHAGEAL $24,291.55 02781753 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $26,990.61 02781754 HB EMBOLIZATION COIL $13,932.72 02781755 HB TRACEIT HYDROGEL $10,256.43 02781760 HB CATHETER,COOLLINE $5,297.50 02781761 HB CATHETER, ICY $8,444.07 02781762 HB CATHETER, QUATTTRO $9,458.48 02781763 HB ER REBOA CATHETER C1760 $21,538.50 02781764 HB CARTRIDGE, CARTOSS 5CC $8,410.28 02781765 HB CEMENT AUTOPLEX SYS W VERTAPLEX HV $9,176.81 02781766 HB COIL, EMBOLIZATION 5 $2,569.51 02781767 HB STENT, BILLIARY $11,336.06 02781768 HB COIL, EMBOLIZATION 6 $10,688.29 02781769 HB COIL, EMBOLIZATION 7 $13,927.16 02781770 HB STENT, COATED/COV W/DEL SYSTEM 15 C1874 $35,843.52 02781771 HB RE-ENTRY CATHETER SYSTEM $29,149.86 02781782 HB AUDITORY OSSEO, INTERNAL/EXTERNAL COMPONENTS L8690 $31,732.65 02781783 HB REP DEV URINARY W/SLING C1771 $56,874.85 02781784 HB KIT, URINARY SPHINCTER ACCESSORY $10,375.07 02781785 HB PROSTHESIS, URINARY SPHINCTER C1815 $52,081.79 02781786 HB EVENT RECORDER, CARDIAC IMPLANTABLE C1764 $55,547.26 02781787 HB PROSTHETIC IMPLANT BONE MATRIX L8699 $7,368.73 02781789 HB GENERATOR, NEUROSTIMULATOR W/RECHARGING SYSTEM L8687 $194,775.00 02781790 HB CATHETER, IMPELLA RP $213,940.00 02781791 HB GENERATOR, NEUROSTIMULATOR W/RECHARGING SYSTEM L8689 $10,796.25 02781805 HB BONE FILLER $14,971.25 02781806 HB ALLOGRAFT FLEXHD 4X12 Q4128 $247.04 02781807 HB ALLOGRAFT FLEXHD 16X20 Q4128 $268.88 02781808 HB PROSTHETIC IMPLANT SPEEDGRAFT TENDON L8699 $25,114.39 02781811 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $112,700.00 02781812 HB HUMAN TISSUE ALLODERM 10 X 19 Q4116 $285.27 02781813 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $12,832.33 02781814 HB PROSTHESIS ENT $6,751.19 02781822 HB CARD/DEFI,OTHR THNSIN/DUAL C1882 $185,220.00 02781823 HB CARD/DEFI,OTHR THNSIN/DUAL C1882 $198,703.96

Ancillary FY22 64 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781824 HB LEAD, PACEMAKER C1898 $4,515.11 02781825 HB PROSTHESIS, URINARY SPHINCTER C1815 $50,174.57 02781826 HB PROSTHESIS, URINARY SPHINCTER C1815 $23,828.56 02781827 HB ELECTRODE ANCHOR BOLT $3,683.49 02781828 HB PROSTHESIS, PENILE INFLATABLE C1813 $17,283.03 02781833 HB FLEXHD BREAST 11 X 20 Q4128 $294.79 02781834 HB FLEXHD BREAST 13 X 22 Q4128 $281.48 02781835 HB CARDIO-DEFIB, OTHR THN SING/DUAL C1882 $194,999.01 02781836 HB REFLUX MANAGEMENT SYSTEM $59,410.41 02781837 HB IMPLANT TISSUE MARKER A4648 $10,261.80 02781838 HB ADAPTER/LEAD IMPLANTABLE C1883 $7,129.70 02781840 HB CARDIO DEFIB DUAL CHAMBER C1721 $140,627.98 02781851 HB TOTAL ARTIFICIAL HEART 70CC $899,368.00 02781852 HB VALVE PROGRAMMABLE $44,136.35 02781853 HB PROSTHESIS, PENILE NONINFLATABLE C2622 $45,367.95 02781854 HB PROSTHESIS, PENILE NONINFLATABLE C2622 $76,617.72 02781855 HB BONE FILLER $21,603.78 02781856 HB KIT, XLIF 2 LEVEL $54,272.83 02781857 HB CARDIAC VALVE HUMAN TISSUE $77,753.25 02781858 HB AURICAL IMPLANT EAR BASE $8,538.69 02781859 HB AURICAL IMPLANT HELICAL RIM $3,947.88 02781860 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $7,021.23 02781861 HB HEARTMATE III MINI APICAL CUFF $6,102.62 02781862 HB HEARTMATE III IMPLANT KIT $709,926.00 02781863 HB JOINT DEVICE C1776 $91,838.25 02781864 HB SPACER, SPINE $45,956.39 02781865 HB GRAFT ARTHROFLEX 4X7 Q4125 $1,522.64 02781866 HB LEAD, PACEMAKER C1898 $4,590.80 02781867 HB HUMAN TISSUE C1762 $26,871.80 02781868 HB ZEPHYR ENDOBRONCHIAL VALVE $23,764.17 02781869 HB SIENTRA ALLOX2 DUAL PORT $1.00 02781871 HB HUMAN TISSUE ALLODERM 16X20 Q4116 $316.63 02781872 HB PROSTHESIS, PENILE INFLATABLE C1813 $84,373.40 02781873 HB PROSTHESIS, PENILE INFLATABLE C1813 $85,960.92 02781874 HB HUMAN TISSUE ALLODERM 16X20 Q4116 $326.11 02781875 HB HUMAN TISSUE BILAYER (BMWD) 2X2 Q4104 $8,092.56 02781876 HB HUMAN TISSUE BILAYER (BMWD) 4X5 Q4104 $2,822.33 02781877 HB HUMAN TISSUE BILAYER (BMWD) 4X10 Q4104 $2,273.16 02781878 HB HUMAN TISSUE BILAYER (BMWD) 8X10 Q4104 $1,799.71 02781879 HB KIT, XLIF 3 LEVEL $79,393.90 02781880 HB IMPLANT TISSUE MARKER A4648 $10,261.80 02781881 HB STENT, GRAFT THORACIC $194,485.90

Ancillary FY22 65 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781882 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $21,484.96 02781883 HB CLIP, OCCLUSION $40,507.10 02781884 HB SEPTAL DEFECT IMPLANT SYSTEM $85,194.51 02781885 HB HUMAN TISSUE C1762 $4,623.20 02781889 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $23,224.07 02781890 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $21,484.96 02781891 HB JOINT DEVICE C1776 $107,691.61 02781892 HB VASCULAR PATCH $2,095.57 02781893 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $12,692.22 02781897 HB NEUROSTIMULATOR, RECHARGEABLE C1820 $224,372.00 02781898 HB NEUROSTIMULATOR, RECHARGEABLE C1820 $213,940.00 02781899 HB COVER, BURR HOLE $8,640.45 02781900 HB TISSUE MARKER A4648 $680.43 02781901 HB CATHETER, PERITONEAL $5,572.55 02781902 HB GENERATOR, NEUROSTIMULATOR C1767 $201,715.00 02781903 HB GRAFT VASCULAR C1768 $7,733.21 02781904 HB GRAFT VASCULAR C1768 $25,068.11 02781905 HB GRAFT SYNTHETIC TISSUE C1763 $45,092.34 02781906 HB TESTICULAR PROSTHESIS $18,468.96 02781907 HB HUMAN TISSUE C1762 $38,301.95 02781908 HB STENT, GRAFT THORACIC $189,370.59 02781909 HB BONE GRAFT MATRIX $12,960.68 02781910 HB BONE GRAFT PUTTY $20,521.07 02781911 HB STENT, GRAFT THORACIC $182,691.60 02781912 HB CLIP, OCCLUSION $59,403.10 02781913 HB STENT, GRAFT BIFURCATED $65,829.42 02781914 HB MESH C1781 $40,750.52 02781915 HB MESH C1781 $73,875.85 02781916 HB MESH C1781 $93,316.86 02781917 HB GRAFT VASCULAR C1768 $47,349.67 02781918 HB STENT, NON/COATED W/DELIVERY SYSTEM C1876 $18,587.77 02781919 HB CATHETER, IMPELLA $298,400.00 02781920 HB COCHLEAR DEVICE L8614 $209,943.24 02781921 HB COCHLEAR DEVICE L8614 $214,050.84 02781922 HB COCHLEAR DEVICE L8614 $233,144.23 02781923 HB COCHLEAR DEVICE L8614 $206,735.40 02781924 HB JOINT DEVICE C1776 $65,563.73 02781925 HB COCHLEAR DEVICE L8614 $119,011.20 02781926 HB COCHLEAR IMPLANT EXT PROC/CONTR REPLACEMENT L8619 $119,011.20 02781927 HB DISC, CERVICAL SPINE C1889 $43,202.25 02781928 HB SHEET, MEDPOR $10,162.04 02781929 HB STENT, COATED/COV W/O DELIVERY SYSTEM C1875 $58,809.06

Ancillary FY22 66 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781930 HB PROSTHESIS, URINARY SPHINCTER C1815 $63,204.90 02781931 HB VALVE, ENDOBRONCHIAL $37,261.94 02781932 HB GENERATOR, NEUROSTIMULATOR C1767 $278,697.00 02781933 HB 5.5 IMPELLA CATHETER $298,400.00 02781935 HB CARDIAC VALVE HUMAN TISSUE $107,800.00 02781937 HB STENT, ATLAS NEUROVASCULAR $80,442.59 02781938 HB SPACER ORTHO $32,315.28 02781939 HB ADAPTER/LEAD IMPLANTABLE C1883 $18,360.96 02781940 HB CARDIO-DEFIB DUAL CHAMBER C1721 $126,655.20 02781941 HB STENT, NON-COR, TEM, W/O DEL C2617 $65,224.59 02781942 HB INTRAUTERINE TANDEM IMPLANTABLE $891.05 02781943 HB MESH ABSORBABLE ANTIBACTERIAL $12,366.65 02781944 HB CARDIO DEFIB DUAL CHAMBER C1721 $133,946.40 02781945 HB LEAD, NEUROSTIMULATOR C1778 $5,400.29 02781946 HB ENDOBRONCHIAL VALVE - ZEPHYR $23,769.90 02781947 HB ENDOBRONCHIAL VALVE - SPIRATION $28,091.70 02781949 HB LEAD, AICD ENDO SINGLECOIL C1777 $33,493.95 02781950 HB GRAFT VASCULAR C1768 $29,355.83 02781951 HB CARDIAC VALVE HUMAN TISSUE $164,279.85 02781952 HB GRAFT VASCULAR C1768 $87,300.36 02781953 HB HUMAN TISSUE C1762 $125,229.30 02781954 HB HUMAN TISSUE C1762 $122,708.25 02781955 HB STRATTICE TISSUE MATRIX 4X16 Q4130 $335.27 02781956 HB STRATTICE TISSUE MATRIX 6X16 Q4130 $260.49 02781957 HB STRATTICE TISSUE MATRIX 8X16 Q4130 $246.77 02781958 HB STRATTICE TISSUE MATRIX 9X18.5 Q4130 $189.72 02781959 HB STRATTICE TISSUE MATRIX 10X20 Q4130 $174.16 02781960 HB STRATTICE TISSUE MATRIX 10X20 Q4130 $260.49 02781961 HB STRATTICE TISSUE MATRIX 16X20 Q4130 $260.49 02781962 HB STRATTICE TISSUE MATRIX 20X30 Q4130 $260.49 02781963 HB STRATTICE TISSUE MATRIX 30X30 Q4130 $260.49 02781964 HB MESH C1781 $17,469.36 02781965 HB HUMAN TISSUE C1762 $66,544.92 02781966 HB HUMAN TISSUE C1762 $115,525.83 02781967 HB MATRISTEM MICROMATRIX 1000MG Q4118 $23.88 02781968 HB SPACER/CAGE, SPINE $43,218.00 02781969 HB HUMAN TISSUE ALLODERM 9.6X19.3 Q4116 $232.73 02781970 HB EXCLUDER ENDOPROSTHESIS $31,333.05 02781971 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $71,773.21 02781972 HB CARDIAC VALVE HUMAN TISSUE $46,740.27 02781973 HB BONE GRAFT MATRIX $20,528.55 02781974 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $94,539.38

Ancillary FY22 67 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 02781975 HB JOINT DEVICE C1776 $83,950.97 02781976 HB KIT BRIGADE ANTERIOR LUMBAR LEVEL 2 $77,792.40 02781977 HB CARD/DEFI,OTHR THNSIN/DUAL C1882 $196,652.19 02781978 HB LEAD, CORONARY VENOUS C1900 $22,106.01 02781979 HB INTRAVERTEBRAL BODY FX AUGMNT W/ IMPLANT C1062 $26,054.28 02781981 HB KIT, XLIF LEVEL 1 $45,378.90 02781982 HB KIT, TLIF LEVEL 1 $52,725.96 02781983 HB CARDIAC VALVE HUMAN TISSUE $144,008.55 02781984 HB GENERATOR, NEUROSTIMULATOR C1767 $303,196.04 02781985 HB NEUROSTIMULATOR, RECHARGEABLE C1820 $217,106.40 02781986 HB SPACER/CAGE, SPINE $68,716.62 02781987 HB SPACER/CAGE, SPINE $93,134.79 02781988 HB SPACER/CAGE, SPINE $111,337.80 02781989 HB ANCHOR/SCREW C1713 $35,546.81 02781990 HB CARDIAC RING ANNULOPLASTY $66,771.81 02781991 HB CARDIAC PLEDGET $720.33 02781992 HB STENT CLIP $6,471.90 02781993 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $32,024.54 02781994 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $7,563.15 02781995 HB COUPLER $10,750.48 02781996 HB OCCLUSION CLIP $19,988.33 02781997 HB KIT, XLIF LEVEL 4 $104,533.54 02781998 HB GRAFT VASCULAR C1768 $19,091.55 02781999 HB STENT, GRAFT BIFURCATED $47,728.88 02782004 HB PACEMAKER, SINGLE CHAMBER C1786 $141,487.50 02782005 HB LEAD, AICD ENDO SINGLECOIL C1777 $37,977.82 02782006 HB ANCHOR/SCREW C1713 $32,992.62 02782007 HB GENERATOR, NEUROSTIMULATOR C1767 $97,755.00 02782008 HB BONE FILLER $25,725.00 02782009 HB MESH C1781 $56,306.88 02782010 HB JOINT DEVICE C1776 $121,324.00 02782011 HB ALLOGRAFT FLEXHD 11X20 Q4128 $357.17 02782012 HB NEUROSTIMULATOR, RECHARGEABLE C1820 $102,334.05 02782013 HB LEAD, NEUROSTIMULATOR C1778 $34,728.75 02782014 HB MESH C1781 $7,350.66 02782015 HB HARMONY TPV 25 PULMONARY VALVE $120,799.00 02782016 OPTIMIZER SMART IPG C1824 $220,460.00 02782017 HB STENT, COATED/COV W/DELIVERY SYSTEM C1874 $32,011.20 02782018 HB ALLOGRAFT FLEXHD 16X20 Q4128 $277.62 03000002 HB NEONATE HEEL STICK 36416 $101.89 03000007 HB BM/PB CRYOPRESVE STEM CELLS 38207 $5,802.20 03000027 HB LYMPHOCYTE BLASTOGENESIS 86353 $2,951.47

Ancillary FY22 68 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03000029 HB PROCESS AUTOLOGUS UNIT 86890 $771.33 03000030 HB AG TYPE /UNIT/AG 86902 $1,034.05 03000031 HB IRRADIATION OF BLOOD PRODUCT 86945 $275.60 03000033 HB PROCESS OUTSIDE POOL CRYO 86965 $771.33 03000036 HB CRYSTAL ID BY LIGHT MICROSCOPY 89060 $635.92 03000038 HB LAB SWEAT COL, IONTOPHERESIS 89230 $701.09 03000040 HB SEMEN PREP FOR IUI - FRESH SAMPLE 89261 $701.09 03000050 HB LAB POC - FERN TEST Q0114 $230.49 03000051 HB RSH LAB DRAW (PIC/HEMA/CHEMO) $80.11 03000084 HB LAB LIPID PANEL 80061 $845.37 03000087 HB LAB RENAL FUNCTION PANEL 80069 $1,137.40 03000107 HB LAB OPIATES UR G0480 $1,098.44 03000109 HB LAB COCAINE UR G0480 $1,098.44 03000136 HB DIGOXIN 80162 $970.94 03000160 HB LAB DILANTN QN SE SC 80185 $1,131.02 03000168 HB LAB SIROLIMUS 80195 $237.84 03000169 HB LAB SALICYL QN SE SC 80329 $420.39 03000250 HB SEMEN ANALYSIS 89320 $367.04 03000264 HB LAB COLLECTION CAPILLARY 36416 $101.89 03000265 HB LAB BLOOD COLLECTION FEE 36416 $101.89 03000266 HB LAB MICRO EOSINOPHILS URN 89050 $241.05 03000267 HB LAB CELL CT TOTAL & DIFF 89051 $465.83 03000268 HB LAB CELL CT TOTAL & DIFF CSF 89051 $465.83 03000269 HB LAB MICRO CRYSTL UNS 89060 $241.05 03000271 HB LAB MICRO EOSINO 89190 $241.05 03000273 HB LAB CELL CT TOT & DF 89051 $465.83 03000274 HB LAB COLLECTION CAPILLARY* 36416 $101.89 03000276 HB T-CELL FLOW CROSSMATCH-ADDLSERA/DIL 86826 $2,266.28 03000277 HB B CELL FLOW CROSSMATCH-ADDL-SERA/DIL 86826 $2,266.28 03000278 HB FACS AUTO B-CELL ADDLSERA/D 86826 $2,266.28 03000279 HB FACS AUTO T-CELL ADDLSERA/D 86826 $2,266.28 03000280 HB T-CELL FLOW CROSSMATCH 1ST SERUM 86825 $2,266.28 03000281 HB B-CELL FLOW CROSSMATCH 1ST SERUM 86825 $2,266.28 03000282 HB FACS AUTO B-CELL-1ST SERUM 86825 $2,266.28 03000283 HB FACS AUTO T-CELL-1ST SERUM 86825 $2,266.28 03000285 HB SEMEN ANAL POST VASECTOMY 89321 $265.42 03000286 HB SERUM PRE TREATMENT 86975 $597.13 03000287 HB CELLS PRE TREATMENT W/PRON 86970 $220.54 03000288 HB CELLS PRE TREAT WITH CD20 86977 $771.33 03000289 HB LAB SPLIT BLD PRODUCT EA UN 86985 $771.33 03000290 HB LAB MRSA+MSSA SCREEN 87081 $125.01 03000291 HB SEMEN PREP FOR IUI - CRYO SAMPLE UNWASHED 89261 $701.09

Ancillary FY22 69 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03000292 HB RETROGRADE EJACULATION URINANALYSIS 89331 $406.54 03000293 HB SEMEN PREP FOR IUI - CRYO SAMPLE WASHED 89260 $701.09 03000298 HB WASHING BLOOD PRODUCTS 86999 $392.90 03000299 HB COVID-19 IGG/IGM RAPID TEST 86328 $178.16 03000300 HB RAPID COVID-19 PCR ASSAY 87635 $480.00 03000301 HB COVID-19 SARS-COV-2 IGG 86769 $400.00 03000302 HB COVID-19 SWABBING C9803 $261.83 03000303 HB SEMEN CRYO WASHED (IUI) - SPERM COUNT AND MOTILITY 89310 $367.04 03000304 HB COVID SEASONAL INFLUENZA PCR PANEL RESP (COVID-19) 0241U $830.00 03000305 HB COVID-19 SARS-COV-2 IGM 86769 $300.00 03000307 HB VAGINAL PANEL, PCR, VAGINOSIS 81514 $1,044.09 03010001 HB LAB BASIC METABOLIC PANEL POC 80047 $911.22 03010002 HB LAB ELECTROLYTES 80051 $430.88 03010004 HB LAB BASIC METABOLIC PANEL 80048 $876.14 03010005 HB LAB ACUTE HEPATITIS PANEL 80074 $1,649.56 03010006 HB LAB COMP METABOLIC PANEL 80053 $1,508.15 03010008 HB LAB CANNABINOIDS G0480 $1,098.44 03010013 HB LAB BARBITURATES URN G0480 $1,098.44 03010014 HB LAB BENODIAZEPINES URN G0480 $1,098.44 03010018 HB LAB AMPHETAMIN UR SC G0480 $1,098.44 03010021 HB LAB AMIKACIN 80150 $571.90 03010022 HB LAB CARBAMAZEPINE 80161 $855.72 03010023 HB LAB CYCLOSPORINE, MONOCLONAL 80158 $802.37 03010025 HB LAB VALPROIC ACID 80164 $571.90 03010026 HB LAB GENTAMICIN 80170 $817.30 03010027 HB LAB LITHIUM 80178 $285.96 03010028 HB LAB PHENOB QN SE SC 80184 $1,222.75 03010034 HB LAB FK506 80197 $262.89 03010036 HB LAB TOBRAMYCIN 80200 $817.30 03010037 HB LAB VANCOMYCIN 80202 $864.24 03010038 HB LAB METHOTREXATE 80204 $558.11 03010041 HB LAB ALBUMIN, SERUM - ER 82040 $543.77 03010044 HB LAB URN MICROALBUMIN, TIMED 82043 $192.05 03010045 HB LAB URN MICROALBUMIN, RANDOM 82043 $192.05 03010048 HB LAB ETHANOL QUAN ER 80320 $802.37 03010050 HB LAB ALPHA FETOPROT 82105 $475.87 03010052 HB LAB AMMONIA BL ER 82140 $475.87 03010054 HB LAB AMYLASE SE 82150 $558.11 03010057 HB LAB AMYLASE UR SC 82150 $558.11 03010060 HB LAB BETA-2 MICROGLOBULIN 82232 $642.33 03010061 HB LAB BILIRU TOTAL ER 82247 $457.56 03010063 HB LAB BILIRU TOTAL SC 82247 $457.56

Ancillary FY22 70 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03010067 HB LAB POC OCCULT BLOOD 82272 $185.64 03010069 HB LAB OCCULT BLOOD, GASTRIC 82271 $172.85 03010071 HB LAB OCCULT BLOOD (AB) 82274 $307.29 03010073 HB LAB CALCIUM, FREE 82310 $475.87 03010076 HB LAB CALCIUM SE AU 82310 $457.56 03010081 HB LAB CARBON DIOXIDE BICARBONATE 82374 $457.56 03010082 HB LAB BICARB-CO2 SE AU 82374 $457.56 03010085 HB CARBON DIOXIDE (BICARBONATE) 82374 $457.56 03010086 HB PF CO OXIMETRY 82375 $1,022.16 03010087 HB LAB CARCINOEMB AN SE 82378 $970.94 03010089 HB LAB CERULOPLASMIN 82390 $834.37 03010093 HB CHLORIDE 82435 $457.56 03010094 HB LAB CHLORIDE UR AU 82436 $475.87 03010098 HB LAB CHOLESTROL SE AU 82465 $475.87 03010103 HB LAB CPK TOTAL SE AU 82550 $612.44 03010106 HB CREATININE 82565 $457.56 03010107 HB LAB CREATININE 82565 $457.56 03010111 HB LAB CREATININ-CLR AU 82575 $475.87 03010113 HB LAB CRYOGLOBULIN SE 82595 $405.46 03010115 HB LAB ERYTHROPOIETIN LEVEL 82668 $802.37 03010116 HB LAB ESTRADIOL 82670 $495.13 03010120 HB LAB FOLATE SE RI 82746 $909.07 03010122 HB LAB IG M, CORD BL 82784 $571.90 03010124 HB LAB IG M SE 82784 $571.90 03010129 HB LAB BLOOD GASES, ART POC 82803 $1,871.49 03010130 HB PF BLD GAS RESTING 82803 $1,466.02 03010133 HB LAB GLUCOSE SF AU 82945 $475.87 03010135 HB LAB GLUCOSE, PRENATAL SCREEN 82947 $457.56 03010137 HB LAB GLUCOSE FAST AU 82947 $457.56 03010143 HB LAB GLUCOSE TOTAL 3H AU 82951 $1,510.85 03010147 HB LAB GLUCOS-G6PD SCRN 82960 $580.43 03010151 HB LAB FOLLICLE STIM HORMONE 83001 $329.20 03010152 HB LAB LUTENIZING HORMONE 83002 $328.14 03010153 HB LAB HAPTOGLOBIN 83010 $802.37 03010154 HB HELIOBACTER PYLORI 83013 $1,133.41 03010156 HB LAB HGB ELECTROPH ACID BL 83020 $970.94 03010158 HB LAB HGB EVAL W/ CONF - HPLC 83021 $318.59 03010159 HB LAB HGB FETAL APT 83033 $352.09 03010163 HB LAB MICRO HEMOSID UR 83070 $313.69 03010164 HB LAB HOMOCYSTEINE 83090 $298.68 03010177 HB LAB LACTIC AC BL SC 83605 $612.44 03010180 HB LAB LDH SE AU 83615 $361.51

Ancillary FY22 71 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03010188 HB LAB LDL CHOLESTEROL 83721 $167.12 03010189 HB LAB MAGNESIUM SE ER 83735 $486.29 03010193 HB LAB MUCIN CLOT 83872 $313.69 03010289 HB DRB1*04 OLIGO 81376 $1,697.31 03010306 HB HLA-DRB3,4,5 (SEROLOGICAL EQUIV LVL) 81376 $1,697.31 03010309 HB DPB OLIGO 81376 $2,586.38 03010312 HB DPA OLIGO 86817 $2,266.28 03010313 HB HLA-A (SEROLOGICAL EQUIVALENT LEVEL) 81373 $2,186.12 03010314 HB DRB4 OLIGO 81376 $1,697.31 03010318 HB HLA-B (SEROLOGICAL EQUIVALENT LEVEL) 81373 $2,186.12 03010319 HB DQA1 (LOW RESOLUTION) 81376 $2,991.86 03010321 HB HLA-DRB1 (SEROLOGICAL EQUIVALENT LEVEL) 81376 $2,573.58 03010322 HB DQA OLIGO 81376 $2,405.21 03010323 HB GENERIC DR OLIGO 81375 $4,532.62 03010325 HB DRB5 OLIGO 81376 $1,697.31 03010326 HB DQB OLIGO 81376 $2,142.54 03010329 HB GENERIC ABC OLIGO 81372 $6,458.59 03010342 HB HLA-A HIGH RESOLUTION 81380 $14,907.05 03010343 HB CHIMERISM TESTING FOLLOW UP 81267 $9,915.31 03010390 HB LAB PROTEIN ELECT SP 83916 $1,060.58 03010393 HB LAB PTH 83970 $731.32 03010398 HB LAB ALK PHOS SE AU 84075 $486.29 03010399 HB LAB ALK PHOS SE ER 84075 $454.48 03010401 HB LAB PHOSPHOR SE AU 84100 $457.56 03010405 HB LAB POTASSIUM * 84132 $457.56 03010407 HB LAB POTASSIUM SE AU 84132 $453.48 03010410 HB LAB POTASSIUM UR AU 84133 $475.87 03010411 HB LAB PREALBUMIN 84134 $537.77 03010413 HB LAB PROLACTIN 84146 $343.29 03010414 HB LAB PROSTATE SPECIFIC ANTGN 84153 $394.78 03010417 HB LAB PROTEN TOT SE AU 84155 $418.59 03010420 HB LAB PROTEN TOT FL SC 84157 $435.32 03010421 HB LAB PROTEN TOT SF SC 84157 $435.32 03010423 HB LAB PROTEIN ELECTROPHORESIS UR 84166 $1,060.58 03010427 HB LAB SODIUM SE AU 84295 $457.56 03010432 HB LAB THYROXINE 84436 $361.51 03010433 HB LAB THYRO TSH SE RI 84443 $361.51 03010434 HB LAB S G O T SE ER 84450 $457.56 03010436 HB LAB SGPT SE ER 84460 $457.56 03010438 HB LAB TRANSFERRIN SE 84466 $580.43 03010439 HB LAB TRIGLYCER SE SC 84478 $580.43 03010442 HB LAB T UPTAKE 84479 $361.51

Ancillary FY22 72 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03010443 HB LAB TROPONIN I 84484 $338.06 03010444 HB LAB UREA NITROGEN 84520 $457.56 03010445 HB UREA NITROGEN 84520 $457.56 03010447 HB LAB UREA NITRO SE AU 84520 $457.56 03010450 HB LAB URIC ACID SE AU 84550 $453.48 03010455 HB LAB BETA HCG, QUAL 84703 $571.90 03010456 HB LAB PSA, SCREEN G0103 $394.78 03010480 HB LAB PROTEIN ELECTROPHORESIS SE 84165 $970.94 03010489 HB LAB SODIUM 84295 $457.56 03010505 HB ACETAMINOPHEN 80143 $627.37 03010527 HB LAB ETHANOL QUAN SC 80320 $802.37 03010538 HB LAB ALPHA ANTI TRYPS 82103 $612.44 03010568 HB LAB AMMONIA BL 82140 $475.87 03010632 HB LAB BILIRUBIN, DIRECT 82248 $457.56 03010635 HB LAB OCCULT BLOOD FE 82272 $185.64 03010655 HB LAB CALCIUM UR AU 82340 $475.87 03010695 HB LAB CHLORIDE SE AU 82435 $457.56 03010700 HB LAB CHLORIDE, SWEAT 82438 $1,372.15 03010771 HB LAB CORTISOL SE RI 82533 $970.94 03010783 HB CKMB FRACTION 82553 $275.30 03010787 HB LAB CREATININE FLD 82570 $457.56 03010789 HB LAB CREATININE UR AU 82570 $457.56 03010798 HB LAB VITAMIN B-12 RI 82607 $1,282.49 03010843 HB LAB FERRITIN 82728 $749.01 03010844 HB FETAL FIBRONECTIN 82731 $2,385.61 03010852 HB LAB IG A, CORD BL 82784 $571.90 03010854 HB LAB IG A SE 82784 $571.90 03010858 HB LAB IG G, CORD BL 82784 $571.90 03010861 HB LAB IG G SE 82784 $571.90 03010877 HB LAB O2 SATURATION 82803 $342.83 03010881 HB LAB GLUCOSE URN 82945 $475.87 03010883 HB LAB GLUCOSE FL AU 82945 $475.87 03010886 HB LAB GLUCOSE 82947 $457.56 03010887 HB LAB GLUCOSE 2H PP 82950 $457.56 03010891 HB LAB GLUC TOL, EA ADNL SPEC 82952 $475.87 03010896 HB LAB GAM GLUT TRAN SC 82977 $389.87 03010911 HB LAB HGB ELECTROPH BL 83020 $970.94 03010925 HB LAB HEMOGLOBIN A1C 83036 $245.41 03010926 HB LAB GLYCATED HEMOGLOBIN 83036 $245.41 03011084 HB LAB PANEL IRON, TOTAL 83540 $351.22 03011085 HB LAB PANEL IRON BIND CAPACITY 83550 $351.22 03011095 HB LAB LDH FL SC 83615 $588.89

Ancillary FY22 73 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03011111 HB LAB LAMELLAR BODY DENSITY 83664 $181.37 03011114 HB LAB LIPASE SE ST 83690 $486.48 03011120 HB LAB HDL CHOLESTEROL 83718 $144.93 03011127 HB LAB MAGNESIUM UR SC 83735 $486.29 03011129 HB LAB MAGNESIUM SE SC 83735 $486.29 03011167 HB LAB NATRIURETIC PEPTIDE ASSY 83880 $601.56 03011168 HB LAB FREE KAPPA LIGHT CHAINS 83883 $241.18 03011169 HB LAB IGG SYNTHETIC RATE, CSF 83883 $324.37 03011171 HB LAB FREE LAMBDA LIGHT CHAINS 83883 $241.18 03011175 HB LAB ANTI-STREPTOLYSIN O ANTIBD 83883 $420.39 03011632 HB LAB OSMOLALITY SE AU 83930 $352.09 03011633 HB OSMOLALITY, URINE 83935 $352.09 03011646 HB LAB PH, URINE 83986 $130.18 03011647 HB LAB POC - PH, BODY FLUIDS 83986 $473.74 03011671 HB LAB PHOSPHOR UR AU 84105 $457.56 03011740 HB LAB SODIUM UR AU 84300 $457.56 03011792 HB ASPARTATE AMINOTRANSFERA 84450 $457.56 03011817 HB LAB UREA NITRO UR 84540 $475.87 03011821 HB LAB URIC ACID UR AU 84560 $475.87 03011860 HB DRB3 OLIGO 81376 $1,697.31 03011861 HB LAB BETA-HCG QUAL 84703 $571.90 03011865 HB MICA TYPING 81403 $2,496.77 03011866 HB HLA-C (SEROLOGICAL EQUIVALENT LEVEL) 81373 $2,186.12 03011867 HB HLA-A, B, C (SEROLOGICAL EQUIVALENT LEVEL) 81372 $6,458.59 03011872 HB LAB CREATININE SE AU 82565 $457.56 03011874 HB LAB PROTEIN TOTAL - ER 84155 $435.32 03011877 HB LAB ACETOACETI BL ER 82009 $313.69 03011881 HB LAB HEPATIC FUNCTION PANEL 80076 $754.05 03011883 HB PC BLOOD GAS NEONATE 82803 $1,466.02 03011884 HB PC BLDG GAS ANALYSIS 82803 $1,466.02 03011886 HB PF BLD GAS SHUNT 82803 $1,466.02 03011888 HB LAB AMYLASE FL SC 82150 $558.11 03011889 HB LAB CHLORIDE 82435 $457.56 03011890 HB LAB S G P T SE AU 84460 $457.56 03011891 HB LAB HCG B SUB RI * 84702 $870.65 03011899 HB LAB STOOL K 84999 $8.10 03011900 HB HEPATIC FUNCTION PANEL A 80076 $754.05 03011901 HB LAB CALCIUM, FREE** 82330 $457.56 03011902 HB LAB ALDOLASE 82085 $213.41 03011921 HB LAB URINE PREGNANCY TEST 81025 $571.90 03011961 HB HLA-B HIGH RESOLUTION 81380 $15,950.53 03011962 HB HLA-C HIGH RESOLUTION 81380 $15,950.53

Ancillary FY22 74 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03011963 HB HLA CLASS II DNA HI RES, 1 LOCUS 81382 $11,920.54 03011967 HB LAB TROPONIN I 84484 $338.06 03011970 HB LAB SODIUM* 84295 $457.56 03011974 HB LAB CALCIUM, FREE* 82330 $475.87 03011975 HB LAB CPK TOTAL SE AU* 82550 $612.44 03011977 HB LAB GLUCOSE** 82947 $457.56 03011978 HB LAB NATRIURETIC PEPTIDE ASSY* 83880 $601.56 03011979 HB LAB ALBUMIN, SERUM - ER* 82040 $543.77 03011980 HB LAB ACETOACETI BL ER* 82009 $313.69 03011981 HB LAB ELECTROLYTES* 80051 $391.72 03011982 HB LAB BASIC METABOLIC PANEL* 80048 $754.05 03011985 HB LAB AMYLASE SERUM 82150 $558.11 03012046 HB VIT D:25-HYDROXY 82306 $524.48 03012051 HB CHIMERISM TESTING SORTED CELLS 81268 $3,432.44 03012052 HB HLA-A, B, C, DR, DQB1 TYPING 81370 $9,966.51 03012053 HB HLA-A, B, DR TYPING 81371 $6,530.56 03012063 HB ENGRAFTMENT PRE TRANSPLANT 81265 $8,344.01 03012064 HB ENGRAFTMENT 1ST DONOR 81265 $8,344.01 03012065 HB ENGRAFTMENT 2ND DONOR-CORD 81266 $8,344.01 03012068 HB LAB MP BCR/ABL1 T922 MAJOR 81206 $2,159.08 03012069 HB LAB MP BCR/ABL1 T922 MINOR 81207 $2,159.10 03012072 HB LAB MP BRAF GEN ANALY V600E 81210 $1,456.66 03012080 HB LAB MP CTFR GEN ANAL COMMON 81220 $7,670.71 03012088 HB LAB MP CYTOGEN CONST MICANL 81228 $6,356.37 03012090 HB LAB MP F2 GENE ANALYSIS 81240 $958.89 03012091 HB LAB MP F5 GENE ANALYSIS 81241 $1,214.97 03012102 HB LAB MP IGH@ GEN REARR ANAL 81261 $4,922.25 03012105 HB LAB MP IGK@ GEN REARR ANAL 81264 $4,586.48 03012110 HB LAB MP JAK2 GENE ANALYSIS 81270 $1,365.57 03012111 HB LAB MP KRAS GENE ANALYSIS 81275 $4,199.35 03012116 HB LAB MP MTHFR GENE ANALYSIS 81291 $993.06 03012131 HB LAB MP PML/RARALP TRNSL ANL 81315 $5,754.00 03012139 HB LAB MP TRB@ GEN REARR ANAL 81340 $2,008.18 03012141 HB LAB MP TRG@ GENE REARR ANAL 81342 $2,138.77 03012155 HB LAB MP PROC LEVL 1 81400 $1,126.79 03012167 HB LAB TESTOSTERONE, TOTAL 84403 $457.34 03012168 HB IMMUNOASSAY,NOT SPEC QUANTI 83520 $403.68 03012176 HB LAB FREE T4 84439 $159.70 03012182 HB LAB MP F2 GENE ANALY TOMB 81240 $1,086.93 03012185 HB LAB MP F5 GENE ANALY TOMB 81241 $1,086.93 03012186 HB LAB MP PROC LEVL 3 81402 $2,237.67 03012187 HB HUM ERYTHR AG GEN ANLYS 81403 $18,501.57

Ancillary FY22 75 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03012189 HB LAB MP PROC LEVL 4 81403 $2,707.95 03012191 HB LAB LACTATE - VENOUS POCT 83605 $932.77 03012192 HB LAB LACTATE - ARTERIAL POCT 83605 $932.77 03012196 HB HLA-A,B,C,DRB1 HIGH RESOLUTION 81378 $63,985.16 03012205 HB CHROM MA CONSTITUTIONAL 81229 $6,992.01 03012206 HB ANGTNSN II TYPE I REC ANTI AT1R 86316 $1,319.48 03012209 HB BRAF V600E MUT DT NETGEN SQ 81210 $1,423.46 03012212 HB EGFR COM VAR NET-GEN SEQ 81235 $2,047.41 03012222 HB KIT NET-GEN SEQ 81402 $3,205.05 03012223 HB KRAS COD 12/13 NETGEN SEQ 81275 $2,040.68 03012228 HB LAB NRAS NET-GEN SEQ 81404 $3,253.00 03012234 HB UNLISTED MOLECULAR CODE 81479 $20.77 03012235 HB EVEROLIMUS 80169 $234.69 03012236 HB SUPAR 83520 $1,759.30 03012237 HB LAB MP EGFR GENE ANALYSIS 81235 $2,047.41 03012238 HB INSULIN 83525 $196.91 03012239 HB KIR GENOTYPING 81403 $2,530.79 03012276 HB PCA3/KLK3 ANTIGEN 81313 $3,299.61 03012277 HB TARGETED GENOMIC SEQ ANALYS 81445 $38,961.97 03012278 HB DRUG SCREEN CLASS LIST A 80307 $3,134.79 03012286 HB ANTI-PHOS A2 RECEP(APLA2R-ELISA) 83520 $1,759.30 03012287 HB LAB PLASMA FREE HEMOGLOBIN 83051 $243.94 03012288 HB LAB T3;FREE 84481 $322.06 03012290 HB KRAS GENE ADDL VARIANTS 81276 $2,604.03 03012292 HB AMNISURE 84112 $1,074.13 03012293 HB INTERLEUKIN - 1BETA - LUMINEX 83520 $1,759.30 03012294 HB INTERLEUKIN - 2 - LUMINEX 83520 $1,759.30 03012295 HB INTERLEUKIN - 6 - LUMINEX 83520 $1,759.30 03012296 HB INTERLEUKIN - 17A - LUMINEX 83520 $1,759.30 03012297 HB INTERLEUKIN - 10 - LUMINEX 83520 $1,759.30 03012298 HB TUMOR NECROSIS FACT ALPH - LUMINEX 83520 $1,759.30 03012299 HB INTERFERON GAMMA - LUMINEX 83520 $1,759.30 03012300 HB RHD GENE ANALYSIS 81403 $2,766.40 03012301 HB RHCE GENE ANALYSIS 81403 $2,766.40 03012302 HB TARGETED GENOMIC SEQ ANALYS LTD 81445 $35,773.24 03012303 HB TARGETED GENOMIC SEQ ANALYS MOD 81445 $35,773.24 03012304 HB TARGETED GENOMIC SEQ ANALYS HEMATO LTD 81450 $35,773.24 03012305 HB TARGETED GENOMIC SEQ ANALYS HEMATO MOD 81450 $35,773.24 03012306 HB TARGETED GENOMIC SEQ ANALYS EXTENDED 81455 $35,773.24 03012307 HB PROCALCITONIN 84145 $316.46 03012308 HB PH, PLEURAL FLUID 83986 $64.70 03012327 HB B-HYDROXYBUTYRATE:QUANT 82010 $140.37

Ancillary FY22 76 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03012328 HB IL-21-LUMINEX 83520 $1,759.30 03012329 HB SIL-6R-LUMINEX 83520 $1,759.30 03012330 HB VEGF-A-LUMINEX 83520 $1,759.30 03012331 HB TGFB1-LUMINEX 83520 $1,759.30 03012334 HB INTERLEUKIN - 8 - LUMINEX 83520 $1,759.30 03012335 HB IHC MULTIPLEX STAIN ONLY 2 AB 88344 $1,034.05 03012336 HB MTHFR 1298C GENE ANALYSIS 81291 $753.69 03012337 HB CALRETICULIN 81219 $2,130.02 03012338 HB RED BLOOD CELL GENOTYPING 81403 $2,467.25 03012339 HB PROTEASE 3 (PR3) IGG ABS 83516 $377.66 03012340 HB MYELOPEROXIDASE (MPO) IGG ABS 83516 $377.66 03012341 HB APIXABAN 80299 $199.22 03012342 HB RIVAROXABAN 80299 $199.22 03012343 HB LUMINEX VIMENTIN ANTIBODY 86832 $1,975.43 03012345 HB TUMOR HCG 84702 $197.10 03012346 HB B-TYPE NATRIURETIC PEP 83880 $443.21 03012347 HB FENTANYL, QUALITATIVE 80354 $248.80 03012348 HB LACTATE, WHOLE BLOOD 83605 $612.44 03012349 HB STOOL CALPROTECTIN 83993 $299.69 03020001 HB LAB ANCA 86021 $431.08 03020008 HB LAB C-REACT PROT CORD BL 86140 $642.33 03020009 HB LAB C-REACT PROT QT 86141 $642.33 03020011 HB LAB BETA 2 GLYCOPROTEIN1-IGM 86146 $450.53 03020017 HB LAB ANTIBD DNA 1F 86225 $785.31 03020019 HB LAB SS-A ANTIBODIES 86235 $269.82 03020020 HB LAB SCL 70 ANTIBODIES 86235 $269.82 03020028 HB LAB SM ANTIBODIES * 86235 $269.82 03020037 HB LAB CA 19-9 86301 $368.46 03020041 HB LAB PROTEIN IFE, SERUM 86334 $1,510.85 03020042 HB LAB PROTEIN IFE, URINE 86335 $1,587.66 03020050 HB LAB ANTIB RA QUANT 86431 $352.09 03020053 HB LAB ANTIBD SY RPR QL 86592 $337.14 03020057 HB LAB COCCI IGG 86635 $206.13 03020058 HB LAB CSF COCCI IGG 86635 $206.13 03020060 HB LAB CSF COCCI IGM 86635 $206.13 03020067 HB LAB ANTIBODY EBV IGG 86665 $661.52 03020068 HB LAB ANTIBD EBV IGM 86665 $661.52 03020081 HB LAB HERPES SIMPLEX TYP 2 IGG 86696 $915.49 03020091 HB LAB ANTI-HEP B SURF ANTIBD 86706 $360.63 03020092 HB LAB ANTI-HAV TOTAL 86708 $212.32 03020093 HB LAB ANTI-HAV IGM 86709 $192.89 03020096 HB LAB ANTIBD MEASLES IGG 86765 $345.69

Ancillary FY22 77 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03020114 HB T-CELL CYTOTOXIC CROSSMATCH 86805 $2,285.47 03020123 HB T-CELL CYTOTOXIC CROSSMATCH WITH DTT 86805 $1,700.75 03020132 HB IVIG B-CELL XM NO DTT 86805 $1,700.75 03020135 HB GLYCINE T-CELL XM NO DTT 86805 $1,700.75 03020140 HB B-CELL CYTOTOXIC CROSSMATCH 86805 $2,285.47 03020144 HB GLYCINE B-CELL XM W/DTT 86805 $1,700.75 03020146 HB B-CELL CYTOTOXIC CROSSMATCH WITH DTT 86805 $1,700.75 03020150 HB CLASS II QUICK SCREEN W/DTT 86806 $744.75 03020152 HB CLASS II IVIG QS NO DTT 86806 $744.75 03020153 HB CLASS II QUICK SCREEN NO DTT 86806 $744.75 03020155 HB AS & ID W/DTT 86807 $951.75 03020158 HB HLA ANTIBODY SRN & ID/SERUM 86807 $1,278.26 03020186 HB LAB CA125 IA 86304 $368.46 03020251 HB CYTOMEGALOVIRUS (CMV)-PCR, QUAL 87496 $2,466.89 03020252 HB HERPES SIMPLEX VIRUS (HSV)-PCR, QUAL 87529 $2,466.89 03020349 HB LAB POTASSIUM 84132 $457.56 03020350 HB LAB PROGESTERONE 84144 $369.64 03020352 HB LAB PSA, FREE 84154 $394.78 03020353 HB LAB PROTEN TOT UR SC 84156 $435.32 03020356 HB STOOL REDUCING SUBSTANCE 84376 $230.49 03020433 HB LAB CENTROMERE ANTIBODY 86039 $802.37 03020434 HB LAB ANTIBODY ANA, TITER 86039 $802.37 03020445 HB LAB BETA 2 GLYCOPROTEIN1-IGG 86146 $450.53 03020447 HB LAB ANTIBD ANTICARDIOLIPIN 86147 $352.09 03020449 HB LAB COMPLMNT C4 ASSY 86160 $817.30 03020454 HB LAB COMPLMNT C3 ASSY 86160 $612.44 03020462 HB LAB CYCLIC CITRULINATD PEP IGG 86200 $224.36 03020480 HB LAB RNP ANTIBODIES * 86235 $269.82 03020482 HB LAB SS-B ANTIBODIES 86235 $269.82 03020509 HB LAB ANTIBD SM MS TITER 86256 $802.37 03020524 HB LAB ANTIBD ANTIPARIETAL 86256 $802.37 03020526 HB LAB CA 27.29 86300 $535.63 03020527 HB LAB CA 15-3 86300 $368.46 03020545 HB LAB ANTIBD MONO S ER 86308 $435.32 03020591 HB LAB B LYMPH QUANTITATION 86355 $653.78 03020592 HB LAB NK LYMPH QUANTITATION 86357 $653.78 03020593 HB LAB CD34 STEM CELL QUANT 86367 $889.86 03020607 HB LAB TB TEST CELL IMMUN, MEASUR 86480 $1,074.13 03020662 HB LAB COCCI IGM 86635 $206.13 03020668 HB LAB CMV AB, IGG 86644 $661.52 03020672 HB CMV SCREEN 86644 $399.06 03020675 HB LAB CMV AB, IGM 86645 $661.52

Ancillary FY22 78 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03020720 HB LAB H. PYLORI ANTIBODY 86677 $263.86 03020741 HB LAB HERPES SIMPLEX TYP 1 IGG 86695 $902.66 03020742 HB LAB HERPES SIMPLEX TYP 1 IGM 86695 $902.66 03020754 HB AB; HIV-1 & HIV-2 SGL ASSAY 86703 $535.63 03020757 HB LAB HEP ANTI-HBC 86704 $313.69 03020803 HB LAB ANTIBD RUBELLA 86762 $435.32 03020805 HB LAB ANTIBD RUBELLA CORD BL 86762 $435.32 03020818 HB LAB ANTIBD TOX IGG 86777 $661.52 03020819 HB LAB ANTIBD TOXO IGM 86778 $661.52 03020825 HB LAB ANTIBD SY FTA 86780 $1,060.58 03020860 HB LAB HEP C ANTIBD 86803 $313.69 03020866 HB PROCESS PLT HLA MATCHING 86813 $1,135.26 03020868 HB AB SCREEN FICIN (EZ) 86850 $701.09 03020875 HB DAT, POLYSPECIFIC 86880 $462.99 03020880 HB TITRATION EACH 86886 $771.33 03020892 HB LAB HEP B S ANTIG 87340 $275.30 03020893 HB LAB TOXO IGM - EIA 86778 $661.52 03020923 HB LAB HEPATITIS B CORE AB, IGM 86705 $201.82 03020924 HB LAB ANTIBD MITO TITER 86256 $787.26 03020925 HB LAB HERPES SIMPLEX TYP 2 IGM 86696 $897.96 03020926 HB LAB PLT AB - HIT PF4-HEP EIA 86022 $559.09 03020927 HB LAB VARICELLA ZOSTER IGG 86787 $418.03 03020931 HB EPSTEIN-BARR VIRUS (EBV)-PCR, QUAL 87798 $2,466.89 03020932 HB PARVOVIRUS B19 (PARVO B19)-PCR, QUAL 87798 $2,466.89 03020933 HB POLYOMAVIRUS BK (BKV)-PCR, QUAL 87798 $2,466.89 03020934 HB POLYOMAVIRUS JC (JCV)-PCR, QUAL 87798 $2,466.89 03020936 HB THYROGLOBULIN ANTIBODY IGG 86800 $281.74 03020937 HB THYROID PEROXIDASE ANTIBODY 86376 $259.45 03020938 HB LAB BETA 2 GLYCOPROTEIN1-IGA 86146 $450.53 03020939 HB MUMPS IGG EIA 86735 $233.68 03020941 HB HLA-DRB1,3,4,5,DQB1 (SEROLOGICAL EQUIV LVL) 81375 $6,269.69 03020942 HB DPA1 (LOW RESOLUTION) 81376 $2,496.77 03020943 HB GENERIC A LOCUS OLIGO 81373 $2,186.12 03020947 HB HLA-DQB1 HIGH RESOLUTION 81382 $11,920.54 03020950 HB LAB C-REACTIVE PROTEIN 86140 $160.55 03020951 HB ANTBDY SCRN BY FLOW CL I&II 86828 $2,635.34 03020952 HB ANTIBODY SCRN FLOW CL IORII 86829 $1,317.58 03020953 HB PRA SCREENING HLA ANTIBODY CLASS I 86830 $1,741.73 03020954 HB PRA SCREENING HLA ANTIBODY CLASS II 86831 $1,741.73 03020955 HB SINGLE ANTIGEN HLA ANTIBODY CLASS I 86832 $1,977.46 03020956 HB SINGLE ANTIGEN HLA ANTIBODY CLASS II 86833 $1,977.46 03020957 HB C1Q HLA ANTIBODY CLASS I 86832 $3,054.17

Ancillary FY22 79 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03020958 HB C1Q HLA ANTIBODY CLASS II 86833 $3,054.17 03020959 HB SNGL ANTGN HLA ANTIBODY TITRATION CLASS I 86834 $4,121.91 03020960 HB SNGL ANTGN HLA ANTIBODY TITRATION CLASS II 86835 $3,723.02 03020962 HB MULTISPOT HIV1 86701 $189.46 03020963 HB MULTISPOT HIV2 86702 $243.33 03020970 HB DONOR SPEC ENDOTHELIA PRE-CROSSMATCH XM-ONE 86849 $3,998.45 03020971 HB LUMINEX MICA SINGLE ANTIGEN 86832 $1,976.83 03020972 HB ANTI-HAV IGG 86790 $418.03 03020977 HB AB;HIV1 86701 $153.38 03020978 HB AB;HIV2 86702 $237.22 03020979 HB NON-HLA SOLID PHASE 86808 $1,090.19 03020980 HB CYTOMEGALOVIRUS (CMV)-PCR, QUANT 87497 $3,206.96 03020981 HB EPSTEIN-BARR VIRUS (EBV)-PCR, QUANT 87799 $3,206.96 03020982 HB HERPES SIMPLEX VIRUS (HSV)-PCR, QUANT 87530 $3,206.96 03020983 HB PARVOVIRUS B19 (PARVO B19)-PCR, QUANT 87799 $3,206.96 03020984 HB POLYOMAVIRUS BK (BKV)-PCR, QUANT 87799 $3,206.96 03020985 HB POLYOMAVIRUS JC (JCV)-PCR, QUANT 87799 $3,206.96 03020986 HB VARICELLA-ZOSTER (VZV)-PCR, QUANT 87799 $3,206.96 03020987 HB COVID-19 IGG ELISA 86769 $153.84 03020988 HB COVID-19 IGM ELISA 86769 $153.84 03020989 HB DPB1 (LOW RESOLUTION) 81376 $2,142.54 03020990 HB DQB1 (SEROLOGICAL EQUIVALENT LEVEL) 81376 $2,142.54 03020991 HB CHIMERISM TESTING SORTED CD3 CELLS 81268 $3,432.44 03020992 HB CHIMERISM TESTING SORTED CD14 CELLS 81268 $3,432.44 03020993 HB CHIMERISM TESTING SORTED CD15 CELLS 81268 $3,432.44 03020994 HB CHIMERISM TESTING SORTED CD19 CELLS 81268 $3,432.44 03020995 HB CHIMERISM TESTING SORTED CD34 CELLS 81268 $3,432.44 03020996 HB CHIMERISM TESTING SORTED CD56 CELLS 81268 $3,432.44 03020997 HB CHIMERISM TESTING FOR GVH CD3 SORTED 81268 $3,432.44 03020998 HB DPA1 HIGH RESOLUTION 81382 $11,920.54 03020999 HB DPB1 HIGH RESOLUTION 81382 $11,920.54 03021000 HB DQA1 HIGH RESOLUTION 81382 $11,920.54 03021001 HB DRB1 HIGH RESOLUTION 81382 $11,920.54 03021002 HB DRB3 HIGH RESOLUTION 81382 $11,920.54 03021003 HB DRB4 HIGH RESOLUTION 81382 $11,920.54 03021004 HB DRB5 HIGH RESOLUTION 81382 $11,920.54 03021005 HB TYPING FOR NARCOLEPSY (DQB1*06:02) 81383 $11,920.54 03021006 HB B*1502 TYPING 81381 $15,950.53 03021007 HB B*5701 TYPING 81381 $15,950.53 03021008 HB B*5801 81381 $15,950.53 03021009 HB A0201 HIGH RESOLUTION 81381 $15,950.53 03021010 HB B51 TYPING 81373 $2,186.12

Ancillary FY22 80 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03021011 HB BRAIN TUMOR VACCINE PANEL 81373 $2,186.12 03021012 HB A2 TYPING BY DNA 81373 $2,186.12 03021013 HB B27 TYPING BY DNA 81374 $2,186.12 03021014 HB SARS-COV-2-IGG QUANT II 86769 $438.00 03050002 HB AUTOMATED DIFFERENTIAL* 85004 $458.79 03050003 HB MANUAL DIFFERENTIAL 85007 $588.97 03050012 HB LAB CELL C EOSINO BL 85032 $352.09 03050014 HB RETICULOCYTE; AUTOMATED 85045 $435.32 03050018 HB LAB FACTOR 5 ASSAY 85220 $749.01 03050019 HB LAB FACTOR 7 ASSAY 85230 $749.01 03050020 HB LAB FACTOR 8 ASSAY 85240 $706.35 03050021 HB LAB RISTOCETIN CO-FACTOR 85245 $749.01 03050025 HB LAB FACTOR 11 ASSAY 85270 $749.01 03050030 HB LAB PROTEIN S ASSAY 85306 $1,058.44 03050034 HB LAB ACTIVATED CLOTTING TIME 85347 $418.25 03050035 HB LAB WHOLE BLOOD ACT 85347 $418.25 03050036 HB LAB HEPARIN DOSE RESPONSE 85348 $687.15 03050038 HB LAB FIBRIN MONOMER 85362 $420.39 03050040 HB LAB D-DIMER QUANT 85379 $757.53 03050046 HB LAB UNFRACTIONATED HEPARIN 85520 $197.06 03050047 HB LAB HEPARIN ASSAY 85520 $687.15 03050048 HB LAB LOW MOL WT HEPARIN 85520 $197.06 03050054 HB LAB ASPIRIN ASSAY 85576 $399.06 03050058 HB LAB PFA - ADP 85576 $323.37 03050059 HB LAB PLAVIX RESISTANCE ASSAY 85576 $593.26 03050062 HB LAB PFA - EPINEPHRINE 85576 $323.37 03050065 HB LAB LUPUS ANTICOAG/ HEXA PL 85598 $603.90 03050066 HB LAB WHOLE BLOOD PROTIME 85610 $452.39 03050067 HB LAB PRO TIME ER 85610 $452.39 03050069 HB LAB PRO TIME ROU PL 85610 $340.22 03050076 HB LAB SICKLE CELL SCRN 85660 $313.69 03050077 HB LAB THROMBIN TIME PL 85670 $435.32 03050079 HB LAB PTT ER 85730 $340.22 03050080 HB LAB PTT DIFF PL 85732 $435.32 03050093 HB LAB HEMATOCRIT* 85014 $298.74 03050094 HB HEMOGLOBIN BY HEMOCUE* 85018 $202.73 03050096 HB CBC WITH AUTO DIFF 85025 $713.84 03050102 HB PLATELET CT AUTOMATED 85049 $185.64 03050108 HB FACTOR II ASSAY 85210 $749.01 03050113 HB LAB CBC WITH AUTO DIFF 85025 $713.87 03050115 HB VON WILLEBRAND FACTOR AG 85246 $717.03 03050116 HB LAB CBC HEMOGRAM W/PLT* 85027 $389.87

Ancillary FY22 81 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03050117 HB PLATELET COUNT, AUTOMATED 85049 $185.64 03050118 HB LAB PROTEIN S TOTAL AG 85305 $845.04 03050119 HB LAB PROTEIN S FREE AG 85306 $802.37 03050120 HB LAB PTT LA 85730 $340.22 03050121 HB FACTOR IX ASSAY 85250 $749.01 03050122 HB FACTOR X ASSAY 85260 $749.01 03050124 HB FACTOR XII ASSAY 85280 $749.01 03050125 HB FACTOR XIII SCREEN 85291 $475.87 03050129 HB ANTI-THROMBIN 3 85301 $687.15 03050132 HB PROTEIN C FUNCTIONAL 85303 $1,122.47 03050138 HB FACTOR INHIBITOR TEST 85335 $714.87 03050142 HB PLASMA D-DIMER 85379 $757.53 03050144 HB D-DIMER ULTRASENS 85379 $757.53 03050146 HB FIBRINOGEN 85384 $475.87 03050157 HB FETAL KLEIHAUER BETKE 85460 $802.37 03050158 HB SCRN FETAL-MATERNAL 85461 $305.17 03050168 HB LEUKOCYTE ALKALINE PHOSP 85540 $665.79 03050192 HB LAB PRO TIME DIFF PL 85611 $435.32 03050196 HB LAB SED RATE WESTEGN 85651 $399.06 03050208 HB LAB VISCOSITY SE SC 85810 $352.09 03050245 HB LAB T CELLS, TOTAL COUNT 86359 $669.52 03050246 HB LAB CD4 AND CD8 T CELL COUNT 86360 $889.86 03050336 HB LAB PTT PL 85730 $441.14 03050338 HB HGBS PER UNIT 85660 $163.35 03050341 HB MANUAL DIFFERENTIAL* 85007 $588.97 03050344 HB LAB CBC HEMOGRAM W/PLT 85027 $389.87 03050345 HB LAB SED RATE WESTEGN* 85651 $399.06 03050346 HB LAB HEMATOCRIT 85014 $298.74 03050348 HB LAB ACTIVATED CLOTTING TIME* 85347 $418.25 03050350 HB LAB HP TEG PLATELET MAPPING 85390 $357.54 03050351 HB LAB HP TEG MA-ACTIVATOR-A 85576 $323.37 03050352 HB LAB HP TEG MA-ADP 85576 $323.37 03050353 HB LAB HP TEG MA-ARACHIDONIC ACID 85576 $323.37 03050354 HB LAB HP TEG BASIC 85390 $357.54 03050355 HB LAB HP TEG HEPARINASE 85390 $491.41 03050356 HB LAB P2Y12 ASSAY 85576 $335.78 03050357 HB LAB ASPIRIN ASSAY 85576 $323.37 03050358 HB LAB DRVV CONFIRM 85613 $175.01 03050359 HB LAB DRVV SCREEN 85613 $175.01 03050360 HB LAB DRVV MIXING 85613 $175.01 03050361 HB LAB COLLAGEN 1UG/ML ATP REL 85576 $345.34 03050362 HB LAB COLLAGEN 5UG/ML AGG 85576 $345.34

Ancillary FY22 82 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03050363 HB LAB COLLAGEN 5UG/ML ATP REL 85576 $345.34 03050364 HB LAB RISTO LOW DOSE AGG 85576 $345.34 03050365 HB LAB RISTO HIGH DOSE AGG 85576 $345.34 03050366 HB LAB THROMBIN PLT ATP REL 85576 $345.34 03050367 HB LAB ARACHODON ACID AGG 85576 $345.34 03050368 HB LAB ARACHODON ACID ATP REL 85576 $345.34 03050369 HB LAB ADP AGG 85576 $345.34 03050370 HB LAB ADP ATP RELEASE 85576 $345.34 03050371 HB LAB COLLAGEN 1UG/ML AGG 85576 $345.34 03050372 HB LAB PBMC ISOLATION 85999 $269.41 03050373 HB LAB RETICULOCYTE AUTO 85046 $284.68 03050374 HB VWF ACTIVITY RISTOCETIN CO-FACTOR 85245 $749.01 03050384 HB HP TEG6S MA-KAOLIN 85576 $315.25 03050385 HB HP TEG6S MA-RAPID TEG 85576 $315.25 03050386 HB HP TEG6S MA-FUNCTIONAL FIBRINOGEN 85576 $315.25 03050387 HB HP TEGS R-KAOLIN 85347 $73.50 03050388 HB HP TEGS R-KAOLIN HEPARINASE 85347 $73.50 03050389 HB SEDIMENTATION RATE, RBC, AUTOMATED 85652 $372.95 03050390 HB HP TEG6S CK-K, ANGLE 85384 $115.50 03060002 HB CONCENTRATION - ANY TYPE 87015 $118.34 03060005 HB CONCENTRATION, CSF FOR GS 87015 $118.34 03060007 HB LAB CULT BLOOD LEGIONELLA 87040 $930.43 03060008 HB LAB CULT BLOOD BRUCELLA ONLY 87040 $985.88 03060012 HB CULTURE, BACT FECAL ROUTINE 87045 $384.12 03060013 HB SRN VRE C. DIFF TOX POS STOOL 87046 $194.18 03060015 HB LAB CULTURE ABSCESS 87070 $503.62 03060016 HB LAB CULT RESPIR CYSTIC FIBRO 87070 $373.45 03060023 HB LAB CULTURE EAR 87070 $503.62 03060024 HB LAB CULTURE GASTRIC 87070 $475.87 03060028 HB LAB CULTURE CSF 87070 $503.62 03060029 HB LAB CULTURE WOUND 87070 $503.62 03060030 HB LAB CULTURE FLUID 87070 $503.62 03060033 HB LAB CULTURE CATHETER TIP 87070 $855.72 03060036 HB LAB CULTURE SKIN 87070 $503.62 03060039 HB LAB ANAEROBE IDENTIFICATION 87076 $223.18 03060040 HB LAB CHLAMYDIA ADNL WORK 87076 $243.30 03060041 HB LAB CULT ADNL WORKUP 87076 $482.27 03060042 HB LAB ANA DEFIN ID, EACH ORG 87076 $223.18 03060043 HB LAB IDENTIF, BACTERIAL 87076 $855.72 03060048 HB LAB CULT LEGIONELLA 87081 $793.83 03060050 HB LAB BETA STREP SCREEN 87081 $435.32 03060053 HB LAB CULT BAC-PERTUS 87081 $435.32

Ancillary FY22 83 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03060058 HB CULTURE, URINE 87088 $970.94 03060059 HB LAB CULT FUNG UNSPCF 87102 $985.88 03060070 HB CHLAMYDIA PNEUMONIAE 87110 $406.54 03060073 HB LAB CULT AFB BLOOD 87116 $985.88 03060077 HB LAB SEROTYPING, EACH ORG 87147 $93.89 03060084 HB LAB MICRO PINWORMS 87172 $332.90 03060085 HB TISSUE GRINDING 87176 $328.61 03060086 HB LAB O & P DIRECT WET MOUNT 87177 $198.44 03060087 HB LAB O&P CONC/IODN MNT NONSTO 87177 $198.44 03060089 HB LAB O&P CONC/WET MOUNT STOOL 87177 $396.91 03060090 HB WET MOUNT 87210 $187.78 03060095 HB CLIND INDUCED RES.TEST 87184 $122.05 03060096 HB LAB SUSCEPT KB 87184 $603.90 03060101 HB LAB CONFIRM AGAR DIL MIC 87186 $153.19 03060106 HB LAB GRAM STAIN FOR BV SCREEN 87205 $352.09 03060107 HB LAB MICRO WRIGHT ST 87205 $245.41 03060112 HB ZIEHL-NEELSEN STAIN-CONF 87206 $192.05 03060114 HB SMEAR, AFB STOOL 87206 $125.92 03060116 HB LAB MICRO MALARIA BL 87207 $352.09 03060120 HB LAB WETMT FUNG UNSPC 87210 $413.98 03060121 HB LAB (KOH) FUNGAL EXAM 87210 $362.79 03060123 HB LAB INDIA INK CRYPTO 87210 $337.14 03060129 HB LAB VIRUS INOCULATION, SHELL V 87254 $166.44 03060132 HB LAB GENET VIRUS ISOLATE, HSV 87255 $599.86 03060136 HB LAB CRYPTO DFA 87272 $230.49 03060138 HB LAB HERPES TYPE TWO DFA 87273 $303.01 03060139 HB LAB HERPES TYPE ONE DFA 87274 $303.01 03060141 HB LAB INFLUENZA A IFA STAIN 87276 $159.24 03060142 HB LAB RSV IFA STAIN 87280 $159.24 03060144 HB LAB PNEUMOCYSTIS DFA 87281 $554.86 03060145 HB LAB VARICELLA ZOSTER DFA 87290 $603.90 03060152 HB LAB ANTGN CRYPTO SE 87327 $535.63 03060153 HB LAB DIRECT GIARDIA AG 87328 $740.48 03060154 HB LAB H. PYLORI STOOL AG EIA 87338 $354.21 03060155 HB LAB RAPID HELICOBACTER SCRN 87339 $164.48 03060157 HB LAB HBSAG CONFIRMATION 87341 $945.34 03060160 HB LAB INFLUENZA B MEMBRANE EIA 87400 $377.73 03060161 HB LAB INFLUENZA A MEMBRANE EIA 87400 $377.73 03060164 HB LAB ROTAVIRUS BY EIA 87425 $793.83 03060165 HB LAB CAMPYLOBACTER DR AG IN STL 87427 $392.68 03060167 HB LAB RAPID STREP GROUP A 87430 $207.00 03060170 HB LAB DNA PROBE CANDIDA SP 87480 $343.78

Ancillary FY22 84 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03060173 HB CHLAMYDIA BY AMPLIFICATION 87491 $827.98 03060183 HB LAB LEGIONELLA DIRECT 87540 $535.63 03060201 HB LAB STREP A RPD SCN 87880 $360.63 03060207 HB LAB SPECIMEN CONCENTRATION 87015 $118.34 03060210 HB CONCENTRATION - STOOL 87015 $125.92 03060212 HB LAB CONCENTRATION(BROTH ENRICH 87015 $118.34 03060215 HB LAB CULT BAC BLOOD 87040 $985.88 03060218 HB LAB BLOOD STEM CELL CULTURE 87040 $182.87 03060223 HB ADDITIONAL WORKUP 87046 $179.26 03060227 HB LAB CULTURE RESPIRATORY 87070 $855.72 03060237 HB LAB CULTURE TISSUE 87070 $503.62 03060238 HB LAB CULTURE GENITAL 87070 $152.45 03060239 HB LAB CULT RESPIRATORY QUANT 87070 $855.72 03060240 HB LAB CULTURE BONE 87070 $503.62 03060241 HB CULTURE ANY SOURCE 87070 $657.27 03060243 HB LAB CULTURE ENVIRONMENTAL 87070 $855.72 03060244 HB LAB CULTURE BONE MARROW 87070 $503.62 03060246 HB LAB CULTURE UMBILICUS 87070 $475.87 03060247 HB LAB CULTURE EYE 87070 $503.62 03060248 HB LAB CULTURE ACTINOMYCES 87075 $1,480.98 03060249 HB LAB CULT BAC-ANAROB 87075 $1,480.98 03060267 HB LAB BACTI ADDNL. ID, EACH 87077 $183.53 03060271 HB LAB URINE DEFIN ORG ID, EACH 87077 $143.03 03060292 HB LAB IDENTIF, FUNGAL 87106 $985.88 03060293 HB LAB FUNG DEFIN. ID, 1ST ORG 87106 $182.87 03060294 HB LAB FUNG DEFIN. ID, 4TH ORG 87106 $182.87 03060295 HB LAB FUNG DEFIN. ID, 3RD ORG 87106 $182.87 03060296 HB LAB FUNG DEFIN. ID, 2ND ORG 87106 $182.87 03060298 HB LAB CULT BLOOD MYCOPLASMA 87109 $985.88 03060299 HB LAB CULTURE STERILE GENITAL 87070 $503.62 03060301 HB LAB CHLAMYDIA CULTURE 87110 $406.54 03060303 HB CULTURE, AFB UNSPECIFIED 87116 $985.88 03060306 HB LAB CULT URINE STERILE 87088 $970.94 03060308 HB LAB AFB ID 87118 $1,045.62 03060309 HB LAB CULT FUNG BLOOD 87103 $985.88 03060314 HB BACT ID BY FLUOR - STAPH 87149 $488.68 03060315 HB BACT ID BY FLUOR - YST 87149 $488.68 03060326 HB LAB ETEST MIC, EACH DRUG 87181 $102.42 03060335 HB BETA LAC ENZ DETECT 87185 $102.42 03060337 HB LAB WETMT FUNG 87210 $290.24 03060339 HB LAB SUSCEPT MIC 87186 $855.72 03060343 HB LAB HEP C VIR QUANT NUC ACID 87522 $1,135.26

Ancillary FY22 85 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03060388 HB LAB MICRO WBC FE 87205 $290.24 03060400 HB LAB MICROSPORIDIUM STAIN 87207 $170.71 03060401 HB LAB O&P TRICHROME STAIN 87209 $396.91 03060422 HB LAB VIRUS INOCULATION, TISSUE 87252 $461.84 03060438 HB LAB VIR RAP INFLU A & B CULT 87254 $490.78 03060441 HB LAB GIARDIA DFA 87269 $230.49 03060454 HB LAB VIR RESP IFA STAIN, NOS 87299 $320.09 03060481 HB LAB RSVMEMBRANE EIA 87420 $618.85 03060485 HB LAB MRSA RAPID LATEX 87450 $236.89 03060493 HB LAB ENTEROVIRUS AMP PROBE 87498 $1,173.67 03060494 HB LAB DNA PROBE GARD VAGINALIS 87510 $343.78 03060519 HB LAB HIV QUANTITATION BY PCR 87536 $932.55 03060521 HB LAB AFB DNA PROBE, 1ST ID 87550 $343.78 03060522 HB LAB AFB DNA PROBE, 4TH ID 87550 $343.78 03060523 HB LAB AFB DNA PROBE, 2ND ID 87550 $343.78 03060524 HB LAB AFB DNA PROBE, 3RD ID 87550 $343.78 03060528 HB GC BY AMPLIFICATION 87591 $827.98 03060533 HB LAB DNA PROBE TRICH VAGINALIS 87660 $356.53 03060551 HB LAB E COLI TOXIN AG DETCT OTHR 87899 $189.93 03060552 HB E COLI TOXIN AG DETECT 87899 $159.24 03060567 HB LAB UPPER RESP CULTURE 87070 $524.97 03060570 HB LAB GENITAL MYCOPLASMA CULT 87109 $924.01 03060571 HB CORD BLOOD/STEM CELL CX 87040 $182.87 03060573 HB HCV GENOTYPING 87902 $4,558.34 03060575 HB LAB HEP B RT PCR QUANT 87517 $1,160.86 03060597 HB LAB FUNGAL BLD CULTURE PEDS 87103 $985.88 03060598 HB LAB CULTURE STERILE RESPIRTY 87070 $806.66 03060603 HB LAB MICRO WRIGHT ST 87205 $245.41 03060606 HB LAB ANTGN CRYPTO SF 87327 $525.61 03060607 HB LAB UPPER RESP CULT MRSA SCRN 87081 $323.08 03060608 HB LAB YERSINIA CULTURE 87081 $116.52 03060609 HB LAB GRAM ST UNSPCFD 87205 $345.06 03060610 HB AFB TB SUSCEPT, EACH DRU 87190 $123.65 03060611 HB LAB CULT BAC-GC 87081 $426.82 03060612 HB LAB HISTOPLASMA BLD CULT 87103 $966.35 03060613 HB LAB SURVEILLANCE CULTURE 87081 $426.82 03060614 HB SMEAR, AFB UNSPECIFIED 87206 $118.86 03060615 HB LAB CULT BAC-STREP A 87081 $426.82 03060616 HB LAB SENST BAC ANAERO 87186 $1,451.81 03060617 HB MRSA SCREEN ONLY 87081 $116.52 03060618 HB LAB CULT STOOL-VIBRIO 87081 $906.58 03060619 HB LAB RHODAMINE AUROMN 88312 $701.09

Ancillary FY22 86 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03060621 HB C.DIFFICILE TOXIN B PCR 87798 $601.66 03060623 HB LAB ADENOVIRUS AG, DFA 87260 $149.05 03060624 HB LAB CYTOMEGALOVIRUS AG,DFA 87271 $161.00 03060627 HB LAB VARICELA ZOSTER AG, DF 87290 $159.24 03060640 HB RSV BY AMPL PCR 87798 $601.66 03060660 HB LAB HIV AG/AB COMBO 87389 $355.67 03060680 HB LAB INFLUENZA A/H1 87503 $297.83 03060681 HB LAB INFLUENZA A/H3* 87503 $297.83 03060682 HB LAB INFLUENZA A/2009H1N1 87503 $297.83 03060683 HB LAB INFLUENZA A UNSUBTYPEABLE 87502 $1,220.92 03060684 HB LAB INFLUENZA B* 87502 $1,220.92 03060685 HB LAB RSVA 87798 $601.66 03060686 HB LAB RSVB 87798 $601.66 03060687 HB VIRAL RESP PNL - 16 TARGETS 87633 $6,053.65 03060688 HB CHLAMYDIA PNEUMONIAE* 87486 $601.66 03060689 HB MYCOPLASMA PNEUMONIAE 87581 $601.66 03060690 HB BORDETELLA PERTUSSIS 87798 $601.66 03060692 HB MALDI MYCOBACTERIA ID ORGS 1 87118 $1,045.62 03060695 HB MALDI BACTI ANAEROB ID ORGS 1 87076 $223.18 03060696 HB MALDI BACTI ANAEROB ID ORGS 2 87076 $223.18 03060697 HB MALDI BACTI ANAEROB ID ORGS 3 87076 $223.18 03060698 HB MALDI BACTI ANAEROB ID ORGS 4 87076 $223.18 03060699 HB MALDI BACTI ANAEROB ID ORGS 5 87076 $223.18 03060700 HB MALDI BACTI ANAEROB ID ORGS 6 87076 $223.18 03060701 HB MALDI BACTI ANAEROB ID CONTAM 87076 $208.59 03060702 HB MALDI YEAST ID ORGS 1 87106 $182.87 03060703 HB MALDI YEAST ID ORGS 2 87106 $182.87 03060704 HB MALDI YEAST ID ORGS 3 87106 $182.87 03060706 HB MALDI BACTI AEROB ID ORGS 1 87077 $143.03 03060707 HB MALDI BACTI AEROB ID ORGS 2 87077 $143.03 03060708 HB MALDI BACTI AEROB ID ORGS 3 87077 $143.03 03060709 HB MALDI BACTI AEROB ID ORGS 4 87077 $143.03 03060710 HB MALDI BACTI AEROB ID ORGS 5 87077 $143.03 03060711 HB MALDI BACTI AEROB ID ORGS 6 87077 $143.03 03060712 HB MALDI BACTI AEROB ID CONTAM 87077 $143.03 03060713 HB MALDI MOLD ID ORGS 1 87107 $182.87 03060718 HB GRAM-POS BLD CULT NUCL ACID 87149 $354.97 03060719 HB MTB CMPLX RIFAMPIN PCR RESP 87556 $601.66 03060720 HB RIF MARKER 87500 $581.12 03060722 HB LAB HSV PCR 1+2 87529 $584.08 03060724 HB LAB GRAM NEG BLD CULT NA 87149 $354.97 03060726 HB HPV HIGH-RISK TYPES 87624 $744.75

Ancillary FY22 87 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03060727 HB HPV TYPES 16 & 18 ONLY 87625 $1,185.56 03060728 HB LAB ENTERIC BACTERIA PCR 87505 $1,692.96 03060729 HB VARICELLA-ZOSTER (VZV)-PCR, QUAL 87798 $2,466.89 03060730 HB LAB BINAXNOW MALARIA ANTIGN 87899 $485.12 03060734 HB BORDETELLA DNA FLEX 87798 $464.56 03060735 HB FLUA+B+RSV DNA FLEX 87632 $4,039.38 03060736 HB ENTERIC PARASITE PCR 87505 $1,692.96 03060737 HB RESP VIRUS DNA, 12-15 TARGETS 87633 $6,053.65 03060738 HB INFECTIOUS AGENT DNA, EA ORG 87798 $855.72 03060739 HB RESP VIRUS DNA FLEX 87633 $6,053.65 03060748 HB PHENO SUSCEPTIBILITY ID FISH 87149 $346.08 03060749 HB PHENO SUSCEPTIBILITY MIC WITH INTERP 87186 $149.31 03060750 HB MENINGITIS ENCEPHALITIS PCR PANEL 87483 $5,776.93 03060751 HB MRSA CONFIRMATION 87147 $89.61 03060752 HB CRYPTO AG LF CSF 87899 $155.25 03060753 HB CRYPTO AG TITER LF BLD 87899 $155.25 03060754 HB CRYPTO AG LF BLD 87899 $155.25 03060755 HB CRYPTO AG TITER LF CSF 87899 $155.25 03060756 HB VRE SCREEN 87081 $426.82 03060759 HB EXT ENTERIC BACT PCR 8 TARGET 87506 $2,639.72 03060760 HB RECTAL MDRO SCREEN 87081 $407.55 03060761 HB SUPPLEMENTAL RESPIRATORY VIRUS FLEX PNL 87631 $1,692.96 03060765 HB RANDOM VIRUSES OF RESPIRATORY TRACT PANEL FLEX 87631 $1,418.82 03060766 HB INFLUENZA WITH H1/H3 TYPING PANEL FLEX 87631 $1,418.82 03060767 HB PRIMARY SEASONAL INFLUENZA PANEL FLEX 87631 $1,418.82 03060768 HB INFLUENZA A RAPID SCREEN, RESPIRATORY 87804 $122.96 03060769 HB INFLUENZA B RAPID SCREEN, RESPIRATORY 87804 $122.96 03060770 HB PARAINFLUENZA PANEL FLEX 87631 $1,692.96 03060771 HB INFLUENZA A RAPID ANTIGEN, RESPIRATORY 87804 $431.08 03060772 HB INFLUENZA B RAPID ANTIGEN, RESPIRATORY 87804 $431.08 03060773 HB SARS-COVID-19 DETECTION BY NUCLEIC ACID 87635 $480.00 03060774 HB SARS-COV-S PCR ROUTINE RESP (COVID-19) 87635 $480.00 03060776 HB COVID-19 SARS-COV-2 PCR RAPID RESP 87635 $480.00 03060777 HB VIRAL RESPIRATORY PANEL WITH COVID19 - 22 TARGETS 0202U $6,826.05 03060778 HB CAMPYLOBACTER RAPID ANTIGEN, STOOL 87899 $298.71 03060779 HB SENSITITRE MDRO SUSCEPTIBILITY MIC WITH INTERP 87186 $592.23 03060780 HB SENSITITRE NONMTB SUSCEPTIBILITY MIC WITH INTERP 87186 $1,059.69 03060781 HB ENTERIC VIRAL PANEL, PCR, STOOL 87505 $1,597.13 03060782 HB HSV 1+2 PCR LESION 87529 $511.59 03060783 HB VZV PCR LESION 87798 $511.59 03060784 HB H PYLORI AG STOOL 87338 $334.16 03070002 HB LAB URINALYSIS W/ MICROSCOPY 81001 $348.00

Ancillary FY22 88 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03070003 HB LAB URINALYSIS 81002 $288.10 03070004 HB LAB SPECIFIC GRAV UR 81003 $130.18 03070008 HB LAB PREGNANCY TEST URINE 81025 $571.90 03070014 HB URINALYSIS AUTO W/O MICRO 81003 $290.24 03070025 HB LAB POC URINE CHEMISTRY 81003 $290.24 03070026 HB LAB URINALYSIS W/ MICRO 81001 $348.01 03070027 HB LAB PREGNANCY TEST URINE* 81025 $571.90 03090018 HB LAB HGH SE 83003 $12.06 03090019 HB MYELIN BASIC PROTEIN 83873 $18.34 03090020 HB PROPAFENONE (RHYTHMOL) 80299 $30.40 03090021 HB PROZAC (FLUOXETINE) 80299 $18.82 03090024 HB URN METHYLMALONIC ACID 83921 $21.53 03090025 HB PHENYLALANINE 84030 $19.30 03090028 HB INFLUENZA VIRUS TYPES A & B 86710 $10.71 03090031 HB LAB ESTRADIOL SE 82670 $17.85 03090032 HB RIBOSOMAL P PROTEIN 83520 $9.99 03090046 HB ESTRIOL, UNCONJUGATED 82677 $19.30 03090048 HB HEPATITIS BE ANTIBODY 86707 $7.72 03090055 HB LAB TBG RIA SE 84442 $17.61 03090056 HB TRIGLYCERIDES 84478 $6.03 03090057 HB CHOLESTEROL 82465 $6.03 03090060 HB SOMATOSTATIN 84307 $86.24 03090063 HB XYLOSE, BLOOD 84620 $63.32 03090067 HB PARAINFLUENZA AB 86790 $23.16 03090071 HB MYELOPEROXIDASE AB 86021 $10.62 03090072 HB PROTEIN C ANTIGEN 85302 $21.23 03090073 HB PROTEINASE-3 AB 86021 $14.48 03090076 HB ASPERGILLUS AB 86606 $12.30 03090079 HB LAB ESTROGEN TOTAL 82672 $14.48 03090083 HB LAB VIP 84586 $107.90 03090087 HB LAB ANTIBD PM-1 86235 $31.85 03090091 HB ANTI CHROMATIN AB IGG 86235 $19.30 03090092 HB BORRELIA BURGDORFERI DNA 87476 $226.78 03090103 HB LAB TESTOSTERONE TOTAL 84403 $11.83 03090107 HB LAB SEX HORM BINDING GLOB 84270 $11.42 03090110 HB LAB FREE T4 BY DIALYSIS 84439 $10.62 03090132 HB LAB BONE SPECIFIC ALK PHOSPH# 84080 $12.55 03090136 HB LAB CREATINE, 24 HR URINE 82540 $62.20 03090137 HB LAB ALPHA SUBUNIT BLOOD # 83519 $55.97 03090141 HB LAB TRANSGLUTAMIN IGG/IGA 83516 $9.91 03090142 HB LAB DEOXYCORTICOSTERONE # 82633 $47.29 03090144 HB LAB INHIBIN B 83520 $125.00

Ancillary FY22 89 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03090149 HB LAB 17-HYDROXYPREGNENOLONE 84143 $32.09 03090173 HB LAB CLOZAPINE 80159 $25.09 03090174 HB LAB SEROTONIN 84260 $41.01 03090178 HB LAB 17-OH-CORTICOSTEROIDS 83491 $24.13 03090182 HB LAB FECAL FAT, TIMED 82710 $43.23 03090184 HB LAB CLONAZEPAM 80346 $13.51 03090185 HB TRYPTOPHAN 82131 $41.90 03090188 HB LAB BILE ACIDS, FRAC 83789 $57.90 03090192 HB LAB MUMPS IGM 86735 $16.65 03090194 HB LAB B. PERTUSSIS PCR 87801 $28.95 03090199 HB LAB IG GAMAGLOB 82784 $6.84 03090204 HB LAB HIV-1 DIRECT AG 87390 $106.80 03090205 HB LAB EPIDERMAL AB, IFA 86255 $28.95 03090207 HB LAB TULAREMIA AGGLUTININ 86000 $51.15 03090208 HB LAB ANTIBD CYSTICER 86682 $54.04 03090217 HB LAB TWAR PNL AB CHLAMYDIA IGM 86632 $11.56 03090222 HB LAB ANTIBD SCHISTOSOM 86682 $40.53 03090223 HB TOXOCARA AB 86682 $35.46 03090224 HB LAB ANTIBD CA EQ ENCP 86651 $17.37 03090226 HB LAB ANTIBD LCM 86727 $15.00 03090230 HB LAB CHLAMYDIA GROUP AB 86631 $41.44 03090231 HB VARICELLA ZOSTER ACIF 86787 $6.87 03090236 HB LAB ANTIBD TETANUS ANTITOXID# 86774 $19.30 03090252 HB LAB BLASTOMYCOSIS - CF # 86612 $28.95 03090254 HB BORDETELLA IGG (PT) 86615 $18.00 03090257 HB LAB LYME WESTERN BLOT IGG # 86617 $10.61 03090258 HB LAB LYME WESTERN BLOT IGM # 86617 $10.62 03090261 HB LAB VARICELLA ZOSTER IGM AB # 86787 $9.89 03090277 HB LAB MYCOPLASMA IGM ANTIBODY 86738 $14.48 03090278 HB CALIFORNIA ENCEPH AB, IGG 86651 $15.92 03090282 HB ST. LOUIS ENCEPH AB, IGG 86653 $15.93 03090286 HB C. PNEUMONIAE IGG 86631 $8.96 03090287 HB C. PNEUMONIAE IGA 86631 $8.96 03090288 HB C. PNEUMONIAE IGM 86632 $8.97 03090289 HB C. TRACHOMATIS IGG 86631 $8.96 03090290 HB C. TRACHOMATIS IGA 86631 $8.96 03090291 HB C. TRACHOMATIS IGM 86632 $8.97 03090292 HB C. PSITTACI IGG 86631 $8.96 03090293 HB C. PSITTACI IGA 86631 $8.96 03090294 HB C. PSITTACI IGM 86632 $8.97 03090301 HB ECHOVIRUS TYPE 4 86682 $5.79 03090302 HB ECHOVIRUS TYPE 7 86682 $5.79

Ancillary FY22 90 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03090304 HB ECHOVIRUS TYPE 11 86682 $5.79 03090305 HB ECHOVIRUS TYPE 30 86682 $5.79 03090315 HB STRONGYLOIDES IGG AB 86682 $45.11 03090316 HB WESTERN EQ ENCEPH IGG 86654 $3.95 03090319 HB GIARDIA IGG AB 86674 $14.71 03090320 HB GIARDIA IGA AB 86674 $17.71 03090321 HB GIARDIA IGM AB 86674 $14.73 03090326 HB STREPTOZYME 86063 $14.48 03090327 HB VARICELLA ZOSTER IGM 86787 $6.88 03090328 HB CSF CMV IGG 86644 $14.48 03090348 HB WEST NILE VIRUS IGM AB 86317 $16.89 03090352 HB HERPESVIRUS 7 IGM AB 86790 $27.02 03090353 HB HERPESVIRUS 6 DNA, PCR 87532 $175.44 03090370 HB CON A MITOGEN 86353 $31.67 03090371 HB PHA MITOGEN 86353 $31.67 03090372 HB POKEWEED MITOGEN 86353 $31.67 03090373 HB SPOTTED FEVER IGG AB 86757 $9.65 03090374 HB SPOTTED FEVER IGM AB 86757 $9.65 03090376 HB SOLUBLE LIVER ANTIGEN AB 83520 $28.95 03090388 HB LAB URN FREE LIGHT CHAINS NEPH 83883 $30.88 03090389 HB LAB CHRONIC GRANULO DIS 82657 $19.30 03090394 HB LAB CANDIDA ANTIBODY PANEL 86628 $13.51 03090396 HB LAB HEPATITIS E IGM 86790 $45.36 03090398 HB LAB W NILE ANTIBODY PNL, CSF 86317 $29.44 03090401 HB LAB PAN ANCA EVAL ANA 86038 $9.08 03090409 HB LAB URN CITRATE 82507 $13.70 03090411 HB LAB THYROGLOBULIN ANTIB 86800 $28.00 03090412 HB LAB FITZGERALD FACTOR 85293 $125.00 03090415 HB LAB IGF-II 83519 $85.00 03090493 HB LAB CARNITINE, FREE # 83789 $24.30 03090501 HB LAB COPPER, URINE # 82525 $15.75 03090525 HB PANCREATIC AMYLASE 82150 $14.00 03090551 HB FLURAZEPAM 80346 $36.05 03090558 HB NEURONAL CELL AB, SERUM 83520 $74.77 03090560 HB INSULIN, TOTAL 83525 $10.40 03090562 HB INSULIN, FREE 83527 $13.20 03090593 HB ZINC,URINE 84630 $11.20 03090597 HB STREP DNASE B AB 86215 $11.20 $25.84 03090607 HB ASPERGILLUS AB BY ID 86606 $10.85 03090621 HB H. PYLORI IGA AB 86677 $12.80 03090624 HB HEMOGLOBIN, PLASMA 83051 $14.65 03090626 HB LEPTOSPIRA AB 86720 $30.40

Ancillary FY22 91 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03090629 HB MEASLES IGG 86765 $11.03 03090653 HB VIT B2, RIBOFLAVIN 84252 $53.08 03090663 HB LAB CSF MENINGO PNL RUBELLA 86765 $18.25 03090668 HB LAB INSULIN, FASTING 83525 $9.60 03090670 HB LAB INSULIN, 60 MINUTES 83525 $9.60 03090672 HB LAB INSULIN, 120 MINUTES 83525 $9.60 03090675 HB LAB SULFONAMIDES 80299 $31.50 03090683 HB LAB N-TELOPEPTIDE SE GC/MS 82523 $105.00 03090685 HB LAB MYCOPHENOLIC ACID 80180 $14.62 03090699 HB LAB PANCREATIC ELASTASE 83520 $100.00 03090706 HB LAB ALPHA-1-ANTITRYPSIN TOTAL 82103 $19.27 03090707 HB LAB ALPHA-1-ANTITRYPSIN PHNTYP 82104 $20.73 03090731 HB ALPHA 1 ANTITRYPSIN, STOOL 82103 $19.30 03090732 HB CARBOHYDRATE DEF TRNSFRN 82373 $82.80 03090738 HB VITAMIN K 84597 $57.90 03090770 HB LAB ANTI-GLIADIN ELISA, IGG 82397 $23.45 03090774 HB LAB TTG IGA 82397 $30.15 03090793 HB LAB FIBR IA NOT INFCT AGNT NOS 83520 $73.70 03090796 HB LAB TPMT ENZ NON-RADIO SUBSTRA 82657 $73.70 03090800 HB LAB GENOTYPE DNA HIV REVERSE T 87901 $398.44 03090802 HB LAB PHENOTYPE DNA HIV W/CLT AD 87904 $40.56 03090806 HB LAB COCCI ID IGG & IGM 86331 $16.25 03090820 HB OPIATE CONFIRMATION 80362 $15.00 03090824 HB PROPOXYPHENE CONFIRMATION 80362 $9.73 03090830 HB BARBITURATES, IDENTIFICATION 80345 $122.41 03090839 HB METHAQUALONE 80102 $9.73 03090849 HB SERTRALINE (ZOLOFT) 82542 $66.77 03090856 HB LAB MEXILETENE 82542 $50.08 03090864 HB LAB METHOTREXATE * 80204 $24.13 03090871 HB LAB PRIMIDONE 80188 $10.40 03090875 HB CALCITONIN 82308 $26.54 03090876 HB PARAINFLUENZA AB * 86790 $11.58 03090878 HB PROSTATIC ACID PHOSPHATASE 84066 $9.41 03090879 HB ALDOSTERONE 82088 $11.58 03090909 HB LAB CSF CA 19-9 86301 $34.66 03090914 HB LAB FLD CEA PERICARDIAL 82378 $11.70 03090916 HB LAB FLD CEA PLEURAL 82378 $8.69 03090920 HB LAB CSF HCG 84702 $11.58 03090922 HB LAB TUMOR NECROSIS FACTOR 83520 $48.25 03090934 HB LAB BIOTINIDASE 82261 $18.25 03090935 HB LAB IMMUNOREACTIVE TRYPSINOGEN 83516 $18.25 03090941 HB CHROMAGRANIN A 86316 $33.75

Ancillary FY22 92 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03090943 HB LAB NB TSH 84443 $18.25 03090947 HB LAB PLASMINOGEN # 85421 $72.69 03090955 HB LAB N-TELOPEPTIDE 82523 $10.22 03090956 HB CAFFEINE 80155 $19.30 03090959 HB LAB GONADOTROPIN RELEAS HRM 83727 $225.00 03090960 HB LAB GROWTH HORMONE AB 86277 $104.22 03090961 HB LAB SERUM FREE CORTISOL 82530 $24.13 03090964 HB LAB SOUTH CA ALLERGY PANE 86003 $6.19 03090969 HB LAB PROTHROMBIN ABS 83520 $38.34 03090970 HB LAB PLASMA RENIN ACTIVITY 84244 $11.58 03090977 HB LAB ANTITHROMBIN III ANTIGEN 85301 $25.09 03090987 HB LAB ANLZR - IMMUNOASSAY, RIA 83520 $9.66 03090988 HB LAB ANLZR - ANTINUCLEAR ABS 86038 $9.02 03090990 HB LAB ANLZR - DNA ANTIBODY 86225 $10.24 03090991 HB LAB ANLZR - NUCLEAR ANTIGEN AB 86235 $66.85 03090995 HB LAB PH, BODY FLUID 83986 $5.44 03091007 HB LAB COBALT SERUM 83018 $21.40 03091011 HB LAB PHENOBARBITAL 80184 $7.20 03091012 HB VIT D: 1,25-DIHYDROXY 82652 $26.00 03091014 HB URN VMA 84585 $17.92 03091016 HB LAB URN OXALATE 83945 $22.08 03091017 HB LAB URN METANEPHRINE 83835 $23.15 03091034 HB LAB CYSTATIN C 82610 $52.11 03091035 HB FOOD ALLERGY PROFILE 86003 $5.78 03091043 HB LAB CALPROTECTIN, STOOL 83993 $45.00 03091045 HB LAB HIV GENOTYPING 87901 $241.25 03091083 HB CHOLINESTERASE, PSEUDO 82480 $11.94 03091084 HB CHOLINESTERASE, PSEUDO 82480 $9.55 03091085 HB DIBUCAINE NUMBER 82638 $14.33 03091086 HB CK TOTAL 82550 $16.11 03091087 HB CK ISOENZYMES 82552 $21.18 03091089 HB LAB GASTRIN SE 82941 $11.58 03091090 HB HEPATITIS BE ANTIGEN 87350 $7.72 03091092 HB INTRINSIC FACTOR ANTIBODY 86340 $12.06 03091095 HB LIPOPROTEIN ELECTR SEP 82664 $12.07 03091100 HB TYROSINE 84510 $24.13 03091101 HB COMPLEMENT COMPONENT C2 86160 $18.34 03091102 HB COMPLEMENT COMPONENT C5 86160 $31.85 03091105 HB COMPLEMENT COMPONENT C6 86160 $32.09 03091106 HB CARDIOLIPIN IGA AB 86147 $5.11 03091107 HB AB BY GEL DIFFUSION 86331 $1.96 03091108 HB NOCARDIA AB 86744 $20.55

Ancillary FY22 93 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091110 HB IGF-I BINDING PROTEIN 3 83519 $23.79 03091111 HB INHIBIN A 83520 $19.30 03091113 HB METHYLMALONIC ACID, SERUM 83921 $13.51 03091116 HB FOLATE, RBC 82747 $6.27 03091117 HB URN ALDOSTERONE 82088 $24.30 03091124 HB LAB SOMATOMEDIN-C, RIA 84305 $15.59 03091125 HB LAB MAGNESIOUM, RBC 83735 $34.42 03091126 HB LAB TESTOSTERONE TOT (FE/CH) 84403 $6.05 03091127 HB LAB TESTOSTERONE FREE 84402 $25.83 03091129 HB LAB SEX HORMONE BIND GLOB 84270 $14.96 03091130 HB LAB TESTOSTERONE BIOAV TOT 84403 $14.20 03091132 HB LAB ALBUMIN 82040 $2.85 03091136 HB FACTOR 8 MULTIMERIC 85247 $25.00 03091156 HB HCV RNA (TMA), QUAL 87521 $56.94 03091159 HB LAB ADINOPECTIN 83520 $152.00 03091160 HB LAB INTERLEUKIN 2 83520 $91.68 03091161 HB LAB HEP B PCR, QUAL 87516 $91.68 03091165 HB LAB AMNIO FLD AFP W/REF 82106 $12.10 03091166 HB LAB CKIE-CK 82550 $13.00 03091167 HB LAB ISLET CELL AB W/REFLEX 86341 $24.13 03091169 HB LAB OSTEOCALCIN # 83937 $26.61 03091172 HB LAB CREATININE, NOT BLOOD 82570 $10.22 03091174 HB LAB PEDIATRIC ALLERGY PNL 86003 $5.58 03091175 HB THYROTROPIN RELEASE HORM 83519 $205.00 03091181 HB LAB CITRATE # 82507 $35.80 03091185 HB GABAPENTIN 80171 $24.13 03091186 HB LAB PORPHOBILINOGEN, URINE 84110 $32.96 03091187 HB LAB FATTY ACIDS, FREE 82725 $14.48 03091191 HB LAB LEUCINE AMINOPEPTIDASE 83670 $32.00 03091193 HB LAB CREATINE 82540 $5.00 03091195 HB LAB RESP MYCOPLASMA CULT 87109 $19.65 03091196 HB HEPATITIS D IGM AB 86692 $64.75 03091198 HB LAB WEST NILE VIRUS, PCR 87798 $196.86 03091203 HB LAB IGG SUBCLASSES 82787 $6.82 03091204 HB LAB FTA-ABS (IGM) 86780 $5.79 03091207 HB LUK ADH DF FLW CYT 1STMRK 88184 $158.25 03091208 HB LAB LUK ADH DF FLW CYT ADL MKR 88185 $79.50 03091210 HB LAB HEPATITIS D PCR 87798 $37.44 03091211 HB LAB ASPERGILLUS PPT, ID 86606 $17.86 03091213 HB LAB TYSABRI ABS 83516 $243.75 03091214 HB LAB FREE LIGHT CHAINS, 24H URN 83883 $30.88 03091215 HB LAB ANTIBD COXSACK A 86658 $6.60

Ancillary FY22 94 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091216 HB LAB TWAR PNL ID GEL QUAL EA 86631 $5.78 03091218 HB ST. LOUIS EQ ENCEPH AB 86653 $15.00 03091219 HB LAB ANTIBD CRYPTO 86641 $14.40 03091225 HB LAB ANTIBD RESP SYN 86756 $18.34 03091226 HB TRICHINELLA AB 86784 $36.91 03091227 HB LYME IGG AB 86618 $11.23 03091229 HB LAB ANTIBD MYCOPLASMA CF 86738 $33.78 03091230 HB PARVOVIRUS (B19) AB 86747 $14.48 03091231 HB LAB DIPHTHERIA ANTITOXOID # 86648 $19.30 03091248 HB BORDETELLA IGA (PT) 86615 $18.00 03091251 HB LAB CSF LYME AB IGG # 86618 $11.36 03091252 HB LAB CSF LYME AB IGM # 86618 $11.36 03091256 HB LAB HISTO YEAST AB - CF # 86171 $9.00 03091257 HB LAB HISTO MYCELIAL AB-CF # 86171 $9.00 03091258 HB CALIFORNIA ENCEPH AB, IGM 86651 $15.92 03091259 HB EASTERN EQUINE AB, IGG 86652 $15.93 03091260 HB EASTERN EQUINE AB, IGM 86652 $15.92 03091262 HB ST. LOUIS ENCEPH AB, IGM 86653 $15.92 03091264 HB WESTERN EQUINE AB, IGM 86654 $15.92 03091277 HB MUMPS IGG AB 86735 $12.53 03091278 HB MUMPS IGM AB 86735 $12.54 03091280 HB ECHOVIRUS TYPE 9 86682 $5.79 03091285 HB MYOCARDIAL AB 86255 $11.82 03091288 HB WESTERN EQ ENCEPH IGM 86654 $1.67 03091296 HB CSF EBV IGG 86665 $35.00 03091297 HB CSF TOXO IGG 86777 $41.50 03091305 HB S. PNEUMO IGG AB 86609 $9.65 03091306 HB TOXOPLASMA DNA, PCR QUAL 87798 $82.03 03091309 HB WEST NILE VIRUS IGG AB 86317 $16.89 03091310 HB HANTAVIRUS IGG AB 86790 $24.12 03091311 HB HANTAVIRUS IGM AB 86790 $24.13 03091312 HB HERPESVIRUS 7 IGG AB 86790 $27.02 03091313 HB MYCOPLASMA DNA, PCR 87581 $91.68 03091315 HB A1 ACID GLYCOPROTEIN 83883 $17.90 03091316 HB HIV-1 PROVIRAL DNA, PCR 87535 $120.63 03091317 HB HERPESVIRUS 8 DNA, PCR 87798 $249.45 03091318 HB HERPESVIRUS 8 IGG AB 86790 $43.91 03091319 HB MITOCHONDRIAL M2 AB 83520 $14.48 03091320 HB LYME IGM AB 86618 $11.23 03091321 HB MAG AB-WESTERN BLOT 84181 $73.50 03091324 HB TOPHERYMYA WHIPPELLI DNA, PCR 87798 $91.68 03091325 HB POLIOVIRUS INNOC STUDY 87253 $11.23

Ancillary FY22 95 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091326 HB POLIOVIRUS ISOL - INNOC 87252 $32.10 03091327 HB PLATELET CIRCULATING AB PNL 86022 $12.87 03091328 HB LAB SUBSTANCE P 83520 $141.40 03091329 HB LAB NEISSERIA GONORRHOEAE AB 86171 $29.05 03091332 HB LAB HEPATITIS E IGG 86790 $13.99 03091333 HB LAB HEPATITIS E IGG AND IGM 86790 $29.68 03091334 HB LAB COCCI CF 86635 $11.34 03091335 HB LAB ANTIBD DNA-FARR 86225 $68.00 03091336 HB LAB PAN ANCA EVAL LEUK AB 86021 $15.00 03091342 HB LAB PHOSPHATIDYLGLYCEROL ABS 84081 $25.08 03091345 HB LAB ANLZR - COMPLEMENT, AG 86160 $17.90 03091346 HB LAB ANLZR - MICROSOMAL AB 86376 $10.84 03091347 HB LAB ANLZR - RHEUM FAC, QUANT 86431 $4.25 03091350 HB LAB THYROGLOBULIN 84432 $29.00 03091352 HB LAB CORTICOSTERONE 82528 $69.00 03091353 HB PREGNENOLONE 84140 $110.00 03091403 HB LAB VITAMIN A # 84590 $11.58 03091405 HB LAB VITAMIN B6 # 84207 $11.63 03091409 HB LAB NICKEL, SERUM # 83885 $16.70 03091416 HB LAB PORPHYRINS, URINE 84120 $29.12 03091422 HB LAB TRYPSINOGEN 83519 $22.40 03091428 HB RUBELLA IGM ANTIBODY 86762 $9.60 03091435 HB TRICYCLIC ANTIDEPRESS SCR G0480 $16.60 03091438 HB SALIVARY AMYLASE 82150 $13.99 03091442 HB ARSENIC,URINE 82175 $22.05 03091445 HB URN B-2-MICROGLOBULIN 82232 $15.50 03091447 HB URN CADMIUM 82300 $16.00 03091448 HB VIT D: 25, HIDROXY 82306 $15.00 03091449 HB CALCIUM, IONIZED 82330 $6.00 03091450 HB LAB CARBOXYHEMOGLOBIN 82375 $68.15 03091455 HB ESTRONE 82679 $32.00 03091457 HB T3 FREE 84481 $6.80 03091461 HB URN HISTAMINE 83088 $29.20 03091462 HB URN HOMOCYSTINE 83090 $36.80 03091464 HB LAB NEURONAL CELL AB, CSF 86316 $74.77 03091465 HB INSULIN, SERUM 83525 $9.60 03091473 HB LAB URN MERCURY 83825 $14.98 03091476 HB MYOGLOBIN 83874 $14.70 03091481 HB TOTAL ALKALINE PHOSPHATASE 84075 $4.50 03091482 HB ALK PHOS ISOENZYMES 84080 $12.75 03091496 HB INSULIN ANTIBODIES 86337 $43.40 03091499 HB ASPERGILLUS AB BY CF 86606 $10.85

Ancillary FY22 96 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091501 HB B. HENSELAE IGG 86611 $12.13 03091514 HB H. PYLORI IGM AB 86677 $12.80 03091516 HB E. HISTOLYTICA IGG AB 86753 $12.80 03091517 HB LAB PANCREASTATIN 83519 $255.00 03091518 HB MEASLES IGM 86765 $11.03 03091522 HB VARICELLA ZOSTER VIRUS PCR 87798 $100.00 03091525 HB CIC RAJI CELL 86332 $156.00 03091526 HB SOLUBLE TRANSFERRIN RECPT 84238 $18.00 03091528 HB LAB TRYPTASE 83520 $47.29 03091529 HB LAB URN LEAD 83655 $8.00 03091530 HB LAB FLD LIPASE 83690 $8.00 03091532 HB LAB PLASMINOGEN ACTIVTR INHIB 85415 $68.00 03091533 HB LAB PYRUVATE KINASE 84220 $58.00 03091534 HB LAB FECAL FAT, QUAL 82705 $14.33 03091543 HB LAB INSULIN, 30 MINUTES 83525 $9.60 03091544 HB LAB ADENOSINE DEAMINASE,FLD 84311 $32.00 03091554 HB LAB ACETYLCHOL RECEPT AB PNL 83519 $42.58 03091556 HB LAB HER 2 / NEU 83950 $64.59 03091563 HB LAB B PERTUSSIS AB 86615 $17.00 03091566 HB LAB PORPHYRINS 84311 $19.80 03091567 HB HEINZ BODIES, DIRECT 85441 $45.05 03091568 HB HEINZ BODIES, INDUCED 85445 $72.95 03091574 HB LAB URN CATECHOLAMINES, FRAC 82384 $26.46 03091580 HB PLASMINOGEN ACTIVITY 85420 $100.00 03091597 HB LAB QUANTITATIVE IRON # 83540 $48.52 03091598 HB LAB QUANTITATIVE COPPER # 82525 $57.90 03091601 HB PTH RELATED PROTEIN 82397 $24.55 03091602 HB PANCREATIC POLYPEPTIDE 83519 $65.74 03091604 HB LAB MUCOPOLYSACCH, ACID QUANT 83864 $59.95 03091607 HB LAB PYRUVIC ACID 84210 $22.80 03091610 HB PROTEIN S AG, TOTAL 85305 $23.00 03091613 HB SPOROTHRIX AB 86671 $97.08 03091615 HB LAB METANEPHRINES, FRAC 83835 $68.45 03091616 HB LAB STOOL CL 82438 $16.20 03091617 HB LAB STOOL MG 83735 $16.20 03091619 HB LAB STOOL NA 84302 $16.20 03091623 HB LAB TUMOR HCG 84702 $20.00 03091624 HB LAB BETA 2 TRANSFERRIN 86335 $215.56 03091626 HB LAB 6MP METABOLITES 82542 $90.45 03091630 HB LAB ANTI-GLIADIN ELISA, IGA 82397 $23.45 03091631 HB LAB ANTI-HU-TTG ELISA IGA REC 82397 $30.15 03091633 HB LAB TOT SE IGA BY NEPHELOMETRY 82784 $16.75

Ancillary FY22 97 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091644 HB LAB FIBRO NEPH, EA ANALYTE NES 83883 $87.10 03091646 HB LAB TPMT ENZ COLMN SGL ANALYTE 82542 $73.70 03091648 HB LAB HIV PHENOTYPE, COMPREHEN 87903 $777.82 03091649 HB LAB HIV PHENOTYPING, ADDL DRGS 87904 $41.72 03091650 HB LAB PHENOTYPE DNA HIV W/CULT 87903 $756.26 03091651 HB LAB TROFILE 87999 $1,960.00 03091661 HB COCAINE CONFIRMATION 80353 $15.00 03091663 HB AMPHETAMINE CONFIRMATION 80324 $25.00 03091664 HB BARBITURATE CONFIRMATION 80345 $89.02 03091665 HB METHADONE CONFIRMATION 80358 $13.91 03091666 HB BENZODIAZEPINE CONFIRMATION 80346 $89.02 03091669 HB PHENCYCLIDINE CONFIRMATION 83992 $38.95 03091671 HB AMOBARBITAL 80345 $44.51 03091679 HB METHADONE 80358 $77.90 03091682 HB NICOTINE 80323 $35.00 03091688 HB CITALOPRAM (CELEXA) 82542 $83.46 03091691 HB LAB KEPPRA (CHROMATOGRAPHY) 80177 $14.72 03091699 HB LAB STELAZINE 80342 $37.50 03091716 HB LAB NB GAL1PO4 URD TRANS SCN# 82776 $18.25 03091717 HB LAB NB HGB ELECTROPHORESIS # 83021 $18.25 03091718 HB LAB NB TANDEM MS.MS QUANT 83789 $19.75 03091719 HB LAB NB 17-OHP 83498 $18.25 03091723 HB LAB CA125 86304 $49.00 03091728 HB LAB FLD CA 125, PERITONEAL 86304 $15.25 03091729 HB LAB FLD CA 19-9 PERITONEAL 86301 $34.66 03091730 HB LAB FLD CA 19-9 PLEURAL 86301 $34.66 03091731 HB LAB CSF CEA 82378 $29.66 03091732 HB LAB FLD CEA PERITONEAL 82378 $29.29 03091744 HB RAST ANTIBODY 86003 $5.58 03091745 HB LAB HEPATITIS DELTA ANTIBODY 86692 $24.13 03091754 HB COMPLIMENT C1Q 86160 $12.81 03091756 HB LIVER-KIDNEY MICROSOMAL AB 86376 $14.67 03091766 HB LAB NEUTROPHIL ANTIBODY 86021 $72.38 03091769 HB VITAMIN B3 84591 $58.87 03091773 HB LAB URN ORGANIC ACIDS,QUANT 83918 $135.00 03091781 HB URN TELPEP 24H COL CX LNK 82523 $16.98 03091782 HB LAB URN TELPEP 24H CRT OTH SRC 82570 $4.25 03091784 HB LAB RA, IGG 86431 $12.15 03091785 HB LAB RA, IGA 86431 $12.15 03091786 HB LAB RA, IGG, IGA, IGM 86431 $36.45 03091791 HB LAB WESTERN EQUINE AB, IGG 86654 $15.92 03091793 HB LAB MACROAMYLASE 84999 $99.86

Ancillary FY22 98 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091807 HB URINE CYSTINE 82131 $69.40 03091808 HB ALLERGY PROF ASSY GAMMA IGE 82785 $73.75 03091812 HB C3 ACTIVATOR 83883 $44.40 03091813 HB ALPHA2 MACCROGLOBULIN 83883 $27.99 03091841 HB ALLERGY PRF ALLERG SPEC IGE 86003 $1.55 03091846 HB HISTOPLASMA ANTIGEN * 87385 $71.25 03091847 HB SULFONYLUREA HYPOGLYCEMICS G0480 $88.10 03091849 HB URINE HISTOPLASMA ANTIGEN 87385 $71.25 03091850 HB LAB CSF MENIN PNL WNV AB 86789 $20.30 03091851 HB LAB CSF MENN PL WNV AB, IGM 86788 $23.80 03091852 HB LAB CSF MENINGO PL AB MUMPS 86735 $18.30 03091853 HB LAB CSF MENINGO PL AB VZ 86787 $18.10 03091854 HB LAB CSF MENIN PNL AB HSV NS 86694 $20.25 03091857 HB CSF HSV 1 IGG 86695 $20.00 03091858 HB CSF HSV 2 IGG 86696 $20.00 03091859 HB MANGANESE, BLOOD 83785 $16.70 03091863 HB NEUROKININ A 83519 $255.00 03091871 HB C-TELOPEPTIDE, SERUM 82523 $24.61 03091872 HB HIAA, URINE 83497 $17.92 03091875 HB EUGLOBULIN CLOT LYSIS 85360 $28.95 03091877 HB TB COMPLEX PCR STERILE FLDS 87556 $82.03 03091878 HB HE4 OVARIAN CANCER MONITOR 86305 $96.50 03091882 HB VORICONAZOLE LEVEL 80299 $72.38 03091883 HB ITRACONAZOLE AND METABOLITE 80335 $55.64 03091884 HB RICKETTSIA IGG TITER 86757 $24.61 03091885 HB RICKETTSIA IGM TITER 86757 $5.25 03091886 HB BRUCELLA IGG/IGM 86622 $9.42 03091887 HB CRYOFIBRINOGEN 82585 $23.28 03091888 HB CRYOGLOB - QUAL/SEMI QUAN 82595 $11.71 03091890 HB Y ENTEROCOLITICA IGG/IGA 86793 $14.48 03091892 HB AB; TOXOPLASMA 86777 $19.30 03091893 HB AB; TOXOPLASMA, IGM 86778 $19.30 03091897 HB TSH RECEPTOR ANTIBODY 83520 $35.80 03091898 HB PROCALCITONIN 84145 $180.00 03091900 HB MYCOPLASMA IGG/IGM, IFA 86738 $14.48 03091901 HB OVARIAN AB, RFLX TTR (IFA) 86255 $62.40 03091902 HB RESP REGN XIII GAM GLOB IGE 82785 $21.00 03091903 HB RESP REGN XIII EA ALLERGEN 86003 $5.26 03091904 HB HISTAMINE RELEASE 86343 $96.50 03091911 HB THYROID STIMULAT IGG 84445 $33.78 03091915 HB IGF BIND PROTEIN-1 83519 $44.39 03091919 HB EASTERN EQ ENCEPH AB 86652 $17.37

Ancillary FY22 99 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03091924 HB LAB COCCI PPTN (LATEX)# 86635 $28.12 03091926 HB LAB FLD CA 19-9 PERICARDIAL 86301 $34.66 03091942 HB LAB RETICULIN AB IGG 86255 $57.90 03091946 HB LAB WHOLE BLOOD VISCOSITY 85810 $19.10 03091947 HB TRNSF GRWTH FAC BETA, PL 83520 $150.00 03091948 HB INTERFERON GAMMA 83520 $85.00 03091956 HB LACOSAMIDE LEVEL 80299 $82.03 03091958 HB CONCT TIS DIS PRF ENA EA AB 86235 $19.78 03091959 HB CONCT TIS DIS PRF IMM ASSY 83516 $10.25 03091960 HB CORTISOL BINDING GLOBULIN 84449 $75.00 03091961 HB ESTROGENS, FRACT ESTRADIOL 82670 $19.87 03091962 HB ESTROGENS, FRACT ESTRIOL 82677 $19.87 03091963 HB ESTROGENS, FRACT ESTRONE 82679 $19.88 03091964 HB SEROTONIN, SERUM/PLASMA 84260 $47.29 03091965 HB ALPHA 2 ANTIPLASMIN 85410 $48.73 03091966 HB CSF CYSTERCERCUS ANTIBODY 86682 $16.41 03091967 HB NOROVIRUS PCR 87798 $86.85 03091969 HB ENTEROVIRUS PCR 87498 $86.85 03091970 HB HERPESVIRUS 8 PCR, QUANT 87799 $173.70 03091971 HB ADAMTS-13 ACTIVITY 85397 $142.00 03091972 HB AMD13X FAC INHIBITOR TST 85335 $151.00 03091973 HB AMD13Y IMM ASY INF AGNT 83520 $175.00 03091974 HB DRUG DEPENDENT PLATELET AB 86022 $225.00 03091990 HB THYROGLOB PNL THYROGLOBULIN 84432 $53.47 03091991 HB THYROGLOB PNL THYROGLOB AB 86800 $30.08 03091998 HB OCTREOTIDE 80299 $175.00 03092002 HB ADRENAL AB W RFLX 86255 $21.23 03092003 HB VW COLLAGEN BINDING 83520 $57.90 03092004 HB FLD MUCIN CLOT TEST 83872 $21.58 03092005 HB LAB COCCI COMP FIX TEST 86171 $16.25 03092008 HB LAB HIV PHENO INFECT AG DRG 87900 $201.72 03092011 HB LAB PROCOLLAGEN TYPE I 83519 $60.00 03092021 HB LAB NUT ALLERGEN PANEL 86003 $8.89 03092023 HB LAB CMV IGG AVIDITY 86644 $41.43 03092024 HB LAB STREP PNEU AG 86403 $43.43 03092025 HB LAB CAROTENES, FRACTIONATED 82380 $48.00 03092027 HB LAB CSF NMO 86255 $300.00 03092028 HB LAB URN OROTIC ACID 83921 $107.00 03092029 HB LAB URN FAT STAIN 89125 $24.40 03092030 HB LAB BARTONELLA PCR 87471 $120.63 03092032 HB LAB PROSTAGLANDIN D2 84150 $275.00 03092033 HB LAB PROSTAGLANDIN E2 84150 $275.00

Ancillary FY22 100 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092034 HB LAB INTERLEUKIN 8 83519 $275.00 03092035 HB LAB CSF PROT WB; IM ID BNDS 84182 $24.65 03092036 HB LAB CSF IA INF AGNT AB QUAN 86317 $16.65 03092037 HB LAB PEPTIDE YY 83519 $225.00 03092039 HB LAB B PERTUSSIS IGG BY IB 86615 $31.30 03092040 HB LAB B PERTUSSIS IGM BY IB 86615 $29.40 03092041 HB LAB B PERTUSSIS IGA BY IB 86615 $31.30 03092042 HB LAB TROFILE DNA 87999 $1,960.00 03092045 HB LAB CHOLINESTERASE, SERUM 82480 $11.94 03092046 HB LAB CHOLINESTERASE, RBC 82482 $11.94 03092047 HB URN FREE CORTISOL 82530 $17.60 03092054 HB URN ETHANOL 80320 $19.30 03092060 HB GENTAMICIN LEVEL 80170 $86.58 03092061 HB VANCOMYCIN LEVEL 80202 $18.02 03092063 HB DIGOXIN LEVEL 80162 $15.00 03092065 HB BETA-HCG, QUANT 84702 $6.80 03092066 HB AMIKACIN LVL 80150 $11.00 03092067 HB CYCLOSPORINE LVL 80158 $40.00 03092068 HB AFB SLOW GROWER MIC 87186 $97.95 03092069 HB AFB ID, HPLC, CONVEN METHOD 87143 $52.21 03092070 HB H PYL CULTURE P PATHO SCRN 87081 $13.89 03092071 HB H PYL CUL SMEAR GRAM/GIEMSA 87205 $13.89 03092072 HB H PYLORI MIC PANEL 87181 $35.78 03092073 HB NOCARDIA/ACTINO MIC PNL 87186 $82.03 03092075 HB BACTERIAL ID, AEROBIC 87077 $2.90 03092076 HB COCCI IMMITIS DNA PROBE 87149 $144.75 03092079 HB FUNGAL IDENTIFICATION 87106 $25.00 03092090 HB HTLV-1/HTLV-2 DNA PCR 87798 $75.76 03092091 HB URN NICOTINE/COTININE SCRN 80323 $35.00 03092092 HB GHRELIN 83519 $305.00 03092093 HB GASTRIN RELEASING PEPTIDE 83519 $200.00 03092094 HB GROWTH HORMONE RELEAS HORM 83519 $225.00 03092095 HB INTERLEUKIN 1A 83519 $225.00 03092096 HB INTERLEUKIN 10 83519 $325.00 03092098 HB NMO ANTIBODY 83516 $314.36 03092099 HB RISPERIDONE 83789 $38.60 03092100 HB INTERLEUKIN 1 BETA 83519 $225.00 03092101 HB TESTOSTERONE, FR (MALE) 84402 $13.50 03092102 HB TESTOSTERONE, FR (FEM/CHLD) 84402 $47.90 03092103 HB LAB T CRUZI ANTIBODY, RIPA 86753 $360.00 03092104 HB LAB B PERTUSSIS IGG 86615 $14.07 03092105 HB LAB BABESIA MICROTI PCR 87798 $245.30

Ancillary FY22 101 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092106 HB HERPESVIRUS 7 (HHV-7) PCR 87799 $140.89 03092108 HB LAB ANNA FLUOR AB; TIT EA 86256 $89.19 03092109 HB LAB INTERLEUKIN 3 83519 $325.00 03092110 HB LAB INTERLEUKIN 4 83519 $275.00 03092114 HB LAB URN SALICYLATE 80329 $65.00 03092117 HB LAB URN CYCLIC AMP 82030 $25.60 03092122 HB LAB STOOL LACTOFERRIN 83630 $60.31 03092127 HB LAB FACTOR H 86160 $55.00 03092128 HB LAB BIOTIN 84591 $90.00 03092129 HB LAB STOOL CHYMOTRYPSIN 84311 $14.48 03092130 HB LAB THROMBOPOIETIN 83520 $86.85 03092131 HB LAB INF A H1N1 (2009) PCR 87502 $91.68 03092132 HB LAB HMPV PCR 87798 $276.71 03092134 HB LAB ADENOVIRUS PCR 87798 $79.13 03092136 HB LAB INFLUENZA A-B PCR 87502 $72.38 03092140 HB LAB LEGIONELLA PCR AMP PRB 87541 $39.58 03092141 HB LAB LEGION PCR AMP PRB NOS 87798 $39.55 03092147 HB LAB IBDSGI IMM ASS QU NOS 83520 $18.74 03092148 HB LAB IBDSGI CHEM LUM ASSAY 82397 $20.45 03092149 HB LAB IBDSGI CRP 86140 $7.49 03092156 HB LAB METHEMOGLOB REDUCTASE 82657 $250.46 03092157 HB LAB FLUCYTOSINE,SERUM 82542 $125.14 03092158 HB LAB MP ASPA GENE ANALYSIS* 81200 $75.00 03092163 HB LAB MP BLM GENE ANALYSIS* 81209 $75.00 03092184 HB LAB MP FANCC GENE ANALYSIS* 81242 $75.00 03092185 HB LAB MP FMR1 GEN ANAL EVAL* 81243 $228.00 03092187 HB LAB MP FLT3 GENE ANALYSIS* 81245 $150.00 03092190 HB LAB MP HEXA GENE ANALYSIS* 81255 $75.00 03092193 HB LAB MP IKBKAP GENE ANALYSIS* 81260 $75.00 03092207 HB LAB MP MCOLN1 GENE ANALYSIS* 81290 $75.00 03092222 HB LAB MP NPM1 GENE ANALYSIS* 81310 $300.00 03092228 HB LAB MP SMPD1 GENE ANALYSIS* 81330 $75.00 03092248 HB LAB MP PROC LEVL 2* 81401 $166.67 03092250 HB LAB MP PROC LEVL 4* 81403 $340.00 03092269 HB LAB NMRLP LIPOPROT BLD NMR 83704 $38.50 03092270 HB LAB NMRLP LIPID PANEL 80061 $16.50 03092282 HB LAB PFRBC ASY RBC PRTPRPH 84202 $63.50 03092285 HB LAB BHRM BORRELIA AB 86619 $69.58 03092286 HB LAB LGVF CHLAMYDIA AB 86631 $5.78 03092287 HB LAB LGVF CHLAMYDIA IGM AB 86632 $5.78 03092288 HB LAB HGEGM EHRLICHIA AB 86666 $15.68 03092289 HB LAB MI2Q NUCLEAR AG AB 86235 $84.92

Ancillary FY22 102 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092290 HB LAB NMPQ IMASY QT NS NONAB 83520 $67.06 03092292 HB LAB LPTN CHEMILUM ASSAY 82397 $70.88 03092293 HB LAB RNP3R IMSY QT NS NONAB 83520 $56.94 03092294 HB LAB AGAL ENZYME CELL ACTV 82657 $200.00 03092298 HB LAB TPA FIBRNLYTIC PLASMIN 85415 $119.00 03092308 HB MALARIA IGG 86750 $88.00 03092336 HB T-CELL LYMPH SUBSETS BAL 86356 $12.33 03092340 HB HEPATITIS DELTA ANTIGEN* 87380 $125.00 03092341 HB PORPHOBILIN DEAMINASE, RBC 82657 $77.00 03092349 HB COCAINE/BENZOYLECGONINE 80353 $54.88 03092350 HB PHOSPHATIDYLSERINE AB 86148 $11.58 03092351 HB ASPERGILLUS AB, EIA 86606 $6.17 03092352 HB PHOSPHATIDYLETHANOLAMINE AB 83520 $14.48 03092353 HB MULLERIAN INHIBITORY SUBS 83520 $36.67 03092354 HB PHOSPHATIDYLINOSITOL AB 83520 $11.58 03092355 HB PHOSPHATIDYLCHOLINE AB 83520 $14.48 03092356 HB FIP1L1-PDGFRA CYG DNA PRB 88271 $22.52 03092357 HB FIP1L1 CYG 100-300 88275 $135.10 03092358 HB FIP1L1 CYG INTERP & RPT 88291 $67.55 03092359 HB HERPES SIMPLEX WESTERN BLOT 86695 $60.79 03092360 HB HERPES SIMPLEX TYPE 2 86696 $140.00 03092367 HB CTCB CIRCULATING TUM BREAST 86152 $503.73 03092369 HB CTCC CIRCULATING TUM COLON 86152 $503.73 03092371 HB CRTCP CIRCULATING TUM PROST 86152 $503.73 03092373 HB VWF QUANTITATIVE MULTIMERS 85247 $147.00 03092374 HB SEROTONIN RLS ASSAY 86022 $166.00 03092376 HB JCV ANTIBODY NEUTRALIZATION 86790 $563.56 03092377 HB FACTOR V BLD CLOT TEST 85220 $93.13 03092378 HB FACTOR INHIBITOR TEST 85335 $93.12 03092379 HB FACTOR VIII BLD CLT TEST 85240 $78.50 03092381 HB FACTOR IX BLD CLT TEST 85250 $142.81 03092382 HB FACTOR IX INHIBITOR TEST 85335 $84.91 03092383 HB FACTOR XI BLD CLT TEST 85270 $89.60 03092384 HB FACTOR XI INHIBITOR TEST 85335 $64.40 03092386 HB INTERLEUKIN 6* 83520 $95.54 03092388 HB FACTOR 13 ACTIVITY 85290 $38.60 03092389 HB INTERLEUIN 2 RECEPTOR 84238 $123.62 03092390 HB HU, YO, RI RFLX TO TITER/WB 86255 $51.71 03092391 HB HU WESTERN BLOT 84181 $96.50 03092392 HB HU TITER 86256 $50.00 03092393 HB YO WESTERN BLOT 84181 $100.00 03092395 HB RI WESTERN BLOT 84181 $96.50

Ancillary FY22 103 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092397 HB HU AB RFLX TO WB/TITER 86255 $28.95 03092398 HB HU, YO, RI RFLX WB/TIT, CSF 86255 $93.55 03092399 HB YO AB REFLEX TO WB/TITER 86255 $40.28 03092400 HB MOT SEN NEUR WEST BLOT 84181 $16.67 03092401 HB MOT SEN NEUR FLUOR AB SCRN 86255 $16.67 03092402 HB MOT SEN NEUR IMMASSY NO AB 83520 $16.67 03092403 HB RI ANTIBODY RFLX WB/TITER 86255 $85.89 03092404 HB HU WESTERN BLOT, CSF 84181 $269.24 03092406 HB YO WESTERN BLOT, CSF 84181 $135.10 03092408 HB RI WESTERN BLOT, CSF 84181 $96.50 03092410 HB MAG WB RFLX SGPG/MAG EIA 84181 $43.43 03092411 HB MAG-SGPG IGM EIA 83520 $44.41 03092412 HB MAG IGM EIA 83520 $47.29 03092413 HB SENP FLUOR AB SCRN 86255 $37.56 03092414 HB SENP WESTERN BLOT 84181 $37.55 03092415 HB GANGLIOSIDE PANEL 83520 $59.15 03092416 HB MNP WESTERN BLOT 84181 $90.70 03092417 HB MNP IMMASSY QU NOS NONAB 83520 $82.20 03092418 HB C PSITTACI ANTIBODY 86631 $7.71 03092419 HB C PSITTACI ANTIBODY IGM AB 86632 $7.70 03092420 HB ARBOVIRUS AB, CA, IFA (CSF) 86651 $45.56 03092421 HB ARBOVIRUS AB, EA EQ 86652 $45.56 03092422 HB ARBOVIRUS AB, ST LO 86653 $41.56 03092423 HB ARBOVIRUS AB, WE EQ 86654 $41.56 03092424 HB BLADDER TUMOR AG 86294 $156.00 03092425 HB FACTOR II PT 85730 $54.98 03092426 HB FACTOR II PT 85610 $35.96 03092427 HB FACTOR II PROTHROMBIN 85611 $36.09 03092428 HB FACTOR II BLD CLT FAC 85210 $118.95 03092429 HB FACTOR II FAC INHIB TEST 85335 $117.92 03092430 HB FACTOR X THROMB TIM PART 85730 $49.41 03092431 HB FACTOR X PT 85610 $32.32 03092432 HB FACTOR X PROTHROMBIN 85611 $32.44 03092433 HB FACTOR X BLD CLT FAC 85260 $147.42 03092434 HB FACTOR X FAC INHIB TEST 85335 $105.97 03092436 HB SENSORY NEUROPATH XP AB 83516 $143.19 03092437 HB SENSORY NEUROPATH IMM ASSY 83520 $143.19 03092438 HB GALOP AB 83520 $145.04 03092439 HB SULFATIDE AB 83520 $129.50 03092440 HB NEOCOMPLETE IMMASSY NONAB 83516 $75.00 03092441 HB NEOCOMPLETE RIA NONAB 83519 $50.00 03092442 HB NEOCOMPLETE WEST BLT 84181 $150.00

Ancillary FY22 104 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092443 HB NEOCOMPLETE PROT WB 84182 $25.00 03092444 HB NEOCOMPLETE FLUOR AB SC 86255 $50.00 03092445 HB NEOENCEPHALITIS IMMASSY NAB 83516 $154.95 03092446 HB NEOENCEPHALITIS RIA NONAB 83519 $154.91 03092447 HB NEOENCEPHALITIS WEST BLT 84181 $154.95 03092448 HB NEOENCEPHALITIS PROT WB 84182 $154.95 03092449 HB NEOENCEPHALITIS FLUOR AB SC 86255 $154.95 03092450 HB LEMS ANTIBODY 83519 $149.63 03092459 HB MUSK RIA NON-AB 83519 $491.40 03092481 HB ENDOMYSIAL ANTIBODY, IGG 86256 $47.50 03092483 HB ADEN DEAMINASE, PERIT FL 84311 $39.20 03092489 HB COMPLEMENT C7 86160 $41.98 03092490 HB COMPLEMENT C8 86160 $78.73 03092491 HB COMPLEMENT C9 86160 $57.90 03092492 HB HOUST DUST GREER (H1) IGE 86003 $5.58 03092493 HB HSE DST HOLL-STR (H2) IGE 86003 $5.58 03092494 HB SUNFLOWER SEED (K84) IGE 86003 $5.58 03092495 HB A FUMIGATUS (M3) IGE 86003 $5.58 03092497 HB BRUCELLA IGM AGGLUTINATION 86622 $11.58 03092498 HB CSF GAD 86341 $120.00 03092499 HB ADEN DEAM, PERICARD FL 84311 $109.24 03092500 HB 5 HIAA PLASMA 82542 $305.00 03092501 HB FEB AGLUT AB; RICKETTSIA 86757 $9.28 03092502 HB FEB AGLUT AB; BRUCELLA 86622 $9.28 03092503 HB FEB AGLUT AB; SALMONELLA 86768 $9.28 03092504 HB PT.SERA DIFF ABSORPTION-ARC 86978 $60.00 03092505 HB PRETREAT RBC'S ENZM EA-ARC 86971 $20.00 03092507 HB PLATELET ANTIBODY SCREEN* 86022 $252.00 03092508 HB LAB PLATELET XROSSMATCH 86022 $160.00 03092510 HB ANTIBODY ELUTION (RBC)-ARC 86860 $75.00 03092514 HB LAB HLA MATCHING LARC 86813 $383.00 03092515 HB LAB AJWQ F5 GENE 81241 $75.00 03092516 HB LAB CELG HLA II TYP1 LOC HR 81382 $217.75 03092517 HB LAB CELPL HLA II TYP LOC HR 81382 $232.83 03092518 HB LAB CX26 GJB2 GENE FULL SEQ 81252 $495.00 03092519 HB LAB CYP2D6 GENE COM VAR 81226 $199.76 03092520 HB LAB FLT3R UNLISTED MOL PATH 81479 $150.00 03092521 HB LAB HB5GQ GENOTYPE DNA HEPB 87912 $125.00 03092522 HB LAB IBDSGI UNLISTD MOL PATH 81479 $42.13 03092525 HB LAB LACTP MOPATH PROC LEV 1 81400 $198.32 03092526 HB LAB MEN1 MOPATH PROC LEV 6 81405 $543.75 03092527 HB LAB MEN1 MOPATH PROC LEV 5 81404 $543.75

Ancillary FY22 105 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092528 HB LAB PANCR CFTR GENE FUL SEQ 81223 $786.67 03092529 HB LAB PANCR MOPATH PROC LEV 5 81404 $786.67 03092531 HB LAB PCDQ UNLISTED MOLPAT 81479 $668.75 03092534 HB LAB SMAQ MOPATH PRO LEVEL 4 81401 $475.00 03092536 HB MOL SPINK1 POLYMORPHISM 81404 $490.00 03092537 HB LAB TPMT MOPATH PROC LEV 2 81335 $264.65 03092540 HB LAB ATHALI HBA1/HBA2 GENE 81257 $378.00 03092541 HB LAB ATHAL MOPATH PROC LEV 6 81405 $600.00 03092542 HB LAB APOEA MOPATH PROC LEV 2 81401 $383.50 03092543 HB LAB ATAX UNLISTED MOL PATH 81443 $277.35 03092544 HB LAB ATAX MOPATH PROC LEV 6 81443 $277.35 03092545 HB LAB ATAX MOPATH PROC LEV 2 81443 $277.35 03092546 HB LAB ATAX MOPATH PROC LEV 7 81443 $277.35 03092547 HB LAB ATAX MOPATH PROC LEV 5 81443 $277.35 03092548 HB LAB CMTA MOPATH PROC LEV 6 81405 $319.76 03092549 HB LAB CMTA UNLISTED MOL PATH 81479 $319.78 03092550 HB LAB CMTA MOPATH PROC LEV 5 81404 $319.76 03092551 HB LAB CMTA MOPATH PROC LEV 7 81406 $319.76 03092552 HB LAB CMTA PMP22 GEN FULL SEQ 81325 $319.78 03092553 HB LAB CMTA PMP22 GEN DUP/DEL 81324 $319.78 03092554 HB LAB CMTA MOPATH PROC LEV 4 81403 $319.78 03092555 HB LAB DM1 MOPATH PROC LEV 2 81401 $570.50 03092556 HB LAB MP ASPA GENE ANALYSIS* 81200 $137.51 03092557 HB LAB MP FLT3 GENE ANALYSIS* 81245 $166.67 03092558 HB LAB MP HEXA GENE ANALYSIS* 81255 $114.59 03092560 HB LAB MP NPM1 GENE ANALYSIS* 81310 $166.67 03092561 HB LAB MP PROC LEVL 5* 81404 $490.00 03092562 HB LAB GROWTH HORMONE, 5 SPEC 83003 $12.06 03092563 HB LAB GROWTH HORMONE, 9 SPEC 83003 $12.06 03092564 HB LAB MYG PANEL RIA NONAB 83519 $26.38 03092565 HB LAB MYG PNL FL AB; SC EA AB 86255 $79.13 03092566 HB LAB MOLD ALLERGY ASY OF IGE 82785 $26.72 03092567 HB LAB MOLD ALRGN SP IGE Q/SQ 86003 $1.78 03092568 HB LAB PLATELET AB INDIRECT 86022 $79.61 03092569 HB LAB PLATELET AB DIRECT 86023 $33.78 03092570 HB LAB 1,5-ANHYDROGLUCITOL 84378 $26.06 03092571 HB LAB ANSER/INFLIXIMAB LEVEL 84999 $400.00 03092572 HB PT ABO TYPE (ARC) 86900 $24.00 03092573 HB PT RH TYPE (ARC) 86901 $15.00 03092575 HB PT RBC PHENOTYPE EACH (ARC) 86905 $22.00 03092576 HB ANTIBODY SCR EA TECH (ARC) 86850 $38.00 03092577 HB ANTIBODY ID EACH TECH (ARC) 86870 $50.00

Ancillary FY22 106 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092578 HB DAT EACH ANTISERA (ARC) 86880 $17.00 03092579 HB ABID EA SELECTED CELL (ARC) 86885 $10.00 03092580 HB TITRATION EACH (ARC) 86886 $76.00 03092581 HB RH PHENOTYPE (ARC) 86906 $42.00 03092582 HB COLD AGGLUT. SCREEN (ARC) 86156 $32.00 03092584 HB INHIBITION OF SERUM (ARC) 86977 $40.00 03092585 HB INCUB. OF SER W DRUGS (ARC) 86975 $138.00 03092586 HB 17-KETOSTEROIDS, FRAC. 83586 $19.30 03092587 HB ALPHA-1-ANTITRYPSIN 82103 $21.23 03092588 HB AMINO ACID, LC/MS, PLASMA 82139 $72.38 03092589 HB ACETYLCHOLINE REC BLOC AB 83519 $46.32 03092590 HB ACE, SERUM 82164 $8.69 03092591 HB ACETYLCHOLINE REC MOD AB 83519 $38.00 03092593 HB ACYLCARNITINE, PLASMA 82017 $82.99 03092594 HB ACETYLCHOLINE REC BINDING 83519 $43.43 03092595 HB ACTH, PLASMA 82024 $9.65 03092596 HB ARGININE VASOPRESSIN 84588 $24.13 03092597 HB ADENOVIRUS ANTIBODY,SERUM 86603 $10.62 03092598 HB GBM AB 83520 $24.13 03092599 HB ALUMINUM 82108 $21.23 03092600 HB ALUMINUM RANDOM U 82108 $44.87 03092602 HB AMIODARONE & METABOLITE 80151 $27.99 03092603 HB AMITRIPTYLINE 80335 $11.58 03092605 HB AMPHETAMINE BY GC/MS, UR 80324 $22.00 03092607 HB ANDROSTENEDIONE, LS/MS/MS 82157 $18.50 03092608 HB CLOMIPRAMINE 80299 $16.89 03092609 HB ALK. PHOSPHATASE ISO 1 84080 $7.40 03092610 HB ALK. PHOSPHATASE ISO 2 84075 $2.60 03092611 HB ALDOSTERONE 82088 $15.05 03092612 HB PRA,LC/MS/MS 84244 $8.11 03092614 HB ARYLSULFATASE A 84311 $60.80 03092617 HB VITAMIN B12 BIND CAPACITY 82608 $24.20 03092619 HB B MICROTI AB (IGG, IGM) 86753 $16.89 03092620 HB ASPERGILLUS ANTIGEN 87305 $60.00 03092621 HB BETA-HYDROXYBUTYRATE 82010 $40.14 03092622 HB BENZODIAZEPINES, SERUM 80346 $68.52 03092624 HB BETA-GLOBIN GENE DOSAGE 81404 $437.82 03092625 HB BUPROPION AND METAB,S/P 80299 $95.54 03092626 HB ANGIOTENSIN CONV ENZ 82164 $12.00 03092628 HB CANDIDA ANTIBODY, ID 86628 $52.06 03092629 HB CARNITINE, LC/MS/MS 82379 $29.92 03092630 HB CAROTENE, SERUM 82380 $14.48

Ancillary FY22 107 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092631 HB CATECHOLAMINES, PLASMA 82384 $47.55 03092632 HB COBALT, BLOOD 83018 $24.13 03092633 HB CADMIUM, 24-HOUR URINE 82300 $15.44 03092634 HB CADMIUM,RANDOM URINE 82300 $15.44 03092635 HB CADMIUM, BLOOD 82300 $24.61 03092636 HB IMMUNOGLOBULINS(G,A,M)CSF 82784 $10.62 03092637 HB HIV-1 RNA, QN PCR, CSF 87536 $72.38 03092638 HB CHROMIUM, SERUM 82495 $21.47 03092639 HB HSV 1/2 (IGG) 86694 $99.40 03092640 HB IMMUNE COMPLEX, C1Q 86332 $15.68 03092642 HB C1 INHIBITOR, FUNCTIONAL 86161 $16.41 03092643 HB C1 INHIBITOR, PROTEIN 86160 $16.41 03092644 HB LACTIC ACID, CSF 83605 $24.90 03092657 HB 11-DEOXYCORTISOL,LC/MS/MS 82634 $26.21 03092658 HB NSE, CSF 86316 $48.25 03092659 HB COLD HEMAGGLUTININS 86157 $8.80 03092660 HB COENZYME Q10 82542 $54.04 03092661 HB C-PEPTIDE 84681 $10.62 03092662 HB COMPLEMENT, TOTAL (CH50) 86162 $8.44 03092663 HB TREPONEMA PALLIDUM AB 86780 $5.79 03092664 HB COPPER 82525 $9.65 03092665 HB VDRL, CSF 86592 $4.83 03092666 HB COXSACKIE B (1-6) AB,S 86658 $11.21 03092667 HB CYANIDE, BLOOD 82600 $14.48 03092668 HB CYSTINE, 24-HOUR URINE 82131 $25.73 03092670 HB DNASE-B ANTIBODY 86215 $15.44 03092671 HB DEXAMETHASONE 80299 $61.08 03092672 HB DENGUE FEVER AB (IGG,M) 86790 $36.19 03092673 HB DIGITOXIN, S/P 80299 $53.00 03092674 HB DHEA,UNCONJUGATD,LC/MS/MS 82626 $12.31 03092675 HB DIHYDROTESTOSTERON,LCMSMS 80327 $46.93 03092676 HB DESIPRAMINE 80335 $17.61 03092677 HB DISOPYRAMIDE, SERUM 80299 $14.48 03092680 HB DOXEPIN 80335 $21.23 03092681 HB DIPHENHYDRAMINE, S/P 82542 $56.00 03092683 HB DRUG SCREEN PANEL 1 G0480 $12.59 03092685 HB DHEA SULFATE 82627 $7.00 03092686 HB EBV EA-D AB (IGG) 86663 $6.76 03092687 HB EBV EBNA AB (IGG) 86664 $9.36 03092688 HB E. CHAFFEENSIS AB (M) 86666 $12.07 03092689 HB E. CHAFFEENSIS AB (IGG) 86666 $12.06 03092690 HB ECHINOCOCCUS AB (IGG) 86682 $65.14

Ancillary FY22 108 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092691 HB ENTAMOEBA HIST. IGG, ELIS 86753 $18.34 03092692 HB ESTRONE, LC/MS/MS 82679 $22.47 03092693 HB ETHOSUXIMIDE, SERUM 80168 $16.50 03092694 HB ETHYLENE GLYCOL 82693 $11.58 03092695 HB FECAL FAT, QUALITATIVE 82705 $8.98 03092696 HB FELBAMATE, SERUM 80167 $24.13 03092697 HB FENTANYL AND NORFENTANYL, 80361 $58.87 03092698 HB FUNGITELL(R) (1-3) 87449 $75.00 03092699 HB FIBRINOGEN AG,NEPHLOMETRY 85385 $14.48 03092700 HB FLECAINIDE, SERUM 80181 $17.16 03092701 HB LIPASE, PLEURAL FLUID 83690 $12.61 03092702 HB FAMIL. MEDITERRANEAN FEVE 88299 $241.25 03092704 HB COPPER, FREE 82525 $63.00 03092705 HB FRUCTOSAMINE 82985 $5.79 03092706 HB G-6-PD, QN 82955 $13.51 03092707 HB GAD-65 ANTIBODY 83519 $24.13 03092708 HB ASPERGILLUS ANTIGEN* 87305 $38.60 03092709 HB GLUCAGON 82943 $15.44 03092710 HB GLYCATED ALBUMIN 82985 $37.50 03092711 HB HCV FIBROSURE APOLIPOPROT 82172 $73.65 03092712 HB HCV FIBROSURE BILI TOT 82247 $24.72 03092713 HB HCV FIBROSURE GGT 82977 $35.47 03092714 HB HCV FIBROSURE HAPTOGLOB QU 83010 $61.94 03092715 HB HCV FIBROSURE NEPH N SPEC 83883 $66.96 03092716 HB HCV FIBROSURE 84460 $26.04 03092717 HB HEREDITARY HEMOCHROMATOS 81256 $72.38 03092718 HB H.INFLUENZAE TYPE B IGG 86317 $11.10 03092719 HB HISTAMINE, PLASMA 83088 $51.69 03092720 HB HISTONE ANTIBODIES 83516 $19.30 03092721 HB ARSENIC, BLOOD 82175 $10.21 03092722 HB LEAD, BLOOD 83655 $10.20 03092723 HB MERCURY, BLOOD 83825 $10.20 03092724 HB ARSENIC, 24-HOUR URINE* 82175 $14.70 03092725 HB LEAD, 24-HOUR URINE 83655 $9.55 03092726 HB MERCURY, 24-HOUR URINE 83825 $12.48 03092727 HB 17-HYDROXYPROGESTERONE 83498 $13.99 03092728 HB HTLV-I/II AB W/RFL CONF 86790 $13.80 03092729 HB HTLV-I/II, CONFIRM ASSAY 86689 $22.73 03092730 HB HOMOVANILLIC ACID, 24 HR 83150 $21.23 03092731 HB IA-2 ANTIBODY 86341 $48.25 03092732 HB IGA SUBCLASSES IGA/IGD/IGG/IGM EA 82784 $17.05 03092733 HB IGA SUBCLASSES IGG 1, 2, 3 OR 4, EA 82787 $7.27

Ancillary FY22 109 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092735 HB ACCUTYPE(R) IL28B 81400 $57.90 03092736 HB IMIPRAMINE 80335 $21.23 03092738 HB IODINE, SERUM/PLASMA 82542 $24.13 03092739 HB JAK2 EXONS 12, 13,QL,LEUM 81403 $168.88 03092740 HB JO-1 ANTIBODY 86235 $15.50 03092745 HB LAMOTRIGINE 80175 $9.17 03092746 HB LEAD, BLOOD* 83655 $4.83 03092747 HB LEGIONELLA AB 86713 $23.74 03092748 HB LIDOCAINE 80176 $18.58 03092749 HB LD ISOENZYME PNL - LACTATE 83615 $11.11 03092750 HB LD ISOENZYME PNL - LDH ENZ 83625 $23.60 03092751 HB LORAZEPAM 80346 $31.85 03092752 HB LIPOPROTEIN (A) 83695 $21.00 03092753 HB LP-PLA2 83698 $50.00 03092754 HB LEPTOSPIRA AB SCR W/RFL 86720 $32.00 03092755 HB PREGABALIN 82542 $108.08 03092761 HB MERCURY, BLOOD* 83825 $11.69 03092763 HB MANGANESE 83785 $27.02 03092765 HB PROLACTIN,TOTAL,MONOMERIC 84146 $9.65 03092766 HB METANEPHRINES, 24HR URINE 83835 $16.41 03092767 HB MYOGLOBIN, URINE 83874 $14.48 03092769 HB NEURON SPECIFIC ENOLASE 86316 $34.04 03092770 HB NORTRIPTYLINE* 80335 $15.83 03092771 HB 5' NUCLEOTIDASE 83915 $52.45 03092772 HB VDRL, SERUM 86592 $8.70 03092773 HB OLANZAPINE 80299 $71.41 03092774 HB OXYCODONE SCRN/CONFIRM 80361 $64.66 03092775 HB PENTOBARBITAL 80345 $17.37 03092776 HB B-TYPE NATRIURETIC PEP 83880 $38.60 03092777 HB ADA, PLEURAL FLUID 84311 $79.98 03092778 HB PAI-1 ANTIGEN 85415 $53.08 03092780 HB PORPHYRINS, FRACT, PLASMA 84311 $88.78 03092782 HB PROINSULIN 84206 $38.60 03092783 HB PROCAINAMIDE 80192 $17.37 03092784 HB PORPHYRINS,FRACT,RAND UR 84120 $16.41 03092787 HB QUINIDINE 80194 $13.27 03092788 HB RETINOL BINDING PROTEIN 83883 $17.37 03092789 HB RETT SYNDROME MUTATION 83898 $13.27 03092790 HB B HENSELAE IGG,M W/RFL 86611 $6.03 03092791 HB RUBELLA AB IGM 86762 $8.30 03092792 HB RUFINAMIDE, SERUM/PLASMA 80210 $62.76 03092793 HB T3, REVERSE 84482 $14.23

Ancillary FY22 110 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092794 HB S CEREVISIAE AB (IGG,IGA) 86671 $38.48 03092795 HB E. HISTOLYTICA AG 87337 $32.81 03092796 HB SELENIUM 84255 $24.61 03092799 HB LYSOZYME, SERUM 85549 $17.37 03092800 HB CLARISURE OLIGO-SNP,POST 81229 $910.00 03092803 HB STONE ANALYSIS 82365 $11.58 03092804 HB STRIATED MUSCLE AB 86255 $11.58 03092806 HB T3, TOTAL 84480 $7.27 03092808 HB THIOCYANATE, SERUM 84430 $27.74 03092811 HB TOPIRAMATE 80201 $33.78 03092813 HB TRAZODONE 80299 $23.16 03092814 HB OXCARBAZEPINE METABOLITE 80183 $35.71 03092815 HB TROPONIN T 84484 $16.16 03092816 HB TRYPSIN 83519 $33.78 03092817 HB T.PALLIDUM IGG & IGM AB 86780 $5.79 03092818 HB AMINO ACID, LC/MS, URINE 82139 $72.38 03092819 HB ACYLGLYCINES QUANT.,URINE 82542 $370.15 03092820 HB DELTA ALA, 24 HR URINE 82135 $26.54 03092821 HB ALDOSTERONE, URINE 82088 $30.88 03092824 HB CATECHOLAMINES, 24-HR UR 82384 $26.54 03092826 HB CHROMIUM 82495 $119.49 03092827 HB COPPER, 24-HOUR URINE 82525 $17.37 03092828 HB CORTISOL, FREE, URINE 82530 $11.58 03092829 HB DIURETICS PANEL, URINE 80307 $83.00 03092831 HB LEAD, 24-HOUR URINE* 83655 $8.20 03092832 HB MURAMIDASE, URINE 85549 $80.34 03092833 HB MERCURY, 24-HOUR URINE* 83825 $15.44 03092834 HB MANGANESE, 24-HOUR URINE 83785 $36.19 03092837 HB UREA NITROGEN, 24 HR UR 82397 $215.35 03092838 HB OXALIC ACID 24U W/O CREAT 83945 $11.58 03092839 HB PORPHOBILINOGEN, 24 HR UR 84110 $24.13 03092840 HB FLUNITRAZEPAM AND METAB,U G0480 $160.19 03092841 HB VMA, 24 HR URINE 84585 $11.58 03092842 HB DIAZEPAM AND METABOLITE 80346 $97.74 03092843 HB VAP TM CHOLESTEROL TRIG 84478 $11.59 03092844 HB VAP TM CHOL LIPO BL HR FR 83701 $49.41 03092845 HB VITAMIN B1 (THIAMINE),(B)* 84425 $11.58 03092846 HB VITAMIN B1,LCMSMS 84425 $11.58 03092847 HB VITAMIN B5 84591 $75.00 03092848 HB VITAMIN D, 25-HYDROXY 82306 $9.00 03092849 HB VITAMIN D(1,25OHD),LCMSMS 82652 $13.12 03092850 HB VITAMIN C, SERUM 82180 $14.00

Ancillary FY22 111 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092851 HB VERY LONGCHAIN FATTY ACID 82726 $147.00 03092853 HB VITAMIN E (TOCOPHEROL) 84446 $12.60 03092854 HB COUMADIN 82542 $17.37 03092855 HB ALPRAZOLAM, QN, SERUM 80346 $100.00 03092858 HB COCAINE CONFIRMATION GCMS 80353 $56.87 03092863 HB CANNABINOIDS 82542 $55.00 03092864 HB BENZODIAZEPINES, CONFIRM 80346 $42.90 03092865 HB ZINC 84630 $8.93 03092866 HB ZINC, 24 HR URINE 84630 $34.84 03092867 HB ZONISAMIDE 80203 $47.77 03092868 HB ZINC PROTOPORPHYRIN (ZPP) 84202 $6.50 03092869 HB OVA1 84999 $585.00 03092870 HB CYP2C19 GENOTYPE 81225 $168.88 03092871 HB UGT1A1 GEN PLYMRPH (TA RP) 81350 $210.00 03092872 HB VKORC1 GENOTYPING 81227 $205.06 03092873 HB CYP2C9 GENOTYPING 81355 $205.07 03092876 HB T-CELL REC EXC CIRC (TRECS) 81479 $1.00 03092877 HB PRTRT RBC W/CHEM OR DRG ARC 86970 $42.00 03092881 HB RICKETTSIA IGM TITER RICKM 86757 $22.20 03092886 HB LAB HMEUR ASSAY ARSENIC 82175 $15.31 03092887 HB LAB HMEUR ASSAY URN CREAT 82570 $4.25 03092888 HB LAB HMEUR ASSAY LEAD 83655 $9.78 03092889 HB LAB HMEUR ASSAY MERCURY 83825 $13.18 03092890 HB LAB MTFRR ASSAY URN CREAT 82570 $8.44 03092891 HB LAB MTFRR METANEPHRINES 83835 $25.34 03092892 HB LAB PRPRQ URINE PORPHYRINS 84120 $16.41 03092893 HB LAB UALAR AMINOLEVULINIC AC 82135 $26.54 03092894 HB LAB UCATR 3 CATECHOLAMINES 82384 $25.85 03092895 HB LAB UCATR ASSAY URN CREAT 82570 $6.48 03092896 HB LAB UCBLTR QUNT SCN METALS 83018 $55.40 03092901 HB LAB UCRTFR CORTISOL FREE 82530 $8.68 03092902 HB LAB UCRTFR ASSAY URN CREAT 82570 $2.90 03092903 HB LAB UHVAR HOMOVANILLIC ACID 83150 $16.98 03092904 HB LAB UHVAR ASSAY URN CREAT 82570 $4.25 03092905 HB LAB ULEDR ASSAY LEAD 83655 $5.74 03092906 HB LAB ULEDR ASSAY URN CREAT 82570 $2.46 03092907 HB LAB UMERR ASSAY MERCURY 83825 $11.58 03092908 HB LAB UMERR ASSAY URN CREAT 82570 $3.86 03092909 HB LAB UMNGR ASSAY MANGANESE 83785 $29.89 03092910 HB LAB UMNGR ASSAY URN CREAT 82570 $6.30 03092911 HB LAB UNIKR ASSAY NICKEL 83885 $38.65 03092912 HB LAB UNIKR ASSAY URN CREAT 82570 $8.15

Ancillary FY22 112 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092913 HB LAB UOXR ASSAY OXALATE 83945 $9.68 03092914 HB LAB UOXR ASSAY URN CREAT 82570 $4.80 03092915 HB LAB UPBGR PORPHOBILINOGEN 84110 $24.13 03092916 HB LAB UVMAR ASSAY URINE VMA 84585 $8.29 03092917 HB LAB UVMAR ASSAY URN CREAT 82570 $8.29 03092918 HB LAB UZNR ASSAY ZINC 84630 $17.42 03092919 HB LAB UZNR ASSAY URN CREAT 82570 $17.42 03092920 HB LAB HAEQ COMPLEMENT ANTIGEN 86160 $9.89 03092921 HB LAB HAEQ COMP/FUNC ACTIVITY 86161 $19.79 03092922 HB LAB FRPN PHENYTOIN FREE 80186 $21.71 03092923 HB LAB UARSQ ASSAY ARSENIC 82175 $13.09 03092924 HB LAB UARSR ASSAY ARSENIC 82175 $10.28 03092925 HB LAB UARSR ASSAY URN CREAT 82570 $2.81 03092926 HB LAB HV6 VIRUS ANTIBODY NOS 86790 $16.89 03092927 HB LAB MYOSQ IMMUNOASSAY NONAB 83516 $11.46 03092928 HB LAB MYOSQ NUC AGEN ANTIBODY 86235 $33.98 03092929 HB LAB UCOPR ASSAY COPPER* 82525 $17.37 03092930 HB LAB UHISQ ASSAY HISTAMINE 83088 $28.09 03092931 HB LAB AVIAN COMPLEX MIC PNL 87186 $144.48 03092932 HB FLUID CREATININE 82570 $8.70 03092933 HB FLUID AMYLASE 82150 $11.60 03092934 HB FLUID LACTATE DEHYDROGENASE 83615 $7.00 03092935 HB FLUID GLUCOSE 82945 $6.00 03092936 HB FLUID PROTEIN 84157 $6.00 03092937 HB FLUID ALBUMIN 82042 $6.00 03092938 HB FLUID CHOLESTEROL 84311 $10.60 03092939 HB FLUID BILIRUBIN 82247 $8.80 03092940 HB FLUID CHLORIDE 82438 $9.80 03092941 HB FLUID TRIGLYCERIDES 84478 $9.60 03092942 HB FLUID URIC ACID 84560 $7.80 03092943 HB FLUID UREA NITROGEN 84520 $8.70 03092944 HB FLUID SODIUM 84302 $9.70 03092945 HB FLUID POTASSIUM 84999 $10.70 03092946 HB BORON LEVEL 83018 $51.00 03092947 HB FLUID RHEUMATOID FACTOR 86431 $11.50 03092948 HB ANSER ADA 84999 $400.00 03092949 HB ANSERI FX SUBSEQUENT SAMPLE 84999 $251.25 03092950 HB ANSWER ADA SUBSEQUENT SMPLE 84999 $251.25 03092953 HB OPIATES, SERUM 80361 $77.20 03092954 HB THYROTROPIN-BIND INHB IMGLB 83519 $19.30 03092955 HB ENDOMYSIAL IGA, RFLX TITER 86255 $9.91 03092956 HB JO-1 ANTIBODY IGG 86235 $12.72

Ancillary FY22 113 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03092957 HB PHOSPHOLIPIDS 84311 $9.65 03092958 HB ASIALO-GM1 IGM 83520 $54.40 03092959 HB ASIALO-GM1 IGG 83520 $88.80 03092960 HB URINE FENTANYL 80361 $78.17 03092961 HB URINE OXYCODONE 80362 $64.66 03092962 HB URINE BUPRENORPHINE 80361 $111.45 03092963 HB CMV GENOTYPE 87910 $292.34 03092964 HB DPD GENE MUTATION 81400 $303.98 03092965 HB HIAA, 24 HOUR URINE 83497 $6.95 03092966 HB ESTRONE SULFATE 82679 $154.59 03092968 HB RETICULIN IGG SCREEN 86255 $11.82 03092969 HB DEAMIDATED GLIADIN IGA 83516 $9.91 03092970 HB DEAMIDATED GLIADIN IGG 83516 $10.27 03092971 HB DEAMIDATED GLIADIN IGA/IGG 83516 $9.91 03092972 HB TISSUE TRANSGLUTAMINASE IGA 83516 $9.91 03092973 HB TISSUE TRANSGLUTAMINASE IGG 83516 $9.60 03092974 HB SINGLE STRANDED DNA 86226 $62.84 03092975 HB IMMUNOGLOBULIN IGD 82784 $20.27 03092976 HB 17OHP, ACTH STIMULATION 83498 $14.50 03092977 HB CORTISOL, ACTH STIMULATION 82533 $2.11 03092979 HB CSF HU 86255 $95.54 03092980 HB CSF YO 86255 $82.03 03092981 HB CSF RI 86255 $103.07 03092982 HB TAYEQ B HEXOSAMINIDASE 83080 $168.00 03092983 HB MFANQ UNLISTD MOL PATH PROC 81479 $620.00 03092984 HB FLCHMQ CHROMIUM 82495 $19.00 03092985 HB FLCBQ QUANT SCREEN METALS 83018 $21.40 03092986 HB FLCCQ CHROMIUM 82495 $19.00 03092987 HB FLCCQ QUANT SCREEN METALS 83018 $21.40 03092988 HB SEAFQ ALLERGEN SPECIFIC IGE 86003 $6.70 03092989 HB DHCQ COL CHROMTGRPHY QUANT 82542 $175.00 03092990 HB 18HC MASS SPECTROMETRY QUNT 83789 $185.00 03092991 HB DLACT LACTIC ACID 83605 $300.56 03092992 HB KITQ MOPATH PROCEDURE LEV 5 81273 $334.86 03092993 HB SNPOCQ CYTG M ARY CPY N&SNP 81229 $1,061.50 03092996 HB PLCHL ASSAY SERUM CHOLINEST 82480 $11.94 03092997 HB FANQ FANCC GENE 81242 $148.37 03092998 HB FMDQ IKBKAP GENE 81260 $144.75 03092999 HB GSDQ1 G6PC GENE 81250 $308.80 03093000 HB YDELQ MOPATH PROC LEVEL 4 81403 $282.61 03093001 HB NPQ SMPD1 GENE COM VARIANTS 81330 $182.00 03093014 HB RCKGQ RICKETTSIA ANTIBODY 86757 $12.06

Ancillary FY22 114 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093015 HB QFEVR Q FEVER ANTIBODY 86638 $11.83 03093016 HB Q1GT Q FEVER ANTIBODY 86638 $28.23 03093017 HB Q2GT Q FEVER ANTIBODY 86638 $28.23 03093018 HB Q1MT Q FEVER ANTIBODY 86638 $32.62 03093019 HB Q2MT Q FEVER ANTIBODY 86638 $32.62 03093020 HB BART BARTONELLA ANTIBODY 86611 $6.03 03093021 HB BLASQ BLASTOMYCES ANTIBODY 86612 $23.81 03093022 HB AIGA IMMASY QUANT NOS NONAB 83520 $138.60 03093025 HB ACRTQ ALDOSTERONE 82088 $14.86 03093026 HB ACRTQ TOTAL CORTISOL 82533 $6.37 03093027 HB CEAPN CARCINOEMBRYONIC AG 82378 $125.00 03093031 HB SHELLFISH ALLERGY PANEL 86003 $5.58 03093032 HB ESTRADIOL, FREE 82670 $63.86 03093033 HB HIAA, CREAT RANDOM URINE 82570 $4.25 03093034 HB HIAA, 5-HIAA RANDOM URINE 83497 $8.49 03093035 HB MOPATH PROC LVL 5 MEN2 MUT 81404 $206.51 03093036 HB MOPATH PROC LVL 6 FMTC MUT 81405 $206.51 03093037 HB LOEDQ MOPATH PROC LEV 6 81405 $311.65 03093038 HB LOEDQ UNLISTED MOL PATH 81479 $311.70 03093039 HB DRGQ ASSAY OF VOLATILES 84600 $13.58 03093040 HB DRGQ DRUG SCREEN MULT CLASS G0480 $61.42 03093041 HB THEOQ ASSAY OF THEOPHYLLINE 80198 $13.51 03093043 HB LPFIMQ LIPOPROT BLD BY NMR 83704 $16.96 03093044 HB IGG4 IGG 1, 2, 3 OR 4, EACH 82787 $8.62 03093045 HB AJ4Q ASPA GENE 81200 $159.63 03093047 HB AJ4Q HEXA GENE 81255 $159.63 03093048 HB AJ4Q IKBKAP GENE 81260 $159.62 03093049 HB NEOP RIA NONANTIBODY 83519 $68.89 03093050 HB HISTD HISTOPLASMA 86698 $18.09 03093053 HB HV6PQ HHV-6, DNA, QUANT 87533 $265.38 03093054 HB MEAPQ RUBEOLA ANTIBODY 86765 $8.45 03093055 HB SLYT ASSAY OF PHOSPHORUS 84100 $16.20 03093070 HB OXL OXALATE 83945 $82.00 03093071 HB CRTSNQ CORTISONE LEVEL 83789 $110.98 03093072 HB CYCSQ CYCLOSERINE LEVEL 80299 $82.33 03093073 HB OSMUQ RBC FRAGILITY 85557 $25.81 03093074 HB SNPPCQ CHROM MICROARRAY POC 81229 $1,590.00 03093075 HB HTLVC HTLV CONFIRMATION 86689 $21.93 03093077 HB GAL3Q GALECTIN-3 82777 $103.10 03093078 HB VOLSQ VOLATILES 84600 $45.40 03093079 HB RISQ RISTOCETIN CO-FACTOR 85245 $27.02 03093080 HB RABVQ VAC RESP END PNT TTR 86382 $90.00

Ancillary FY22 115 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093081 HB LYMR LYME DIS AB W/RFLX IB 86618 $8.69 03093082 HB SALMAB SALMONELLA AB PANEL 86768 $7.00 03093083 HB RTCAQ RETICULIN IGA 86255 $11.77 03093084 HB BHGT B HENSELAE IGG TITER 86611 $14.48 03093086 HB BQGT B QUINTANA IGG TITER 86611 $37.00 03093087 HB BQMT B QUINTANA IGM TITER 86611 $6.03 03093088 HB ATAX MOPATH PROCEDURE LEV 4 81443 $277.35 03093090 HB IMMUNOHISTOCHEMICAL STAIN 88342 $55.00 03093091 HB LAB N-METHYL-D-ASP REC AB CSF 86255 $126.00 03093093 HB LAB URINE CREATINE, 24 HR 82540 $6.00 03093094 HB LAB MSUD MUTATIONAL ANALYSYS 81205 $340.65 03093095 HB LAB CSF RIBOSOMAL P ANTIBODY 83516 $62.06 03093096 HB LAB URN FREE LIGHT CHAINS 83883 $30.88 03093097 HB LAB URN BETA-2-MICROGLOB RAND 82232 $13.52 03093098 HB LAB UB2MR, CREATININE 82570 $6.75 03093099 HB LAB PSA, POST-PROSTATECTOMY 84153 $20.00 03093100 HB LAB PORPHYRINS,PLASMA 82542 $48.25 03093101 HB LAB METHEMGLOBIN 83050 $15.90 03093102 HB LAB MEASLES IGM 86765 $13.75 03093103 HB LAB LYMPHOCYTE MITOGEN SCREEN 86353 $115.80 03093104 HB LAB COCCI TP AND F 86635 $22.68 03093105 HB LAB POSACONAZOLE LEVEL 80299 $176.60 03093107 HB LAB HIV-2 DNA/RNA PCR QL 87538 $84.92 03093108 HB LAB ADENOVIRUS PCR QUANT 87799 $225.57 03093109 HB LAB FILARIA IGG4 86682 $55.97 03093110 HB LAB HEAT SHCK PRT(HSP) 70KD AB 83520 $125.00 03093111 HB LAB HT SHK PROT(HSP) 70KD WB 86804 $125.00 03093112 HB LAB INNER EAR 68KD ANTIBODY 83520 $125.00 03093113 HB N-METHYL-D-ASPARTATE REC AB 86255 $143.50 03093114 HB BRCA,GENE ANALYSIS COMP 81162 $1,763.54 03093120 HB HEP C VIR RNA NS3 GENO 87902 $607.95 03093121 HB MYCOPLASMA/UREAPLASMA PCR 87798 $80.72 03093122 HB MICROARRAY, ONC. MOL LV 7 81406 $1,621.80 03093125 HB INF AGNT DRG SUS PH GN BI 87900 $232.05 03093126 HB INF AGNT GEN NUC ACD RV TR 87901 $468.24 03093127 HB INF AGNT GEN NUC ACID HIV-1 87906 $189.71 03093128 HB LAB CALR MUTATION ANALYSIS 81219 $250.00 03093129 HB LAB C4 BINDING PROTEIN 86329 $19.30 03093130 HB LAB H PYLORI BREATH TEST 83013 $50.00 03093131 HB LAB MYD88 MUTATION 81479 $376.50 03093132 HB LAB URODSK CAL,URN QN TMDSP 82340 $3.60 03093133 HB LAB URODISK CITRATE* 82507 $3.50

Ancillary FY22 116 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093134 HB LAB URODSK CREATININE;URINE 82570 $3.50 03093135 HB LAB URODSK MG BLD;CHEMICAL 83735 $3.50 03093136 HB LAB URODISK OXALATE, URINE 83945 $3.50 03093137 HB LAB URODISK PH BDY FLD, NOS* 83986 $3.50 03093138 HB LAB URODISK PHOS URINE* 84105 $3.50 03093139 HB LAB URODISK POTASSIUM;URINE 84133 $3.50 03093140 HB LAB URODISK SODIUM; URINE* 84300 $3.50 03093141 HB LAB URODISK SULFATE, URINE* 84392 $3.50 03093142 HB LAB URODSK URIC ACID,URINE 84560 $3.50 03093143 HB LAB T CELL IMMUNE FUNCTION 86352 $150.41 03093144 HB LAB CEBPA MUTATION ANALYSIS 81218 $280.82 03093145 HB LAB OMEGA-3&6 FAT ACIDS, PL 82542 $48.25 03093146 HB LAB IMMUNOGLOBULIN IGE 82785 $7.72 03093147 HB LAB CELIAC PANEL 82784 $2.21 03093148 HB LAB CELIAC PANEL* 83516 $12.53 03093149 HB LAB IBD DIF PANEL, LEUK ID 86021 $23.49 03093150 HB LAB IBD DIF PANEL, FUNGUS NOS 86671 $23.51 03093152 HB LAB TPMT ENZYME ACTIVITY 83789 $275.05 03093153 HB LAB LIV FIBROS SCRE BIL TOT 82247 $17.21 03093154 HB LAB LIVER FIBROS SCORE GGT 82977 $24.88 03093155 HB LAB LIV IB SCR IMS INFNS QU 83520 $44.55 03093156 HB LAB LIVER FIBR SCR NEPF NES 83883 $46.85 03093157 HB LAB HIV-1TROPISM,PROVIR DNA 87906 $650.00 03093158 HB LAB MANNOSE BINDING LECTIN 83520 $24.13 03093161 HB LAB APOLIPOPROTEIN A1 82172 $10.62 03093162 HB LAB APOLIPOPROTEIN B 82172 $8.38 03093163 HB LAB APOLIPOPROTEIN A1/B 82172 $9.50 03093164 HB LAB ACQRD ANGIOEDEMA AG EA 86160 $11.41 03093165 HB LAB ACQRD ANGIOEDEMA FUNC 86161 $22.81 03093166 HB LAB CARBO DEFIC TRANSF-ADLT 82373 $82.80 03093167 HB LAB CARNITINE PALMTRNS II D 81404 $1,223.60 03093168 HB LAB STOOL PORPHYRINS 84126 $284.40 03093169 HB LAB STREP PNEUMO 23 SEROTYP 86317 $8.20 03093170 HB LAB ACT PROT C RESISTANCE 85307 $43.43 03093172 HB LAB N MENINGITIDIS IGG 86317 $12.18 03093173 HB LAB CHIKUNGUNYA IGG/IGM 86790 $45.84 03093174 HB LAB THYROGLUBULIN-BILL ONLY 84432 $40.00 03093175 HB LAB THYROGLBLN AB-BILL ONLY 86800 $27.00 03093176 HB LAB ABL T315I MUTATION 81401 $500.00 03093177 HB LAB HYDROXYPROGESTERONE 83498 $14.50 03093178 HB LAB ALZHEIMER EVAL BLD CSFA 81401 $330.13 03093179 HB LAB ALZHEIMER EVAL BLD CSFB 83520 $330.14

Ancillary FY22 117 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093180 HB LAB IGG KAPPA LAMBDA RATIOA 82784 $188.98 03093181 HB LAB IGG KAPPA LAMBDA RATIOB 83883 $138.26 03093182 HB LAB BWS/RSS MOLECULAR ANAL 81401 $148.85 03093183 HB LAB BILIARY TRACT MAL, FISH 88368 $328.80 03093184 HB LAB C TRACH/GC, TMA A 87491 $21.45 03093185 HB LAB C TRACH/GC, TMA B 87591 $21.45 03093186 HB LAB LYME IGG IMMUNOBLOT 86617 $19.30 03093187 HB LAB LEISHMANIA IGG 86717 $44.25 03093188 HB DRUG TEST, GEN TOXICOLOGY, BLOOD 80320 $72.38 03093189 HB DRUG TEST, GEN TOXICOLOGY, URINE 80320 $50.00 03093190 HB DRUG TEST, GEN TOXICOLOGY, SERUM 80320 $72.38 03093191 HB KIT 816V MUTATION ANALYSIS 81402 $442.94 03093192 HB PRADER/WILLI ANGELMAN 81331 $343.06 03093194 HB HLA B27 ANTIGEN 86812 $15.44 03093195 HB L/S RATIO 83661 $50.00 03093197 HB ADV LIP PNL CARDIO IQR CHOL 82465 $7.14 03093198 HB ADV LIP PNL CARDIO IQR LIPD 83718 $7.14 03093199 HB ADV LIP PNL CARDIO IQR TRIG 84478 $7.14 03093200 HB ADV LIP PNL CARDIO IQR LIPO 83704 $7.14 03093201 HB ADV LIP PNL CARDIO APO PROT 82172 $7.14 03093202 HB ADV LIP PNL ASSAY LIPOPROT 83695 $7.14 03093203 HB HIV 1 RNA QUAL, TMA 87535 $77.20 03093204 HB NAT PROCLEIX W/RFLX 87801 $293.28 03093205 HB CORTISOL, SALIVARY 82530 $24.13 03093206 HB IGA KAPPA LAMBDA RATIO A 82784 $188.98 03093207 HB IGA KAPPA LAMBDA RATIO B 83883 $138.26 03093212 HB IMMUNOHISTOCHEMICAL STAIN ADDL' 88341 $69.80 03093228 HB DRUG SCREENING COCAINE 80353 $1.97 03093248 HB IMMUNOFLUOR ANTIBODY INITIAL STAIN 88346 $100.50 03093250 HB LAB IBDSGI IF DNASE SEN 88350 $37.52 03093251 HB LAB IBDSGI IF PANCA 88346 $37.52 03093252 HB LAB ENTCY DIR IFA 88346 $182.49 03093253 HB LAB ENTCY IND IFA 88350 $182.49 03093256 HB RBC SNP HEA ARRAY RUO-RC 81403 $275.00 03093257 HB RHD ZYGOSITY RHZ-RC 81403 $250.00 03093258 HB RHD GENE ANALYSIS-RC 81403 $450.00 03093259 HB RHCE GENE ANALYSIS-RC 81403 $450.00 03093260 HB LICENSED RBC PANEL IVD-RC 81403 $325.00 03093261 HB GENOTYPING FOR WEAK D WKD-RC 81403 $250.00 03093262 HB VSOACTV INTST PLYPEP 84586 $50.00 03093263 HB 14-3-3 PROTEIN, CSF 83520 $145.30 03093264 HB VITAMIN C 82180 $27.52

Ancillary FY22 118 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093265 HB LEPTOSPIRA AB, IGM 86720 $44.80 03093266 HB HISTOPLASMA AG, EIA 87385 $103.00 03093267 HB URN COCAINE/METAB 80353 $21.23 03093268 HB URN CANNABINOID 80349 $12.00 03093269 HB URN BENZODIAZEPINE 80346 $32.81 03093270 HB URN AMPHETAMINE 80359 $7.50 03093271 HB URN AMPHETAMINE 80324 $7.50 03093272 HB URN OPIATES 80361 $7.50 03093273 HB URN OPIATES 80365 $7.50 03093275 HB URN PROPOXYPHENE 80367 $95.00 03093276 HB URN PHENCYCLIDINE 83992 $21.23 03093277 HB URN METHADONE 80358 $10.61 03093278 HB URN METHADONE 80367 $10.62 03093279 HB URN BARBITURATES 80345 $16.41 03093280 HB LUTEINIZING HORM,PEDS 83002 $15.92 03093281 HB FOLLICLE STIM HORM,PEDS 83001 $11.58 03093282 HB T.CRUZI AB, TOTAL 86753 $43.45 03093283 HB DONOR WEST NILE, NAT 87798 $266.59 03093284 HB LEPTOSPIRA DNA, PCR 87798 $313.63 03093285 HB OVA1 81503 $650.00 03093286 HB ZIKA VIRUS, PCR 87799 $125.00 03093287 HB ZIKA VIRUS, IGM 86790 $65.00 03093479 HB T. CRUZI AB, IGG 86753 $41.93 03093480 HB CARBAMAZEPINE, FREE 80157 $33.78 03093481 HB ALDOLASE 82085 $5.79 03093495 HB ARBOVIRUS, CALIFORNIA 86651 $42.12 03093496 HB ARBOVIRUS, EASTERN EQUINE 86652 $42.12 03093497 HB ARBOVIRUS, ST.LOUIS 86653 $42.12 03093498 HB ARBOVIRUS, WESTERN EQUINE 86654 $42.12 03093539 HB FDA PANEL EXTENDED 89398 $525.00 03093542 HB LEISHMANIA IGG 86717 $94.69 03093543 HB LEGIONELLA AB, IGG 86713 $10.13 03093544 HB LEGIONELLA AB, IGM 86713 $68.09 03093545 HB NICOTINE/COT, SERUM 80323 $56.94 03093546 HB URN NICOTINE/COT 80323 $48.40 03093573 HB MYELOID MALIGNANCIES MUTATION PANEL NEXT GEN SEQ 81455 $1,995.00 03093574 HB NEXT GEN SEQ (NGS), MULTIPLE MYELOMA 81455 $3,014.10 03093575 HB FLT3 ITD MUT ANALYSIS 81245 $216.45 03093576 HB FLT3 D835 MUT ANALYSIS 81246 $108.55 03093622 HB NEWBORN METABOLIC SCREENING PANEL S3620 $176.25 03093625 HB MANUAL DIFFERENTIAL 85007 $4.24 03093626 HB LAB CBC HEMOGRAM W/PLT* 85027 $7.98

Ancillary FY22 119 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093627 HB CBC WITH AUTO DIFF 85025 $9.59 03093628 HB LAB BASIC METABOLIC PANEL 80048 $10.44 03093629 HB LAB MAGNESIUM SE ER 83735 $8.27 03093630 HB LAB SED RATE WESTEGN 85651 $4.38 03093631 HB LAB HEPATIC FUNCTION PANEL 80076 $10.09 03093632 HB LAB LIPASE SE ST 83690 $8.51 03093633 HB LAB URINALYSIS W/ MICROSCOPY 81001 $3.92 03093635 HB LAB URINALYSIS 81002 $3.48 03093636 HB LAB WHOLE BLOOD PROTIME 85610 $4.85 03093637 HB LAB COMP METABOLIC PANEL 80053 $13.04 03093638 HB LAB THYRO TSH SE RI 84443 $20.75 03093639 HB LAB POC OCCULT BLOOD 82272 $4.23 03093640 HB LAB LDH SE AU 83615 $7.45 03093641 HB LAB GLUCOSE, PRENATAL SCREEN 82947 $4.85 03093642 HB LAB PHOSPHOR SE AU 84100 $5.85 03093643 HB LAB BILIRU TOTAL ER 82247 $6.19 03093644 HB LAB BILIRUBIN, DIRECT 82248 $6.19 03093645 HB LAB PTT ER 85730 $7.42 03093646 HB LAB LIPID PANEL 80061 $16.53 03093647 HB LAB AMYLASE SE 82150 $8.00 03093648 HB VIT D:25-HYDROXY 82306 $36.55 03093649 HB CREATININE 82565 $6.33 03093650 HB LAB FREE T4 84439 $11.13 03093651 HB LAB CALCIUM, FREE 82310 $6.37 03093652 HB LAB SGPT SE ER 84460 $6.54 03093653 HB LAB CA 27.29 86300 $25.70 03093654 HB LAB CARCINOEMB AN SE 82378 $23.41 03093655 HB LAB URIC ACID SE AU 84550 $5.58 03093656 HB LAB CA125 IA 86304 $25.70 03093657 HB LAB CA 19-9 86301 $25.70 03093658 HB LAB VITAMIN B-12 RI 82607 $18.61 03093659 HB LAB PROSTATE SPECIFIC ANTGN 84153 $22.71 03093660 HB LAB FOLLICLE STIM HORMONE 83001 $22.94 03093661 HB LAB LUTENIZING HORMONE 83002 $22.86 03093662 HB LAB TRIGLYCER SE SC 84478 $7.09 03093663 HB LAB FERRITIN 82728 $16.83 03093664 HB LAB POTASSIUM * 84132 $5.68 03093665 HB LAB SODIUM SE AU 84295 $5.94 03093666 HB LAB IG M, CORD BL 82784 $11.48 03093667 HB LAB PANEL IRON, TOTAL 83540 $7.99 03093668 HB LAB PANEL IRON BIND CAPACITY 83550 $10.79 03093669 HB LAB ALPHA FETOPROT 82105 $20.71

Ancillary FY22 120 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093670 HB LAB GAM GLUT TRAN SC 82977 $8.89 03093671 HB URINALYSIS, NONAUTO, W/SCOPE 81000 $4.02 03093672 HB LAB C-REACT PROT QT 86141 $15.98 03093673 HB LAB UREA NITROGEN 84520 $4.88 03093674 HB LAB CHOLESTROL SE AU 82465 $5.37 03093675 HB LAB ALK PHOS SE AU 84075 $6.39 03093676 HB LAB S G O T SE ER 84450 $6.39 03093677 HB LAB LDL CHOLESTEROL 83721 $11.78 03093678 HB LAB TESTOSTERONE, TOTAL 84403 $31.87 03093679 HB LAB ASPIRIN ASSAY 85576 $26.52 03093680 HB RETICULOCYTE; AUTOMATED 85045 $4.93 03093681 HB LAB FOLATE SE RI 82746 $18.15 03093682 HB GENERAL HEALTH PANEL 80050 $61.50 03093683 HB PHOSPHATIDYLSERINE AB 86148 $19.84 03093684 HB FIBRINOGEN TEST,QUANTITATIVE 85370 $14.02 03093685 HB RETICULATED PLATELET ASSAY 85055 $35.74 03093686 HB ASSAY FREE HYDROXYPROLINE 83500 $27.96 03093687 HB ALDOSTERONE SUPPRESSION EVAL 80408 $154.94 03093688 HB LAB URN CATECHOLAMINES, FRAC 82384 $31.18 03093691 HB MULLERIAN HORM, FEM 82397 $31.17 03093692 HB MULLERIAN HORM, MALE 82397 $36.67 03093695 HB LAB GLUCOSE TOTAL 3H AU 82951 $15.89 03093696 HB LAB ALBUMIN 82040 $6.11 03093697 HB LAB CSF HCG 84702 $18.59 03093698 HB LAB ELECTROLYTES 80051 $8.66 03093699 HB LAB PROTEN TOT SE AU 84155 $4.53 03093700 HB MLH1 HYPERMETHYLATION MLH1 GENE 81288 $508.30 03093701 HB SLIDE REVIEW 88381 $75.00 03093702 HB AMYLOID PROTEIN ID, MICRODISSECTION LASER 88380 $940.71 03093703 HB AMYLOID PROTEIN ID, MASS SPECTROMETRY QUA 82542 $157.89 03093704 HB AMYLOID PROTEIN ID, CONGO RED, STAIN 88313 $159.10 03093705 HB COPPER, LIVER TISSUE 82525 $57.90 03093706 HB MICROSATELLITE INSTABILITY, TUMOR 81301 $435.70 03093707 HB MAML2 CYTO/MOLECULAR REPORT 88291 $239.47 03093708 HB MAML2 CYTOGENETICS DNA PROBE X2 88271 $436.73 03093709 HB INTERPHASES, 100-300 88275 $30.00 03093710 HB PDGFB CYTO/MOLECULAR REPORT 88291 $277.93 03093711 HB PDGFB CYTOGENETICS DNA PROBE X2 88271 $506.87 03093712 HB MGMT PROMOTER METHYLATION, TUMOR 81287 $560.00 03093713 HB AMYLOID PROTEIN MICRODISSECTION LASER 88380 $940.71 03093714 HB AMYLOID PROTEIN MASS SPECTROMETRY QUA 82542 $157.89 03093715 HB TFE3 CYTO/MOLECULAR REPORT 88291 $329.25

Ancillary FY22 121 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093716 HB TFE3 CYTOGENETICS DNA PROBE X2 88271 $620.45 03093717 HB PROBE, +1 88271 $30.00 03093718 HB MYC CYTO/MOLECULAR REPORT 88291 $320.71 03093719 HB MYC CYTOGENETICS DNA PROBE X2 88271 $584.89 03093720 HB INTERPHASES, 25-99 88274 $30.00 03093721 HB COCCIDIOIDES PCR, PARAF 87798 $225.50 03093722 HB FUS, FISH CYTO/MOLECULAR REPORT 88291 $279.81 03093723 HB FUS, FISH CYTOGENETICS DNA PROBE X2 88271 $510.29 03093724 HB MELANOMA, FISH CYTO/MOLECULAR REPORT 88291 $517.58 03093726 HB IHC-TC ONLY INITIAL ANTIBODY 88342 $105.00 03093727 HB IHC-TC ONLY ADDITIONAL ANTIBODY 88341 $92.00 03093750 HB TRIIODOTHYRONINE TOTAL ASSAY, TT-3 84480 $15.75 03093785 HB ANSER VDZ 84999 $400.00 03093786 HB CYSTATIN C W/EGFR 82610 $44.29 03093787 HB COPEPTIN 86255 $24.13 03093788 HB VISCOSITY SERUM 85810 $11.58 03093789 HB CA27.29 86300 $9.65 03093790 HB VITAMIN C 82180 $27.52 03093791 HB MYELOID MUT PNL, NGS 81455 $1,995.00 03093792 HB LEUKOCYTE ALK PHOS 85540 $64.00 03093888 HB COVID 19, QUAL NAAT 87635 $100.00 03093930 HB DNA (DS) ANTIBODY, RIA 86225 $65.00 03093931 HB LEAD, CAPILLARY 83655 $4.83 03093972 HB PHOSPHOETHANOL, BLD 80321 $76.59 03093973 HB RED CELL FRAGILITY 85555 $68.57 03093974 HB HGB EVAL W/RFLX 83021 $33.60 03093975 HB SICKLE SOLUB CHARGE 83020 $30.40 03093976 HB HGB ELECTRO CHARGE 85660 $25.00 03093977 HB FDA PANEL LIMITED 89398 $350.00 03093979 HB ATN1 GENE DETC ABNOR ALLELES 81177 $144.23 03093980 HB ATXN1 GENE DETC ABNOR ALLELE 81178 $144.23 03093981 HB ATXN2 GENE DETC ABNOR ALLELE 81179 $144.23 03093982 HB ATXN3 GENE DETC ABNOR ALLELE 81180 $144.23 03093983 HB ATXN7 GENE DETC ABNOR ALLELE 81181 $144.23 03093984 HB ATXM8OS GEN DETC ABNOR ALLELE 81182 $144.23 03093985 HB ATXN10 GENE DETC ABNOR ALLELE 81183 $144.23 03093986 HB CACNA1A GENE DETC ABNOR ALLELE 81184 $144.23 03093987 HB CACNA1A GENE FULL GENE SEQ 81185 $144.23 03093988 HB FXN GENE DETC ABNOR ALLELES 81284 $144.23 03093989 HB FXN GENE FULL GENE SEQUENCE 81286 $144.23 03093990 HB PPP2R2B GENE DETC ABNOR ALLELE 81343 $144.23 03093991 HB TBP GENE DETC ABNOR ALLELES 81344 $144.23

Ancillary FY22 122 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03093992 HB MOPATH PROCEDURE LEVEL 4 81403 $144.23 03093993 HB MOPATH PROCEDURE LEVEL 5 81404 $144.23 03093994 HB MOPATH PROCEDURE LEVEL 6 81405 $288.47 03093995 HB MOPATH PROCEDURE LEVEL 7 81406 $721.16 03093996 HB MOPATH PROCEDURE LEVEL 8 81407 $144.23 03093997 HB MOPATH PROCEDURE LEVEL 9 81408 $288.46 03093998 HB UNLISTED MOLECULAR PATHOLOGY PROCEDURE 81479 $144.23 03100016 HB LAB FLOW CYTOM-ADDL MARKERS 88185 $443.88 03100023 HB LAB GCSOF-TIS CULT SOLID TIS 88233 $2,116.64 03100036 HB LAB CAK-IN SITU ANL 15 CL/1K 88269 $2,946.62 03100042 HB LAB IISH1-ANALYZE 25-99 CELLS 88274 $3,472.34 03100043 HB LAB IISH2-ANALYZE100-300 CELLS 88275 $4,340.41 03100044 HB LAB ADDITIONAL KARYOTYPE 88280 $444.68 03100049 HB PATH INTROP TCH PRP, INITIAL 88333 $2,889.81 03100050 HB PATH INTROP TCH PRP, ADDL 88334 $177.84 03100052 HB LAB IMMUNOHISTOCHEMISTRY EA AB 88342 $771.33 03100058 HB LAB ESTROGEN RECEPTOR 88361 $1,034.05 03100059 HB LAB PROGESTERONE RRECEPTOR 88361 $1,034.05 03100070 HB LAB MORPHO ANALY, FISH, MYC 88368 $1,034.05 03100072 HB LAB MORPHO ANALY, FISH 13Q DEL 88368 $1,034.05 03100076 HB LAB TUMOR IHC QUANT MAN 88360 $771.33 03100089 HB LAB IISH2-FISH PROBE, EACH 88271 $2,813.24 03100091 HB LAB IISH2-ADDITIONAL PROBE 88271 $2,629.20 03100095 HB LAB IISH1-FISH PROBE, EACH 88271 $2,813.24 03100316 HB LAB CFKS-TISSUE CULTURE LYMPH 88230 $1,752.38 03100328 HB LAB ANALYZE 20-25 CELLS 88264 $2,198.47 03100329 HB LAB CBK-CYT BL 15-20 CLS 2K 88262 $2,208.26 03100352 HB LAB IHC MISC-SLIDE ONLY* 88342 $771.33 03100353 HB BM/PB STEM CELL PLAS DEPLETE 38214 $5,802.20 03100355 HB LAB MDS FISH PROBES * 88368 $1,034.05 03100356 HB LAB MORPHO ANALY, FISH, 14;18 * 88368 $1,034.05 03100357 HB LAB MORPHO ANALY, FISH, 15;17 * 88368 $1,034.05 03100358 HB LAB EGFR FISH ASSAY * 88368 $1,034.05 03100359 HB LAB MORPHO ANALY, FISH, 1P * 88368 $1,034.05 03100360 HB LAB MORPHO ANALY, FISH, 19Q * 88368 $1,034.05 03100361 HB LAB MORPHO ANALY, FISH, 11;14* 88368 $1,034.05 03100362 HB LAB HER-2/NEU FISH PROBE * 88368 $1,034.05 03100363 HB LAB MORPHO ANALY, FISH 13Q DEL * 88368 $1,034.05 03100364 HB LAB UROVYSION * 88121 $1,034.05 03100365 HB LAB MORPHO ANALY, FISH, 9;22 * 88368 $1,034.05 03100366 HB LAB CLL FISH PROBES * 88368 $1,034.05 03100368 HB PATH CON INTRAOP FZS, 1 BLOC 88331 $771.33

Ancillary FY22 123 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03100370 HB BRAF, MICRODISECT, MANL 88381 $2,142.64 03100371 HB KRAS MICRODISECTION MAN 88381 $2,142.64 03100372 HB NERVE TEASING PREPARATION 88362 $2,889.81 03100373 HB MYELOPEROXIDASE STAIN 88319 $2,889.81 03100374 HB LAB ALK FISH ASSAY 88368 $1,034.05 03100375 HB EGFR MICRODISECTION MAN 88381 $2,142.64 03100378 HB IMMUNO CYTOCHEM, EA ADDTL 88344 $1,034.05 03100380 HB IMMUNOHISTO ANTIBODY SLIDE ADDL 88341 $822.23 03100381 HB INSITU HYBRIDIZATION (FISH) 88364 $1,260.91 03100382 HB MORPHO ANAL ADDTL PROBE FISH ALK 88369 $1,289.74 03100384 HB LAB ISH SLIDE ONLY 88365 $771.33 03100385 HB LAB IHC MISC-SLIDE ONLY ADDL' 88341 $926.57 03100387 HB MORPHO ANALYSIS FISH MULTIPLEX PROBE 88377 $771.33 03100388 HB MICRODISSECTION, LASER CAPTURE 88380 $586.87 03100389 HB MICROSATELLITE INSTABILITY ANALYSIS 81301 $2,309.72 03100390 HB TARGETED GEMONIC SEQ ANALYS CSCOMP 81479 $35,773.24 03100391 HB TARGETED GENOMIC SEQ ANALYS MYELOID 81479 $35,773.24 03100392 HB TARGETED GENOMIC SEQ ANALYS MYELOID NGS 81455 $35,773.24 03100393 HB STREP A, PCR IDNOW 87651 $744.75 03110002 HB PATHOLOGY FLUID, SMEAR 88104 $439.01 03110003 HB PATHOLOGY FLUID, CONCENTRATE 88108 $540.44 03110004 HB PATHOLOGY FLUID, SUREPATH 88112 $701.09 03110009 HB PATHOLOGY SMEAR PREP/SCR/INT 88161 $392.90 03110012 HB PATHOLOGY GYN (BETHESDA) MAN 88164 $275.30 03110015 HB PATHOLOGY FNA INTERP & RPT 88173 $701.09 03110016 HB LAB DNA ANAL, TISSUE 88182 $701.09 03110017 HB LAB DNA ANAL, BONE MARROW 88182 $701.09 03110020 HB FLOW CYTOMETRY, FIRST MARKER 88184 $1,034.05 03110025 HB FACS, ADDL MARKER 3 88185 $339.60 03110029 HB FACS, ADDL MARKER 4 88185 $339.60 03110031 HB FACS, ADDL MARKER 2 88185 $339.60 03110032 HB FACS, ADDL MARKER 1 88185 $339.60 03110033 HB FACS, INTERP 2-8 MARKERS 88187 $880.20 03110035 HB PATHOLOGY FNA CYTOTECH ASST 88199 $701.09 03110042 HB CELL CRYOPRESERVE/STORE 88240 $257.71 03110050 HB FROZEN CELL/THAW 88241 $374.87 03110164 HB PATHOLOGY GYN LIQUID/MAN SCR 88142 $250.49 03110174 HB FLOW CYTOM- 1ST MARKER 88184 $1,034.05 03110192 HB LAB ANEU-FISH PROBE, EACH 88271 $2,813.24 03110193 HB LAB MOLEC CYTG INTERPHASE ISH ANALYZE 100-300 CLL 88275 $4,340.41 03110198 HB CYTO QUICK STAIN 88172 $771.33 03110199 HB LAB ADNL CELLS COUNT/KARYOTYPE 88285 $285.91

Ancillary FY22 124 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03110200 HB LAB CBK-BLOOD TISSUE CULTURE 88230 $1,752.38 03110209 HB CYTOPATH FNA - ADQC 2 SM ST 88177 $139.87 03110213 HB CELL CULTURE 88230 $1,752.38 03110216 HB LUMINX C1Q INTERP 88187 $880.20 03110219 HB LUMINX SINGLE AG INTERP 88188 $1,098.20 03110222 HB FLOW SCREEN INTERPRETATION 88189 $1,446.66 03110223 HB FACS, ADD'L MARKER 5 88185 $339.60 03110224 HB FACS, INTERP 2-8 MARKERS (5X) 88187 $1,100.23 03110248 HB FACS, ADDL MARKER 6 88185 $339.60 03110249 HB FACS, ADDL MARKER 7 88185 $339.60 03110250 HB FACS, ADDL MARKER 8 88185 $339.60 03110251 HB FACS, ADDL MARKER 9 88185 $339.60 03110252 HB FACS, INTERP 9-15 MARKERS 88188 $1,098.20 03120001 HB PATHOLOGY LEVEL I SURGICAL 88300 $291.42 03120003 HB PATHOLOGY LEVEL II SURGICAL 88302 $509.08 03120004 HB PATHOLOGY LEVEL III SURGICAL 88304 $701.09 03120006 HB LAB TISSUE GR M 7 88305 $701.09 03120007 HB CYTOLOGY CELL BLOCK 88305 $701.09 03120008 HB LAB TISSUE GR M 7 - BM 88305 $701.09 03120009 HB PATHOLOGY LEVEL V SURGICAL 88307 $1,034.05 03120010 HB PATHOLOGY LEVEL VI SURGICAL 88309 $2,889.81 03120011 HB PATHOLOGY DECALICIFICATION 88311 $130.18 03120012 HB PATHOLOGY DECAL - BM 88311 $130.18 03120013 HB PATHOLOGY TISSUE STAIN GR I 88312 $701.09 03120015 HB PATHOLOGY TISS STN GR II - BM 88313 $250.87 03120016 HB LAB IRON STAIN - BM 88313 $271.15 03120017 HB LAB IRON STAIN 88313 $271.15 03120018 HB PATHOLOGY TISSUE STAIN GR II 88313 $250.87 03120019 HB PATHOLOGY TISSUE STAIN, FROZ 88314 $970.94 03120022 HB PATHOLOGY TISSUE STAIN, ENZ 88319 $2,889.81 03120025 HB PATHOLOGY INTRAOPERATIVE CON 88329 $443.24 03120027 HB PATH CON INTRAOP FZS, ADDL 88332 $155.77 03120028 HB IMMUNOFLUOR ANTB INITIAL STAIN 88346 $1,034.05 03120032 HB PATHOLOGY EM, DIAGNOSTIC 88348 $2,889.81 03120040 HB LAB CTK-TIS CULT SOLID TISSUE 88233 $2,116.64 03120042 HB LAB CAK-TISSUE CULTURE AMNIO 88235 $1,956.23 03120043 HB LAB CCCK-TISSUE CULTURE CVS 88235 $1,956.23 03120044 HB LAB CCBK-TIS CULT CANCER/HEM 88237 $1,899.80 03120045 HB LAB CMS-BLOOD TISSUE CULTURE 88239 $2,529.23 03120048 HB LAB ANALYSIS 5 CELLS/1 KARYT 88261 $2,658.18 03120049 HB LAB CFKS-CHROM ANL 5 CELLS/1K 88261 $2,658.18 03120054 HB LAB CTK-TIS CHROM AN 20 CELLS 88262 $2,208.26

Ancillary FY22 125 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03120055 HB LAB CCBK-ANALYZE 20-25 CELLS 88264 $2,198.47 03120057 HB LAB CKST-ANALYZE 20-25 CELLS 88264 $2,198.47 03120058 HB LAB CCCK-ANALYSIS 15 CELLS/1K 88267 $3,185.06 03120062 HB LAB CCBK-1 CHROM ADD KARYOTYPE 88280 $444.68 03120063 HB LAB CAK-1 CHROMO ADD KARYOTYPE 88280 $444.68 03120065 HB LAB CKST-ADDITIONAL KARYTYPE 88280 $444.68 03120066 HB LAB CCCK-1 CHROM ADD KARYOTYPE 88280 $444.68 03120069 HB LAB CCCK-AD CELLS CNT/KARY 88285 $285.91 03120078 HB LAB HER2/NEU RECEPTOR 88361 $1,034.05 03120079 HB LAB KI67 (MIB-1) 88361 $1,034.05 03120082 HB LAB CAK-ADNL CELLS CNT/KARYO 88285 $285.91 03120084 HB LAB CHRK-CHRM ANL 15-20 CLS/1K 88262 $2,208.26 03120085 HB LAB CMS-CHRM AN 15-20 CELLS/1K 88262 $2,208.26 03120088 HB LAB HPV HIGH RISK IN SITU 88365 $771.33 03120089 HB LAB HPV LOW RISK IN SITU 88365 $771.33 03120090 HB LAB TISSUE INSITU INTRP, RPT 88365 $771.33 03120091 HB OUTSIDE CONSULT, WITH PREP 88323 $701.09 03120098 HB IMMUNOFLUOR ANTB ADDL STAIN 88350 $961.53 03200002 HB XR C-SPINE 1 VW 72020 $1,085.27 $1,410.85 03200003 HB XR L-SPINE 1VW 72020 $1,085.27 $1,410.85 03200004 HB XR T-SPINE 1VW 72020 $1,085.27 $1,410.85 03200011 HB XR KNEE 1-2VW UNILATERAL 73560 $1,085.27 $1,410.85 03200013 HB XR COLON POUCH-O-GRAM 74270 $2,981.37 $3,877.26 03200014 HB XR COLON ENEMA W CONT 74270 $2,981.37 $3,877.26 03200019 HB IMG ABSCESS/FISTULA S&I 76080 $2,240.40 $2,912.51 03200021 HB PATHOLOGY TISSUE XRAY 76098 $2,240.40 03200024 HB PLCMT VEIN DEVICE 77001 $1,379.62 $1,793.29 03200027 HB XR GUIDANCE S&I 77002 $2,021.99 $2,628.59 03200030 HB XR MANDIBLE 1-3VW 70100 $1,085.27 $1,410.85 03200031 HB XR MANDIBLE 4VW/MORE 70110 $1,421.25 $1,847.62 03200032 HB XR MASTOIDS 1-3VW 70120 $1,085.27 $1,410.85 03200033 HB XR FACIAL BONES 1-2VW 70140 $1,238.80 $1,610.44 03200034 HB XR FACIAL BONES 3VW/MORE 70150 $1,421.25 $1,847.62 03200035 HB XR NASAL BONES 3VW/MORE 70160 $1,085.27 $1,410.85 03200037 HB XR ORBITS 4VW/MORE 70200 $1,421.25 $1,847.62 03200038 HB XR SINUSES 1-2VW 70210 $1,085.27 $1,410.85 03200039 HB XR SINUSES 3VW/MORE 70220 $1,421.25 $1,847.62 03200040 HB XR SKULL 1-3VW 70250 $1,421.25 $1,847.62 03200041 HB XR SKULL 4VW/MORE 70260 $1,705.50 $2,217.16 03200042 HB XR TMJ UNILATERAL 70328 $1,014.73 $1,319.16 03200043 HB XR TMJ BILAT 70330 $1,085.27 $1,410.85 03200044 HB XR NECK SOFT TISSUE 70360 $1,085.27 $1,410.85

Ancillary FY22 126 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03200045 HB SIALOGRAM S&I 70390 $2,240.40 $2,912.51 03200048 HB XR PLACEMENT NEEDLE SPINE 77003 $1,695.94 $2,204.47 03200052 HB XR RIBS 2-3VW UNILAT 71100 $1,085.27 $1,410.85 03200053 HB XR RIBS 2-3VW UNI & CHEST 71101 $1,183.15 $1,538.08 03200054 HB XR RIBS 3VW BILAT 71110 $1,421.25 $1,847.62 03200055 HB XR STERNUM 2VW/MORE 71120 $1,085.27 $1,410.85 03200056 HB XR STERNOCLAV JNT 3VW/MORE 71130 $1,085.27 $1,410.85 03200060 HB XR C-SPINE 2-3VW 72040 $1,421.25 $1,847.62 03200061 HB XR C-SPINE 4-5VW 72050 $1,705.50 $2,217.16 03200062 HB XR C-SPINE 6VW/MORE 72052 $2,046.61 $2,660.59 03200063 HB XR T-SPINE 2VW 72070 $1,421.25 $1,847.62 03200064 HB XR T-SPINE 3VW 72072 $1,705.50 $2,217.16 03200065 HB XR T-SPINE 4VW/MORE 72074 $2,046.61 $2,660.59 03200066 HB XR T/L-SPINE MIN 2VW 72080 $1,085.27 $1,410.85 03200068 HB XR L-SPINE 2-3VW 72100 $1,421.25 $1,847.62 03200069 HB XR L-SPINE 4-5VW 72110 $1,705.50 $2,217.16 03200070 HB XR L-SPINE 6VW W BENDING 72114 $2,046.61 $2,660.59 03200071 HB XR L-SPINE 2-3VW BEND ONLY 72120 $1,421.25 $1,847.62 03200072 HB XR PELVIS 1-2VW 72170 $1,421.25 $1,847.62 03200073 HB XR PELVIS 3VW/MORE 72190 $1,705.50 $2,217.16 03200074 HB XR SACROILIAC JNT 2VW/LESS 72200 $1,085.27 $1,410.85 03200075 HB XR SACROILIAC JNT 3VW/MORE 72202 $1,421.25 $1,847.62 03200076 HB XR SACRUM/COCCYX 2VW/MORE 72220 $1,085.27 $1,410.85 03200077 HB MYELOGRAM C-SPINE 72240 $10,550.00 03200078 HB MYELOGRAM T-SPINE 72255 $10,550.00 03200079 HB MYELOGRAM L-SPINE 72265 $10,550.00 03200080 HB MYELOGRAM 2/MORE REGION S&I 72270 $10,550.00 03200081 HB DISCOGRAM LUMBAR S&I 72295 $11,077.10 03200082 HB XR CLAVICLE UNILATERAL 73000 $1,085.27 $1,410.85 03200083 HB XR SCAPULA UNILATERAL 73010 $1,085.27 $1,410.85 03200084 HB XR SHOULDER 1VW UNILATERAL 73020 $1,085.27 $1,410.85 03200085 HB XR SHOULDER 2VW/MORE UNILT 73030 $1,421.25 $1,847.62 03200086 HB XR AC JNTS WO/W WEIGHTS BIL 73050 $1,421.25 $1,847.62 03200087 HB XR HUMERUS 2VW/MORE UNILAT 73060 $1,085.27 $1,410.85 03200088 HB XR ELBOW 2VW UNILATERAL 73070 $1,085.27 $1,410.85 03200089 HB XR ELBOW 3VW/MORE UNILAT 73080 $1,421.25 $1,847.62 03200090 HB XR FOREARM 2VW UNILATERAL 73090 $1,085.27 $1,410.85 03200091 HB XR EXT UPP INFANT 2VW UNI 73092 $1,421.25 $1,847.62 03200092 HB MAMMO DUCTOGRAM SINGLE S&I 77053 $1,966.29 03200093 HB XR WRIST 2VW UNILATERAL 73100 $1,085.27 $1,410.85 03200094 HB XR WRIST 3VW/MORE UNILAT 73110 $1,421.25 $1,847.62 03200095 HB ARTHROGRAM WRIST S&I UNILAT 73115 $3,095.34 $4,023.96

Ancillary FY22 127 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03200096 HB XR HAND 2VW UNILATERAL 73120 $1,085.27 $1,410.85 03200097 HB XR HAND 3VW/MORE UNILATERAL 73130 $1,183.15 $1,538.08 03200098 HB XR FINGERS 2VW UNILATERAL 73140 $1,085.27 $1,410.85 03200106 HB XR BONE SURVEY AGE 77072 $1,421.25 $1,847.62 03200107 HB XR BONE SURVEY LENGTH 77073 $1,421.25 $1,847.62 03200109 HB XR KNEE 4VW/MORE UNILATERAL 73564 $1,705.50 $2,217.16 03200110 HB XR KNEE 1VW STANDING BILAT 73565 $1,085.27 $1,410.85 03200111 HB XR TIBIA/FIBULA 2VW UNILAT 73590 $1,085.27 $1,410.85 03200112 HB XR EXT LOW 2VW UNILAT INFNT 73592 $1,421.25 $1,847.62 03200113 HB XR ANKLE 2VW UNILATERAL 73600 $1,421.25 $1,847.62 03200114 HB XR ANKLE 3VW/MORE UNILAT 73610 $1,705.50 $2,217.16 03200115 HB XR FOOT 2VW UNILATERAL 73620 $1,085.27 $1,410.85 03200116 HB XR FOOT 3VW/MORE UNILAT 73630 $1,421.25 $1,847.62 03200118 HB XR TOES 2VWS/MORE UNILAT 73660 $1,085.27 $1,410.85 03200119 HB XR ABDOMEN 1VW FRONTAL 74018 $1,085.27 $1,410.85 03200121 HB XR ABDOMEN+CHEST 2+ VIEWS 74022 $1,421.25 $1,847.62 03200122 HB XR ESOPHAGRAM SINGLE CONT STUDY 74220 $2,112.47 $2,746.21 03200123 HB XR SWALLOW CINE VIDEO CONT STUDY 74230 $2,112.47 $2,746.21 03200128 HB XR SMALL INTESTINE SINGLE CONT 74250 $2,112.47 $2,746.21 03200129 HB XR SMALL BOWEL ENTEROCLYSIS 74251 $2,441.50 $3,174.91 03200130 HB XR BONE SURVEY OSSEOUS LTD 77074 $1,421.25 $1,847.62 03200132 HB XR COLON ENEMA W CONT & AIR 74280 $3,561.91 $4,632.16 03200136 HB ENDO CATH- BILE DUCT S & I 74328 $1,535.35 03200137 HB ENDO CATH- PANCR DUCT S & I 74329 $1,535.35 03200138 HB ENDO CATH-BIL- PANCR DUCT S& I 74330 $1,966.04 03200139 HB XR PLCMT LONG GI TUBE S&I 74340 $2,067.94 $2,688.32 03200140 HB DILATE BILIARY DUCT S&I 74363 $10,024.82 03200141 HB UROGRAM IVP 74400 $4,106.58 $5,338.56 03200143 HB UROGRAM INFUSION W TOMO 74415 $3,461.57 $4,500.79 03200144 HB UROGRAM RETROGRADE 74420 $2,508.37 $3,260.92 03200145 HB UROGRAM ANTEGRADE S&I 74425 $1,062.31 $1,381.01 03200146 HB CYSTOGRAM 3VW/MORE S&I 74430 $2,109.44 $2,742.50 03200147 HB VESICULOGRAM S&I 74440 $2,391.34 03200148 HB CORPORA CAVERNOSOGRAM S&I 74445 $1,648.36 03200149 HB URETHROCYSTOGRAM RETRO S&I 74450 $2,697.12 03200150 HB URETHROCYSTOGRAM VOID S&I 74455 $3,659.86 $4,756.37 03200153 HB NEPHROS TRACT DILATION 74485 $10,376.78 03200154 HB HYSTEROSALPINGOGRAM S&I 74740 $2,240.40 $2,912.51 03200155 HB VAGINOGRAM/PERINEOGRAM 74775 $1,944.61 $2,527.52 03200157 HB SPLENOPORTOGRAPHY 75810 $6,591.17 03200158 HB VENOGRAM EXTREMITY UNI S&I 75820 $4,242.68 03200159 HB VENOGRAPHY EXTREMITY BILAT 75822 $6,591.17

Ancillary FY22 128 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03200160 HB VENOGRAM VENA CAVA INF S&I 75825 $12,035.14 03200161 HB VENOGRAPHY SUPERIOR CAVAL 75827 $4,665.05 03200162 HB VENOGRAPHY RENAL UNILAT 75831 $10,707.26 03200163 HB VENOGRAPHY RENAL BILAT 75833 $12,451.18 03200164 HB VENOGRAM JUGULAR S&I 75860 $12,035.14 03200165 HB PERC TRANSHEP PORT W HDM 75885 $12,035.14 03200166 HB VENOGRAQM HEPATIC W HDM 75889 $16,087.15 03200167 HB VENOUS SAMPLE W/WO ANGIO 75893 $20,160.23 03200168 HB TRANSCATH EMBOLIZATION S&I 75894 $16,550.70 03200171 HB XR BONE SURVEY CHILD 77076 $1,421.25 $1,847.62 03200172 HB DXA BONE DEN PERIPH SKEL 77081 $1,085.27 03200173 HB CATH REMOVAL OBS MAT S&I 75901 $1,966.04 03200174 HB CATH REMOVAL OBS MAT CV S&I 75902 $1,683.80 03200179 HB REPAIR DEC AORTA W SUB S&I 75956 $6,798.39 03200180 HB REPAIR DEC AORTA WO SUB S&I 75957 $5,825.12 03200182 HB DXA BONE DEN AXIAL SKEL WO VFA 77080 $1,421.25 $1,847.62 03200188 HB BIOPSY TRANSCATHERTER S&I 75970 $8,574.65 03200192 HB XCHANGE DRAINAGE CATH S&I 75984 $3,445.41 03200193 HB XR DRAINAGE S&I 75989 $3,753.45 $4,877.69 03200194 HB XR CALCANEUS 2VW/MORE UNI 73650 $1,085.27 $1,410.85 03200197 HB XR FLUOROSCOPY 1HR/LESS 76000 $1.00 03200200 HB ARTHROGRAM ELBOW S&I UNILAT 73085 $3,095.34 $4,023.96 03200202 HB IMG SURGICAL SPECIMEN 76098 $2,240.40 $2,912.51 03200204 HB XR TOMOGRAPHY SINGLE PLANE 76100 $1,421.25 $1,847.62 03200206 HB XR UL PROC DEFECOGRAPHY 74280 $3,561.91 $4,632.16 03200208 HB SHUNTOGRAM NON-VAS SHUNT SI 75809 $1,421.25 03200211 HB XR BONE SURVEY COMPLETE 77075 $3,757.80 $4,885.41 03200212 HB XR KNEE 3VW UNILATERAL 73562 $1,421.25 $1,847.62 03200215 HB DISCOGRAM CERV/THOR S&I 72285 $11,077.10 03200218 HB PRC TRNHEP ANG WO HDM S&I 75887 $6,591.17 $8,568.52 03200220 HB PLCMT PROX EXT THOR AORTA 75958 $3,676.65 03200242 HB UL PROC DXA FAT COMP ASSMT 76499 $1,085.27 $1,410.85 03200244 HB PLCMT EXT DEV PST ARTA RPS&I 75959 $8,383.49 03200246 HB MAMMO DUCTOGRAM MULT S&I 77054 $2,240.40 $2,912.51 03200249 HB CHOLANGIOGRAM INTRAOP 74300 $2,474.56 $3,219.15 03200255 HB XR NOSE TO RECTUM FB CHILD 76010 $1,004.89 $1,306.34 03200258 HB VENOGRAPHY ADRENAL UNILAT 75840 $12,035.14 03200259 HB VENOGRAM SUP SAG SINUS S&I 75870 $6,591.17 03200261 HB UL PROC ART/VEN STRUCTURE 76496 $679.63 $877.41 03200263 HB XR COLON ENEMA THERAPEUTIC 74283 $2,102.28 $2,735.35 03200274 HB DILATE FOR STRICTURE/OBSTR 74360 $1,535.35 03200275 HB X-RAY EXAM ENTIRE SPI 1 VW 72081 $818.12 $1,063.56

Ancillary FY22 129 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03200276 HB X-RAY EXAM ENTIRE SPI 2/3 VW 72082 $1,354.86 $1,761.33 03200277 HB X-RAY EXAM ENTIRE SPI 4/5 VW 72083 $2,299.73 $2,989.64 03200278 HB X-RAY EXAM ENTIRE SPI 6/> VW 72084 $2,772.18 $3,603.82 03200279 HB X-RAY EXAM HIP UNI 1 VIEW 73501 $2,729.14 $3,547.88 03200280 HB X-RAY EXAM HIP UNI 2-3 VIEWS 73502 $5,144.54 $6,687.90 03200281 HB X-RAY EXAM HIP UNI 4/> VIEWS 73503 $12,505.51 $16,257.16 03200282 HB X-RAY EXAM HIPS BI 2 VIEWS 73521 $1,354.86 $1,761.33 03200283 HB X-RAY EXAM HIPS BI 3-4 VIEWS 73522 $1,827.30 $2,375.47 03200284 HB X-RAY EXAM HIPS BI 5/> VIEWS 73523 $2,299.73 $2,989.64 03200285 HB X-RAY EXAM OF FEMUR 1 73551 $976.74 $1,269.77 03200286 HB X-RAY EXAM OF FEMUR 2/> 73552 $1,085.27 $1,410.85 03200287 HB XR RENAL CYST TRANSLUMBAR S&I 74470 $6,474.96 $6,474.96 03200288 HB LYMPHANGIOGRAM PELVIC/ABD; BILAT 75807 $12,035.14 $15,645.68 03200289 HB LYMPHANGIOGRAM PELVIC/ABD; UNILAT 75805 $6,591.17 $8,568.52 03200290 HB XR EXAM ABDOMEN 2 VIEWS 74019 $1,183.15 $1,538.08 03200291 HB XR EXAM ABDOMEN 3+ VIEWS 74021 $1,421.25 $1,847.62 03200292 HB INSERTION PICC RS&I <5 YR 36572 $5,816.99 $7,562.82 03200293 HB INSERTION PICC RS&I 5 YR+ 36573 $6,591.17 $8,568.52 03200294 HB REPLACE PICC CATH W IMG GUID 36584 $6,591.17 $8,568.52 03200295 HB DILAT XST TRC NEW ACCESS RCS 50437 $11,704.57 03200296 HB DILAT XST TRC NDURLGC PX 50436 $11,704.57 03200297 HB ENDOVENOUS FEM-POP ARTL REVASC 0505T $82,600.93 03200298 HB XR ESOPHAGRAM DOUBLE CONT STUDY 74221 $2,508.37 $3,260.92 03200299 HB XR UPPER GI SINGLE CONT STUDY 74240 $2,367.43 $3,073.46 03200300 HB XR UPPER GI DOUBLE CONT 74246 $2,102.28 $2,735.35 03200301 HB XR SMALL INTESTINE F-THRU STUDY 74248 $3,810.20 $5,123.63 03200312 HB PERQ INJ ALLO CEL UNI/BI W/ FLR LUMB 1ST 0627T $79,500.67 03200313 HB PERQ INJ ALLO CEL UNI/BI W/ FLR LUMB EA ADDL 0628T $38,922.94 03200314 HB PERQ INJ ALLO CEL UNI/BI W/ US GUID LUMB 1ST 0629T $79,500.67 03200315 HB PERQ INJ ALLO CEL UNI/BI W/ US GUID LUMB EA ADDL 0630T $38,922.94 03220003 HB ARTHROGRAM SHOULDER S&I UNI 73040 $3,095.34 $4,023.96 03220004 HB ARTHROGRAM KNEE S&I UNILAT 73580 $3,095.34 $4,023.96 03220005 HB ARTHROGRAM ANKLE S&I UNILAT 73615 $3,095.34 $4,023.96 03220007 HB ARTHROGRAM HIP S&I UNILAT 73525 $3,095.34 $4,023.96 03230001 HB ANGIOGRAM AORTA THORACIC SI 75605 $20,160.23 03230002 HB ANGIOGRAM AORTA ABDOMEN S&I 75625 $11,163.55 03230003 HB AORTOGRAPHY ABD+ILIOFEM BILAT 75630 $13,014.98 03230012 HB ANGIOGRAPHY THRU EXIST CATH, OTHER THAN FOR THRO 75898 $6,591.17 03230019 HB ANGIO SPINAL 75705 $20,160.23 03230020 HB ANGIO EXTREMITY UNI S&I 75710 $14,615.56 03230021 HB ANGIO EXTREMITY BILAT 75716 $16,087.15 03230025 HB ANGIOGRAM VISCERAL S&I 75726 $20,160.23

Ancillary FY22 130 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03230028 HB ANGIOGRAM PELVIC S&I 75736 $20,160.23 03230029 HB ANGIO PULMONARY UNILAT 75741 $8,299.18 03230030 HB ANGIO PULMONRY BILAT 75743 $16,087.15 03230032 HB ANGIO PULM NON SELECT CATH 75746 $6,591.17 03230033 HB ANGIO INTERNAL MAMMARY 75756 $12,035.14 03230034 HB ANGIOGRAM EA ADDL VESSEL SI 75774 $14,205.07 03230039 HB ANGIOGRAM ADRENAL ARTERY, UNI 75731 $6,591.17 $8,568.52 03240005 HB XR RIBS 3VW BILAT & CHEST 71111 $1,421.25 $1,847.62 03240008 HB XR CHEST 1VW FRONTAL 71045 $1,085.27 $1,410.85 03240014 HB XR UL XVIVO LUNG TRANSPLANT 76499 $1,085.27 $1,410.85 03240015 HB XR EXAM CHEST 2 VIEWS 71046 $1,116.37 $1,451.27 03240016 HB XR EXAM CHEST 3 VIEWS 71047 $1,183.15 $1,538.08 03240017 HB XR EXAM CHEST 4+ VIEWS 71048 $1,421.25 $1,847.62 03300001 HB PROVIDE CHEMOTHERAPY AGENT 96549 $893.88 03310002 HB CHEMO ANTI-NEOPL, SC/IM 96401 $973.43 $1,265.45 03310003 HB CHEMO HORMNL ANTI-NEOPL, SC/IM 96402 $893.88 $1,162.04 03310004 HB CHEMO ADMIN, NON HORMONAL 96402 $893.88 $1,162.04 03310005 HB CHEMO IVP/INF 0-15 MIN ADD/SEQ 96411 $1,253.71 $1,629.83 03310006 HB CHEMO INF>8HRS VIA AMB PUMP 96416 $1,965.31 $2,554.90 03310007 HB CHEMOTHERAPY INTRA-ART PUSH 96420 $1,546.36 03310008 HB CHEMO INF,INTRACAV PERITONEAL 96446 $1,965.31 03310009 HB CHEMOTHERAPY, INTO CNS 96450 $1,657.28 03310010 HB CHEMOTHERAPY SPINE PUNCTURE 96450 $1,657.28 $2,154.44 03310011 HB CHEMO HORMONAL INTINEOPL, SC/I 96402 $893.88 $1,162.04 03310012 HB CHEMO IVP/INF 0-15 MIN INITIAL 96409 $2,011.52 $2,614.98 03310013 HB CHEMO PUSH 96409 $2,011.52 $2,614.98 03310014 HB CHEMOTHERAPY INJECTION 96542 $1,965.31 03310015 HB NON-CHEMO INF >8HRS VIA AMB PU 96379 $1,965.31 03310019 HB CHEMO INTRALESIONAL UP TO 7 96405 $891.10 $1,158.41 03310020 HB CHEMO INTRALESIONAL OVER 7 96406 $2,004.62 $2,606.02 03330003 HB RT SIMULATION SIMPLE 77280 $8,110.49 03330004 HB RT SIMULATION COMPLEX 77290 $11,815.70 03330005 HB RT 3-D SIMULATION 77295 $14,150.34 03330010 HB RT DOSIMETRY BASIC 77300 $2,243.20 03330011 HB RT IMRT TX PLANNING 77301 $14,150.34 03330020 HB RT INVIVO DOSIMTRY DIODE/TLD 77331 $2,236.05 03330021 HB RT TX DEVICE SIMPLE 77332 $4,300.10 03330024 HB RT TX DEVICE COMPLEX - MASKS 77334 $4,300.10 03330026 HB RT TX DEVICE COMPLEX - BLOCKS 77334 $4,300.10 03330028 HB RT CONTINUING PHYSICS CNSLT 77336 $2,000.35 03330032 HB RT SUPERFICIAL 77401 $1,331.23 03330046 HB RT PORT IMAGES 77417 $496.39

Ancillary FY22 131 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03330074 HB RT SPECIAL TX PROCEDURE HD 77470 $7,988.63 03330077 HB DESIGN MLC FOR IMRT 77338 $4,327.15 03330079 HB RT PHYSICS CONSL-IMG FUSION 77370 $7,582.77 03330080 HB RESPIRATOR MOTION MGMT SIM 77293 $5,544.80 03330081 HB TELETHX ISODOSE PLAN SIMPLE 77306 $2,250.93 03330082 HB TELETHX ISODOSE PLAN CPLX 77307 $10,530.51 03330083 HB BRACHYTX ISODOSE PLAN SIMPLE 77316 $11,794.98 03330084 HB BRACHYTX ISODOSE INTERMED 77317 $13,331.07 03330085 HB BRACHYTX ISODOSE COMPLEX 77318 $14,867.20 03330086 HB NTSTY MODUL RAD TX DLVR SMPL 77385 $10,630.07 03330087 HB NTSTY MODUL RAD TX DLVR CPLX 77386 $10,630.07 03330088 HB GUIDANCE FOR RADIAJ TX DLVR 77387 $10,630.07 03330089 HB RAD TREATMNT DELVRY SIMPLE 77402 $1,331.23 03330090 HB RAD TREATMNT DELVRY INT 77407 $1,597.48 03330091 HB RAD TREATMNT DELVRY COMPLX 77412 $2,733.35 03330092 HB HDR ELCTRNC SKN SURF BRCHYTX 0394T $2,733.35 03330093 HB HDR ELCTR NTRST/NTRCV BRCHTX 0395T $16,370.36 03330094 HB HDR RDNCL NTRSTL/ICAV BRCHTX 1 CHNL 77770 $16,370.36 03330095 HB HDR RDNCL NTRSTL/ICAV BRCHTX 2-12 CHNLS 77771 $16,370.36 03330096 HB HDR RDNCL NTRSTL/ICAV BRCHTX >12 CHNLS 77772 $16,370.36 03330099 HB SRS LINEAR BASED 1 SESSION 77372 $82,798.68 03330100 HB SBRT DELIVERY PER FRACTION 77373 $22,140.12 03330104 HB IO RAD TX DELIVERY BY X-RAY 77424 $82,798.68 03330105 HB IO RAD TX DELIVER BY ELCTRNS 77425 $82,798.68 03350001 HB CHEMO INFUSION FIRST HOUR 96413 $3,154.36 $4,100.66 03350002 HB CHEMO INFUSION ADDL HOUR 96415 $1,007.27 $1,309.46 03350004 HB CHEMO INF ADD/SEQ 1ST HOUR 96417 $1,007.27 $1,309.46 03350005 HB BAMLANIVIMA INFUSION, ADMIN & MONITOR M0239 $2,460.62 03350006 HB CASIRIVI & IMDEVI INFUSN ADMN & MONITOR M0243 $2,460.62 03350007 HB BAMLAN & ETESEV INFUSN ADMIN & MONITOR M0245 $2,460.62 03400004 HB NM LIVER SCAN STATIC ONLY 78201 $6,358.72 $8,266.33 03400006 HB NM CARDIAC 1ST PASS SINGLE 78481 $6,358.72 $8,266.33 03400011 HB NM CSF LEAK SCAN 78650 $8,150.25 $10,595.33 03410004 HB NM THYROID METS SCAN LTD 78015 $5,069.20 $6,589.96 03410005 HB NM THYRD METS SCAN WHO BODY 78018 $6,358.72 $8,266.33 03410007 HB NM BONE MARROW SCAN MULT 78103 $5,069.20 $6,589.96 03410009 HB NM LYMPHATICS/NODES SCAN 78195 $6,358.72 $8,266.33 03410010 HB NM UL BONE MARROW SPECT 78199 $5,069.20 $6,589.96 03410015 HB NM LIVER/SPLEEN SCAN VAS/FL 78216 $5,069.20 $6,589.96 03410017 HB NM GASTRIC EMPTYING STUDY 78264 $5,069.20 $6,589.96 03410018 HB NM ACUTE GI BLEED STUDY 78278 $5,069.20 $6,589.96 03410021 HB NM PERITONEAL SHUNT PATENCY 78291 $5,069.20 $6,589.96

Ancillary FY22 132 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03410023 HB NM BONE/JNT SCAN MULT AREAS 78305 $5,069.20 $6,589.96 03410024 HB NM BONE/JNT SCAN WHOLE BODY 78306 $5,069.20 $6,589.96 03410025 HB NM BONE/JNT SCAN 3-PHASE 78315 $5,069.20 $6,589.96 03410031 HB NM CARDIAC INFARCT SPECT 78469 $6,358.72 $8,266.33 03410034 HB NM CARDIAC MUGA WM/EF SPECT 78494 $5,069.20 $6,589.96 03410035 HB NM LUNG PERFUSION SCAN 78580 $5,069.20 $6,589.96 03410044 HB NM CSF FLOW/CISTERNOGRAM 78630 $6,358.72 $8,266.33 03410045 HB NM CSF FLOW/SHUNT EVAL 78645 $6,358.72 $8,266.33 03410048 HB NM KIDNEY SCAN FLOW/FUNCT 78707 $6,358.72 $8,266.33 03410050 HB NM KIDNEY FUNCTION STUDY 78725 $5,069.20 $6,589.96 03410052 HB NM TESTICULAR SCAN W VAS FL 78761 $5,069.20 $6,589.96 03410053 HB NM TUMOR SCAN PLANAR SINGLE 78800 $5,069.20 $6,589.96 03410055 HB NM TUMOR SCAN WHOLE BODY 78802 $8,150.25 $10,595.33 03410056 HB NM TUMOR SPECT SINGLE AREA 78803 $8,150.25 $10,595.33 03410057 HB NM TUMOR SCAN 2DAYS/MORE 78804 $8,150.25 $10,595.33 03410061 HB NM INTESTINE SCAN 78290 $5,069.20 $6,589.96 03410063 HB NM CARDIAC MUGA WM/EF SINGL 78472 $5,069.20 $6,589.96 03410069 HB NM HEART SPECT SNGL RST/STR 78451 $8,150.25 $10,595.33 03410070 HB NM HEART SPECT MULT RST/STR 78452 $8,150.25 $10,595.33 03410071 HB NM HEART PLANR SNGL RST/STR 78453 $8,150.25 $10,595.33 03410072 HB NM HEART PLANR MULT RST/STR 78454 $8,150.25 $10,595.33 03410074 HB NM HEPATOBILIARY WO PHARM 78226 $5,069.20 $6,589.96 03410075 HB NM HEPATOBILIARY W PHARM 78227 $6,358.72 $8,266.33 03410076 HB NM LUNG VENT WO PERFUSION 78579 $5,069.20 $6,589.96 03410077 HB NM LUNG VENT W PERFUSION 78582 $6,358.72 $8,266.33 03410078 HB NM LUNG VENT W DIFFERENTIAL 78597 $5,069.20 $6,589.96 03410080 HB NM THYROID UPTAKE SINGLE/MULT 78012 $5,069.20 $6,589.96 03410081 HB NM THYROID IMG W VAS FL ONLY 78013 $5,069.20 $6,589.96 03410082 HB NM THYROID IMG W VAS & UPTKE 78014 $5,069.20 $6,589.96 03410084 HB NM PARATHYRD SCAN W SPECT 78071 $5,069.20 $6,589.96 03410085 HB NM PARATHYRD SCAN W SPECT/CT 78072 $6,358.72 $8,266.33 03410086 HB NM CARDIAC SHUNT DETECT 78428 $5,069.20 $6,589.96 03410089 HB NM CARDIAC SYMP PLANAR ONLY 0331T $8,150.25 $10,595.33 03410090 HB NM CARDIAC SYMP PLANAR & SPECT 0332T $8,150.25 $10,595.33 03410092 HB UNLINSTED NM PET/MR ATTENUATION 78999 $5,069.20 $6,589.96 03410093 HB NM UL MUSCULOSKELETAL PROC 78399 $5,069.20 $6,589.96 03410094 HB NM GASTRIC EMPTYNG IMG W/SM BWL 78265 $5,069.20 $6,589.96 03410095 HB NM KIDNEY SCAN FLOW/FUNCT PHARM 78708 $6,358.72 $8,266.33 03410096 HB RADIOACTIVE TRACER ID SENTINEL NODE 38792 $5,069.20 $6,589.96 03410097 HB TUMOR SPECT CNCRNT CT SINGLE AREA 78830 $8,150.25 $10,595.33 03410098 HB TUMOR SPECT MIN 2 AREAS 78831 $8,150.25 $10,595.33 03410099 HB TUMOR SPECT CNCRNT CT MIN 2 AREAS 78832 $15,720.40 $20,436.69

Ancillary FY22 133 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03410100 HB RADIOPHARM QUANT MEASURE 1 AREA 78835 $5,447.11 $7,081.25 03420007 HB NM RAD DOSE HANDLING/LOADING 77790 $3,552.49 03420010 HB NM RADIOPHARM TX ORAL 79005 $3,289.55 $4,276.43 03420011 HB NM RADIOPHARM THERAPY, IV 79101 $3,289.55 $4,276.43 03420013 HB RADIOPHARM TX INTRAARTERIAL 79445 $3,289.55 03420014 HB PHARM MONOCLONAL THERAPY 79403 $3,289.55 $4,276.43 03430040 HB ISOTOPE, IP AND OP SERVICES C9898 $1.00 03500014 HB CT DRAINAGE S&I 75989 $3,753.45 $4,877.69 03500016 HB CT LIMITED/FOLLOW-UP SCAN 76380 $3,722.93 $4,839.80 03500027 HB CT GUIDANCE S&I 77012 $4,927.78 $6,406.11 03500033 HB CT ANGIO ABDOMINAL RUNOFF W 3D 75635 $3,642.46 $4,735.20 03500035 HB RECON 3D TECH WORKSTATN 76376 $1.00 03500036 HB RECON 3D INDPNDNT WRKSTN 76377 $1.00 03500037 HB CT GUIDANCE FOR ABLATION 77013 $4,231.77 $5,501.46 03500038 HB CT BONE SURVEY SCANOGRAM 77073 $1,421.25 $1,847.62 03500039 HB CT UL PROC 76497 $1,085.27 $1,410.85 03500046 HB CT ANGIO ABDOMEN WO/W CONT W 3D 74175 $7,235.97 $9,406.10 03500047 HB CT NECK SFT TISS WO CONT 70490 $5,385.45 $7,001.06 03500048 HB CT NECK SFT TISS W CONT 70491 $6,499.13 $8,448.89 03500049 HB CT NECK SFT TISS WO/W CONT 70492 $6,806.47 $8,848.42 03500051 HB RECON CTA SURGICAL PLANNING G0288 $4,527.32 $5,885.53 03500053 HB CT HEART W CONT 75572 $7,269.90 $9,450.88 03500054 HB CT HEART W CONT, CONGEN DZ 75573 $6,499.13 $8,448.89 03500058 HB RECON 3D INDPNDNT WRKSTN CL 76377 $1.00 03500067 HB CT THORAX LOW LUNG CNCR SCRN W/O CONT 71271 $5,385.45 $7,001.06 03510001 HB CT PERFUSION BRAIN 0042T $4,265.80 $5,545.53 03510002 HB CT HEAD/BRAIN W CONT 70460 $6,499.13 $8,448.89 03510003 HB CT HEAD/BRAIN WO/W CONT 70470 $6,806.47 $8,848.42 03510012 HB CT ORBITS/SELLA/EAR W CONT 70481 $6,806.47 $8,848.42 03510019 HB CT ANGIO HEAD W 3D 70496 $6,015.87 $7,820.46 03510020 HB CT ANGIO NECK W 3D 70498 $6,015.87 $7,820.46 03510022 HB CT ORBIT/SELLA/EAR WO/W CON 70482 $8,167.77 $10,618.09 03510026 HB CT MAXILLOFACIAL WO CONT 70486 $5,385.45 $7,001.06 03510032 HB CT MAXILLOFACIAL WO/W CONT 70488 $6,806.47 $8,848.42 03510036 HB CT ORBITS/SELLA/EAR WO CONT 70480 $5,385.45 $7,001.06 03510039 HB CT HEAD/BRAIN WO CONT 70450 $5,385.45 $7,001.06 03510044 HB CT MAXILLOFACIAL W CONT 70487 $6,499.13 $8,448.89 03520002 HB CT COLONOGRAPHY SCREENING 74263 $7,059.25 $9,177.05 03520003 HB CT HEART WO CONTRAST 75571 $6,058.25 $7,875.74 03520004 HB CT COLONOGRAPHY DIAG WO CNT 74261 $13,374.42 $17,386.27 03520007 HB CT CHEST WO/W CONTRAST 71270 $6,806.47 $8,848.42 03520008 HB CT ANGIO HEART W 3D 75574 $4,667.65 $6,067.93

Ancillary FY22 134 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03520011 HB CT ANGIO CHEST W 3D 71275 $6,015.87 $7,820.46 03520013 HB CT C-SPINE WO/W CONTRAST 72127 $6,806.47 $8,848.42 03520014 HB CT T-SPINE WO/W CONTRAST 72130 $6,806.47 $8,848.42 03520015 HB CT L-SPINE WO CONTRAST 72131 $5,385.45 $7,001.06 03520016 HB CT L-SPINE W CONTRAST 72132 $6,499.13 $8,448.89 03520017 HB CT L-SPINE WO/W CONTRAST 72133 $6,806.47 $8,848.42 03520018 HB CT ANGIO PELVIS W 3D 72191 $4,628.02 $6,015.87 03520020 HB CT PELVIS W CONTRAST 72193 $6,499.13 $8,448.89 03520022 HB CT EXT UPP WO CONTRAST UNI 73200 $5,385.45 $7,001.06 03520023 HB CT EXT UPP W CONTRAST UNI 73201 $6,499.13 $8,448.89 03520024 HB CT ANGIO EXT UPPER UNILAT W 3D 73206 $3,519.14 $4,575.03 03520028 HB CT LOW EXT WO/W CONT UNILAT 73702 $6,806.47 $8,848.42 03520029 HB CT ANGIO EXT LOW WO/W CN UN 3D 73706 $3,738.08 $4,859.49 03520030 HB CT PELVIS WO CONTRAST 72192 $5,385.45 $7,001.06 03520040 HB CT CHEST W CONTRAST 71260 $6,499.13 $8,448.89 03520041 HB CT C-SPINE WO CONTRAST 72125 $5,385.45 $7,001.06 03520042 HB CT C-SPINE W CONTRAST 72126 $6,499.13 $8,448.89 03520043 HB CT T-SPINE WO CONTRAST 72128 $5,385.45 $7,001.06 03520044 HB CT T-SPINE W CONTRAST 72129 $6,499.13 $8,448.89 03520045 HB CT PELVIS WO/W CONTRAST 72194 $6,806.47 $8,848.42 03520046 HB CT LOW EXT WO CONT UNILAT 73700 $5,385.45 $7,001.06 03520048 HB CT EXT LOW W CONT UNILAT 73701 $6,499.13 $8,448.89 03520049 HB CT ABDOMEN WO CONTRAST 74150 $5,385.45 $7,001.06 03520050 HB CT ABDOMEN W CONTRAST 74160 $6,499.13 $8,448.89 03520051 HB CT ABDOMEN WO/W CONTRAST 74170 $6,806.47 $8,848.42 03520052 HB CT CHEST WO CONTRAST 71250 $5,385.45 $7,001.06 03520054 HB CT COLONOGRAPHY DIAG W CONT 74262 $14,013.33 $18,217.33 03520056 HB CT ABD & PELVIS WO CONTRAST 74176 $10,627.80 $13,816.13 03520057 HB CT ABD & PELVIS W CONTRAST 74177 $13,769.42 $17,900.28 03520058 HB CT ABD & PELVIS WO/W CONT 74178 $16,556.13 $21,522.96 03520059 HB CT ANGIO ABD & PEL WO/W CON 74174 $13,731.11 $17,850.44 03520061 HB CT EXT UPP WO/W CONT UNILAT 73202 $6,806.47 $8,848.42 03520062 HB CT UL FRACTIONAL FLOW RESERVE 76497 $1,902.27 $2,472.95 03520063 HB UL PROC CT BONE SURVEY SKULL-THIGH 76497 $1,106.98 $1,439.07 03520064 HB PLACEMENT, CATH RADIOELEMENT HEAD SOFT TISS 41019 $18,563.85 $24,133.01 03520065 HB PLACEMENT, CATH RADIOELEMENT PELVIC ORG 55920 $24,535.78 03520066 HB PLACEMENT, CATH RADIOELEMENT PROSTATE 55875 $13,679.09 03520067 HB LOC BREAST DEV W IMG GD PRIM 10035 $4,804.93 $6,246.41 03520068 HB LOC BREAST DEV W IMG GD EA ADDL 10036 $3,211.10 $4,174.44 03520069 HB UL PROC PLACEMENT, CATH RADIOELEMENT LYMPH NODES 38999 $5,802.20 $7,542.86 03520070 HB UL PROC PLACEMENT, CATH RADIOELEMENT LUNG 38999 $5,802.20 $7,542.86 03520071 HB UL PROC PLACEMENT, CATH RADIOELEMENT LIVER 38999 $5,802.20 $7,542.86

Ancillary FY22 135 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03520072 HB UL PROC PLACEMENT, CATH RADIOELEMENT KIDNEY 38999 $5,802.20 $7,542.86 03600002 HB OR LEVEL 5 - EA ADDL MINUTE $142.81 03600003 HB OR LEVEL 4 - EA ADDL MINUTE $177.42 03600004 HB OR LEVEL 3 - EA ADDL MINUTE $231.44 03600005 HB OR LEVEL 2 - EA ADDL MINUTE $305.01 03600006 HB OR LEVEL 1 - EA ADDL MINUTE $381.80 03600007 HB BEDSIDE PROCEDURE - MINOR $6,046.78 03600008 HB OR LEVEL 1 - 1ST HOUR $39,628.94 03600010 HB BEDSIDE PROCEDURE - MAJOR $14,649.75 03600011 HB OR LEVEL 4 - 1ST HOUR $21,250.55 03600012 HB OR LEVEL 3 - 1ST HOUR $28,667.75 03600013 HB OR LEVEL 2 - 1ST HOUR $33,683.65 03600014 HB OR LEVEL 5 - 1ST HOUR $11,300.71 03600016 HB OR LEVEL 1 - 1ST HOUR CANCELED $10,954.06 03600017 HB OR LEVEL 2 - 1ST HOUR CANCELED $9,310.67 03600018 HB OR LEVEL 3 - 1ST HOUR CANCELED $7,886.65 03600019 HB OR LEVEL 4 - 1ST HOUR CANCELED $5,633.25 03600020 HB OR LEVEL 5 - 1ST HOUR CANCELED $2,995.66 03600022 HB WHOLE LUNG LAVAGE 32997 $10,105.71 03610002 HB LIVER BIOPSY OR 47000 $9,261.99 $12,040.61 03610004 HB EXC, BENIGN DIA 0.5 CM- LESS 11400 $4,804.93 $6,246.41 03610008 HB BIOPSY NECK/THORAX SFT TISS 21550 $9,261.99 $12,040.61 03610009 HB RMVL IMPACTED CERUMEN, REQ. INSTRMNT, UNILATERAL 69210 $837.24 $1,088.40 03610011 HB SP VIDEOSTROBOSCOPY - (4) EXT 31579 $1,958.35 03610012 HB INDWL TUNN PLEU CATH W/CUFF 32550 $8,260.80 $10,739.02 03610013 HB CHEST TUBE PLMT,WTR SL OPN 32551 $6,591.17 $8,568.52 03610019 HB THR APHER, PLASMA PHERESIS 36514 $8,014.20 03610021 HB THR APHER SEL ADS/FIL PL REINF 36516 $15,932.45 03610022 HB CATH INSRT NON-TUN 5YR/M 36556 $6,591.17 $8,568.52 03610024 HB BLOOD DRAW VIA IMPL. DEVICE 36591 $867.18 $1,127.33 03610026 HB DECLOT VASCULAR DEVICE 36593 $1,818.50 $2,364.04 03610027 HB CATH REPOSITIONING 36597 $6,591.17 $8,568.52 03610028 HB ARTERIAL CATH INSERT PERC 36620 $1,392.78 $1,809.08 03610030 HB FINE NEEDLE ASP W/O IMG GUID FIRST LESION 10021 $1,665.64 $2,165.32 03610033 HB EXCISION 2.1 TO 3.0 CM 11403 $4,804.93 $6,246.41 03610034 HB INCISION & DRAINAGE, ABSCESS 10060 $1,261.52 $1,639.97 03610035 HB PUNCTURE ASPIRATION CYST 10160 $1,665.64 $2,165.32 03610036 HB EXC LES SCLP/NECK/EXT <.5 11420 $9,261.99 $12,040.61 03610037 HB DEBRIDE SURGICAL WOUND 11000 $3,257.90 $4,235.24 03610039 HB ASPIRATION BREAST CYST 19000 $4,804.93 $6,246.41 03610042 HB AUTO PB STEM CELL APHERESIS BD 38206 $8,014.20 03610043 HB EXC,BENIGN DIA 0.6 TO 1.0 11401 $1,665.64

Ancillary FY22 136 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610044 HB ASPIRATION BREAST CYST ADDL 19001 $579.77 03610045 HB BIOPSY NEEDLE CORE WO GDNCE 19100 $9,261.99 03610052 HB BIOPSY MUSCLE PERC NEEDLE 20206 $9,261.99 $12,040.61 03610054 HB BIOPSY BONE DEEP 20225 $9,261.99 $12,040.61 03610055 HB INJ SING TENDON SHEATH/LIG 20550 $1,695.56 $2,204.22 03610060 HB ABLATION R/F BONE 20982 $31,286.66 $40,672.64 03610067 HB UNLISTED SPINE PROCEDURE 22899 $1,795.98 03610068 HB ARTHROGRAM SHOULDER INJ UNI 23350 $4,754.49 03610069 HB ARTHROGRAM ELBOW INJ UNILAT 24220 $1,163.91 03610070 HB ARTHROGRAM WRIST INJ UNILAT 25246 $2,262.46 03610071 HB DIST RAD/COLLES FX W MANIP 25605 $4,923.82 $6,400.95 03610072 HB BIOPSY PELVIS/HIP ST SUPF 27040 $9,261.99 $12,040.61 03610073 HB BIOPSY PELVIS/HIP ST DEEP 27041 $9,261.99 $12,040.61 03610074 HB ARTHROGRAM HIP INJ WO ANES 27093 $1,417.70 03610076 HB ARTHROGRAM KNEE INJ UNILAT 27369 $860.30 $1,118.39 03610078 HB CAST APP - LONG ARM 29065 $2,050.20 $2,665.28 03610079 HB CAST APP - THUMB/FINGER 29086 $1,085.27 $1,410.84 03610080 HB SPLINT APP - SHORT ARM 29125 $867.18 $1,127.33 03610081 HB CAST APP - LONG LEG 29345 $2,050.20 $2,665.27 03610082 HB CAST APP - LONG LEG WALK CAST 29355 $2,050.20 03610083 HB CAST LONG LEG/THIGH TO ANKLE 29365 $2,050.20 $2,665.28 03610084 HB CAST APP - SHORT LEG 29405 $2,050.20 $2,665.28 03610085 HB CAST APP - SHORT LEG WALK CAST 29425 $2,050.20 $2,665.28 03610086 HB CAST APP - PTB 29435 $2,050.20 03610087 HB CAST APP - CLUBFOOT W/ MANI 29450 $1,085.27 03610088 HB REM/BIVALVE - SHOULDER/HIP 29710 $2,050.20 03610089 HB CAST - REPAIR 29720 $1,085.27 03610090 HB CAST - WINDOWING 29730 $1,085.27 $1,410.84 03610091 HB TRACH TUBE CHANGE 31502 $1,671.20 $2,172.57 03610093 HB ENT-LARYNGO, FLEXE, DX 31575 $1,292.08 $1,679.69 03610097 HB TRACHEOSTOMY 31600 $9,768.27 $12,698.75 03610098 HB DX BRONCHOSCOPE/WASH 31622 $9,700.60 $12,610.78 03610099 HB PC BRONCH W/ BRUSHING 31623 $9,700.60 03610100 HB PC BRONCH:ALEVOLAR LAVAGE 31624 $9,700.60 03610101 HB PC BRONCH W/ BIOPSY, SINGLE/MULTI 31625 $9,700.60 03610102 HB BRONCH W TB SGL LOBE LUNG BX 31628 $14,548.85 03610103 HB ASPIR NDL BIOPSY(S) TRNSBRONCH 31629 $14,548.85 03610104 HB PC BRONCH: TRACH STENT 31631 $20,600.24 03610105 HB TB LUNG BIOPSY, EA ADDTL LOBE 31632 $10,691.02 03610106 HB BRONCHOSCOPY; W REMOVAL FB 31635 $9,700.60 $12,610.78 03610107 HB PC BRONCH: BRONCH STENT 31636 $20,600.24 03610108 HB PC BRONCH: ADDL BRONCH STENT 31637 $17,883.74

Ancillary FY22 137 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610109 HB PC BRONCH: STENT REVISION 31638 $20,600.24 03610110 HB BRONCHOSCOPY,TREAT BLOCKAGE 31641 $14,548.85 03610113 HB BIOPSY LUNG 32400 $9,261.99 $12,040.61 03610117 HB REPAIR DECEND AORT W SUBCLAV 33880 $15,091.66 03610118 HB REPAIR DECEND AORT WO SUBCLAV 33881 $12,977.44 03610119 HB REMOV INTRA-AORT BALLOON 33968 $1,168.29 03610125 HB INSERT ILIAC OCCL DEVICE 34808 $2,513.10 03610138 HB PSEUDOANEURYSM INJ EXT UNI 36002 $4,242.68 $5,515.50 03610139 HB VENOGRAM INJ EXT UNILATERAL 36005 $1,610.74 03610140 HB CATH INTRO SVC/IVC 36010 $6,009.23 03610141 HB CATH PLCMT VENOUS 1ST ORD 36011 $7,500.05 03610142 HB CATH PLCMT VENOUS2ND ORD IR 36012 $7,671.01 03610143 HB CATH INTRO RT HEART/PULM AR 36013 $5,775.98 03610144 HB CATH PLCMT RT/LT PULM ART 36014 $7,125.15 03610145 HB CATH PLCMT SEGMENTAL ARTERY 36015 $5,503.55 03610149 HB CATH INTRO AORTIC TRANSLUMN 36160 $6,063.68 03610150 HB CATH AORTA 36200 $5,313.92 03610151 HB CATH PLCMT THORACIC 1ST ORD 36215 $11,017.95 03610152 HB CATH PLCMT THORACIC 2ND ORD 36216 $12,410.71 03610153 HB CATH PLCMT THORACIC 3RD ORD 36217 $14,976.16 03610154 HB CATH PLCMT THORACIC EA ADDL 36218 $2,384.49 03610155 HB CATH PLCMT ABD-EXT 1ST ORD 36245 $5,313.92 03610156 HB CATH PLCMT ABD-EXT 2ND ORD 36246 $7,364.94 03610157 HB CATH PLCMT ABD-EXT 3RD ORD 36247 $11,205.40 03610158 HB CATH PLCMT ABD-EXT EA ADDL 36248 $2,225.39 03610159 HB VENIPUNCTURE INFNT 3YR/OLDER 36410 $72.59 $96.03 03610161 HB VENIPUNCTURE CUTDOWN > 1 YR 36425 $597.13 $776.27 03610164 HB CATH PLCMT PERC PORTAL VEIN 36481 $5,560.19 03610165 HB VENOUS SAMPLING 36500 $2,615.54 03610166 HB TUBE CHANGE G-TUBE TO GJ 49446 $6,023.78 03610167 HB TUBE REPLACE DUOD/JEJ 49451 $4,219.24 $5,485.02 03610168 HB TUBE REPLACE GJ 49452 $4,219.24 03610169 HB TUBE FIX G-GOLON 49460 $4,219.24 $5,485.02 03610170 HB G-COLON CONTRAST INJECTION 49465 $868.30 03610174 HB CATH INSRT TUNNLED 5YR/MORE 36558 $12,035.14 $15,645.68 03610175 HB INSRT TUNN CVC W/PORT >5YRS 36561 $12,035.14 $15,645.68 03610177 HB CATH INSRT PICC 5YR/LESS W/O IMG GUID 36568 $4,242.68 $5,515.50 03610178 HB CATH INSRT PICC 5YR/MORE W/O IMG GUID 36569 $6,591.17 $8,568.52 03610180 HB PAS PORT INSERTION >5 YRS 36571 $12,035.14 $15,645.68 03610181 HB CATH REPAIR CV OR PICC 36575 $4,242.68 $5,515.50 03610183 HB CATH REPLCMT NON-TUN CV 36580 $6,591.17 $8,568.52 03610184 HB CATH REPLCMT TUNNLED CV 36581 $12,035.14 $15,645.68

Ancillary FY22 138 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610185 HB REPL CHEST PORT VIA CATH EX 36582 $12,035.14 $15,645.68 03610186 HB REPL PAS PORT VIA CATH EXCH 36585 $12,035.14 $15,645.68 03610187 HB COMPLEX CMG (CYSTOMETROGRAM) 51726 $3,391.93 03610188 HB CATH REMOVE TUNNLED VAD 36590 $4,242.68 $5,515.50 03610189 HB REMOVE PERICATH OBST CVC 36595 $12,035.14 03610190 HB REMOVE INTRACATH OBST MAT 36596 $6,591.17 $8,568.52 03610191 HB I & D VULVA/PERINEUM 56405 $1,493.97 $1,942.16 03610192 HB HYSTEROSALPINGOGRAM INJECT 58340 $636.38 03610193 HB CONTRAST INJ INTO CV CATH 36598 $1,140.87 03610195 HB AMNIOCENTESIS, THERAPEUTIC 59001 $1,493.97 03610196 HB ASPIR/INJECT THYROID CYST 60300 $4,804.93 03610197 HB SHUNT INSERT HEPATIC TIPS 37182 $82,600.93 03610198 HB SHUNT REVISION HEPATIC TIPS 37183 $38,663.15 03610199 HB THROMBECTOMY PRIM MECH 37184 $82,600.93 03610200 HB THROMBECTOMY SECNDRY MCH 37186 $6,678.10 03610201 HB THROMBECTOMY VENOUS MECH 37187 $82,600.93 03610202 HB THROMBECTOMY VENOUS MECH ADD ON 37188 $12,035.14 03610203 HB BIOPSY TRANSCATHETER 37200 $20,160.23 03610212 HB STENT PLCMT W DIST PROTECT 37215 $23,269.54 03610213 HB STENT PLCMT WO DIST PROTECT 37216 $23,269.54 03610215 HB EPIDURAL INJ CATH CERV/THOR 62324 $5,549.43 $7,214.27 03610218 HB DIAG BONE MARROW ASPIRATION ONLY 38220 $9,261.99 $12,040.61 03610219 HB DIAG BONE MARROW BIOPSY 38221 $9,261.99 $12,040.61 03610220 HB THER/PROPH/DIAG INJ, SC/IM 96372 $332.77 $431.81 03610222 HB BIOPSY LYMPH NODE 38505 $9,261.99 $12,040.61 03610228 HB SIALOGRAM INJECTION 42550 $1,011.34 $1,314.74 03610230 HB REPOSIT NG/OG TUBE 43761 $3,391.93 $4,409.52 03610233 HB BIOPSY LIVER 47000 $9,261.99 $12,040.61 03610235 HB ABLATION R/F LIVER 47382 $20,948.74 $27,233.53 03610236 HB CHOLECYTOSTOMY S&I 47490 $8,260.80 03610237 HB ANTRODUODENAL MANOMETRY 91020 $4,885.95 03610246 HB BIOPSY PANCREAS 48102 $9,261.99 $12,040.61 03610251 HB BIOPSY RETROPERITONEAL MASS 49180 $9,261.99 $12,040.61 03610252 HB INJ PREVIOUS DRAINAGE CATH 49424 $1,837.43 03610253 HB BX RENAL/KIDNEY,PERC 50200 $9,261.99 $12,040.61 03610254 HB REMOVE TUBE NEPHROSTOMY 50389 $3,292.17 03610255 HB ASPIR/INJECT RENAL CYST 50390 $4,804.93 $6,246.41 03610261 HB ABLATION R/F KIDNEY UNILAT 50592 $20,948.74 $27,233.53 03610262 HB URETEROPYELOGRAM/LOOP INJ 50690 $1,785.11 03610264 HB BLADDER INSTILLATION/IRRGTN 51700 $3,391.93 $4,409.52 03610265 HB CATHERIZATION, STRAIGHT 51701 $867.18 $1,127.33 03610266 HB CYSTOSTOMY TUBE CHANGE 51705 $3,391.93 $4,409.52

Ancillary FY22 139 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610270 HB 24 HR ESOPHAGEAL PH STUDY 91034 $4,885.95 03610271 HB UROFLOWMETRY (SIMPLE) 51736 $590.54 03610272 HB UROFLOWMETRY (COMPLEX) 51741 $2,650.27 03610276 HB POST-VOID RESIDUAL MEASUREMENT 51798 $293.61 $381.69 03610277 HB CYSTOSCOPY 52000 $3,292.17 $4,279.82 03610278 HB CYTOURETHROSCOPY 52005 $10,376.78 $13,489.81 03610280 HB CYSTO W/ DILATION URETHRA STRT 52281 $10,376.78 $13,489.81 03610281 HB CYSTO W/ STENT REMOVE (SIMPLE) 52310 $10,376.78 $13,489.81 03610282 HB IMPEDANCE PH REFLUX 91038 $4,885.95 03610283 HB CYSTOURETHROSCOPY 52351 $11,704.57 03610284 HB DILITATION URETHRAL STRICTURE 53600 $3,391.93 03610286 HB CIRCUM., BY CLAMP OR DEVICE 54150 $10,376.78 03610288 HB BIOPSY PROSTATE 55700 $10,376.78 $13,489.81 03610291 HB BIOPSY, VULVA 1ST LESION 56605 $2,414.06 03610294 HB PESSARY FITTING 57160 $1,417.90 $1,843.26 03610295 HB HEMOSTATIC AGENT, INTRODUCTION 57180 $1,417.90 $1,843.26 03610296 HB ECC 57505 $2,414.06 03610297 HB BIOPSY, ENDOMETRIAL 58100 $1,417.90 $1,843.26 03610301 HB CATH INSRT TUNNLED 5YR/LESS 36557 $20,160.23 $26,208.29 03610302 HB PLCMT NG TUBE BY W FLUORO 43752 $597.13 $776.27 03610306 HB CHORIONIC VILLUS SAMPLING 59015 $2,414.06 03610308 HB CELIAC PLEXUS INJ WO/W IMAGE 64530 $5,549.43 03610309 HB INSERT CERVICAL DILATOR 59200 $1,493.97 03610310 HB BIOPSY THYROID PERC NDL 60100 $4,804.93 $6,246.41 03610311 HB PUNCTURE C-SPINE W MEDS 61055 $1,695.56 03610312 HB PUNCTURE OF SHUNT TUBING 61070 $3,686.81 $4,792.87 03610313 HB ENDOVSC TEMP BALLN ART OCCLUSN 61623 $82,600.93 03610314 HB EMBOLIZATION CNS 61624 $92,511.30 03610315 HB EMBOLIZATION EXTRACRANIAL 61626 $82,600.93 03610316 HB ANGIOPLASTY CRANIAL 61630 $23,269.54 03610317 HB ANGIOPLASTY CRANIAL W STENT 61635 $29,086.97 03610318 HB DIL CRANIAL VASOSPASM INIT 61640 $29,086.97 03610319 HB DIL CRANIAL VASOSPASM ADDL 61641 $11,634.78 03610320 HB DIL CRANIAL VASOSPASM ADDON 61642 $23,269.54 03610323 HB INJ EPIDURAL OR BLOOD PATCH 62273 $5,549.43 $7,214.27 03610324 HB MYELOGRAM INJ 62284 $4,300.37 03610326 HB INJ DISCOGRAM L-SPINE 62290 $5,224.55 03610328 HB INJ EPIDURAL CERV/THOR 62320 $5,325.75 03610329 HB INJ EPIDURAL L/S-SPINE 62322 $5,325.75 03610333 HB INJ ANESTH/STEROID PUDENDAL NERVE 64430 $5,549.43 $7,214.25 03610339 HB INJ C/T-SPINE TRNSFORAM INI- IMG GUIDE INCL 64479 $5,549.43 $7,214.25 03610340 HB INJ C/T-SPINE TRNSFORAM ADL-IMG GUIDE INCL 64480 $3,459.05

Ancillary FY22 140 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610341 HB INJ L/S-SPINE TRNSFORAM INI-IMG GUIDE INCL 64483 $5,549.43 $7,214.25 03610342 HB INJ L/S-SPINE TRNSFORAM ADL-IMG GUIDE INCL 64484 $3,345.71 03610343 HB BOTOX, CERVICAL SPINAL MUSCLES 64616 $1,695.56 $2,204.22 03610344 HB ARG/KRYP TRABECULOPLASTY * 65855 $4,395.89 03610345 HB YAG IRIDOTOMY 1 OR MORE 66761 $4,395.89 $5,714.66 03610346 HB YAG DISCISSION A-CATARACT MEM* 66821 $4,395.89 03610347 HB ARG/KRYP ANTERIOR SMGNT EYE * 66999 $7,895.47 03610349 HB ARG/KRYP DESTRUCTION RETINA * 67210 $4,395.89 03610350 HB ARG/KRYP DESTRUCT RETINOPATHY* 67228 $4,395.89 03610354 HB VENOGRAM HEPATIC WO HEMO SI 75891 $18,041.30 03610356 HB ARTHROGRAM INJ SI JOINT UNI G0259 $1,985.81 03610357 HB ESOPHAGEAL MANOMTRY W/INTER RPT 2D 91010 $8,143.23 03610358 HB ESOPHGEAL MOTILITY W/STIM/PERFUS 2D 91013 $6,867.96 03610360 HB ARTHROGRAM ANKLE INJ UNILAT 27648 $4,754.49 03610361 HB PLCMT PROX EXTENSION PROS 33883 $9,060.66 03610362 HB THROMBECTOMY PRIM MECH ADON 37185 $6,756.83 03610366 HB FIBERLAYER PHO OPTHAL NERVE 92499 $392.90 03610371 HB C MOTOR EVOKED, UPPR LIMBS 95928 $13,287.11 $17,273.27 03610372 HB C MOTOR EVOKED, LWR LIMBS 95929 $13,287.11 $17,273.27 03610373 HB CYSTOGRAM/VCUG INJ 51600 $286.76 $372.17 03610376 HB URETHROCYSTOGRAM RETRO INJ 51610 $503.52 $654.55 03610377 HB IR INJ EPIDURAL LS SPINE 62326 $5,549.43 03610380 HB PLCMT PERC GASTROSTOMY TUBE 49440 $6,023.78 03610383 HB GASTRIC LAP BAND ADJUSTMENT S2083 $4,971.74 $6,463.26 03610384 HB INTRODUCTION LONG GI TUBE 44500 $4,219.24 $5,485.02 03610385 HB BX VULVA/PERINEUM EA ADDL LES 56606 $1,355.73 03610386 HB IUD INSERTION 58300 $431.57 03610387 HB IUD REMOVAL 58301 $1,493.97 $1,942.16 03610388 HB HYSTEROSCOPY 58555 $17,494.01 03610392 HB DEBRIDEMENT SQ TISSUE 11042 $1,665.64 $2,165.32 03610393 HB PARING OR CURETTEMENT 1 LESION 11055 $1,261.52 03610395 HB RMVL SKIN TAGS UP TO 15 11200 $1,261.52 $1,639.97 03610396 HB SIMPLE LAC REPAIR UP TO 2.5 CM 12001 $1,261.52 $1,639.97 03610397 HB CAST APP - SHORT ARM 29075 $2,050.20 $2,665.28 03610398 HB SPLINT APP - LONG ARM 29105 $1,085.27 $1,410.84 03610399 HB STRAPPING CHEST 29200 $1,085.27 $1,410.84 03610400 HB STRAPPING, SHOULDER 29240 $867.18 $1,127.33 03610401 HB STRAPPING, ELBOW/WRIST 29260 $323.94 $421.11 03610402 HB SPLINT APP - LONG LEG 29505 $1,085.27 $1,410.84 03610403 HB SPLINT APP - SHORT LEG 29515 $1,085.27 $1,410.84 03610404 HB STRAPPING, KNEE 29530 $867.18 $1,127.33 03610405 HB STRAPPING ANKLE &/OR FOOT 29540 $1,085.27 $1,410.84

Ancillary FY22 141 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610406 HB STRAPPING TOES 29550 $837.24 $1,088.40 03610407 HB REM/BIVALVE - FULL ARM/LEG 29705 $2,050.20 $2,665.28 03610408 HB ANT. EPISTAXIS COMPLEX 30903 $1,661.41 $2,159.84 03610409 HB POSTERIOR EPISTAXIS INITIAL 30905 $867.18 $1,127.33 03610410 HB LARYNGOSCOPY, DIRECT ASPIRATIO 31515 $1,958.35 $2,545.84 03610411 HB INJ ANES/STEROID PERIPHERAL NERVE 64450 $1,697.13 $2,206.28 03610413 HB BIOPSY BONE SUPERFICIAL 20220 $9,261.99 $12,040.61 03610418 HB THORACENTESIS WO IMG GUIDE 32554 $4,242.68 $5,515.50 03610422 HB CATH PLCMT NON-SELECTIVE 36000 $307.31 03610423 HB CATH INSRT NON-TUN 5YR/LESS 36555 $6,591.17 $8,568.52 03610424 HB CATH REMOVE TUNNLED CV 36589 $4,242.68 $5,515.50 03610425 HB BLOOD DRAW PICC 36592 $867.18 $1,127.33 03610426 HB ARTERIAL PUNCTURE 36600 $867.18 $1,127.33 03610428 HB CATHETERIZATION, INDWELLING 51702 $867.18 $1,127.33 03610429 HB TRANS ABD AMNIOINFUSION W/US 59070 $1,493.97 03610430 HB PUNCTURE L-SPINE DIAG 62270 $4,438.25 $5,769.73 03610431 HB DRAINAGE CSF FLUID 62272 $3,078.05 $4,001.45 03610432 HB PEDS ENT-REMOVE-FB-EXTAUDITCAN 69200 $867.18 $1,127.33 03610433 HB PLACEMENT, CATH RADIOELEMENT 19296 $24,574.30 03610435 HB CHEMODENERVATION;FACIAL NERVE 64612 $1,695.56 $2,204.22 03610436 HB DESTRC, NEUROLYTIC AGENT, OTHR 64640 $5,549.43 $7,214.27 03610438 HB SP VIDEOSTROBOSCOPY - (3) MOD 31579 $1,468.77 03610439 HB SP VIDEOSTROBOSCOPY - (2) INT 31579 $979.18 03610441 HB TRIGGER PT INJ >3 MUSCLES 20553 $1,695.56 $2,204.22 03610443 HB ASPIR/INJECT GANGLION CYST(S) 20612 $1,695.56 $2,204.22 03610445 HB SPLENOPORTOGRAPHY INJECTION 38200 $307.31 03610446 HB DEPLOY HEMOSTASIS DEVICE 37799 $4,242.68 03610449 HB MUSCLE TRIGGER PT INJ 1-2 20552 $1,695.56 $2,204.22 03610457 HB SI JOINT ANES/STEROID INJ W IMG 27096 $3,770.29 03610459 HB INJ ANES/STEROID INTRCSTL NRVE SGLE LVL 64420 $3,078.05 $4,001.46 03610460 HB INJ ANES/STEROID INTECSTL NRVE EACH ADDL LVL 64421 $5,549.43 03610466 HB CL TX PROX HUM FX; WO MANIP 23600 $1,795.98 $2,334.78 03610467 HB CL TX HUMERUS FX WO MANIP 24500 $1,795.98 $2,334.78 03610468 HB CL TX SC/TC HUM FX WO MANIP 24530 $1,795.98 $2,334.78 03610469 HB CL TX EC HUM FX WO MANIP 24560 $1,795.98 $2,334.78 03610471 HB CL TX C HUMERUS FX W MANIP 24577 $4,923.82 $6,400.95 03610472 HB CL TX MONTGG ELB FX W MANIP 24620 $4,923.82 $6,400.95 03610473 HB CL TX ULNAR FX; PROX END WO MANIP 24670 $1,795.98 $2,334.78 03610474 HB CL TX RAD SHFT FX; WO MANIP 25500 $1,795.98 $2,334.78 03610475 HB GALEAZZI FX/DISLOC 25520 $4,923.82 $6,400.95 03610476 HB CL TX ULNAR SHFT FX WOMANIP 25530 $1,710.46 $2,223.60 03610477 HB CL TX ULNAR SHFT FX W MANIP 25535 $1,795.98 $2,334.78

Ancillary FY22 142 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610478 HB CL TX DSTL RADIAL FX/EPIPHYSL SEP WO MANIP 25600 $1,795.98 $2,334.78 03610479 HB CL TX MC FX,SGLWO MNP EA BN 26600 $1,795.98 $2,334.78 03610480 HB CL TX MC FX, SGL; W MANIP 26605 $1,795.98 $2,334.78 03610482 HB CL TX FEM SHAFT FX, W MANIP 27502 $4,923.82 $6,400.95 03610483 HB CL TX SC/TC FEM FX, W MANIP 27503 $4,923.82 $6,400.95 03610484 HB CL TX D FEM FX WO MANIP 27508 $1,795.98 $2,334.78 03610485 HB CL TX DIST FEM EPIPHYS SEP; WO MANIP 27516 $1,795.98 $2,334.78 03610487 HB CLOSED TX PTLLR FX,WO MANIP 27520 $1,795.98 $2,334.78 03610488 HB CL TX PROX TIB FX, WO MANIP 27530 $1,795.98 $2,334.78 03610490 HB CL TX IC SP ORTUBEROSITY W OR W/O MANIP 27538 $1,795.98 $2,334.78 03610491 HB CL TX PRX FIB/SHFT FX WOMNP 27780 $1,795.98 $2,334.78 03610492 HB CL TX DSTL FIB FX WO MANIP 27786 $1,795.98 $2,334.78 03610493 HB CL TX WB DSTL TIB WO MANIP 27824 $1,795.98 $2,334.78 03610494 HB CL TX CALCANEAL FX;WO MANIP 28400 $1,795.98 $2,334.78 03610495 HB CL TX TALUS FX; WO MANIP 28430 $1,795.98 $2,334.78 03610496 HB TX TARSAL BONE FX;WO MANIPU 28450 $1,795.98 $2,334.78 03610498 HB CL TX METATARSAL FX;WOMANIP 28470 $1,795.98 $2,334.78 03610499 HB CL TX METATARSAL FX;W MANIP 28475 $1,795.98 $2,334.78 03610500 HB CL TX RADIAL SHFT FX WMANIP 25505 $4,923.82 $6,400.95 03610501 HB SINUS TRACT INJ THERAPEUTIC 20500 $5,444.96 03610503 HB CHANGE URETER STENT, PERCUT 50382 $10,376.78 03610504 HB INSTILATN OF ANTICARCINOGNC 51720 $3,391.93 03610505 HB INSERT ABD. PLEURX CATH 49418 $8,260.80 $10,739.02 03610507 HB EXC, BENIGN DIA 1.1-2.0 CM 11402 $4,804.93 03610508 HB REMOVE URETER STENT PERCUT 50384 $10,376.78 $13,489.81 03610509 HB PHOTOPHERESIS, EXTRACORP 36522 $15,932.45 03610511 HB ABLATION CRYO RENAL UNILAT 50593 $18,653.55 $24,249.62 03610513 HB UL VASCULAR INJECTION 36299 $5,410.50 $7,033.63 03610516 HB REMOVAL OF NAIL BED 11750 $1,665.64 $2,165.32 03610518 HB CL TX SHLDR DISL,MANIP;ANES 23655 $4,923.82 $6,400.95 03610519 HB LARYNGOSCOPY, IND; DIAGNOSTIC 31505 $1,292.08 $1,679.69 03610522 HB TX CL ELBOW DISLOC W ANESTH 24605 $4,923.82 $6,400.95 03610523 HB CL LAC, MTH VESTIB; >2.5 CM 40831 $2,386.91 $3,102.98 03610530 HB REM FB,EXTEYE;CRNL,SLT LAMP 65220 $597.13 $776.27 03610531 HB REPLACE CATH ONLY OF VAD 36578 $12,035.14 $15,645.68 03610534 HB PLACE DUOD/JEJ TUBE PERC 49441 $6,023.78 03610535 HB INJ ANES/STEROID SCIATIC NERVE 64445 $4,438.25 $5,769.73 03610541 HB BIOPSY MUSCLE SUPERFICIAL 20200 $9,261.99 $12,040.61 03610542 HB BIOPSY MUSCLE; DEEP 20205 $10,098.89 $13,128.58 03610543 HB STENT PLCMT INTERNAL CAROT 93799 $2,650.27 03610545 HB PLCMT RT DEV/MARKER PROSTATE 55876 $14,150.34 03610546 HB EXC FACE-MM B9+MARG 0.5< CM 11440 $4,804.93 $6,246.41

Ancillary FY22 143 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610547 HB BRONCH W FLUORO COMPTR ASST 31627 $9,503.11 03610550 HB REMOVAL OF PLEURX CATHETER 32552 $4,242.68 $5,515.50 03610565 HB EXC NECK LES SC = 3 CM 21552 $10,098.89 03610566 HB EXC BACK LES SC = 3 CM 21931 $9,261.99 03610576 HB EXC THIGH/KNEE LES SC> 3 CM 27337 $10,098.89 03610580 HB ABLATION CRYO FIBROADENOMA 19105 $14,926.53 $19,404.47 03610582 HB ABLATION CRYO LIVER 47383 $20,948.74 $27,233.53 03610587 HB SINUS INJECTION, DIAGNOSTIC 20501 $1,611.46 $2,094.92 03610594 HB DEEP I & D, THIGH/KNEE 27301 $10,098.89 $13,128.58 03610595 HB ILIAC ENDARTERECTOMY 35351 $16,558.07 03610596 HB THROMBOENDARTARECTOMY OF RF 35371 $16,558.07 03610600 HB CL TX DISTL FIB FX W MANIP 27788 $2,155.18 $2,801.73 03610603 HB DRAIN BL W/CATH INSERTION 51102 $10,376.78 $13,489.81 03610604 HB NASOPHARYNGOSCOPY W ENDOSCP 92511 $1,292.08 $1,679.69 03610605 HB UGI W BX. SGL/MULTIPLE 43239 $4,219.24 $5,485.02 03610606 HB UGI W REMOVAL OF FB 43247 $4,219.24 $5,485.02 03610608 HB EXC,BLES,S/N/EX,G;1.1-2.0CM 11422 $9,261.99 $12,040.61 03610609 HB REM FB, UP ARM OR ELBOW; SQ 24200 $9,261.99 $12,040.61 03610613 HB UNLISTED VASC PROCEDURE 37799 $4,242.68 $5,515.50 03610615 HB REMOVE FECAL IMPACTION OR FB 45915 $9,859.57 $12,817.43 03610616 HB CNTRL OROPHRYNGEAL HEMORRH;SIMPL 42960 $2,386.91 $3,102.98 03610620 HB DX LARYNGOSCOPY EXCL NB 31525 $9,700.60 $12,610.78 03610621 HB SKIN TEST; TB, ID 86580 $392.90 $510.77 03610622 HB BRONCHOSCOPY DILATE/FX REPR 31630 $14,548.85 $18,913.51 03610625 HB ATT F/C/M/N/A/G/H/F; 10 SQ CM 14040 $6,416.19 $8,341.03 03610627 HB REM GAUNTLET,BOOT - BDY CST 29700 $2,050.20 $2,665.28 03610628 HB DEEP REM FB FROM UA/ELBOW 24201 $10,098.89 $13,128.58 03610630 HB ENDOVASC PROSTH TAA ADD-ON 33884 $5,313.92 03610631 HB EXPOSE FEM ART PROSTH UNI 34812 $5,313.92 03610632 HB BIOPSY SALIVARY GLAND NDL 42400 $4,804.93 $6,246.41 03610633 HB CERV COLP W EC CURETT 57456 $1,493.97 03610634 HB COLPOSCOPY OF VULVA 56820 $1,417.90 03610635 HB EXAM/BIOPSY OF VAG W/SCOPE 57421 $2,414.06 03610639 HB HYSTEROSCOPY BX ENDM-PLYPT 58558 $17,494.01 03610644 HB ANGIO ILIAC, INITIAL VESSEL 37220 $38,663.15 03610645 HB STENT, ILIAC INITIAL VESSEL 37221 $82,600.93 03610646 HB ANGIO ILIAC, ADDL VESSEL 37222 $36,027.00 03610647 HB STENT ILIAC, ADDL VESSEL 37223 $38,810.66 03610648 HB ANGIO FEM/POP SYSTEM 37224 $38,663.15 03610649 HB ATHERECTOMY FEM/POP SYSTEM 37225 $82,600.93 03610650 HB STENT PLACEMENT FEM/POP 37226 $82,600.93 03610651 HB STENT PLCMNT W/ATHRCTMY FEM 37227 $92,511.30

Ancillary FY22 144 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610652 HB ANGIO PTA TIB/PERON INI VSL 37228 $82,600.93 03610653 HB ATHERECTOMY TIB/PERON INI 37229 $92,511.30 03610654 HB STENT PLCMNT TIB/PERON, INI VSL 37230 $92,511.30 03610655 HB STENT PLCMNT W/ATH TIB, INITIAL VESSEL 37231 $92,511.30 03610656 HB ANGIO TIB/PERONEAL,EA ADDL 37232 $30,887.49 03610657 HB ATHERECTOMY TIB/PERON EA 37233 $33,785.39 03610658 HB STENT PLCMNT TIB/PERON,EA 37234 $33,671.10 03610659 HB STENT PLCMNT TIB/PER W/ATH, EA ADDL 37235 $63,177.84 03610661 HB STENT PLACEMENT INTRACRANIAL 37799 $4,242.68 03610663 HB PARTNER TRANSFEMORAL 33361 $60,317.62 03610664 HB PARTNER TRANSAPICAL 33366 $23,428.57 03610668 HB DEBRIDE MUSC/FASCIA ADD-ON 11046 $1,280.07 $1,664.09 03610669 HB DEBRIDE BONE ADD-ON 11047 $869.23 $1,130.00 03610671 HB BIOPSY BACK/FLANK; SUPERF 21920 $9,261.99 $12,040.61 03610674 HB CHNGE CYSTO TUBE COMPLICATD 51710 $3,292.17 $4,279.82 03610675 HB INJ ANES/STEROID BRACH PLEX CONT INF 64416 $5,549.43 $7,214.27 03610677 HB THROMECTOMY PRIM MECH ADDON 37185 $6,756.83 03610679 HB AVULSION NAIL PLATE; SGL 11730 $1,261.52 $1,639.98 03610680 HB AVULSION NP; SGL EA ADDL 11732 $773.78 $1,005.92 03610682 HB EXC INTRDG MRTN NERM EA SGL 28080 $4,923.82 03610684 HB INJ TENDON ORIGIN/INSERT 20551 $1,695.56 03610685 HB CARPAL TUNNEL TX INJ 20526 $1,695.56 $2,204.22 03610686 HB CHEMODENRV EXTRCLR MUSCLE 67345 $1,286.99 $1,673.11 03610687 HB CHEMODENRV ECRN GLNDS 2AXIL 64650 $1,695.56 $2,204.22 03610688 HB CHEMODENRV ECRN GLNDS OTHR 64653 $1,695.56 $2,204.22 03610691 HB CHEMODENERV SALIV GLANDS 64611 $1,695.56 $2,204.22 03610696 HB CL TX NSL BN FX; W STABILIZ 21320 $9,768.27 $12,698.75 03610699 HB CATHETERIZATION,NON-INDWELLNG 51701 $867.18 03610712 HB INSERT TEMP PACELEAD SGL CL 33210 $36,063.89 $46,883.05 03610731 HB INTERDISCAL PERQ ASPIR, DX 62267 $4,804.93 03610747 HB ASPIRATION/INJ RNL CYST IR 50390 $4,804.93 03610753 HB REPLACE G/C TUBE PERC 49450 $4,219.24 03610754 HB INJ C/T-SPINE FACET FRST 64490 $5,549.43 03610755 HB INJ C/T-SPINE FACET SECOND 64491 $3,105.96 03610756 HB INJ C/T-SPINE FACET ADDL 64492 $3,105.96 03610757 HB INJ L/S-SPINE FACET FIRST 64493 $5,549.43 03610758 HB INJ L/S-SPINE FACET SECOND 64494 $3,105.96 03610759 HB INJ L/S-SPINE FACET ADDL 64495 $3,105.96 03610761 HB EXCHANGE PREVIOUS DRAINAGE CATH 49423 $6,023.78 $7,830.91 03610762 HB NERVE INJ GANGLN IMPR BLCK 64999 $1,695.56 03610768 HB REMOVAL FB SQ SIMPLE* 10120 $1,665.64 03610769 HB I&D HEMATOMA 10140 $9,261.99 $12,040.61

Ancillary FY22 145 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610776 HB EXC,BEN LES,T/A/L;3.1-4.0CM 11404 $9,261.99 03610777 HB EXC BEN LESS T/A/L; >4.0CM 11406 $9,261.99 03610778 HB EXC MLES T/A/L; 0.6-1.0CM* 11601 $4,804.93 03610779 HB EXC MLES T/A/L; 1.1-2.0CM* 11602 $1,665.64 03610780 HB EXC MLES T/A/L; 2.1-3.0CM* 11603 $4,804.93 03610781 HB EXC MLES T/A/L; 3.1-4.0CM* 11604 $4,804.93 03610782 HB EXC MLES T/A/L; >4.0CM* 11606 $9,261.99 03610788 HB EXC BACK LESS SC < 3 CM* 21930 $9,261.99 03610794 HB ARTERIAL CATH INSERT PERC 36620 $1,348.95 03610797 HB SGL/MLT INJ SPDR VN;LMB/TRK 36468 $1,665.64 03610799 HB INJ SCLRSNG SOLN - SGL VEIN 36470 $1,665.64 03610800 HB INJ SCLRSNG SOLN;MLT SM LG 36471 $1,665.64 03610802 HB DEBRIDEMENT MUSCLE/FASCIA 11043 $3,257.90 $4,235.24 03610803 HB DEB BONE 20 SQ CM/< 11044 $9,261.99 $12,040.61 03610804 HB EXC BLES S/N/EX G; > 4.0CM 11426 $10,098.89 03610806 HB EXC MLS F/E/E/N/L;0.6-1.0CM 11641 $4,804.93 03610807 HB EXC MLS F/E/E/N/L;1.1-2.0CM 11642 $4,804.93 03610812 HB TX S WND DEHISC; SMPL - 12020 $3,257.90 $4,235.24 03610813 HB WOUND DEHISCENCE PACKING 12021 $1,665.64 $2,165.33 03610822 HB EXPL PNTRTNG WND;ABD/FLNK 20102 $6,416.19 $8,341.03 03610828 HB INJ ANES/STEROID ILING/ILHYPGSTRC 64425 $3,078.05 $4,001.46 03610829 HB PLCMT EXT DEV PST ARTA REP 33886 $7,274.26 03610830 HB DEBRIDE SKIN MUSC AT FX STE 11011 $4,804.93 $6,246.41 03610831 HB INJ SUP HYPOGASTRIC PLXUS 64517 $5,549.43 03610832 HB INJ ANES/STEROID FEMORAL NRV 64447 $4,438.25 $5,769.73 03610833 HB INJ AIR PERITONEUM 49400 $697.48 03610834 HB INJ MAMMARY DUCT(S) 19030 $2,020.51 $2,626.68 03610835 HB UL PROC ABLATION LIVER ALCOHOL 47399 $4,804.93 $6,246.41 03610836 HB UL PROC ABLATION LIVER MICROWAVE 47382 $20,948.74 $27,233.53 03610841 HB UL PROC ABLATION SPINE RADFREQ 20982 $31,286.66 $40,672.64 03610842 HB UL PROC ABLATION BONE MICROWAVE 20982 $31,286.66 $40,672.64 03610844 HB INS CATH REN ART 1ST UNILAT 36251 $61,219.59 03610845 HB INS CATH REN ART 1ST BILAT 36252 $66,824.33 03610846 HB INS CATH REN ART 2ND+ UNILAT 36253 $45,464.31 03610847 HB INS CATH REN ART 2ND+ BILAT 36254 $56,947.38 03610848 HB INS VENA CAVA FILTER 37191 $20,160.23 $26,208.29 03610849 HB REPOSITION VENA CAVA FILTER 37192 $12,035.14 03610850 HB REMOVAL VENA CAVA FILTER 37193 $12,035.14 03610851 HB PARACENTESIS W IMG 49083 $4,219.24 $5,485.02 03610852 HB ESOPH IMPED FUNCTION TEST 91037 $3,204.04 03610853 HB DESTR W NEURLYTC CELC PLEXS 64680 $5,549.43 03610854 HB INJ ANES/STEROID BRACH PLEXUS 64415 $5,549.43 $7,214.27

Ancillary FY22 146 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610855 HB BM/PB WASH HARVST STM CELLS 38209 $5,802.20 03610856 HB BM/PB WASH HARVST STM CELLS 38208 $5,802.20 03610857 HB REP TENDN/MSCL - FARM.WRIST 25260 $13,149.09 $17,093.81 03610858 HB CYSTO W MULTI OBSTR CLOT REM 52001 $11,704.57 $15,215.94 03610860 HB ABLATION RENAL MICROWAVE UN 50592 $20,948.74 $27,233.53 03610861 HB ABLATION RENAL ALCOHOL UNI 53899 $3,391.93 $4,409.52 03610862 HB INJ PLATELET PLASMA & IMG 0232T $597.13 03610863 HB INJ ANESTH/STEROID GRTR OCCPTL NRV 64405 $1,695.56 $2,204.22 03610865 HB INJ ANES SPHENOPALATE GANG 64505 $1,695.56 $2,204.22 03610868 HB UNLIST PROC HEMIC/LYMPH 38999 $5,802.20 $7,542.86 03610874 HB UL PROC URETEROPLASTY 53899 $3,391.93 $4,409.52 03610880 HB CSF SHUNT REPROGRAM 62252 $1,008.44 $1,310.97 03610881 HB BRONCHIAL VALVE INIT INSERT 31647 $20,600.24 03610882 HB BRONCHIAL VALVE REMOV INIT 31648 $14,548.85 03610883 HB BRONCHIAL VALVE REMOV ADDL 31649 $9,700.60 03610884 HB BRONCHIAL VALVE INSETN ADDL 31651 $17,883.74 03610887 HB THORACENTESIS W IMG 32555 $5,091.23 $6,618.61 03610888 HB DRAINAGE PLEURA W CATH W IMG 32557 $6,591.17 $8,568.52 03610889 HB AORTIC VLV RPLMT;OPEN FEMOL 33362 $60,317.62 03610890 HB AORTIC VLV RPLMT;OPEN AXLRY 33363 $60,317.62 03610892 HB AORTIC VLV RPLMT;TRANSRTC 33365 $60,317.62 03610893 HB AORTIC VLV W/BYP;FEMORAL 33367 $60,317.62 03610896 HB PLACE CATH THORACIC AORTA 36221 $12,035.14 03610897 HB PLACE CATH CAR/INOM ART,UNI 36222 $35,730.86 03610898 HB PLACE CATH CAR/INOM ART,BIL 36222 $36,893.39 03610899 HB PLACE CATH CAR/INOM ART,UNI * 36223 $48,300.75 03610900 HB PLACE CATH CAR/INOM ART,BIL * 36223 $52,752.68 03610901 HB PLACE CATH CAROTD ART,UNI 36224 $49,463.32 03610902 HB PLACE CATH CAROTD ART,BIL 36224 $54,894.06 03610903 HB PLACE CATH SUBCLAV ART,UNI 36225 $36,996.49 03610904 HB PLACE CATH SUBCLAV ART, BIL 36225 $38,159.04 03610905 HB PLACE CATH VERTEBRL ART,UNI 36226 $38,159.04 03610906 HB PLACE CATH VERTEBRL ART,BIL 36226 $40,300.40 03610907 HB PLACE CATH XTRNL CAR,UNI 36227 $12,270.24 03610908 HB PLACE CATH XTRNL CAR, BIL 36227 $17,241.77 03610909 HB PLACE CATH INTRCRNL ART,UNI 36228 $14,568.98 03610910 HB PLACE CATH INTRCRNL ART,BIL 36228 $29,137.99 03610911 HB REMOVE INTRAVS FOREIGN BODY 37197 $12,035.14 03610912 HB THROMBOLYTIC ART THERAPY 37211 $20,160.23 03610913 HB THROMBOLYTIC VENOUS THERAPY 37212 $12,035.14 03610914 HB THROMBLYTIC ART/VEN THERAPY 37213 $6,591.17 03610915 HB CESS THERAPY CATH REMOVAL 37214 $6,591.17

Ancillary FY22 147 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03610917 HB CYSTOSCOPY CHEMODENERVATION 52287 $10,376.78 $13,489.81 03610918 HB GI WIRELESS CAPSULE MEASURE 91112 $4,219.24 03610920 HB DUODENAL MOTILITY STUDY 91022 $13,287.11 03610922 HB REMOVAL TUN ABD PLEURX CATH 49422 $12,035.14 $15,645.68 03610923 HB CHEMODENERV MUSC MIGRAINE 64615 $1,695.56 03610926 HB EXC TR-EXT MAL+MARG 0.5 < CM 11600 $4,804.93 03610927 HB INJECTION INTO SKIN LESIONS =<7 11900 $1,261.52 03610930 HB ATT TRUNK; D 10 SQ CM/< 14000 $6,416.19 $8,341.03 03610931 HB ATT S/A/L; D 10 SQ CM/< 14020 $6,416.19 03610935 HB I&D DEEP ABSC SFT TISS NK/THOR 21501 $10,098.89 $13,128.58 03610942 HB CYSTOMETROGRAM W/VP 51728 $3,292.17 03610944 HB DESTRUCT PREMALIG LES 2-14 17003 $1,342.83 03610947 HB CYSTO REM FB/ST URE/BLD;COM 52315 $10,376.78 $13,489.81 03610948 HB VULVA COLPOSC W BX 56821 $1,493.97 03610951 HB SHAVE LES T/A/L; 0.6-1.0CM 11301 $1,261.52 03610954 HB SHAVE LES S/N/H/F/G; 0.6-1.0CM 11306 $1,261.52 $1,639.97 03610964 HB BIOPSY THIGH/KNEE ST DEEP 27324 $10,098.89 $13,128.58 03610966 HB EXC S/N/H/F/G MAL+MRG 2.1-3 11623 $9,261.99 03610968 HB EXC S/N/H/F/G MAL+MRG 0.6-1 11621 $4,804.93 03610969 HB EXC H-F-NK-SP MAL+MARG 0.5 < 11620 $9,261.99 03610970 HB EXC F/E/E/N/L MAL+MRG > 4 CM 11646 $10,098.89 03610972 HB EXC F/E/E/N/L MAL+MRG 0.5CM< 11640 $4,804.93 03610974 HB EXC BLES S/N/EX G; 0.6-1.0CM 11421 $4,804.93 03610975 HB COLPOSCOPY OF VAGINA 57420 $1,493.97 $1,942.17 03610976 HB CERVIC COLP W CERVIX BX 57455 $1,493.97 03610978 HB ABD PARACENTESIS 49082 $4,219.24 $5,485.02 03610986 HB PERITONEAL VENOUS SHUNT INJ 49427 $1,597.77 $2,077.08 03610992 HB EXC THIGH/KNEE LES SC <3 CM 27327 $9,261.99 03610995 HB ARTIFI INSEMINTN; INTRA-CER 58321 $1,493.97 03610997 HB INSERT DRUG IMPLANT 11981 $867.18 03610998 HB REMOVE DRUG IMPLANT 11982 $597.13 03610999 HB REMOVE W INS DRUG IMPLANT 11983 $597.13 03611002 HB APPLY SHORT ARM SPLNT;DYNAM 29126 $867.18 $1,127.33 03611003 HB CL TX ULN FRC PROX END WMNP 24675 $4,923.82 $6,400.95 03611005 HB CL TX CLAVICULAR FX; WO MANIP 23500 $1,795.98 $2,334.78 03611006 HB INTMD WND REPAIR S/A/T/EXT 12036 $3,257.90 $4,235.24 03611007 HB CL TX RAD HD/NECK FX;W MAN 24655 $4,923.82 $6,400.95 03611009 HB CL TX WB DSTL TIB FX W MAN 27825 $4,923.82 $6,400.95 03611010 HB CL TX PROX FIB/SHFT FX WMAN 27781 $4,923.82 $6,400.95 03611012 HB INC & REM FB SQ; COMPL 10121 $9,261.99 $12,040.61 03611013 HB REMOVAL OF SUPPORT IMPLANT 20670 $9,261.99 $12,040.61 03611014 HB TENOTOMY TOE MULT PERQ 28011 $5,908.58

Ancillary FY22 148 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611015 HB TENOTOMY TOE SNGL PERQ 28010 $4,923.82 03611019 HB EXC FACE-MM B9+MARG 0.6-1 CM 11441 $4,804.93 03611021 HB TRIM NONDYSTROPHIC NAILS 11719 $837.24 $1,088.40 03611022 HB UL PROC TRANSFORAM GLUE INJ 64999 $1,695.56 03611027 HB SURG TX INCOMPL ABORTION 59812 $17,494.01 $22,742.21 03611028 HB SURG TX MSD ABORT;1ST TRIM 59820 $17,494.01 $22,742.21 03611030 HB APPLY R & L PULM ART BANDS 33620 $23,428.57 03611031 HB TRANSTHOR CATH FOR STENT 33621 $22,312.93 03611034 HB BX DONE W/COLPOSCOPY ADD-ON 58110 $975.64 03611036 HB TRNSCTH RNL SYMP DNRV BIL 0339T $38,663.15 03611040 HB TRNSCTH MTRAL VLVE RPR 0345T $60,317.62 03611057 HB TRNSCTH STNT PLMNT RTR CRTD,UNI 37217 $76,359.07 03611058 HB TRNSCTH STNT PLMNT RTR CRTD,BIL 37217 $129,448.56 03611059 HB TRNSCTH PLMNT OPN/PRQ STNT 1ST 37236 $82,600.93 03611060 HB TRNSCTH PLMNT OPN/PRQ STNT EA 37237 $62,551.69 03611061 HB TRNSCTH PLMNT OPN/PRQ STNT SAME 37238 $82,600.93 03611062 HB TRNSCTH PLMNT OPN/PRQ STNT EA 37239 $68,572.38 03611063 HB VASC EMBOLIZE/OCCLUDE VEN 37241 $82,600.93 03611064 HB VASC EMBOLIZE/OCCLUDE ARTRY 37242 $82,600.93 03611065 HB VASC EMBOLIZE/OCCLUDE ORGAN 37243 $82,600.93 03611066 HB VASC EMBOLIZE/OCCLUDE BLEED 37244 $82,600.93 03611067 HB DRAINAGE SUBQ SFT TISS W IMG 10030 $4,804.93 $6,246.41 03611068 HB BIOPSY BREAST W MAM PRIM 19081 $9,261.99 $12,040.61 03611069 HB BIOPSY BREAST W MAM EA ADDL 19082 $8,545.76 $11,109.50 03611070 HB BIOPSY BREAST CORE WUS PRIM 19083 $9,261.99 $12,040.61 03611071 HB BIOPSY BREAST W US PRIM 19083 $9,261.99 $12,040.61 03611072 HB BIOPSY BREAST W US EA ADDL 19084 $6,631.50 $8,620.93 03611073 HB BIOPSY BREAST W MRI PRIM 19085 $9,261.99 $12,040.61 03611074 HB BIOPSY BREAST W MRI EA ADDL 19086 $8,665.43 $11,265.06 03611075 HB LOC BREAST DEV W MAM PRIM 19281 $4,804.93 $6,246.41 03611076 HB LOC BREAST DEV W MAM EA ADL 19282 $3,211.10 $4,174.44 03611077 HB LOC BREAST DEV W US PRIM 19285 $4,804.93 $6,246.41 03611078 HB LOC BREAST DEV W US EA ADDL 19286 $3,211.10 $4,174.44 03611079 HB LOC BREAST DEV W MRI PRIM 19287 $4,804.93 $6,246.41 03611080 HB LOC BREAST DEV W MRI EA ADL 19288 $3,211.10 $4,174.44 03611081 HB DRAINAGE VISCERA W IMG 49405 $9,261.99 $12,040.61 03611082 HB DRAINAGE RETRO/PERITON W IMG 49406 $9,261.99 $12,040.61 03611084 HB CHEMODENER MUSCLE LARYNX EMG 64617 $1,695.56 $2,204.22 03611085 HB CHEMODENERV 1 EXTRM 1-4 MUS 64642 $3,078.05 $4,001.45 03611086 HB CHEMODENERV 1 EXTRM 1-4 EA 64643 $1,028.78 $1,337.41 03611087 HB CHEMODENERV 1 EXTRM 5/>MUS 64644 $3,078.05 $4,001.45 03611088 HB CHEMODENERV 1 EXTRM 5/> EA 64645 $1,028.78 $1,337.41

Ancillary FY22 149 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611089 HB CHEMODENERV TRUNK MUSC 1-5 64646 $3,078.05 $4,001.45 03611090 HB CHEMODENERV TRUNK MUSC 6/> 64647 $3,078.05 $4,001.45 03611091 HB IMPLT SUBQ DEFB INTEROGAT 93261 $1,163.17 03611092 HB IMPLT SUBQ DEFB SYS DEV EVL 93260 $1,163.17 03611098 HB PLCMT RT DEV/MARKER ABD/PEL 49411 $14,150.34 $18,395.43 03611099 HB PLCMT RT DEV/MARKER CHEST 32553 $14,150.34 $18,395.43 03611100 HB BRONCHOSCOPY CLEAR AIRWAY 31645 $9,700.60 03611101 HB BRONCHOSCOPY RECLEAR AIRWAY 31646 $1,958.35 03611103 HB RPR LIP FT;UP HLF VRT HGHT 40652 $2,386.91 $3,102.98 03611107 HB ATT TRUNK; D 10.1-30 SQ 14001 $6,416.19 03611108 HB ATT S/A/L; D 10.1-30 SQ CM 14021 $6,416.19 03611109 HB ATT F/C/M/N/A/G/H/F;10.1-30 14041 $6,416.19 03611112 HB SKN TIS RERNG 30.1-60.0SQCM 14301 $8,464.51 03611113 HB SKN TIS RERNG ADDL 30.0SQCM 14302 $6,930.88 03611124 HB REP LIP FT;>1/2 V HT / COMP 40654 $5,444.96 $7,078.46 03611125 HB RECTAL SENSATION TEST 91120 $3,204.04 03611126 HB DRAIN/INJECT SM JNT/BURSA WO US 20600 $1,695.56 $2,204.22 03611127 HB DRAIN/INJ SM JNT/BURSA W/US 20604 $1,695.56 $2,204.22 03611128 HB DRAIN/INJ INTERM JNT/BURSA WO US 20605 $1,695.56 $2,204.22 03611129 HB DRAIN/INJ IN JNT/BURSA W/US 20606 $1,697.13 $2,206.28 03611130 HB DRAIN/INJ MAJOR JNT/BURSA WO US 20610 $1,695.56 $2,204.22 03611131 HB DRAIN/INJ MJ JNT/BURSA W/US 20611 $1,695.56 $2,204.22 03611132 HB ABLATION CRYO BONE 20983 $31,286.66 03611133 HB VERTEBROPLASTY C/T SPINE W IMG 22510 $13,149.09 03611134 HB VERTEBROPLASTY L/S SPINE W IMG 22511 $13,149.09 03611135 HB VERTEBROPLASTY ADDL SPINE W IMG 22512 $13,698.19 03611136 HB KYPHOPLASTY T-SPINE W IMG 22513 $31,286.66 03611137 HB KYPHOPLASTY L-SPINE W IMG 22514 $31,286.66 03611138 HB KYPHOPLASTY ADDL SPINE W IMG 22515 $24,250.35 03611139 HB INS/REP SUBQ DEFIBRILLATOR 33270 $211,451.52 03611140 HB REPR TCAT MITRAL VALV INTL 33418 $60,317.62 03611141 HB REPR TCAT MITRAL VALV ADDL 33419 $60,317.62 03611142 HB ECMO/ECLS INITIATION VENOUS 33946 $14,280.85 03611143 HB ECMO/ECLS INITIATION ARTERY 33947 $14,280.85 03611144 HB ECMO/ECLS DAILY MGMT-VENOUS 33948 $7,140.41 03611145 HB ECMO/ECLS DAILY MGMT ARTERY 33949 $7,140.41 03611146 HB ECMO/ECLS INSJ PRPH CAN PERC<5 33951 $15,085.51 03611147 HB ECMO/ECLS INSJ PRPH CAN PERC>5 33952 $15,085.51 03611148 HB ECMO/ECLS INSJ PRPH CAN OPEN<5 33953 $15,085.51 03611149 HB ECMO/ECLS INSJ PRPH CAN OPEN>5 33954 $15,085.51 03611150 HB ECMO/ECLS INSJ CTR CAN <5YR 33955 $15,085.51 03611151 HB ECMO/ECLS INSJ CTR CAN >5YR 33956 $15,085.51

Ancillary FY22 150 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611153 HB ECMO/ECLS REPOS PRPH CAN PERC>5 33958 $10,781.52 03611155 HB ECMO/ECLS REPOS PRPH CAN OPEN>5 33962 $10,781.52 03611157 HB ECMO/ECLS REPOS CTR CAN>5YR 33964 $10,781.52 03611158 HB ECMO/ECLS RMVL PRPH CAN PERC<5 33965 $6,160.87 03611159 HB ECMO/ECLS RMVL PRPH CAN PERC>5 33966 $6,160.87 03611160 HB ECMO/ECLS RMVL PRPH CAN OPEN<5 33969 $6,160.87 03611161 HB ECMO/ECLS RMVL PRPH CAN OPEN>5 33984 $6,160.87 03611162 HB ECMO/ECLS RMVL CTR CAN <5YR 33985 $6,160.87 03611163 HB ECMO/ECLS RMVL CTR CAN >5YR 33986 $6,160.87 03611164 HB ARTERY EXPOS/GRAFT ARTERY 33987 $10,781.52 03611165 HB INSERTION OF LEFT HEART VENT 33988 $13,861.94 03611166 HB REMOVAL OF LEFT HEART VENT 33989 $10,781.52 03611167 HB STENT PLACEMT ANTE CAROTID 37218 $23,269.54 03611168 HB PERQ STENT/CHEST VERT ART 0075T $23,269.54 03611170 HB MYELOGRAM C-SPINE VIA LP W S&I 62302 $10,550.00 03611171 HB MYELOGRAM T-SPINE VIA LP W S&I 62303 $10,550.00 03611172 HB MYELOGRAM L-SPINE VIA LP W S&I 62304 $10,550.00 03611173 HB MYELOGRAM 2/MORE REGN VIA LP W S&I 62305 $10,550.00 03611175 HB TRACHEOBRONCH THRU OLD INC 31615 $2,386.91 $3,102.98 03611176 HB BRONCHOSCOPY W/MARKERS 31626 $20,600.24 03611177 HB BRONCH W/BALLOON OCCLUSION 31634 $20,600.24 03611178 HB ABLATION R/F BONE TUMOR(S) 20982 $31,286.66 $40,672.64 03611180 HB PERQ SACRAL AUGMT BILAT INJ 0201T $31,286.66 03611181 HB BIOPSY LUNG/PLEURA 32400 $9,261.99 $12,040.61 03611182 HB UL PROC LOCALIZATION LUNG 32999 $4,242.68 $5,515.50 03611183 HB BIOPSY, NERVE 64795 $11,077.10 $14,400.23 03611185 HB INS VAG BRACHYTX DEVICE 57156 $1,493.97 03611188 HB BX OF ANORECTAL WALL ANAL APPROACH 45100 $9,615.33 03611189 HB TENOTOMY HIP ADDUCTOR PERQ 27000 $4,923.82 $6,400.95 03611190 HB TENOTOMY HAM/ADCTR SNGL PERQ 27306 $13,149.09 $17,093.81 03611191 HB TENOTOMY ELBOW PERQ 24357 $13,149.09 $17,093.81 03611192 HB TENOTOMY HAM/ADCTR MULT PERQ 27307 $14,817.71 $19,263.01 03611193 HB TENOTOMY FINGER PERQ 26060 $4,923.82 $6,400.95 03611194 HB TENOTOMY ACHILLES PERQ 27605 $4,923.82 $6,400.95 03611195 HB UNLISTED TENOTOMY SHOULDER PERQ 23929 $1,795.98 $2,334.78 03611197 HB UNLISTED TENOTOMY FOOT PERQ 28899 $1,795.98 $2,334.78 03611199 HB BRONCHOSCOPY/NEEDLE BX ADDL 31633 $10,165.52 03611201 HB UL PROC SPINAL HARDWARE INJ 64999 $1,695.56 03611202 HB BIOPSY UPPER ARM SFT TISS SUPERF 24065 $9,261.99 03611203 HB EXC NECK LES SC < 3 CM 21555 $9,261.99 $12,040.61 03611205 HB BIOPSY LEG/ANKLE SOFT TISSUE SUPERFICIAL 27613 $9,261.99 $12,040.61 03611207 HB NEPHROSTOLITHOTOMY PERQ <2CM 50080 $15,426.85 $20,054.90

Ancillary FY22 151 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611208 HB NEPHROSTOLITHOTOMY PERQ >2CM 50081 $15,426.85 $20,054.90 03611210 HB DX NASAL ENDOSCOPY 31231 $1,292.08 $1,679.69 03611211 HB REM EMBEDDED FB MOUTH VESTIB; SIMPLE 40804 $4,219.24 $5,485.02 03611212 HB THROMBECTOMY VC ILIAC FEM LEG INCS 34421 $12,035.14 03611213 HB EVASC PRLNG ADMN RX AGNT 1ST 61650 $118,155.52 03611214 HB EVASC PRLNG ADMN RX AGNT ADD 61651 $112,338.14 03611215 HB INJECTION FOR CHOLANGIOGRAM EXISTING ACCESS 47531 $8,260.80 03611216 HB INJECTION FOR CHOLANGIOGRAM NEW ACCESS 47532 $8,260.80 03611217 HB PLMT BILIARY DRAINAGE CATH EXTERNAL 47533 $8,260.80 03611218 HB PLMT BILI DRAINAGE CATH INTERNAL-EXTERNAL 47534 $8,260.80 03611219 HB CONVERSION EXT BIL DRG CATH 47535 $8,260.80 03611220 HB EXCHANGE BILIARY DRG CATH 47536 $8,260.80 03611221 HB REMOVAL BILIARY DRG CATH 47537 $4,219.24 03611222 HB PERQ PLMT BILE DUCT STENT EXISTING ACCESS 47538 $20,948.74 03611223 HB PERQ PLMT BILE DUCT STENT NEW ACCESS 47539 $20,948.74 03611224 HB PERQ PLMT BILE DUCT STENT 47540 $20,948.74 03611225 HB PLMT ACCESS BIL TREE SM BWL 47541 $8,260.80 03611226 HB DILATE BILIARY DUCT/AMPULLA 47542 $18,465.39 03611227 HB ENDOLUMINAL BX BILIARY TREE 47543 $10,490.50 03611228 HB NJX PX NFROSGRM &/URTRGRM NEW ACCESS 50430 $3,292.17 03611229 HB NJX PX NFROSGRM &/URTRGRM EXISTING ACCESS 50431 $3,292.17 03611230 HB PLMT NEPHROSTOMY CATHETER 50432 $10,376.78 03611231 HB PLMT NEPHROURETERAL CATHETER 50433 $11,704.57 03611232 HB CONVERT NEPHROSTOMY CATHETER 50434 $10,376.78 03611233 HB CHANGE NEPHROSTOMY CATH 50435 $10,376.78 03611235 HB PLMT URETERAL STENT PRQ PRE-EXISTING TRACT 50693 $11,704.57 03611236 HB PLMT URETERAL STENT PRQ NEW ACCESS 50694 $11,704.57 03611237 HB PLMT URETERAL STENT PRQ NEW ACCESS W/NEPH CATH 50695 $11,704.57 03611238 HB PERQ ART M-THROMBECT &/NFS UNI 61645 $66,644.48 03611239 HB PVB THORACIC SINGLE INJ SITE 64461 $3,078.05 03611240 HB PVB THORACIC 2ND+ INJ SITE 64462 $3,206.59 03611241 HB PVB THORACIC CONT INFUSION 64463 $3,078.05 03611242 HB BIOPSY PENIS DEEP 54105 $10,098.89 03611243 HB BRONCH EBUS SAMPLNG 1/2 NODE 31652 $14,548.85 03611244 HB BRONCH EBUS SAMPLNG 3/> NODE 31653 $14,548.85 03611245 HB BRONCH EBUS IVNTJ PERPH LES 31654 $8,801.24 03611246 HB REMOVE IMPACTED EAR WAX UNI 69209 $837.24 $1,088.40 03611247 HB CONZ OF CERVIX W/SCOPE LEEP 57461 $17,494.01 03611249 HB BLEPHAROTOMY DRAIN ABSC EYELID 67700 $1,286.99 $1,673.11 03611253 HB NEPHROURETHRAL CATH CHANGE 50387 $10,376.78 $13,489.81 03611254 HB URETERAL EMBO W IMG GUIDANCE 50705 $13,599.75 03611255 HB URETERAL BALLOON DIL W IMG GUIDANCE 50706 $13,599.75

Ancillary FY22 152 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611256 HB PIERCE SKULL IMPLANT DEVICE 61210 $6,290.42 03611257 HB DRAINAGE OF SCROTAL WALL ABSCESS 55100 $9,261.99 $12,040.61 03611258 HB DR EXT EAR ABSCESS/HEMATOMA; COMPLIC 69005 $9,261.99 $12,040.61 03611259 HB CL TX IP JOINT DISL; W ANESTH 28665 $2,050.20 $2,665.28 03611260 HB CL TX ACLAV DISLOC; WO MANIP 23540 $1,795.98 $2,334.78 03611261 HB CL TX TARSAL BONE DISLO; WO ANESTH 28540 $1,795.98 $2,334.78 03611262 HB CL TX TALOTARSAL JOINT DIS; WO ANEST 28570 $1,795.98 $2,334.78 03611263 HB CL TX TMT JNT DISL; W ANESTHESIA 28605 $2,155.19 $2,801.73 03611264 HB CL TX TMT JNT DISL; WO ANESTHESIA 28600 $1,795.98 $2,334.78 03611265 HB CL TX DSTL RADIOULNAR DISLOC W MANIP 25675 $1,795.98 $2,334.78 03611266 HB CL TX CMC DISLOC THUMB W MANIP 26641 $1,795.98 $2,334.78 03611267 HB CL TX CMC DISL W M EA 26670 $1,795.98 $2,334.78 03611268 HB CL TX TALOTARSAL JOINT DISL; W ANESTH 28575 $13,149.09 $17,093.81 03611269 HB CL TX MTP JNT DISLOC; W ANESTH 28635 $4,923.82 $6,400.95 03611270 HB CL TX LUNATE DISLOC W MANIP 25690 $4,923.82 $6,400.95 03611271 HB CL TX CMC DISLOC W MANIP & ANESTH 26675 $4,923.82 $6,400.95 03611272 HB CL TX MCP DISLOC W MANIP & ANESTH 26705 $4,923.82 $6,400.95 03611273 HB CL TX TARSAL BONE DISLOC; W ANESTH 28545 $13,149.09 $17,093.81 03611274 HB DR ABSC/HEMATOMA NASAL INT 30000 $1,671.20 $2,172.57 03611275 HB DR ABSC/HEMATOMA NASAL SEPTUM 30020 $2,386.91 $3,102.98 03611276 HB I&D ABSC/CYST TONGUE FOM; SUPERF 41005 $1,671.20 $2,172.57 03611277 HB I&D ABSC/CYS FOM; MASTIC SPACE 41009 $2,386.91 $3,102.98 03611278 HB DRAINAGE OF ABSCESS OF PALATE UVULA 42000 $1,671.20 $2,172.57 03611279 HB DR ABSC CYST HEMAT-MOUTH; COMPLICATED 40801 $2,386.91 $3,102.98 03611280 HB I&D ABSC/CYST TONGUE FOM; LINGUAL 41000 $2,386.91 $3,102.98 03611281 HB I&D ABSC/CYST FOM; SUBMENTAL 41007 $5,444.96 $7,078.46 03611282 HB CL TX TMJ DISLOCATION; COMPLIC 21485 $5,444.96 $7,078.46 03611283 HB I&D ABSC/CYS FOM; SUBMANDIB 41008 $9,768.27 $12,698.75 03611284 HB MARSUPIALIZATION BARTHOLIN'S GLAND CYST 56440 $17,494.01 $22,742.21 03611285 HB CANTHOTOMY 67715 $7,636.34 $9,927.24 03611286 HB CL TX ACLAV DISLOC; W MANIP 23545 $2,155.19 $2,586.23 03611287 HB CL TX SCAPULAR FX; WO MANIP 23570 $1,795.98 $2,334.78 03611288 HB CL TX CARPAL SCAPHOID FX; WO MANIP 25622 $1,795.98 $2,334.78 03611289 HB CLTX CARPL BONE FX WO MANIP EA BONE 25630 $1,795.98 $2,334.78 03611290 HB CL TX PROX FEM FX WO MANIP 27230 $1,795.98 $2,334.78 03611291 HB CL TX PROX TIB-FIB JNT DISL; WO ANESTH 27830 $1,795.98 $2,334.78 03611292 HB CL TX OF ULNAR STYLOID FX 25650 $1,795.98 $2,334.78 03611293 HB CL TX TRANS-SPL FX DISL; W MANIP 25680 $1,795.98 $2,334.78 03611294 HB CL TX ART FX MCP/IP JNT; WO MANIP 26740 $1,795.98 $2,334.78 03611295 HB CL TX PELV RNG FX WO MANIP 27197 $1,795.98 $2,334.78 03611296 HB CL TX PELV RNG FX W MANIP 27198 $2,155.19 $2,586.23 03611297 HB CL TX OF ACETABULUM X(S); WO MANIP 27220 $1,795.98 $2,334.78

Ancillary FY22 153 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611298 HB CL TX GTR TROCHNTRC FX WO MANIP 27246 $1,795.98 $2,334.78 03611299 HB CL TX FEMORAL SHAFT FX WO MANIP 27500 $1,795.98 $2,334.78 03611300 HB CL TX SC/TC FEMUR FX WO MANIP 27501 $1,795.98 $2,334.78 03611301 HB CL TX POST ANKLE FX W/O MANIP 27767 $1,795.98 $2,334.78 03611302 HB CL TX SCLAV DISLOC WO MANIP 23520 $4,923.82 $6,400.95 03611303 HB CL TX SCAPULAR FX; W MANIP 23575 $4,923.82 $6,400.95 03611304 HB CL TX GR TUBEROSITY FX; W MANIP 23625 $4,923.82 $6,400.95 03611305 HB CL TX SHLDR DISLOC & FX GT; W MANIP 23665 $4,923.82 $6,400.95 03611306 HB CL TX CARPL SCAPHOID FX W MANIP 25624 $4,923.82 $6,400.95 03611307 HB CLTX CARPL BONE FX W MANIP EA BONE 25635 $4,923.82 $6,400.95 03611308 HB CL TX MC FX W M+F EA 26607 $13,149.09 $17,093.81 03611309 HB CL TX CMC FX DISLOC THUMB W MANIP 26645 $4,923.82 $6,400.95 03611310 HB CL TX INTER/PERI/SBTRCHNTC FEM FX WO MANIP 27238 $4,923.82 $6,400.95 03611311 HB CLTX THIGH FX W/O MANIP 27267 $13,149.09 $17,093.81 03611312 HB CL TX FEMUR FX OR EPIPHYS SEP W MANIP 27510 $4,923.82 $6,400.95 03611313 HB CL TX POST ANKLE FX W/MANIP 27768 $4,923.82 $6,400.95 03611314 HB OPEN TX TOE FRACTURE 28525 $13,149.09 $17,093.81 03611315 HB CL TX SCCLAV DISLOC W MANIP 23525 $1,795.98 $2,334.78 03611316 HB THORACOTOMY W/ EXPLORATION 32100 $7,188.38 03611317 HB CL TX LEFORT I FX; W ID W FIX 21421 $9,768.27 $12,698.75 03611318 HB CL TX OF MAND FX W ID FIX 21453 $18,563.85 $24,133.01 03611319 HB APPLY FINGER SPLINT; DYNAMIC 29131 $837.24 $1,088.40 03611321 HB CL TX STERNUM FX 21820 $1,795.98 $2,334.78 03611326 HB CL TX SESAMOID FRACTURE 28530 $1,795.98 $2,334.78 03611327 HB CL TX VERTEBRAL BODY FX WO MANIP 22310 $1,795.98 $2,334.78 03611338 HB CRANIAL TONGS/ST FRAME 20660 $4,923.82 $6,400.95 03611339 HB CL TX VERTEBR FX/DISLOC W CAST/BRACE 22315 $13,149.09 $17,093.81 03611347 HB CL TX ORBIT FX NOT "BOT"; WO MANIP 21400 $2,386.91 $3,102.98 03611348 HB CL TX ORBIT FX NOT "BOT"; W MANIP 21401 $5,444.96 $7,078.46 03611349 HB CL TX LEFORT II FX; W FIXATION 21345 $5,444.96 $7,078.46 03611350 HB CL TX NASAL SEPTAL FX 21337 $9,768.27 $12,698.75 03611351 HB CL TX MAND/MAXILL ALVEOLAR RIDGE FX 21440 $9,768.27 $12,698.75 03611352 HB LARYNGOSCOPY FLEX; W REM FB 31577 $1,958.35 $2,545.84 03611353 HB REPAIR FOOT EXTENSOR TENDON EACH 28208 $13,149.09 $17,093.81 03611354 HB THER APHER RED CELL DEPLETION 36512 $8,014.20 03611355 HB ACCESS AV DIALYSIS GRAFT EVAL 36901 $6,591.17 03611356 HB ACCESS AV DIALYSIS GRAFT W PTA 36902 $38,663.15 03611357 HB ACCESS AV DIALYSIS GRAFT W STENT 36903 $82,600.93 03611358 HB THROMBECTOMY/LYSIS DIALYSIS CIRCT 36904 $38,663.15 03611359 HB THROMBECTOMY/LYSIS W/ PTA DIALYSIS CIRCT 36905 $82,600.93 03611360 HB THROMBECTOMY/LYSIS W/ STENT DIALYSIS CIRCT 36906 $92,511.30 03611361 HB PTA CENTRAL DIALYSIS SEGMENT 36907 $45,652.78

Ancillary FY22 154 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611362 HB DIALYSIS CIRCUIT EMBOL 36909 $91,957.46 03611363 HB PTA UE/VISCERAL ARTERY INITIAL 37246 $38,663.15 03611364 HB PTA UE/VISCERAL ARTERY EA ADDL 37247 $34,527.83 03611365 HB PTA VEIN INITIAL 37248 $38,663.15 03611366 HB PTA VEIN EA ADDL 37249 $34,527.83 03611367 HB INJ INTERLAMINAR CERV/THOR 62321 $10,151.16 03611368 HB INJ INTERLAMINAR LUMBAR/SACRAL 62323 $10,151.16 03611369 HB INJ INTERLAMINAR CERV/THOR W/ INDWELL CATH 62325 $5,549.43 03611370 HB INJ INTERLAMINAR LUMBAR/SACRAL W/ INDWELL CATH 62327 $5,549.43 03611371 HB SCLEROTX FLUID COLLECTION 49185 $4,804.93 $6,246.41 03611372 HB DIAPHRAGM OR CERVIAL CAP FITTING 57170 $1,417.90 $1,843.26 03611373 HB AMPUTATE FING/TH SGL; W LOC ADV FLAP 26952 $13,149.09 $17,093.81 03611374 HB STENT PLMT CTR DIALYSIS SEG 36908 $68,572.38 03611375 HB CATHETER ASPIRATION FIBERSCOPE BEDSIDE 31725 $13,215.18 03611376 HB I & D SHLDR ABSC/HEMA,DEEP 23030 $13,128.58 03611377 HB I & D ARM,DEEP ABSC/HEMATOMA 23930 $13,128.58 03611378 HB I & D FOREARM DEEP ABSCESS 25028 $17,093.81 03611379 HB I & D FOREARM INFECTED BURSA 25031 $6,400.95 03611380 HB DRAIN LOWER LEG DEEP ABSC/HEMATOMA 27603 $10,098.89 $13,128.58 03611381 HB I & D BURSA OF FOOT 28001 $12,040.61 03611382 HB I & D RECTAL SUBMUCOSAL ABSCESS 45005 $12,817.43 03611383 HB INCISE/DRAIN CONJUNCTIVA 68020 $3,336.19 $4,337.06 03611384 HB SUTURE EYELID WOUND,PARTIAL THICK 67930 $9,927.24 03611385 HB SUTURE EYELID WOUND,FULL THICK 67935 $9,927.24 03611386 HB REPR FOREARM TEND/MUSC,EXTEN,PRIM,EA 25270 $17,093.81 03611387 HB MUSC/TENDON REPAIR EACH; ARM/ELBOW 24341 $40,672.64 03611388 HB CLOSED RX PROX TIB/FIB DISLOC+ANESTH 27831 $17,093.81 03611389 HB INSERT AND REMOVE BONE PIN 20650 $17,093.81 03611390 HB LARYNGOSCOPY,DIRCT,OP,F.B. REMVL 31530 $12,610.78 03611391 HB LARYNGOSCOPY,INDIRECT+REMV FOR.BODY 31511 $1,679.69 03611392 HB DILATE ESOPHAGUS 43450 $5,485.02 03611393 HB SIGMOIDOSCOPY FLX W/RMVL FOREIGN BODY 45332 $12,817.43 03611394 HB ASPIRATION BLADDER NEEDLE 51100 $4,409.52 03611395 HB ASPIRATION BLADDER TROCAR/INTRACATHETER 51101 $16,577.04 03611396 HB INJECT NERV BLCK,TRIGEMINAL EACH BRANCH 64400 $1,695.56 $2,204.22 03611398 HB BIOPSY, URETHRA 53200 $10,376.78 $13,489.81 03611399 HB REMOVAL OF BREAST IMPLANT 19328 $14,926.53 $19,404.47 03611400 HB REMOVAL OF EXTERNAL PENILE RING 55899 $3,391.93 $4,409.52 03611401 HB REPAIR CARDIAC WOUND; WO CPB 33300 $6,898.63 03611402 HB OP TX OF NASAL FX; UNCOMPLICATED 21325 $9,768.27 $12,698.75 03611403 HB TRANSPERINEAL PLCMT BIODEGRADEABLE MATRL 55874 $13,679.09 03611404 HB INJECTION FOR LYMPHANGIOGRAPHY 38790 $3,786.00

Ancillary FY22 155 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611405 HB REPAIR BLOOD VESSEL DIRECT; UPPER EXTREMITY 35206 $12,035.14 $15,645.68 03611406 HB SUTURE OF DGTL NERVE, HAND/FOOT; 1 NERVE 64831 $11,077.10 $14,400.24 03611408 HB ENDOVENOUS ABLATION THERAPY RF, 1ST VEIN 36475 $14,480.50 $18,824.65 03611410 HB EXCISION AND REPAIR OF EYELID TO 1/4 LID MARG 67961 $7,636.34 $9,927.24 03611411 HB NASAL ENDO W BLD CNTRL 31238 $9,700.60 $12,610.78 03611413 HB INJ ANES/STEROID FEMORAL NRV CONT INF W/ CATH PLCM 64448 $5,549.43 $7,214.25 03611414 HB TMVI PERCUTANEOUS APPROACH 0483T $60,317.62 03611415 HB TMVI TRANSTHORACIC EXPOSURE 0484T $23,428.57 03611416 HB COR FFR DATA PREP & TRANS 0502T $1,350.05 $1,755.08 03611417 HB ABLAT THER PULM TUMOR PERQ CRYOABL 32994 $20,948.74 $27,233.53 03611418 HB EVASC RPR A-AO NDGFT 34701 $26,346.68 03611419 HB EVASC RPR A-AO NDGFT 34702 $26,346.68 03611420 HB EVASC RPR A-UNILAC NDGFT 34703 $25,450.43 03611421 HB EVASC RPR A-UNILAC NDGFT RPT 34704 $25,450.43 03611422 HB EVAC RPR A-BIILIAC NDGFT 34705 $22,593.37 03611423 HB EVASC RPR A-BIILIAC RPT 34706 $22,593.37 03611424 HB EVASC RPR ILIO-ILIAC NDGFT 34707 $17,696.44 03611425 HB EVASC RPR ILIO-ILIAC NDGFT 34708 $17,696.44 03611426 HB PLCMT EXTN PROSTH EVASC RPR 34709 $10,293.97 03611427 HB PLCMT EXTN PROSTH EVASC RPR 34710 $15,225.90 03611428 HB DLYD PLCMT EXTN PROSTH EA ADDL 34711 $8,514.85 03611429 HB TRANSCATH DLVRY ENHNCD FIX DEV AND S&I 34712 $5,313.92 03611430 HB PERQ ACCESS & CLSR FEM ART 34713 $4,094.23 03611432 HB OPN AX/SUBCLA ART EXPOS 34715 $5,313.92 03611433 HB OPEN AX/SUBCLA ART EXPOS W CONDUIT 34716 $5,313.92 03611434 HB INJ NONCMPND SCLRSNT SNGL VEIN 36465 $5,490.13 03611435 HB INJ NONCMPND SCLRSNT MULT VEINS 36466 $6,416.19 03611436 HB ENDOVEN THER CHEM ADHES 1ST VEIN 36482 $20,160.23 03611437 HB ENDOVEN THER CHEM ADHES SUB VEIN 36483 $1,735.19 03611439 HB ABLATION R/F CHEST/LUNG UNI 32998 $20,948.74 $27,233.53 03611440 HB CATH INTRO ARTERY UPPER/LOWER EXT 36140 $2,868.69 03611441 HB DIAG BONE MARROW BX & ASPIR 38222 $10,098.89 $13,128.58 03611442 HB ATT E/N/E/L; D 10.1 - 30 SQ CM 14061 $6,416.19 $8,341.03 03611443 HB, LATERAL CANTHOPEXY 21282 $9,768.27 $12,698.75 03611444 HB CORPUS SPONGIOSUM SHUNT – PRIAPISM 54430 $12,807.90 03611445 HB REPAIR, SECONDAY,SINGLE EACH TENDON OR MUSCLE 25263 $31,286.66 $40,672.64 03611446 HB INJ ANESTH/STEROID VAGUS NERVE 64408 $1,695.56 $2,204.22 03611451 HB CL TX THIGH FX W MANIP J 27268 $15,778.91 03611452 HB CL TX SHDR DISLOC W NK FX W MANIP 23675 $4,923.82 03611453 HB INJ ANESTH/STEROID AXILLARY NERVE 64417 $5,549.43 $7,214.26 03611454 HB INJ ANESTH/STEROID SUPRASCAPULAR NERVE 64418 $4,438.25 $5,769.73 03611455 HB WEDGING OF CLUBFOOT CAST 29750 $2,050.20

Ancillary FY22 156 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611456 HB HYSTEROSCOPY W RMVL IMPCTD FOREIGN BODY 58562 $17,494.01 03611457 HB HYSTEROSCOPY W LYSIS INTRAUT ADHESIONS 58559 $24,535.78 03611458 HB HYSTEROSCOPY W RMVL LEIOMYOMATA 58561 $24,535.78 03611459 HB HYSTEROSCOPY BILAT STERILIZATION 58565 $24,535.78 03611460 HB MULTILAYER COMPRESSION LOWER LEG 29581 $1,085.27 03611461 HB MULTILAYER COMPRESSION ARM/HAND 29584 $1,085.27 03611462 HB CAST APP - HIP CAST 1 LEG 29305 $2,050.20 03611463 HB CAST APP - HIP CASTS 1.5 SPICA/2 LEGS 29325 $2,050.20 03611464 HB CAST APP - RIGID TOTAL CONTACT LEG CAST 29445 $2,050.20 03611466 HB ENDOVENOUS ABLATION THERAPY RF SUB VEIN 36476 $1,735.19 $2,255.74 03611467 HB BIOPSY, INTERVERTEBRAL DISC, CORE 64999 $1,695.56 $2,204.22 03611468 HB ENDOVENOUS ABLATION THERAPY MCHNCHEM, 1ST VEIN 36478 $14,480.50 $18,824.65 03611469 HB ENDOVENOUS ABLATION THERAPY LASER SUB VEIN 36479 $1,735.19 03611470 HB ENDOVENOUS ABLATION THERAPY LASER, 1ST VEIN 36473 $14,480.50 $18,824.65 03611471 HB ENDOVENOUS ABLATION THERAPY MCHNCHEM SUB VEIN 36474 $11,386.75 $14,802.77 03611472 HB EMBOLIZATION BONE TUMOR 20999 $1,795.98 $2,334.78 03611473 HB DEBRIDE ASSOC OPEN FX/DISLOC SKIN/SUBQ 11010 $4,804.93 $6,246.41 03611474 HB STAB PHLEBECTOMY, LESS THAN 10 37799 $4,242.68 $5,515.50 03611475 HB STAB PHLEBECTOMY, 1 EXTREMITY 20+ 37766 $12,035.14 $15,645.68 03611476 HB STAB PHLEBECTOMY, 1 EXTREMITY 10-20 37765 $12,035.14 $15,645.68 03611477 HB INJ ANES/STEROID SCIATIC CONT INF 64446 $5,549.43 03611478 HB INJ ANES/STEROID LUMBAR PLEXUS 64449 $5,549.43 03611483 HB TAP BLOCK BY INJECTION UNILATERAL 64486 $4,623.59 03611484 HB TAP BLOCK BY CONTINUOUS INFUSION UNILATERAL 64487 $4,623.59 03611485 HB TAP BLOCK BY INJECTION BILATERAL 64488 $4,623.59 03611486 HB TAP BLOCK BY CONTINUOUS INFUSION BILATERAL 64489 $4,623.59 03611487 HB LIGATION OR BIOPSY, TEMPORAL ARTERY 37609 $9,261.99 $12,040.61 03611488 HB LENSTAR 92136 $867.18 03611489 HB SPECULAR MICROSCOPYE 92286 $867.18 03611490 HB MYOMECTOMY VAG METHOD 1-4 MYOMAS 58145 $17,494.01 $22,742.21 03611491 HB PHOTODYNAMIC THERAPY ENDOSCOPIC INITIAL 30 MIN 96570 $1,253.82 03611492 HB PHOTODYNAMIC THERAPY ENDOSCOPIC ADDL 15 MIN 96571 $265.23 03611493 HB DIR THROMBIN INJ ABLATN NON EXTR PSEUDOANEURYSM 37799 $3,686.81 $4,792.87 03611494 HB HPC PLATELET DEPLETION 38213 $5,802.20 03611495 HB NASOLACR DUCT PROBING W/WO IRRIGATION 68810 $1,286.99 03611496 HB LACRIMAL CANALICULI PROBING 68840 $1,286.99 03611497 HB EXC OF CHALAZION; SINGLE 67800 $1,286.99 03611498 HB BIOPSY EYELID & LID MARGIN 67810 $1,286.99 03611499 HB EYELASH PILATION BY ELECTROSURGERY 67825 $1,286.99 03611500 HB EXC OF CHALAZION; MULTI SAME LID 67801 $3,336.19 03611501 HB EXC EYELID LESION WO CLOSE/SIMP REPAIR 67840 $3,336.19 03611502 HB EPILATION BY FORCEPS 67820 $867.18

Ancillary FY22 157 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611504 HB CLOSURE LAC PUNCTUM; BY PLUG (EACH) 68761 $1,283.39 03611505 HB REPAIR CORNEA LAC,APPLY GLUE 65286 $7,895.47 03611506 HB EXCIS PTERYGIUM,W GRAFT 65426 $7,636.34 03611507 HB EXCIS PTERYGIUM 65420 $7,636.34 03611508 HB CORNEAL SMEAR 65430 $597.13 03611509 HB PLACE AMNIOTIC MEMBRA OCULAR SURFACE W/O SUTURE 65778 $3,336.19 03611510 HB INJECT ANTER CHMBR EYE,MEDICATN 66030 $7,895.47 03611511 HB INJECTION,ANT CHAMBER,EYE,AIR/LIQUID 66020 $7,895.47 03611512 HB TEMP CLOSURE EYELID BY SUTURE 67875 $3,336.19 03611513 HB EXPRESS CONJUNC FOLLICLES 68040 $1,283.39 03611514 HB BIOPSY OF CONJUNCTIVA 68100 $7,636.34 03611515 HB REPAIR CORNEA LAC,NONPERFORATING 65275 $8,491.44 03611516 HB PLACE AMNIOTIC MEMBRANE OCULAR SURFACE SUTURED 65779 $8,491.44 03611517 HB REPAIR CORNEA LAC,PERF,NO UVEAL 65280 $10,387.85 03611518 HB REPAIR CORNEA LAC,PERF,RESEC UVEAL 65285 $10,387.85 03611519 HB REPAIR FLEX TENDON,ZONE 2,HAND 26356 $13,149.09 $17,093.81 03611520 HB PERC SKTL FIX D PHLNG FX FINGR 26756 $13,149.09 $17,093.81 03611521 HB BIOPSY OF BREAST; OPEN, INCISIONAL 19101 $14,926.53 03611522 HB SLITTING OF PREFUCE, DORSAL OR LATERAL 54001 $10,376.78 $13,489.81 03611523 HB FINE NEEDLE ASP W/O IMG GUID EA ADDL LESION 10004 $1,214.64 $1,579.03 03611524 HB FINE NEEDLE ASP W/ US GUID FIRST LESION 10005 $4,804.93 $6,246.41 03611525 HB FINE NEEDLE ASP W/ US GUID EA ADDL LESION 10006 $3,211.10 $4,174.44 03611526 HB FINE NEEDLE ASP W/ FLUORO GUID FIRST LESION 10007 $4,804.93 $6,246.41 03611527 HB FINE NEEDLE ASP W/ FLUORO GUID EA ADDL LESION 10008 $3,211.10 $4,174.44 03611528 HB FINE NEEDLE ASP W/ CT GUID FIRST LESION 10009 $4,804.93 $6,246.41 03611529 HB FINE NEEDLE ASP W/ CT GUID EA ADDL LESION 10010 $3,211.10 $4,174.44 03611530 HB FINE NEEDLE ASP W/ MRI GUID FIRST LESION 10011 $4,804.93 $6,246.41 03611531 HB FINE NEEDLE ASP W/ MRI GUID EA ADDL LESION 10012 $3,281.09 $4,265.41 03611532 HB BX SKIN TANGENTIAL SIMP CLS SNGL LESION 11102 $1,261.52 $1,639.97 03611533 HB BX SKIN TANGENTIAL SIMP CLS ADDL LESION 11103 $354.97 $460.85 03611534 HB BX SKIN PUNCH SIMP CLS SNGL LESION 11104 $1,665.64 $2,165.32 03611535 HB BX SKIN PUNCH SIMP CLS ADDL LESION 11105 $354.97 $460.85 03611536 HB BX SKIN INCISIONAL SIMP CLS SNGL LESION 11106 $3,257.90 $4,235.24 03611537 HB BX SKIN INCISIONAL SIMP CLS ADDL LESION 11107 $354.97 $460.85 03611538 HB REPLACE GTUBE NO REVJ TRC 43762 $3,391.93 $4,409.52 03611539 HB REPLACE GTUBE REVJ GSTRST TRC 43763 $3,391.93 $4,409.52 03611540 HB ERECTOR SPINAE 64999 $1,695.59 $2,204.22 03611541 HB STENT PLACEMENT (CCA) CERV CAROTID ART 37799 $17,181.87 $22,336.42 03611542 HB INJECTION PAROTID GLAND 42699 $1,671.20 $2,172.57 03611543 HB PROSTATIC RF THERMOTHERAPY 53852 $11,704.57 03611544 HB EXCIS CHALAZION,MULT,BOTH LIDS 67805 $1,286.99 03611545 HB CLOSE TEAR DUCT OPENING 68760 $1,286.99

Ancillary FY22 158 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611546 HB INJECT PROC PENILE PLAQUE 54200 $3,391.93 03611547 HB UL PROC LOCALIZATION BREAST 19499 $14,926.53 $19,404.47 03611548 HB UL PROC ABLATION NERVE MICROWAVE 64999 $1,695.56 $2,204.22 03611549 HB PLACE ANGEL FILTER/CATHETER 37799 $43,371.79 $56,383.33 03611550 HB RF MAGNETIC-GUIDE AV FISTULA G2171 $92,511.30 $120,264.69 03611552 HB CREATION OF ACCESS,RPLCMNT WIRE,SHEATH,ANGIO CATH 53899 $3,391.93 03611553 HB DRAINAGE OF SKENE'S GLAND ABSCESS OR CYST 53060 $10,376.78 $13,489.81 03611554 HB BRONCHOSCOPY W/ EXCISION OF TUMOR 31640 $14,548.85 $18,913.51 03611555 HB CRTJ SUBQ INSJ IMPLTBL GLUCOSE SENSOR SYS TRAIN 0446T $6,416.19 03611556 HB RMVL IMLTBL GLUCOSE SENSOR 0447T $1,261.52 03611557 HB RMVL INSJ IMPLTBL GLUC SENSOR DIF ANATOMIC SITE 0448T $6,416.19 03611558 HB INTRAOSS DES LUMB/SAC W/FLUORO GDN, 1ST 2 C9752 $79,500.67 03611559 HB INTRAOSS DES LUMB/SAC W/FLUORO GDN, EA ADDL C9753 $38,810.66 03611561 HB TRANSCATH TRI PERQ APPR INITIAL PROSTH 0569T $60,317.62 03611562 HB TRANSCATH TRI PERQ APPR EACH ADDL PROSTH 0570T $60,317.62 03611563 HB PERICARDIOCENTESIS W W/O IMG 33016 $6,591.17 $8,568.52 03611564 HB EVASC RPR ILIAC ART ENDOGRAFT UNI 34717 $29,451.59 03611565 HB EVASC RPR ILIAC ART N/A A-ILIAC ENDOGRAFT UNI 34718 $29,451.59 03611566 HB DIAG LUMB SPINAL PUNCT W/ FLUORO/CT 62328 $6,016.53 $7,821.49 03611567 HB THERA LUMB SPINAL PUNCT DRN CSF W/ FLUORO/CT 62329 $4,656.33 03611568 HB INJ ANESTHETIC/STEROID SI JOINT W/ IMG 64451 $4,438.25 $5,769.73 03611569 HB INJ ANESTHETIC/STEROID GENICULAR NERV 64454 $4,438.25 $5,769.73 03611570 HB DESTRUCT NEURO AGNT GENIC NERV W/ IMG 64624 $11,077.10 $14,400.24 03611571 HB RADIOFREQ ABLTN SI JOINT W/ IMG 64625 $11,077.10 $14,400.24 03611572 HB ANGIOPLASTY CCA, DOTTER CATH 37799 $42,225.98 03611578 HB DESTRUCT PREMALIG LESION 15/> 17004 $1,665.64 $2,165.32 03611579 HB INJ ANES FACIAL, PHRENIC OR C-SPINE NERVE 64999 $1,695.56 $2,204.22 03611580 HB ABLTN MALIG BRST TUMOR PERC CRYO UNI 0581T $15,888.73 $20,655.31 03611581 HB THROMBOLYSIS CEREBRAL IV INFUSION 37195 $3,154.36 03611582 HB PERC ARTERIOVENOUS FISTULA, DIRECT G2170 $92,511.30 03611583 HB LIGATION OF A-V FISTULA 37607 $12,035.14 $15,645.68 03611584 HB FIBRIN SHEATH DISRUPTION 37799 $13,685.39 03611585 HB BAKRI BALLOON PLACEMENT 59899 $1,840.92 03611586 HB PUNCTOPLASTY 68440 $1,286.99 $1,673.11 03611587 HB TRANSRECTAL DRAINAGE OF PELVIC ABSCESS 45000 $9,859.57 $12,817.43 03611588 HB REMOVE BRAIN CAVITY FLUID 61020 $5,549.43 $7,214.25 03611590 HB GJ TUBE REMOVAL 43870 $4,932.21 03611591 HB INJECT/TREAT EYE SOCKET 67515 $1,286.99 03611592 HB BIOPSY CORE NDL LUNG/MEDIA PERQ 32408 $9,261.99 $12,040.61 03611593 HB PERQ TCAT US ABL PUL ART RT HRT CATH PUL ART ANG 0632T $92,511.30 03611594 HB EXCISION OF VAGINAL CYST/TUMOR 57135 $17,494.01 $22,742.21 03611595 HB INJ C/T-SPINE FACET W/US, SNGL LVL 0213T $5,549.43 $7,214.27

Ancillary FY22 159 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03611596 HB INJ C/T-SPINE FACET W/US, 2ND LVL 0214T $3,105.96 03611597 HB INJ C/T-SPINE FACET W/US, 3RD LVL 0215T $3,105.96 03611598 HB UNLISTED FETAL INVASIVE PROC W/US 59897 $1,417.90 03611599 HB INS STABL DEV W IMG GD LUMBAR SINGLE 22869 $79,500.67 $103,350.88 03611600 HB INS STABL DEV W IMG GD LUMBAR SECOND 22870 $38,810.66 03611601 HB HYSTEROSCOPY DIV/RESECT INTRAUT SEPTUM 58560 $24,535.78 03611602 HB INDUCED ABORT BY 1/> VAG SUPPOS 59855 $17,195.53 03611603 HB CURETTAGE, POSTPARTUM 59160 $17,494.01 $22,742.21 03611604 HB PUNCTURE ASPIR HYDROCELE W/WO INJ MED 55000 $4,804.93 $6,246.41 03611605 HB CERCLAGE CERVIX, PREGNANCY VAGINAL 59320 $16,582.00 03620003 HB HEMATOPOIETIC PROG CELL HPC; AUTO TRANS 38241 $8,014.20 03700001 HB ANES-CAT 2-BASIC+A LINE-1ST HR $13,745.34 03700002 HB ANES-CAT 2 - EA ADDL MIN $135.33 03700003 HB ANES-CAT 1-BASIC - 1ST HOUR $9,859.58 03700004 HB ANES-CAT 2+ALINE OUTLYING AREA $10,474.94 03700005 HB ANES-CAT 3 - EA ADDL MIN $209.33 03700006 HB ANES-CAT 1-BASIC OUTLYING AREA $5,973.10 03700007 HB ANES-CAT 1 - EA ADDL MIN $101.48 03700008 HB ANES-CAT 3+CVP,SWAN-1ST HOUR $21,672.33 03700010 HB MODERATE SEDATION <5YRS 15 MIN 99151 $811.87 $1,055.04 03700011 HB MODERATE SEDATION >5YRS 15 MIN 99152 $811.87 $1,055.04 03700014 HB MODERATE SEDATION EA ADDL 15 MIN 99153 $335.23 $435.80 03700015 HB CX ANES-CAT 1-BASIC -1ST HR $2,255.01 03700018 HB ANES-CAT 3+ALINE OUTLYING AREA $16,487.65 03700019 HB MOD SED OTH PHYS/QHP <5 YRS 99155 $811.87 $1,055.04 03700020 HB MOD SED OTH PHYS/QHP 5/>YRS 99156 $811.87 $1,055.04 03700021 HB MOD SED OTHER PHYS/QHP EA 99157 $317.14 $414.39 03820001 HB WHOLE BLOOD, LEUKOREDUCED, IRRADIATED, EACH UNIT P9056 $2,429.75 03830001 HB PROCESS PLAS, FRZ 8-24HR CS P9059 $366.17 03900001 HB AB SCREEN LISS 86850 $701.09 03900003 HB AB SCREEN, GEL 86850 $701.09 03900005 HB ANTIBODY ELUTION (RBC) 86860 $771.33 03900007 HB ANTIBODY RBC IDENTIFICATION 86870 $1,034.05 03900008 HB ANTIBODY I.D. LISS 86870 $1,034.05 03900009 HB ANTIBODY I.D. GEL EZ 86870 $1,034.05 03900011 HB ANTIBODY I.D. GEL 86870 $1,034.05 03900012 HB ANTIBODY I.D. PEG 86870 $1,034.05 03900013 HB CORD BLOOD SCREEN 86880 $691.27 03900014 HB DAT C3D 86880 $134.45 03900016 HB DAT C3 86880 $118.94 03900017 HB DAT (COOMBS) IGG 86880 $103.43 03900020 HB PATIENT ABO TYPE 86900 $867.18

Ancillary FY22 160 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 03900021 HB ALLO BM/PBSC DONOR ABO * 86900 $867.18 03900022 HB ALLO BM/PBSC DONOR RH (D) 86901 $145.71 03900023 HB PATIENT RH TYPE 86901 $463.70 03900028 HB RBC PHENO PT/BLD GRP AG 86905 $1,034.05 03900030 HB ALLO BM/PBSC CROSSMATCH 86920 $0.01 03900031 HB I. S. CROSSMATCH 86920 $0.01 03900034 HB PLASMA THAW FFP 86927 $771.33 03900035 HB HLA LYMPHOCYTE PREP 86930 $1,034.05 03900036 HB HEMOL/AGGLUTININ INCUBA 86941 $584.78 03900037 HB DONATH LANDSTEINER, BLOOD 86941 $677.74 03900039 HB PRETREAT RBC'S ENZM EA 86971 $1,034.05 03900045 HB PT. SERA DIFF ABSORPTION 86978 $517.98 03900053 HB PROCESS CRYOPRECIPITATE P9012 $117.00 03900058 HB PROCESS PACKED RBC-OS P9038 $846.50 03900062 HB PROCESS PCK RBC WASHED P9022 $2,206.37 03900064 HB PROCESS PLATELETPHERESIS P9036 $1,615.88 03900066 HB PROCESS PLT PHERS LEUKO RED-OS P9037 $2,345.85 03900068 HB PROCESS PCK RBC DEGLYCEROLIZE-OS P9057 $3,127.21 03900071 HB PROCESS PLASMA FFP P9059 $366.17 03900073 HB PROCESS GRANULOCYTE PHER P9050 $1,933.00 03900074 HB PROCESS PLASMA, FRZ BET 8-24HR P9059 $366.17 03900075 HB TRANSFUSION REACT WORKUP 86078 $771.33 03900081 HB PRE SC UNIT PT 86904 $136.05 03900084 HB RH PHENOTYPE 86906 $188.16 03900086 HB AHG CROSSMATCH 86922 $0.01 03900090 HB PROCESS POOLING CRYO 86965 $771.33 03900092 HB PRETREAT RBC'S/DRUGS - ARC 86975 $597.13 03900094 HB ANTIBODY RBC TITRE 86886 $771.33 03900097 HB LAB ELECTRONIC CROSSMATCH 86923 $0.01 03900108 HB PROCESS PCK RBC WASHED* P9022 $2,202.60 03900109 HB PROCESS PLASMA FFP-OS P9059 $366.17 03900110 HB PROCESS CRYOPRECIPITATE* P9012 $117.00 03900111 HB PROCESS PLT PHERESIS LEUKO RED* P9037 $2,345.85 03900112 HB PROCESS PACKED RBC* P9038 $846.50 03900114 HB PROCESS PCK RBC LEUKOREDUCED-OS P9040 $992.22 03900115 HB PROCESS PCK RBC LEUKOREDUCED* P9040 $992.22 03900119 HB PLATELETS, PHERESIS, PATHOGEN REDUCED EACH UNIT P9073 $2,348.70 03910001 HB TRANSFUSION, BLOOD COMPLEX 36430 $4,389.74 $5,706.64 03910002 HB TRANSFUSION, BLOOD INTERM 36430 $3,702.77 $4,813.61 03910003 HB TRANSFUSION, BLOOD COMPONENT 36430 $2,328.87 $3,027.55 03910004 HB TRANSFUSION, BLOOD SIMPLE 36430 $3,341.11 $4,342.89 04010004 HB MAMMO DIAG DIGITAL BILAT INCL CAD 77066 $1,484.65

Ancillary FY22 161 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04010005 HB MAMMO DIAG DIGITAL UNILAT INCL CAD 77065 $1,159.72 04010006 HB MAMMO TOMOSYNTHESIS UNILAT 77061 $758.11 $985.56 04010007 HB MAMMO TOMOSYNTHESIS BILAT 77062 $999.26 $1,299.04 04020001 HB US DRAINAGE S&I 75989 $3,753.45 $4,877.69 04020002 HB US HEAD/NECK SOFT TISSUE 76536 $2,465.11 $3,204.65 04020005 HB US RETROPERITONEUM LIMITED 76775 $1,568.72 $2,039.33 04020006 HB US TRANSPLANTED KIDNEY 76776 $2,465.11 $3,204.65 04020007 HB CHD RISK IMT STUDY 93998 $392.90 04020008 HB AMNIOCENTESIS 59000 $2,414.06 04020009 HB U/S OB W/ DETAIL FETAL EXAM 76811 $3,781.49 04020010 HB US BRAIN W DOPPLER 76506 $1,568.72 $2,039.33 04020011 HB U/S OB, ADDL GESTATION 76812 $3,034.22 04020012 HB OB U/S NUCHAL MEAS, 1 GEST 76813 $1,568.72 04020013 HB U/S OB NUCHAL, ADDL GESTATION 76814 $637.49 04020014 HB US CHEST 76604 $2,465.11 $3,204.65 04020020 HB US ABDOMEN COMPLETE 76700 $2,913.32 $3,787.29 04020021 HB US OB FU/EVAL PER FETUS 76816 $1,142.82 $1,485.67 04020022 HB US ABDOMEN LIMITED 76705 $2,465.11 $3,204.65 04020023 HB US RETROPERITONEUM COMPLETE 76770 $2,465.11 $3,204.65 04020025 HB FETAL BIOPH PROFILE W/O NST 76819 $2,465.11 $3,204.66 04020026 HB US SPINAL CANAL 76800 $1,142.82 $1,485.67 04020027 HB US OB < 14 WKS SINGLE FETUS 76801 $1,568.72 $2,039.34 04020028 HB OB US < 14 WKS, ADD'L FETUS 76802 $608.29 04020029 HB ULTRASOUND OB >14 WEEKS 76805 $2,351.83 $3,057.37 04020030 HB US OB > 14 WKS ADD'L GEST 76810 $1,438.04 04020031 HB US PELVIS TRANSVAGINAL 76830 $1,568.72 $2,039.33 04020033 HB US PELVIS NON-OB COM 76856 $2,465.11 $3,204.66 04020034 HB US PELVIS LIMITED 76857 $1,142.82 $1,485.67 04020035 HB US PREG UTERUS LMTD 76815 $1,568.72 $2,039.34 04020037 HB US PELVIS TRANSABDOMEN COM 76856 $2,465.11 $3,204.65 04020039 HB U/S GUID VASCULAR ACCESS 76937 $1,603.46 $2,085.26 04020040 HB US GUIDE IUT/CORDOCENTESIS 76941 $1,104.70 04020041 HB US PLACEMENT NEEDLE S&I 76942 $2,705.74 $3,518.41 04020042 HB UMBILICAL ARTERY DOPPLER 76820 $1,142.82 04020043 HB FETAL MID CEREBRAL ARTERY DPLR 76821 $1,142.82 04020044 HB FETAL ECHO COMPLETE 76825 $2,312.32 04020045 HB FETAL ECHO FOLLOW UP 76826 $1,445.32 04020046 HB FETAL ECHO COMPLETE DOPPLER 76827 $1,142.82 04020047 HB FETAL ECHO FOLLOW UP DOPPLER 76828 $1,142.82 04020050 HB US PELVIS HYSTEROSONOGRAM 76831 $3,781.49 04020055 HB US EXAM PELVIC/FOLLICLE LIMITED 76857 $1,350.10 $1,755.13 04020056 HB US SCROTUM & TESTICLE(S) 76870 $2,465.11 $3,204.65

Ancillary FY22 162 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04020057 HB US TRANSRECTAL 76872 $2,465.11 $3,204.65 04020058 HB US COMPLETE JOINT 76881 $2,465.11 $3,204.65 04020059 HB U/S GUID PSEUDOANEURYSM REPR 76936 $3,204.04 04020061 HB VASCULAR ACCESS GUIDANCE 76937 $1,603.46 $2,085.26 04020062 HB US GUIDE FOR AMNIOCENTESIS 76946 $1,326.11 04020063 HB US INTRAOPERATIVE GUIDANCE 76998 $1,544.14 $2,007.42 04020064 HB US UL PROC 76999 $1,142.82 $1,485.66 04020066 HB VAS SCREENING ABDOMEN 76706 $1,142.82 $1,485.66 04020067 HB US GUIDANCE FOR ABLATION 76940 $1,470.58 $1,912.50 04020069 HB US PELVIS OB TRANSVAGINAL 76817 $1,568.72 $2,039.33 04020070 HB PRENATAL CVS GUIDANCE 76945 $805.40 04020074 HB FETAL BIOPHYS PROF W NONSTRESS 76818 $2,913.32 04020079 HB US LTD JOINT/NON-VASC EXT 76882 $1,142.82 $1,485.67 04020085 HB US INFANT HIPS; LIMITED/STATIC 76886 $1,142.82 $1,485.67 04020087 HB US EXAM CHEST 76604 $2,465.11 $3,204.65 04020088 HB US BREAST COMPLETE UNILATERAL 76641 $1,568.72 $2,039.34 04020089 HB US BREAST LIMITED UNILATERAL 76642 $1,142.82 $1,485.66 04020091 HB OPHTH US B & QUANT A 76510 $867.18 04020092 HB DX OPHTHAL B-SCAN US 76512 $940.85 04020093 HB CORNEAL US 76514 $392.90 04020094 HB A-SCAN EYE US W IOL MEASR 76519 $940.85 04020095 HB US TRGT DYN MBUBB 1ST LES 76978 $6,499.13 $8,448.89 04020096 HB US TRGT DYN MBUBB EA ADDL 76979 $2,771.97 $3,486.72 04020097 HB US PARENCHYMA 76981 $5,385.45 $7,001.06 04020098 HB US 1ST TARGET LESION 76982 $5,385.45 $7,001.06 04020099 HB US EA ADDL TARGET LESION 76983 $1,615.64 04030002 HB MAMMO SCREENING BILATERAL INCL CAD 77067 $1,348.70 04030005 HB MAMMO TOMOSYNTHESIS SCREEN BILAT 77063 $544.47 $707.80 04030006 HB MAMMO SCREENING UNILATERAL INCL CAD 77067 $1,226.09 04040001 HB NM PET CARDIAC METABOLIC 78459 $8,150.25 $10,595.33 04040002 HB NM PET CARDIAC PERF SINGLE 78491 $11,484.82 $14,930.28 04040003 HB NM PET CARDIAC PERF MULT 78492 $28,114.57 $36,548.93 04040004 HB NM PET BRAIN METABOLIC EVAL 78608 $14,191.26 $18,448.65 04040005 HB NM PET LIMITED AREA 78811 $8,150.25 $10,595.33 04040006 HB NM PET SKULL-THIGH 78812 $10,223.64 $13,290.72 04040007 HB NM PET/CT LIMITED AREA 78814 $15,637.13 $20,463.39 04040008 HB NM PET/CT SKULL-THIGH 78815 $15,720.40 $20,436.69 04040009 HB NM PET/CT WHOLE BODY 78816 $13,163.60 $17,112.68 04040010 HB NM PET WHOLE BODY 78813 $11,842.05 $15,394.67 04040012 HB PET CARDIAC META SNGL CNCRNT CT 78429 $15,720.40 $20,436.69 04040013 HB PET CARDIAC PERF SNGL CNCRNT CT 78430 $15,720.40 $20,436.69 04040014 HB PET CARDIAC PERF MULT CNCRNT CT 78431 $8,150.25 $10,595.33

Ancillary FY22 163 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04040015 HB PET CARDIAC PERF/META DUAL RADTRCR 78432 $8,150.25 $10,595.33 04040016 HB PET CARD PERF/META DUAL RAD CNCRNT CT 78433 $8,150.25 $10,595.33 04040017 HB PET AQMBF REST AND PHARM STRESS 78434 $8,757.85 $11,385.20 04100009 HB AEROSOL INHAL, HHN TRT,SUBS 94640 $518.25 04100012 HB PC IPPB TRT SUBSEQUENT 94640 $518.25 04100013 HB PC PENTAMIDINE TREATMENT 94642 $1,315.91 04100014 HB AEROSOL INHAL, PENTAMIDINE 94642 $1,315.91 04100015 HB PENTAMIDINE TREATMENT ADDL 10* 94642 $1,315.91 04100016 HB PC AEROSOL TREATMENT INIT HR 94644 $867.18 04100017 HB PC AEROSOL TRMNT EA ADDL HOUR 94645 $376.23 04100026 HB SURFACTANT TREATMENT-NICU 94664 $992.26 04100027 HB PC SPUTUM INDUCTION 94640 $518.25 04100029 HB AEROSOL INHAL, INITIAL HHN 94640 $518.25 04100030 HB PAG-HEART NEB INITIAL 94644 $867.18 04100031 HB BRONCHODILATOR ADMIN 94640 $518.25 04100033 HB PC HEATED AERO. TRT. 94640 $518.25 04100034 HB BRONCHODILATOR ADMINISTATION 94640 $518.25 04100036 HB PC MDI INITIAL 94640 $518.25 04100037 HB PC INITIAL IPPB TRT 94640 $518.25 04100038 HB PC INITIAL HAND NEBULIZER TRT 94640 $518.25 04100039 HB PC O/P SPUTUM INDUCT 94640 $518.25 04100041 HB PC INITIAL CHEST PHYSIOTHERAP 94667 $867.18 04100042 HB PC POST.DRAINAGE TRT 94667 $867.18 04100044 HB PC CHEST PHYSIO THER SUBS 94668 $867.18 04100045 HB PR THER PROCEDURE 15 MIN 94799 $2,650.27 04100046 HB PR SELF CARE/HOME MGT G0238 $392.90 04100047 HB PULMONARY INSTRUCTIONS G0238 $392.90 04100049 HB PR THER GROUP 2 OR G0239 $1,203.07 04100051 HB IPPB TRT, INITIAL 94664 $992.26 04100053 HB AIRWAY INHALATION TREATMENT 94640 $518.25 04100054 HB PAG-HEART NEB EACH ADDL HR 94645 $376.23 04100055 HB PC BIPAP, INITIAL 94660 $5,938.44 04100056 HB PC BIPAP, SUBSEQUENT 94660 $5,398.57 04100057 HB PC CPAP, INITIAL 94660 $5,956.36 04100058 HB PC CPAP, SUBSEQUENT 94660 $5,414.71 04100059 HB PC VENT, INITIAL 94002 $9,798.12 04100060 HB PC VENT, SUBSEQUENT 94003 $8,908.56 04100061 HB PC VENT JET, INITIAL 94002 $16,570.56 04100062 HB PC VENT JET, SUBSEQUENT 94003 $15,116.02 04100064 HB MECHN CHST WALL OSCIL,PR SN 94669 $680.92 04100065 HB PC INITIAL CHFO/CPAP/NEBULIZER (METANEB) TRT 94640 $518.25 04100066 HB PC CHFO/CPAP/NEBULIZER (METANEB) SUBSEQUENT 94640 $518.25

Ancillary FY22 164 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04120001 HB PC HAND NEB. TRT SUBS 94640 $518.25 04120002 HB PEDS PULM -INHAL. TREAT, MLTP 94640 $567.48 04120003 HB AEROSOL INHAL, TREATMENT 94640 $518.25 04200002 HB M CAL PT EXRCSE EA ADDL 15M $423.25 $548.64 04200003 HB M CAL PT EVALUATION $1,800.00 $2,340.81 04200004 HB M CAL PT EXRCSE 1ST 30M $843.87 $1,097.24 04200005 HB M CAL PT MOD/EXER 1ST 30M $843.87 $1,097.24 04200008 HB M CAL PT MOD/EXER EA ADDL 15M $423.25 $548.64 04200010 HB PT TAPE/STRAP LOW BACK 29799 $1,085.27 04200013 HB PT TAPE/STRAP HIP 29520 $837.24 $1,088.40 04200022 HB PT HOT OR COLD PACK 97010 $331.79 $431.07 04200023 HB PT TRACTION, MECHANICAL 97012 $365.74 $475.45 04200024 HB PT ELEC STIM, UNATTEND EA 15M 97014 $475.45 04200026 HB WHIRLPOOL/FLUIDTHERAPY 97022 $901.32 $1,170.44 04200027 HB ELEC STIM, ATTENDED EA 15M 97032 $449.34 $585.20 04200028 HB IONTOPHORESIS 15 MIN 97033 $449.34 $584.17 04200029 HB PT ULTRASOUND EA 15M 97035 $433.68 $564.31 04200030 HB THER EXERCISE EA 15M 97110 $423.25 $548.64 04200031 HB NEUROMUSC REED EA 15M 97112 $438.53 $569.15 04200032 HB PT GAIT TRAINING EA 15M 97116 $449.34 $585.20 04200033 HB PT MASSAGE THERAPY EA 15M 97124 $493.77 04200034 HB MANUAL THERAPY EA 15M 97140 $401.22 $522.51 04200035 HB EXERCISE GRP OF 2 OR MORE 97150 $579.99 $752.40 04200038 HB THER ACTVTIES, DIR EA 15M 97530 $438.53 $571.48 04200039 HB COMM TRN/REINT 15M 97537 $451.99 $587.80 04200040 HB PT W/C MAN/PROPLSN TRN EA 15M 97542 $391.87 $509.46 04200041 HB PT WND CARE SELECT DEBRDMNT 97597 $1,261.52 $1,639.97 04200042 HB PT WND CARE NONSELECT DEBRDMNT 97602 $1,261.52 $1,639.97 04200046 HB PT PHYS PERFRM TEST EA 15M 97750 $449.34 04200047 HB ORTHTC ASSESS/TRN EA 15M 97760 $436.19 $566.83 04200049 HB PT PROSTHETIC TRAIN EA 15M 97761 $465.03 $603.47 04200051 HB ORTH/PROS CHECK EA 15M 97763 $579.99 $755.03 04200052 HB PATIENT/FAM CONF INTERM 97799 $683.27 $888.27 04200053 HB PATIENT/FAM CONF BRIEF 97799 $540.63 $702.79 04200054 HB ELEC STIM, UNATTENDED 97014 $365.74 04200055 HB M CAL PT SNGL MODAL, INIT 30M $1,063.04 04200056 HB PT NEG PRES WND THER <50CM* 97605 $1,261.52 $1,639.97 04200057 HB PT NEG PRES WND THER >50CM* 97606 $1,665.64 $2,165.32 04200085 HB CANALITH REPOSITIONING PROC 95992 $448.75 04200086 HB M-CAL PT EVVAL ADDL 15 MIN $900.02 $1,170.03 04200087 HB NEG PRESS WND TX <=50 SQ CM 97607 $1,665.64 $2,165.32 04240002 HB PT EVAL MOD COMPLEXITY 97162 $1,350.68 $1,755.63

Ancillary FY22 165 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04240004 HB PT EVAL LOW COMPLEXITY 97161 $901.32 $1,167.51 04240006 HB PT RE-EVALUATION - (2) INT 97164 $901.32 $1,170.44 04240009 HB PT EVAL HIGH COMPLEXITY 97163 $1,800.00 $2,340.81 04240011 HB PT REEVALUATION (3) MOD 97164 $1,350.68 $1,755.63 04240012 HB PT REEVALUATION (4) EXT 97164 $1,800.63 $2,340.81 04240013 HB PT REEVALUATION (1) BRF 97164 $450.15 $585.20 04300002 HB OT NEUROMUSC RE-ED 15M 97112 $569.15 04300003 HB M CAL OT TRTMNT EA ADDL 15M $465.03 $603.47 04300004 HB M CAL OT TRTMNT INIT 30 MIN $930.04 $1,206.98 04300005 HB SWALLOW THERAPY - (2) INT 92526 $1,065.94 $1,387.25 04300006 HB SWALLOW THERAPY - (4) EXT 92526 $2,131.83 $2,771.87 04300007 HB SWALLOW THERAPY - (3) MOD 92526 $1,598.86 $2,079.58 04300008 HB SWALLOW THERAPY - (1) BRF 92526 $532.95 $692.32 04300009 HB VIDEO SWALLOW EVAL 92611 $2,327.78 $3,025.30 04300010 HB OT MODALITY HOT COLD PACK 97010 $331.79 $431.07 04300011 HB OT ELEC STIM, UNATTEND EA 15M 97014 $475.45 04300014 HB OT ELEC STIM, ATTENDED EA 15M 97032 $449.34 $585.20 04300015 HB OT CONTRAST BATH EA 15M 97034 $195.93 $256.05 04300016 HB OTM ULTRASOUND EA 15M 97035 $433.68 04300017 HB OT UPPER EXT EXERCISE EA 15M 97110 $423.25 04300021 HB OT ADL THERAPY EA 15M 97535 $445.53 $578.49 04300022 HB OT JOB SITE EVAL EA 15M 97750 $449.34 04300023 HB PT ASSIST TECH ASSESS EA 15M 97755 $684.47 04300024 HB ORTHOTIC SPLINT/TRN 15M 97760 $566.83 04300025 HB OT PARAFFIN BATH EA 15M 97018 $384.04 $501.61 04300027 HB OT MASSAGE EA 15M 97124 $493.77 04300028 HB M CAL SINGLE MODAL, INIT 30M $817.70 $1,063.04 04300029 HB SENSORY INTEGRATION, 15 MIN 97533 $2,340.81 04300031 HB THER INTERVENTION W FOCUS COG FUNC, 1ST 15MIN 97129 $346.58 $395.71 04300032 HB THER INTERVENTION W FOCUS COG FUNC,EA ADDL 15MIN 97130 $346.58 $395.71 04340001 HB M CAL OT EVAL ADD'L 15M $410.17 $532.95 04340002 HB M CAL OT EVAL INIT 30 MIN $817.70 $1,063.26 04340010 HB OT EVAL HIGH COMPLEXITY 97167 $1,638.04 $2,129.46 04340011 HB OT EVAL LOW COMPLEXITY 97165 $817.70 $1,048.33 04340012 HB OT EVAL MOD COMPLEXITY 97166 $1,227.87 $1,596.22 04340018 HB M CAL OT EVAL EA ADDL 15M $410.17 04340019 HB OT REEVALUATION (2) INT 97168 $901.32 $1,170.44 04340020 HB OT DRIVING EVAL EA 15M 97750 $449.34 04340023 HB SWALLOW EVAL (2) INT 92610 $901.32 $1,170.44 04340027 HB OT REEVALUATION (1) BRF 97168 $450.15 $585.20 04340028 HB OT REEVALUATION (4) EXT 97168 $1,800.63 $2,340.81 04340029 HB OT REEVALUATION (3) MOD 97168 $1,350.68 $1,755.63

Ancillary FY22 166 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04400001 HB M CAL LANG SWALL IND TX 30M $1,387.25 04400002 HB M CAL SLP IND TX 30 MIN $969.24 $1,259.99 04400003 HB M CAL SWALLOW EVAL 60 MIN $1,800.00 $2,340.81 04400004 HB M CAL VIDEO SWALLOW $2,327.78 04400005 HB M CAL SP SWALLOW THERAPY INIT 60 MIN $2,771.39 04400007 HB M CAL SPEECH EVAL $2,340.81 04400008 HB M CAL LANG SWALL IND TX 60M $2,771.39 04400009 HB M CAL SP SWALLOW THER 30 MIN $1,259.22 04400010 HB M CAL LANG SWALL IND TX 60 MIN $2,131.83 04400011 HB SP BIOFEEDBACK 90901 $410.17 04400017 HB SP VOICE LANG THER - (1) BRF 92507 $532.95 04400018 HB SP VOICE LANG THER - (4) EXT 92507 $2,131.83 04400020 HB SP LNG VC SPCH IND TRT (4) EXT 92507 $2,771.87 04400021 HB SP LNG VC SPCH IND TRT (3) MOD 92507 $2,079.58 04400022 HB SP VOICE LANG THER - (3) MOD 92507 $1,598.86 04400023 HB SP VOICE LANG THER - (2) INT 92507 $1,065.94 $1,387.25 04400024 HB SP LNG VC SPCH IND TRT (1) BRF 92507 $692.32 04400025 HB SP LNG VC SPCH IND TRT (2) INT 92507 $1,387.25 04400026 HB SP LANGUAGE/SWALLOW GROUP 92508 $579.99 $752.40 04400028 HB SP LARYN FUNC STUDY - (3) MOD 92520 $1,045.51 04400029 HB SP LARYN FUNC STUDY - (1) BRF 92520 $349.21 04400030 HB SP LARYN FUNC STUDY - (2) INT 92520 $696.28 04400032 HB HEARING SCREENING 92551 $472.88 $613.95 04400034 HB SP VOICE PROSTHETIC TRAINING 92597 $2,340.81 04400035 HB SP AUG DEV TRAINING EXTEND 92609 $1,800.62 $2,340.81 04400042 HB SP PATIENT/FAM CONF INTERM * 97799 $888.27 04400043 HB SP PATIENT/FAM CONF INTERM 97799 $888.27 04400059 HB VOICE RESN BEH QLT ANL(1)BRF 92524 $585.21 $760.77 04400060 HB VOICE RESN BEH QLT ANL(3)MOD 92524 $1,755.63 $2,282.33 04400061 HB VOICE RESN BEH QLT ANL(4)EXT 92524 $2,340.81 $3,043.06 04400062 HB VOICE RESN BEH QLT ANL(2)INT 92524 $1,170.41 $1,521.53 04400063 HB COGNITIVE TEST BY HC PRO 96125 $1,206.45 04440001 HB M CAL LANGUAGE EVAL $2,340.81 04440002 HB SP LANG/COGNITIVE EVALUATION $2,340.81 04440003 HB M CAL LANG COG EVAL 60 MIN $1,800.00 04440004 HB M CAL SPEECH VOICE EVALUATION $1,800.00 04440013 HB SP VC PRSTH DEV EVAL - (4) EXT 92597 $1,800.00 $2,340.81 04440016 HB SP ENDOSCOPIC SWALLOW EVAL 92612 $2,340.81 04440018 HB SP ENDO SWALLOW EVAL - (3) MOD 92612 $1,350.68 04440019 HB SP ENDO SWALLOW EVAL - (4) EXT 92612 $1,800.00 04440020 HB SP END/SWALLW EVAL W/SENS 92616 $2,095.23 04440022 HB SWALLOW EVAL - (3) MOD 92610 $1,350.68 $1,755.63

Ancillary FY22 167 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04440023 HB SWALLOW EVAL (1) BRF 92610 $449.34 $585.20 04440024 HB SWALLOW EVALUATION- (4) EXT 92610 $1,800.00 $2,340.81 04440027 HB EVAL SGD 1HR 92607 $1,800.00 04440028 HB EVAL SGD EACH ADD 30 MIN. 92608 $900.02 04440033 HB SP FLUENCY EVAL (1) BRF 92521 $449.34 $584.15 04440034 HB SP SOUND PROD EVAL(1) BRF 92522 $449.34 $584.15 04440035 HB SP SOUND PROD W/LAN EVAL(1)BRF 92523 $449.34 $584.15 04440036 HB SP FLUENCY EVAL (2) INT 92521 $901.32 $1,171.70 04440037 HB SP FLUENCY EVAL (3) MOD 92521 $1,350.68 $1,755.87 04440038 HB SP FLUENCY EVAL (4) EXT 92521 $1,800.00 $2,340.01 04440039 HB SP SOUND PROD EVAL(2) INT 92522 $901.32 $1,171.70 04440040 HB SP SOUND PROD EVAL(3) MOD 92522 $1,350.68 $1,755.87 04440041 HB SP SOUND PROD EVAL(4) EXT 92522 $1,800.00 $2,340.01 04440042 HB SP SOUND PROD W/LAN EVAL(2)INT 92523 $901.32 $1,171.70 04440043 HB SP SOUND PROD W/LAN EVAL(3)MOD 92523 $1,350.68 $1,755.87 04440044 HB SP SOUND PROD W/LAN EVAL(4)EXT 92523 $1,800.00 $2,340.01 04440045 HB EVAL APHASIA PER HOUR 96105 $1,800.00 $2,340.01 04500003 HB I&D BARTHOLIN ABSCESS 56420 $1,417.90 $1,843.26 04500004 HB VAGINAL DELIVERY ED 59409 $17,494.01 $22,742.21 04500005 HB PLACENTAL DELIVERY 59414 $17,494.01 $22,742.21 04500007 HB I & D ABSCESS COMPL/MULTI 10061 $1,665.64 $2,165.32 04500008 HB I&D PILONIDAL CYST 10080 $1,731.31 $2,250.71 04500009 HB PILONIDAL CYST COMPLEX 10081 $4,374.54 $5,686.89 04500010 HB REMOVAL FB SQ SIMPLE 10120 $1,665.64 $2,165.32 04500013 HB SUBUNGUAL HEMATOMA EVAC 11740 $867.18 $1,127.33 04500014 HB REPAIR NAIL BED 11760 $3,257.90 $4,235.24 04500016 HB WEDGE EXCISON SKIN NAIL FOLD 11765 $1,665.64 $2,165.32 04500018 HB SIMPLE LAC REPAIR 2.6-7.5 CM 12002 $1,261.52 $1,639.97 04500019 HB SIMPLE LAC REPAIR 7.6-12.5 CM 12004 $1,261.52 $1,639.97 04500020 HB SIMPLE LAC REPAIR 12.6-20.0 CM SCALP 12005 $1,665.64 $2,165.32 04500021 HB SIMPLE LAC REPAIR 20.1-30.0 CM 12006 $1,665.64 $2,165.32 04500022 HB SIMPLE LAC REPAIR OVER 30.0 CM 12007 $1,261.52 $1,639.97 04500023 HB SIMPLE LAC REPAIR UP TO 2.5 CM FACE 12011 $1,261.52 $1,639.97 04500024 HB SIMPLE LAC REPAIR 2.6 - 5.0 CM 12013 $1,261.52 $1,639.97 04500025 HB SIMPLE LAC REPAIR 5.1 - 7.5 CM 12014 $1,261.52 $1,639.97 04500026 HB SIMPLE LAC REPAIR 7.6-12.5 CM FACE 12015 $1,261.52 $1,639.97 04500027 HB SIMPLE LAC REPAIR 12.6-20.0 CM FACE 12016 $1,665.64 $2,165.32 04500029 HB INTERM LAC REPAIR UP TO 2.5 CM 12031 $1,665.64 $2,165.32 04500030 HB INTERM LAC REPAIR 2.6-7.5 CM SCALP 12032 $1,665.64 $2,165.32 04500031 HB INTERM LAC REPAIR 7.6-12.5 CM 12034 $1,665.64 $2,165.32 04500032 HB INTERM LAC REPAIR 12.6-20.0 CM 12035 $1,665.64 $2,165.32 04500033 HB INTERM LAC REPAIR UP TO 2.5 CM 12041 $1,665.64 $2,165.32

Ancillary FY22 168 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04500034 HB INTERM LAC REPAIR 2.6-7.5 CM 12042 $1,665.64 $2,165.32 04500035 HB INTERM LAC REPAIR 7.6-12.5 CM 12044 $3,257.90 $4,235.24 04500036 HB INTERM LAC REPAIR UP TO 2.5 CM FACE 12051 $1,665.64 $2,165.32 04500037 HB INTERM LAC REPAIR 2.6-5.0 CM 12052 $1,665.64 $2,165.32 04500038 HB INTERM LAC REPAIR 5.1-7.5 CM 12053 $1,665.64 $2,165.32 04500039 HB INTERM LAC REPAIR 7.6-12.5 CM 12054 $1,665.64 $2,165.32 04500040 HB INTERM LAC REPAIR 12.6-20.0 CM FACE 12055 $1,665.64 $2,165.32 04500042 HB COMPLEX REPAIR 2.6 TO 7.5 CM TRUNK 13101 $3,257.90 $4,235.24 04500043 HB CMPLX REPAIR TRUNK@ADD 5CM- 13102 $3,329.98 04500044 HB COMPLEX REPAIR 1.1 TO 2.5 CM 13120 $3,257.90 $4,235.24 04500045 HB COMPLEX REPAIR 2.6 TO 7.5 CM 13121 $3,257.90 $4,235.24 04500046 HB CMPLX RPR HEAD/EXTR @ADD 5CM 13122 $3,329.98 04500047 HB COMPLEX REPAIR 1.1 TO 2.5 CM FOREHEAD 13131 $1,665.64 $2,165.32 04500048 HB COMPLEX REPAIR 2.6 TO 7.5 CM FOREHEAD 13132 $3,257.90 $4,235.24 04500049 HB CMPLX RPR FACE/HANDS @ADD 5CM 13133 $3,329.98 04500051 HB COMPLEX REPAIR 1.1 TO 2.5 CM EYE 13151 $3,257.90 $4,235.24 04500052 HB COMPLEX REPAIR 2.6 TO 7.5 CM EYELID 13152 $3,257.90 $4,235.24 04500053 HB CMPLX RPR EYELID @ADD 5CM 13153 $3,329.98 04500055 HB BURN DRESSING SMALL 16020 $1,261.52 $1,639.97 04500056 HB BURN DRESSING MEDIUM 16025 $1,261.52 $1,639.97 04500057 HB BURN DRESSION LARGE 16030 $1,665.64 $2,165.32 04500060 HB EXPLORE PENE WOUND EXTREMITY 20103 $4,804.93 $6,246.41 04500061 HB REMOVE FB MUSCLE SIMPLE 20520 $9,261.99 $12,040.61 04500064 HB NASAL FX W/O MANIPULATION 21310 $1,795.98 $2,334.78 04500065 HB NASAL FX W/O STABILIZATION 21315 $5,444.96 $7,078.46 04500066 HB CLOSED TX MANDIBLAR FX WO MANI 21450 $2,386.91 $3,102.98 04500067 HB CLOSED TX MANDIBLAR FX W MANIP 21451 $5,444.96 $7,078.46 04500068 HB TM JOINT DISLOCATION 21480 $1,795.98 $2,334.78 04500069 HB UNLIST PROC ABD/MUSK SYS 22999 $1,795.98 $2,334.78 04500070 HB FB SQ SHOULDER 23330 $4,890.65 $6,357.85 04500071 HB HUMERAL NECK FX W/MANIP 23605 $4,923.82 $6,400.95 04500072 HB HUMERAL FX WO MANIPULATE CLOSE 23620 $1,795.98 $2,334.78 04500073 HB CL TX SHLDR DISL W MANIP; WO ANESTH 23650 $1,795.98 $2,334.78 04500074 HB I&D UPPER ARM/ELBOW BURSA 23931 $9,261.99 $12,040.61 04500075 HB HUMERAL SHAFT FX W/ MANIP 24505 $4,923.82 $6,400.95 04500076 HB FX HUMERAL W MANIPULATION 24535 $4,923.82 $6,400.95 04500077 HB ELBOW DISLOCATION 24600 $1,795.98 $2,334.78 04500078 HB CL TX "NURSEMAID ELBOW" W MANIP 24640 $1,795.98 $2,334.78 04500079 HB CL TX RADIAL HD/NECK FX; WO MANIP 24650 $1,795.98 $2,334.78 04500080 HB RAD/ULNAR SHAFT FX WO MANIP 25560 $1,795.98 $2,334.78 04500081 HB CLTX RDCRPL/INTERCARPL DISLC 1+ BONES W MANIP 25660 $1,795.98 $2,334.78 04500082 HB I&D ABSCESS FINGER SIMPLE 26010 $1,261.52 $1,639.97

Ancillary FY22 169 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04500083 HB I&D ABSCESS FINGER COMPLICATED 26011 $9,261.99 $12,040.61 04500084 HB REV/REP EXTEN TENDON FINGER 26418 $4,923.82 $6,400.95 04500085 HB CLOSED TX METACARPAL FX W/MA @ 26605 $1,795.98 $2,334.78 04500086 HB CL TX MCP DISLOC SGL W MANIP 26700 $1,795.98 $2,334.78 04500087 HB FINGER SHAFT PROX FX 26720 $1,795.98 $2,334.78 04500088 HB CL TX PHALANG SHFT FX; W MANIP 26725 $1,795.98 $2,334.78 04500089 HB CLOSED TX ARTICULAR FX W MANIP 26742 $4,923.82 $6,400.95 04500090 HB CL TX D PHAL FX FGR/THMB; WO MANIP 26750 $1,795.98 $2,334.78 04500091 HB DIST PHALANGEAL FX W/MANIP 26755 $1,795.98 $2,334.78 04500092 HB CL TX IP JNT D W MANIP ; WO ANESTH 26770 $1,795.98 $2,334.78 04500094 HB COCCYGEAL FRACTURE 27200 $1,795.98 $2,334.78 04500095 HB HIP DISLOCATION 27250 $1,795.98 $2,334.78 04500096 HB FB KNEE/THIGH DEEP 27372 $10,098.89 $13,128.58 04500097 HB KNEE DISLOCATION 27550 $1,795.98 $2,334.78 04500098 HB PATELLAR DISLOCATION 27560 $1,795.98 $2,334.78 04500099 HB CL TX TIB SHFT FX W/O MANIP 27750 $1,795.98 $2,334.78 04500100 HB FX TIBIAL SHAFT W MANIPULATION 27752 $4,923.82 $6,400.95 04500101 HB CLTX MEDIAL ANKLE FX; W/O MANIP 27760 $1,795.98 $2,334.78 04500102 HB FX MEDIAL MALLEOLUS W MANIPUL 27762 $4,923.82 $6,400.95 04500103 HB CL TX BIMALLEOLAR ANKLE FX W/O MANIP 27808 $1,795.98 $2,334.78 04500104 HB BIMALLEOLAR ANKLE FX CLD W/MAN 27810 $4,923.82 $6,400.95 04500105 HB TRIMALLEOLAR ANK FX W/O MAN 27816 $1,795.98 $2,334.78 04500106 HB TRIMALLEOLAR ANK FX W/MAN 27818 $4,923.82 $6,400.95 04500107 HB ANKLE DISLOCATION W/O ANES 27840 $1,795.98 $2,334.78 04500108 HB FB REMOVE FOOT SQ 28190 $4,804.93 $6,246.41 04500109 HB FX TALUS W MANIPULATION 28435 $4,923.82 $6,400.95 04500110 HB CL TX FX GT PHALANX(S); W/O MANIP 28490 $1,795.98 $2,334.78 04500111 HB FX TOE W MANIPULATION 28495 $1,795.98 $2,334.78 04500112 HB TOES 2-5 FX W/O MAINIP 28510 $1,710.46 $2,223.60 04500113 HB TOES 2-5 FX W/MAINIP 28515 $1,795.98 $2,334.78 04500114 HB METATARSAL-PHALANGEAL DISLOC 28630 $1,795.98 $2,334.78 04500115 HB INTERPHALANGEAL DISLOCATION 28660 $1,795.98 $2,334.78 04500117 HB CAST GAUNTLET 29085 $1,085.27 $1,410.84 04500119 HB APPLICATION, FINGER SPLINT 29130 $837.24 $1,088.40 04500121 HB ED FACILITY LEVEL 1 99281 $2,808.42 $2,808.42 04500122 HB ED FACILITY LEVEL 1 W/PROC 99281 $2,808.42 $2,808.42 04500123 HB STRAPPING HAND/FINGER 29280 $323.94 $421.11 04500126 HB ED FACILITY LEVEL 2 99282 $4,320.62 $4,320.62 04500127 HB ED FACILITY LEVEL 2 W/PROC 99282 $4,320.62 $4,320.62 04500128 HB ED FACILITY LEVEL 3 99283 $6,647.10 $6,647.10 04500130 HB CAST WEDGING 29740 $2,050.20 $2,665.28 04500131 HB REMOVE INTRANASAL FB 30300 $867.18 $1,127.33

Ancillary FY22 170 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04500132 HB ANT. EPISTAXIS SIMPLE 30901 $829.88 $1,078.85 04500135 HB ENDOTRACHEAL INTUBATION 31500 $1,671.20 $2,172.57 04500137 HB TRACHEOSTOMY (CRICO) 31605 $1,671.20 $2,172.57 04500138 HB THORACOTOMY W/ CARDIAC MASSAGE 32160 $7,188.38 04500140 HB VENIPUN/IV <3YRS CENTRAL 36400 $550.54 04500143 HB ED FACILITY LEVEL 3 W/PROC 99283 $6,647.10 $6,647.10 04500145 HB ED FACILITY LEVEL 4 99284 $9,495.85 $9,495.85 04500147 HB ED FACILITY LEVEL 4 W/PROC 99284 $9,495.85 $9,495.85 04500148 HB INTRAOSSEOUS NEEDLE INSERTION 36680 $597.13 $776.27 04500149 HB RPR LIP THRU&THRU/VERM BORDER 40650 $2,386.91 $3,102.98 04500150 HB DRAIN ABSCESS VEST MOUTH SIMP 40800 $4,804.93 $6,246.41 04500151 HB REPAIR VEST MOUTH <2.5 CM 40830 $1,671.20 $2,172.57 04500152 HB TONGUE LAC REPAIR UNDER 2.6 CM 41250 $597.13 $776.27 04500153 HB RPR TONGUE >2.5/COMPLEX 41252 $1,671.20 $2,172.57 04500154 HB I&D ABCESS/CYST DENTOALVEOLAR 41800 $867.18 $1,127.33 04500155 HB I&D ABSCESS PERITONSILAR 42700 $1,671.20 $2,172.57 04500156 HB FB THROAT REMOVAL 42809 $597.13 $776.27 04500160 HB RECTAL PROLAPSE MAN REDUC 45999 $4,482.06 $5,826.67 04500161 HB ABSCESS ISCHOIO/PERIANAL 46040 $9,859.57 $12,817.43 04500162 HB I&D PERIANAL ABSCESS 46050 $4,482.06 $5,826.67 04500163 HB INC THROMBOSED HEMORRHOID EXT 46083 $3,391.93 $4,409.52 04500164 HB HEMORRHOID ENUC/EXC 46320 $9,859.57 $12,817.43 04500165 HB ANOSCOPY DIAGNOSTIC 46600 $867.18 $1,127.33 04500166 HB ANOSCOPY FB REMOVAL 46608 $4,482.06 $5,826.67 04500168 HB INSERT FOLEY CATH COMPLICATED 51703 $2,650.27 $3,445.35 04500169 HB I&D TEST/SCROTUM EPIDIDYMIS 54700 $10,376.78 $13,489.81 04500170 HB ED FACILITY LEVEL 5 W/PROC 99285 $10,550.96 $10,550.96 04500171 HB ED FACILITY LEVEL 5 99285 $10,550.96 $10,550.96 04500172 HB EPISIOTOMY REPAIR 59300 $17,494.01 $22,742.21 04500173 HB CRITICAL CARE 30-74 MIN 99291 $12,809.09 $12,809.09 04500174 HB CRITICAL CARE 30-74 MIN W/PROC 99291 $12,809.09 $12,809.09 04500177 HB CRITICAL CARE EACH ADD 30 MIN 99292 $5,123.64 $5,123.64 04500178 HB REMOVE FB CONJUNCT SUPERFIC 65205 $867.18 $1,127.33 04500179 HB REMOVAL CORNEAL FB W/SLIT LAMP 65222 $867.18 $1,127.33 04500181 HB I&D ABSCESS AURICLE SIMPLE 69000 $4,804.93 $6,246.41 04500185 HB UNSCHEDULED/EMERGENCY DIALYSIS G0257 $8,627.77 $11,216.10 04500186 HB TX HIP DISLOCATION SPLNT/TRAC 27256 $1,795.98 $2,334.78 04500190 HB INTEST TUBE PLACE/MONITOR 44500 $4,219.24 $5,485.02 04500191 HB GASTRIC LAVAGE/INTUB OD 43753 $3,204.04 $4,165.25 04500192 HB EYE EXAM INTERMEDIATE NEW PATIENT 92002 $885.22 $1,150.78 04500194 HB TRANSCUTANEOUS PACE TEMP 92953 $3,793.09 $4,931.03 04500200 HB ARTHROPLASTY, HIP DISL W/ ANES 27266 $4,923.82 $6,400.95

Ancillary FY22 171 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04500201 HB ARTHROPLASTY, HIP DISL W/O ANES 27265 $1,795.98 $2,334.78 04500203 HB N BLOCK INJ, PLANTAR DIGIT 64455 $1,695.56 $2,204.22 04500204 HB MASTOTOMY W EXPL, DEEP 19020 $9,261.99 $12,040.61 04500205 HB TREAT FINGER DISLOCATION 26785 $13,149.09 $17,093.81 04500208 HB CL TX TRAUMA HIPDISLC WANES 27252 $4,923.82 $6,400.95 04500209 HB IRRIG CRPR CVERNSA PRIAPISM 54220 $3,391.93 $4,409.52 04500210 HB DEBR O FX; SKIN - TO BONE 11012 $10,098.89 $13,128.58 04500211 HB TREAT FINGER FRACTURE, EACH 26765 $13,149.09 $17,093.81 04500214 HB CL TX RADIAL&ULNA FX WMANIP 25565 $4,923.82 $6,400.95 04500215 HB REM IMPL CONTRACEP CAPS 11976 $4,804.93 $6,246.41 04500216 HB REPAIR,INTRINSIC MSCLS HAND 26591 $13,149.09 $17,093.81 04500229 HB COMPLIC REM FB FROM FOOT 28193 $9,261.99 $12,040.61 04500232 HB REM EMBEDDED FB MOUTH VESTIB; COMPLICATED 40805 $2,386.91 $3,102.98 04500233 HB REM EMB FB FROM DENTOALV; SFT TISSUE 41805 $5,444.96 $7,078.46 04500234 HB REMOVE VAGINAL FOREIGN BODY 57415 $17,494.01 $22,742.21 04500235 HB REMOVE EMBEDDED FB EYELID 67938 $1,286.99 $1,673.11 04500236 HB REM FB CONJUNCTIVA; EMBEDDED 65210 $597.13 $776.27 04500237 HB REP LACERAT 2.5 CM/<; POST 1/3 TONGUE 41251 $1,671.20 $2,172.57 04500239 HB REPAIR PALATE LACERATION; OVER 2 CM 42182 $18,563.85 $24,133.01 04500240 HB COLPORRHAPHY 57200 $17,494.01 $22,742.21 04500241 HB VASC EMBOLIZE/OCCLUDE BLEED (ED ONLY) 37244 $107,381.20 04600005 HB METHACHOLINE CHALLENGE 94070 $3,204.04 04600007 HB PF MIPS/MEPS-PIMAX PEMAX 94200 $837.24 04600010 HB THORACIC GAS VOLUME 94726 $3,204.04 04600014 HB PF ALTITUDE 02 STUDY 94452 $867.18 04600015 HB PF ALTITUDE 02 STUDY W/ O2 94453 $867.18 04600017 HB EXERC INDUCED BROCHO SPASM 94060 $3,204.04 04600018 HB O2 PRESCRIPTION 94680 $2,650.27 04600019 HB DIFFUSING CAPACITY 94729 $1,136.45 04600021 HB PRE/POST SPIROMETRY 94060 $3,204.04 04600022 HB SLOW VITAL CAPACITY 94150 $2,650.27 04600023 HB VITAL CAPACITY PER MEASUREMENT 94150 $2,650.27 04600026 HB PULMONARY STRESS; COMPLEX 94621 $3,204.04 04600028 HB PULSE OXIMETRY SNGL 94760 $347.46 04600030 HB INITIAL TRANSCUTANEOUS * 94761 $650.51 04600032 HB 6 MIN WALK/ PULSE OXIMETRY 94618 $867.18 04600034 HB TRANSCUTANEOUS PER HOUR * 94761 $650.51 04600040 HB PC MDI TX 94799 $2,650.27 04600044 HB LUNG VOLUME-HELIUM 94727 $2,650.27 04600045 HB SCREENING SPIROMETRY 94375 $3,204.04 04600046 HB SPIROMETRY 94010 $2,650.27 04600047 HB O2 UPTAKE,EXP GAS, CO2/VO2 EXT 94680 $2,650.27

Ancillary FY22 172 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04600049 HB OXYGEN UPTAKE REST INDIRECT 94690 $556.31 04600050 HB FLOW VOLUME LOOP 94375 $3,204.04 04600051 HB EXERCISE TEST BRONCHOSPASM W/ ECG 94617 $867.18 $1,127.33 04600052 HB INH BRONCH CHALLENGE; W HISTAMINE 95070 $11,207.60 $14,569.91 04600054 HB EXERCISE TEST BRONCHOSPASM W/O ECG 94619 $867.18 $1,127.33 04710004 HB AEP SCRN AUTO W/ STIMULI AUTO ANALYSIS 92650 $2,713.07 $3,526.99 04710005 HB AEP HEAR STAT DET BRDBND STIM I&R 92651 $2,650.27 $3,445.35 04710006 HB AEP THRESH EST MULT FREQ I&R 92652 $3,204.04 $4,165.25 04710007 HB AEP NEURODIAGOSTIC I&R 92653 $3,204.04 $4,165.25 04800001 HB CARDIOVERSION, INTERNAL 92961 $3,793.09 $4,931.03 04800005 HB TILT TABLE TEST 93660 $3,819.01 $4,964.70 04800008 HB CARDIOPULMONARY RESUSCITAT 92950 $3,204.04 $4,165.25 04800011 HB ECG CARDIOVERSION 92960 $3,793.09 $4,931.03 04800012 HB PERI-PROC PRG DEV EVAL LEAD OR LEADLS 93286 $569.55 $741.96 04800013 HB INTERRO REM 90DAYS PPM/ICD 93296 $1,163.17 $1,512.12 04800014 HB PROGRAMMING DUAL LEAD ICD 93283 $1,163.17 $1,512.12 04800018 HB TRANSTELEPHONIC 90 DAYS PPM 93293 $1,163.17 $1,512.12 04800020 HB PROGRAMMING SNG LEAD ICD 93282 $1,163.17 $1,512.12 04800023 HB PROGRAMMING MULT LEAD PPM 93281 $1,163.17 $1,512.12 04800026 HB INTERROGATION IN PERSON ICM 93290 $1,163.17 $1,512.12 04800027 HB INTERROGATION IN PERSON ICD 93289 $1,163.17 $1,512.12 04800029 HB INTERROGATION IN PERSON LEAD OR LEADLS 93288 $1,163.17 $1,512.12 04800031 HB PROGRAMMING MULT LEAD ICD 93284 $1,163.17 $1,512.12 04800032 HB PROG SQ CARD RHYTH PACEMAKER SYSTEM 93285 $1,163.17 $1,512.12 04800035 HB 2D ECHO W/SPEC,COLR FLW DOP 93306 $4,265.00 $5,544.71 04800036 HB STRESS ECHO W ECG,MD SUPRV 93351 $4,265.00 $5,544.71 04800038 HB PROG SNG LEAD OR LEADLESS ONE CHAMBR 93279 $1,163.17 $1,512.12 04800041 HB PROGRAMMING DUAL LEAD PPM 93280 $1,163.17 $1,512.12 04800042 HB PERI-PROC PRG DEV EVAL ICD 93287 $1,321.92 $1,716.42 04800043 HB INTER IN PERSON SQ CARD RHYTH PACE SYS 93291 $392.90 $510.77 04800046 HB INTERROGATION VAD,IN PERSON 93750 $1,060.75 04800052 HB WCD DEVICE INTERROGATE 93292 $1,163.17 04800056 HB EECP PER TREATMENT G0166 $867.18 04800057 HB LEADLESS C PM INS/RPL VENTR 33274 $92,511.30 04800058 HB LEADLESS C PM REMOVE VENTR 33275 $12,035.14 04800059 HB PROG EVAL INPER LEADLS PM 93279 $1,163.17 04800061 HB INTERGT EVAL INPER LEADLS PM 93288 $1,163.17 04800063 HB COR FFR CTA DATA ALYS & GNRJ 0503T $6,527.74 $8,486.06 04800064 HB REM INTERROG ICPMS <30 D PHYS/QHP 93297 $1,297.95 $1,687.35 04800065 HB REM INTERROG SCRMS <30 D PHYS/QHP 93298 $1,297.95 $1,687.35 04810002 HB INSRT NEW OR REPL PERM PCMKR+ATRIAL LEAD 33206 $62,712.66 04810003 HB INSRT NEW OR REPL PERM PCMKR+VNTRC LEAD 33207 $62,712.66

Ancillary FY22 173 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04810004 HB INSRT NEW OR REPL PERM PCMKR+VNTRC/ATRIAL 33208 $62,712.66 04810006 HB INSERT PCMKR GEN ONLY-SNGL; EXISTING LEAD 33212 $36,063.89 04810007 HB INSERT PCMKR GEN ONLY;EXISTING DUAL LEADS 33213 $62,712.66 04810008 HB UPGRADE PCMKR SNGL TO DUAL 33214 $62,712.66 04810009 HB REPOSITION TRNSVN LEAD-RA/RV 33215 $12,035.14 04810010 HB INSERT LEAD SINGLE CHAMBER 33216 $36,063.89 04810011 HB INSERT LEAD DUAL CHAMBER 33217 $36,063.89 04810012 HB REPAIR LEAD SINGLE CHAMBER 33218 $11,629.20 04810013 HB REPAIR LEAD DUAL CHAMBER 33220 $11,629.20 04810014 HB RELOCATION PCMKR POCKET 33222 $6,416.19 04810015 HB RELOCATION ICD POCKET 33223 $6,416.19 04810016 HB INSRT BI-V LEAD PREV PCMKR/ICD 33224 $62,712.66 04810017 HB INSRT BI-V LEAD NEW PCMKR/ICD W/O POCKET REVISION 33225 $56,800.05 04810018 HB REPOSITN LV LEAD+GEN REPLACE 33226 $12,035.14 04810019 HB REMOVE PACEMAKER GEN 33233 $36,063.89 04810020 HB REMOVE PCMKR LEAD SINGLE 33234 $11,629.20 04810021 HB REMOVE PCMKR LEAD DUAL 33235 $11,629.20 04810022 HB INSERT ICD SC/DC GEN. ONLY 33240 $189,230.55 04810023 HB REMOVE ICD GEN SINGLE/DUAL 33241 $11,629.20 04810024 HB REMOVE ICD LEAD SINGLE/DUAL 33244 $11,629.20 04810025 HB INS/REP ICD SNGL/DUAL W LEADS 33249 $211,451.52 04810026 HB IMPLANT CARDIAC LOOP RECRDER 33285 $36,063.89 04810027 HB REMOVE CARDIAC LOOP RECRDR 33286 $4,804.93 04810029 HB INSERT INTRA-AORT BALLOON 33967 $9,054.13 04810031 HB EXTRN CIRCULATORY&CARDIOASSIST 92971 $3,707.18 04810032 HB THROMBECTOMY, CORONARY MECHANICAL 92973 $23,415.59 04810033 HB THRMOBOLYSIS INTRACOR INFUSN 92975 $15,207.45 04810034 HB IVUS/OCT CORONARY GRAFT/VESSEL INITIAL 92978 $20,567.17 04810035 HB IVUS/OCT CORONARY GRAFT/VESSEL EA ADDL 92979 $20,504.51 04810038 HB PTCA RC ARTERY 92920 $38,663.15 04810039 HB PTCA LD ARTERY 92920 $38,663.15 04810040 HB AORTIC VALVUOPLASTY 92986 $38,663.15 04810041 HB VALVULOPLASTY MITRAL 92987 $82,600.93 04810042 HB VALVULOPLASTY PULM VALVE 92990 $82,600.93 04810043 HB ATRIAL SEPTECTOMY SEPTOSTOMY 33741 $65,725.15 04810044 HB PTCA LC ARTERY 92920 $38,663.15 04810045 HB PTCA SINGLE VESSEL 92920 $38,663.15 04810046 HB PTCA EA ADDL VESSL-LD 92921 $36,856.05 04810047 HB PULM ART ANGIOPLASTY 92997 $82,600.93 04810048 HB PULM ART ANGIOPLSTY ADDL VESSL 92998 $21,733.51 04810049 HB ERGONOVINE PROVOCATION TEST 93024 $597.13 04810050 HB RIGHT HEART CATH 93451 $29,836.42

Ancillary FY22 174 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04810051 HB INSERT SWAN GANZ CATH 93503 $6,591.17 $8,568.52 04810052 HB ENDOMYOCARDIAL BIOPSY 93505 $12,035.14 04810058 HB RHC CONGENITAL ANOMALY 93530 $29,836.42 04810059 HB RHC&TRNSPT LHC INTCT SEPT CNGN 93532 $29,836.42 04810060 HB RHC&TRNSPT LHC OPEN SEPT CNGN 93533 $29,836.42 04810070 HB DOPPLER FLOW WIRE INITL VESSL 93571 $19,591.23 04810071 HB DOPPLER FLOW WIRE ADDL VESSL 93572 $11,205.09 04810072 HB CLOSURE ATRIAL DEFECT 93580 $92,511.30 04810073 HB CLOSURE VENTRICULR DEFECT 93581 $92,511.30 04810074 HB BUNDLE OF HIS RECORDING 93600 $30,673.82 04810075 HB INTRA ATRIAL RECORDING 93602 $30,673.82 04810076 HB RT VENTRICULAR RECORDING 93603 $5,778.95 04810077 HB INTRAVENTR OR ATR MAPPING 93609 $29,641.57 04810078 HB INTRA ATRIAL PACING 93610 $30,673.82 04810079 HB INTRAVENTRC PACING 93612 $30,673.82 04810080 HB INTRACARDIAC EP 3D MAPPING 93613 $24,737.91 04810081 HB INDUCT ARRHYTH BY ELECTR PACE 93618 $5,778.95 04810082 HB COMP EP EVAL W/O ARRHYT INDUCT 93619 $30,673.82 04810083 HB COMP EP EVAL W/ARRHYT INDUCT 93620 $30,673.82 04810084 HB COMP EP EVAL LFT ATRIAL PACE 93621 $26,362.91 04810085 HB COMP EP EVAL LFT VNTRC PACE 93622 $26,362.91 04810086 HB EP STIM+PACE POST DRUG INFUSN 93623 $29,641.57 04810087 HB EP F/U STUDY THERAPY TEST 93624 $30,673.82 04810088 HB EP EVAL ICD LEAD W/INSERT 93640 $7,832.32 04810089 HB EP EVAL ICD GEN & LEADS 93641 $12,357.21 04810090 HB EP EVAL ICD W/PROGRAMMING 93642 $5,778.95 04810091 HB ABLATION ATRIOVENTRC NODE 93650 $30,673.82 04810094 HB INTRACARDIAC ECHO 93662 $20,435.09 04810095 HB PTCA EA ADDL VESSL-RC 92921 $36,856.05 04810096 HB PTCA EA ADDL VESSL-LC 92921 $36,856.05 04810097 HB ATHERECTOMY LAD 92924 $82,600.93 04810098 HB ARTHERECTOMY MECHANICAL 92924 $82,600.93 04810099 HB ATHERECTOMY CIRCUMFLEX 92924 $82,600.93 04810100 HB ATHERECTOMY RCA 92924 $82,600.93 04810101 HB ARTHERECTOMY EA ADDL VESSL 92925 $67,646.64 04810103 HB ATHERECTOMY ADD'L LAD 92925 $67,646.64 04810104 HB ATHERECTOMY ADD'L RC 92925 $67,646.64 04810106 HB DEPLOY HEMOSTASIS DEVICE 37799 $4,242.68 04810108 HB ILIAC ANGIO W/HEART CATH 93799 $2,650.27 04810109 HB STENT, PLACE LC RX-ELUT 92928 $82,600.93 04810110 HB STENT, PLACE LD RX-ELUT 92928 $82,600.93 04810111 HB STENT, PLACE RC RX-ELUT 92928 $82,600.93

Ancillary FY22 175 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04810112 HB STENT, PLACE LC RX ADDL VSL 92929 $79,402.40 04810113 HB STENT, PLACE RC RX ADDL VSL 92929 $79,402.40 04810114 HB STENT, PLACE LD RX ADDL VSL 92929 $79,402.40 04810117 HB INS VAD PERQ S&I LT HRT ART ACC ONLY 33990 $32,278.35 04810120 HB STENT, PLACEMENT 92928 $82,600.93 04810121 HB STENT, PLACEMENT LC 92928 $82,600.93 04810122 HB STENT, PLACEMENT LD 92928 $82,600.93 04810123 HB STENT, PLACEMENT RC 92928 $82,600.93 04810125 HB STENT, PLACEMENT LC ADDL VSL 92929 $79,402.40 04810126 HB STENT, PLACEMENT RC ADDL VSL 92929 $79,402.40 04810127 HB STENT, PLACEMENT LD ADDL VSL 92929 $79,402.40 04810128 HB PTCA EA ADDL VESSL 92921 $36,856.05 04810129 HB PROCAINAMIDE CHALLENGE STUDY 93799 $2,650.27 04810130 HB EMBO SHIELD DEP CORONARY 93799 $2,650.27 04810131 HB LHC +/- LV GRAM 93452 $29,836.42 04810132 HB R/LHC +/- LV GRAM 93453 $29,836.42 04810133 HB COR ANGIO W/INJ S & I 93454 $29,836.42 04810134 HB COR ANGIO W/GRFT INJ S & I 93455 $29,836.42 04810135 HB RHC W/COR INJ S & I 93456 $29,836.42 04810136 HB RHC W/COR + GRFT INJ S & I 93457 $29,836.42 04810137 HB LHC W/COR +/- LV GRAM 93458 $29,836.42 04810138 HB LHC W/COR +/- LV GRM W/GRFT 93459 $29,836.42 04810139 HB R/LHC+/-LV GRAM W/COR 93460 $29,836.42 04810140 HB R/LHC +/- LV GRM W/COR+GRFT 93461 $29,836.42 04810141 HB TRNSPTL TRNSAP PUNCTURE 93462 $22,342.22 04810142 HB NITRIC OXIDE/HEMO MEAS 93463 $2,379.24 04810144 HB RHC & RETROGR LHC, CONGENITAL 93531 $29,836.42 04810145 HB INJ CNGNTL COR ANGIO W/S&I 93563 $1,256.58 04810146 HB INJ CNGNTL ART/GRFT WS&I 93564 $1,345.44 04810147 HB INJ CNGNTL LV/LA W/S&I 93565 $901.32 04810148 HB INJ RV/RA W/S&I 93566 $901.32 04810149 HB INJ AORTO W/S&I 93567 $791.60 04810150 HB INJ PULM ART W/S&I 93568 $747.19 04810152 HB CATH-LAA OCCLUSION 93799 $15,538.49 04810156 HB ATHERECTOMY ILIAC,EA VESSEL 0238T $92,511.30 04810157 HB INTRAVSC IMG COR VSL(S) OCT 93799 $2,650.27 04810162 HB INSERT SWAN GANZ CATH CL 93503 $6,591.17 04810163 HB IMPLT PULM VLV EVASC APPR 33477 $60,317.62 04810164 HB INS PPI GEN ONLY-BI-V 33221 $62,814.13 04810165 HB INS PPI GEN ONLY SINGLE 33227 $36,063.89 04810166 HB INS PPI GEN ONLY DUAL 33228 $62,712.66 04810167 HB REMOVE/REPLACE PPI GEN,BI-V 33229 $62,814.13

Ancillary FY22 176 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04810168 HB INS ICD GEN ONLY-DUAL 33230 $189,230.55 04810169 HB INS ICD GEN ONLY-BI-V 33231 $211,451.52 04810170 HB REMOVE/REPLACE ICD, SINGLE 33262 $159,162.58 04810171 HB REMOVE/REPLACE ICD, DUAL 33263 $189,230.55 04810172 HB REMOVE/REPLACE ICD/BI-V 33264 $211,451.52 04810173 HB LAA CLOSURE W/IMPLANT 33340 $64,967.64 04810180 HB REPOSITION VAD DIFF SESSION 33993 $22,312.93 04810181 HB PTCA RI ARTERY 92920 $38,663.15 04810182 HB PTCA LM ARTERY 92920 $38,663.15 04810183 HB PTCA EA ADDL VESSL-RI 92921 $36,856.05 04810185 HB STENT,PLACE RI RX-ELUT 92928 $82,600.93 04810186 HB STENT,PLACE LM RX-ELUT 92928 $82,600.93 04810187 HB STENT,PLACEMENT RI 92928 $82,600.93 04810189 HB STENT,PLACE RI RX ADDL VSL 92929 $79,402.40 04810190 HB STENT,PLACE RX ADDL VSL 92929 $79,402.40 04810193 HB STENT/ATH/ANGIO 92933 $92,511.30 04810194 HB STENT/ATH/ANGIO;EA ADDL 92934 $87,110.74 04810195 HB REVASC BYP GRAFT 1 VSL 92937 $82,600.93 04810196 HB REVASC BYP GRAFT ADDL 92938 $67,646.64 04810197 HB CARD REVASC MI 1 VSL 92941 $150,681.59 04810198 HB REVSC CTO INI VSL 92943 $82,600.93 04810199 HB REVSC CTO ADDL 92944 $78,455.70 04810200 HB EP & SVT ABALATION 93653 $95,044.61 04810201 HB EP & VT ABLATION 93654 $95,044.61 04810202 HB ABLATE ARRHYTHMIA ADD ON 93655 $33,455.85 04810203 HB TX ATRIAL FIB PULM VEIN ISL 93656 $95,044.61 04810204 HB TX L/R ATRIAL FIB ADDL 93657 $33,455.85 04810205 HB INSERT SUBQ DEFIB ELECTRODE 33271 $36,063.89 04810209 HB RMVL SUBQ DEFIB ELECTRODE 33272 $11,629.20 04810210 HB REPOS SUBQ DEF ELTRD &/GEN 33273 $11,629.20 04810211 HB EPHYS EVAL SUBQ IMPLT DEFIB 93644 $12,385.19 04810213 HB IMPLT SUBQ DEFIB SYS DEV EV 93260 $1,163.17 04810214 HB PERQ TRANSCATH CLOSURE PDA 93582 $92,511.30 04810215 HB PERQ TRANSCATH SEPTL REDUXN 93583 $106,883.45 04810216 HB IMPL PRESSURE SENSR W/ANGIO 33289 $70,699.70 04810217 HB EXERCISE W/HEMODYNAMIC MEAS 93464 $3,570.99 04810218 HB INTRVASC US NONCORONARY 1ST 37252 $20,259.75 04810219 HB INTRVASC US NONCORONARY ADDL 37253 $10,723.46 04810221 HB PERQ TRANSCATH CLOSURE MITRAL 93590 $92,511.30 04810222 HB PERQ TRANSCATH CLOSURE AORTIC 93591 $92,511.30 04810223 HB PERQ TRANSCATH CLOSURE EA ADDL 93592 $45,437.03 04810226 HB INTRA-PROC CORONARY FFR W/3D FUNC MAP 0523T $19,591.23

Ancillary FY22 177 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04810227 HB PERICARD DRAIN 6YR+ W/O CONG CAR ANOM 33017 $4,111.98 04810228 HB PERICARD DRAIN 0-5YR/ANY AGE W/ CONG CAR ANOM 33018 $4,111.98 04810229 HB PERICARD DRAIN INSERT INDWELL CATH CT GUID 33019 $8,454.95 04810230 HB TRANSCATH IMPL INTERATRIAL SHUNT IDE STUDY C9758 $61,342.28 04810231 HB REVASC LOW EXT EXCPT TIB/PER INTRVSC LITHO C9764 $38,663.15 04810232 HB REVASC LOW EXT EXCPT TIB/PER INTRVSC LITHO-STENT C9765 $82,600.93 04810233 HB REVASC LOW EXT EXCPT TIB/PER INTRVSC LITHO-ATHRCTM C9766 $82,600.93 04810234 HB REVASC LOW EXT EXCPT TIB/PER INTRVSC LITHO-STENT-AT C9767 $92,511.30 04810235 HB RSH EPS W/EVAL OF ICD SUBSTERNAL ELECTRODE 0577T $5,477.68 04810236 HB TRANSCATH INTRACARDIAC SHUNT, INITIAL 33745 $65,725.15 04810237 HB TRANSCATH INTRACARDIAC SHUNT, EA ADDL 33746 $65,725.15 04810238 HB INS VAD PERQ S&I RT HRT VEN ACC ONLY 33995 $32,278.35 04810239 HB REMOVAL PERQ RT HEART VAD VEN 33997 $23,428.57 04810240 HB REMOVAL PERQ LT HEART VAD ART/ART & VEN 33992 $23,428.57 04810241 HB REVASC TIB/PER ART INTRVSC LITHO C9772 $82,600.93 04810242 HB REVASC TIB/PER ART INTRVSC LITHO-STENT C9773 $92,511.30 04810243 HB REVASC TIB/PER ART INTRVSC LITHO-ATHRCTMY C9774 $92,511.30 04810244 HB REVASC TIB/PER ART INTRVSC LITHO-STENT-ATHRCTMY C9775 $92,511.30 04810245 HB EPS & PVC ABLATION 93654 $90,089.68 04820001 HB CARDIAC STRESS TEST CL 93017 $3,204.04 $4,165.25 04830001 HB 2D ECHO W/O SPEC/COLOR DOP 93307 $4,856.92 $6,313.36 04830002 HB 2D ECHO, LIMITED 93308 $3,764.57 $4,893.94 04830003 HB PULSE WAVE DOPPLER COMPLETE 93320 $2,559.30 $3,327.09 04830004 HB PULSE WAVE DOPPLER LIMITED 93321 $2,060.99 $2,679.29 04830005 HB DOPPLER COLOR FLOW 93325 $2,267.70 $2,946.90 04830008 HB STRESS ECHO 93350 $4,265.00 $5,544.71 04830009 HB TEE WITHOUT CONTRAST 93312 $8,042.54 $10,455.32 04830010 HB TEE WITH CONTRAST 93312 $8,845.10 $11,500.35 04830011 HB 2D ECHO, LIMITED WITH CONTRAST 93308 $9,737.42 $12,658.68 04830012 HB STRESS ECHO WITH CONTRAST, ECG 93351 $8,845.10 $11,500.35 04830013 HB TTE/2D ECHO - WITH CONTRAST 93306 $8,845.10 $11,500.35 04830014 HB TTE CONG ABN;COMPLETE W/O CONT 93303 $3,442.90 04830015 HB TTE CONG ABN;LIM F-UP W/O CONT 93304 $2,333.36 04830016 HB TEE CONGENITAL;GLOBAL W/O CONT 93315 $2,333.36 04830018 HB TTE CONG HRT ANOM W -W/CON 93303 $3,442.90 04830019 HB TTE CONG ANOMALIES W/CONT 93304 $2,333.36 04830020 HB TEE CONG W/CONT 93315 $2,333.36 04830023 HB TEE CONGENITAL; INT & REP 93317 $2,075.26 04830024 HB ECHO TRANSESOPHAGEAL (TEE) 93355 $14,403.03 04830025 HB MYOCRD STRAIN IMG SPECKLE TRCK ASSMT 93356 $2,603.75 04900006 HB ALLOGENEIC LYMPHOCYTE INFUSIONS 38242 $8,014.20 04900009 HB BIOPSY OF VAGINA 57100 $2,414.06 $3,138.29

Ancillary FY22 178 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 04900010 HB COLPOSCOPY 57452 $1,417.90 04900011 HB COLPOSCOPY W/CERVICAL BIO 57454 $1,493.97 04900012 HB BIOPSY OF CERVIX 57500 $2,414.06 $2,974.68 04900013 HB LOOP ELECTRODE EXCISION PROC 57522 $17,494.01 05100006 HB I&D OF POSTOP WOUND COMPLEX 10180 $10,098.89 $13,128.58 05100015 HB DEBRIDEMENT/NAILS ANY METH > 6 11721 $837.24 05100017 HB DESTRUCT BENIGN NONFACE 1ST LE 17000 $1,261.52 05100019 HB CHEMICAL CAUTERIZATION/TISSUE 17250 $1,261.52 $1,639.98 05100023 HB STRAPPING UNNA BOOT 29580 $1,085.27 $1,410.84 05100028 HB THERAPEUTIC PHLEBOTOMY CC 99195 $867.18 05100029 HB ARTIFICAL INSEM/INTRA- UT 58322 $1,417.90 05100030 HB INJ ANES/STEROID PARACERVICAL BLOCK 64435 $3,078.05 $4,001.46 05100038 HB NEW PATIENT, LEVEL 5 W/PROC 99205 $971.34 05100042 HB EST PATIENT, LEVEL 1 99211 $295.45 05100045 HB EST. PATIENT, LEVEL 3 99213 $425.38 05100046 HB ANALYZE NEUROSTIM, NO PROG 95970 $867.18 $1,127.33 05100047 HB GENETIC COUNSELING 16-30MINS 1 UNIT 96040 $537.83 05100049 HB FLUSH IMPLANTABLE PORTS 96523 $837.24 05100051 HB GENETIC COUNSELING 31-60MINS 2 UNITS 96040 $615.57 05100053 HB GENETIC COUNSELING 61-90MINS 3 UNITS 96040 $691.16 05100055 HB NEW PATIENT, LEVEL 4 99204 $693.83 05100057 HB NEW PATIENT, LEVEL 5 99205 $971.34 05100058 HB GENETIC COUNSELING 91-120MIN 4 UNITS 96040 $768.94 05100059 HB GENETIC COUNSELING 121+ MINS 5 UNITS 96040 $844.54 05100061 HB EST. PATIENT, LEVEL 2 99212 $334.26 05100064 HB EST. PATIENT, LEVEL 4 99214 $693.83 05100065 HB EST. PATIENT, LEVEL 5 99215 $971.34 05100071 HB NEW PATIENT, LEVEL 2 99202 $334.26 05100072 HB NEW PATIENT, LEVEL 3 99203 $425.38 05100073 HB EST PATIENT, LEVEL 3 W/PROC 99213 $425.38 05100075 HB EST PATIENT, LEVEL 4 W/PROC 99214 $693.83 05100076 HB NEW PATIENT, LEVEL 2 W/PROC 99202 $334.26 05100079 HB NEW PATIENT, LEVEL 3 W/PROC 99203 $425.38 05100084 HB NEW PATIENT, LEVEL 4 W/PROC 99204 $693.83 05100088 HB EST PATIENT, LEVEL 2 W/PROC 99212 $334.26 05100091 HB EST PATIENT, LEVEL 1 W/PROC 99211 $295.45 05100093 HB EST PATIENT, LEVEL 5 W/PROC 99215 $971.34 05100095 HB INJ TX/DX/PROPHYLACTIC 96373 $640.73 $832.95 05100145 HB RETINAL FUNDUS 92250 $867.18 05100147 HB SLCTV WND DEBRID ADDL20CM/< 97598 $911.22 $911.22 05100149 HB CMPTR OPHTH IMG OPTIC NERVE 92133 $837.24 05100150 HB CPTR OPHTH DX IMG POST SEG 92134 $837.24

Ancillary FY22 179 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 05100152 HB SPIN/BRAIN PMP RFL-PHY SKLL 95991 $1,695.56 $2,204.22 05100158 HB PREV COUNSEL INDIV; 15 MIN 99401 $324.98 05100159 HB PREVEN COUNSEL INDIV;30 MIN 99402 $354.29 05100160 HB PREVEN COUNSEL INDIV;45 MIN 99403 $420.22 05100161 HB PREVEN COUNSEL INDIV;60 MIN 99404 $464.49 05100162 HB AJCC STAGE DOCD B/4 THXPY 3300F $1.00 05100164 HB SLIT LAMP PHOTOGRAPHY (EXT) 92285 $837.24 05100165 HB EYE EXAM NEW PATIENT 1+ VISITS 92004 $934.51 05100166 HB EYE EXAM & TREATMENT EST PATIENT 1+VISITS 92014 $934.51 05100167 HB EYE EXAM INTERMEDIATE EST PATIENT 92012 $934.51 05100168 HB GONIOSCOPY 92020 $867.18 05100169 HB DETERMINE REFRACTION 92015 $924.86 05100170 HB CORNEAL TOPOGRAPHY 92025 $837.24 05100171 HB COMPUTERIZED OPHTHALMIC IMAGING ANTERIOR SEGMEN 92132 $837.24 05100172 HB COMPUTERIZED OPHTHALMIC IMAGING OPTIC NERVE 92133 $837.24 05100173 HB COMPUTERIZED OPHTHALMIC IMAGING RETINA 92134 $837.24 05100174 HB ANT SGM IMAGING W/MICROSCOPY ENDOTHELIAL ANALY 92286 $867.18 05100175 HB ANT SGM IMAGING W/FLUOROSCEIN ANGIO & I&R 92287 $949.32 05100176 HB OPHTHAL BIOMETRY,INTRAOC LENS POW CALC 92136 $867.18 05100177 HB TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES 99406 $148.27 05100178 HB TOBACCO USE CESSATION INTENSIVE >10 MINUTES 99407 $148.27 05100179 HB HEALTH & WELL-BEING COACHING F2F INDIV 1ST ASSMT 0591T $248.23 05100180 HB HEALTH & WELL-BEING COACHING F2F INDIV F-UP SESS 0592T $496.46 05100181 HB HEALTH & WELL-BEING COACHING FACE TO FACE GROUP 0593T $259.93 05100182 HB BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT 90912 $2,957.37 05100183 HB BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTC 90913 $2,957.37 05100184 HB SELF-MEAS BP PT EDUC/TRAINING DEV 99473 $392.90 05100185 HB TELEHEALTH ORIGINATING SITE FACILITY FEE Q3014 $351.45 05100186 HB IMG RET DET/MON POC AUTO A&R UNI/BIL 92229 $837.24 05100187 HB ASSMT & CARE PLN PT WCOG IMPRMT 50 MIN 99483 $471.68 05100188 HB SELF-MGMT EDUC & TRAIN 1 PT 98960 $974.37 05120006 HB XR DENTAL INTRAOR COMP D0210 $3,203.96 $4,165.13 05120007 HB XR DENTAL INTRAOR PERI 1ST D0220 $3,203.96 $4,165.13 05120008 HB XR DENTAL INTRAOR PERI ADL D0230 $3,203.96 $4,165.13 06100007 HB MRI PELVIS W CONTRAST 72196 $5,914.00 $7,688.21 06100015 HB MRI TMJ BILATERAL 70336 $5,316.65 $6,911.65 06100016 HB MRI ORBITS/FACE/NECK WO CONT 70540 $6,753.98 $8,779.26 06100017 HB MRI ORBITS/FACE/NECK W CONT 70542 $10,599.76 $13,779.68 06100025 HB MRI CHEST WO/W CONTRAST 71552 $10,554.43 $13,720.75 06100031 HB MRI PELVIS WO CONTRAST 72195 $5,293.69 $6,881.09 06100033 HB MRI PELVIS WO/W CONT 72197 $10,619.13 $13,804.88 06100037 HB MRI EXT UPP JT WO CONT UNI 73221 $5,320.18 $6,916.38

Ancillary FY22 180 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 06100054 HB MRI ABDOMEN WO/W CONT MRCP 74183 $11,085.32 $14,410.21 06100055 HB MRI ABDOMEN WO/W CONTRAST 74183 $10,619.13 $13,804.88 06100058 HB MRI EXT UPP JT WO/W CNT UNI 73223 $10,599.76 $13,779.68 06100062 HB MRI UL PROC MYELOMA BNE SVY 76498 $4,799.29 $6,240.14 06100068 HB MRI EXT LOW JT W CONT UNI 73722 $10,550.00 $13,715.00 06100072 HB MRI EXT LOW JT WO/W CNT UNI 73723 $10,599.76 $13,779.68 06100079 HB MRI ABDOMEN WO CONT MRCP 74181 $8,957.61 $11,645.06 06100080 HB MRI ABDOMEN WO CONTRAST 74181 $6,387.14 $8,303.25 06100081 HB MRI HEART WO CONTRAST 75557 $9,460.83 $12,300.14 06100083 HB MRI HEART WO/W CONTRAST 75561 $10,085.91 $13,112.38 06100088 HB MRI GUIDANCE S&I 77021 $5,088.98 $6,615.66 06100089 HB MRI BREAST WO/W CONT UNILAT 77048 $6,138.51 $8,407.33 06100094 HB MRI BREAST CA, W & W/O BILAT 77049 $6,622.48 $8,200.59 06100095 HB MR ANGIO PELVIS WO CONT W 3D 72198 $4,793.04 $6,230.94 06100099 HB MRI EXT LOW WO CONT UNI 73718 $5,320.18 $6,916.38 06100101 HB MRI EXT LOW WO/W CONT UNILAT 73720 $9,552.66 $12,418.47 06100102 HB MRI EXT LOW JT WO CONT UNI 73721 $6,190.68 $8,048.24 06100103 HB MRI ORBITS/FCE/NCK WO/W CON 70543 $11,133.59 $14,473.66 06100106 HB MR ANGIO NECK WO/W CONT W 3D 70549 $9,499.03 $12,348.74 06100109 HB MR ANGIO EXT LOW WO CONT W 3D 73725 $4,810.89 $6,254.15 06100112 HB MRI EXT UPP WO CONT UNI 73218 $4,775.93 $6,208.71 06100113 HB MRI EXT UPP WO/W CONT UNI 73220 $7,462.02 $9,699.23 06100115 HB MRI EXT UPP JT W CONT UNI 73222 $10,550.00 $13,715.00 06100116 HB MRI CHEST WO CONTRAST 71550 $4,699.84 $6,109.81 06100121 HB MRI HEART WO/W CONT W STRES 75563 $10,550.00 $13,715.00 06100122 HB MRI HEART FLOW/VELOCITY 75565 $4,303.72 $5,591.39 06100133 HB MRI BREAST WO CONT UNILAT 77046 $3,853.79 $5,009.94 06100144 HB MRI BREAST WO CONT BILAT 77047 $5,017.47 $6,522.72 06100148 HB MRI EXT UPP W CONT 73219 $5,914.00 $7,688.21 06100153 HB MRI FETAL SNGL/1ST GESTATION 74712 $8,792.24 $11,429.91 06100154 HB MRI FETAL EA ADDL GESTATION 74713 $9,447.69 $12,281.99 06100155 HB UNLISTED MRI ELASTOGRAPHY 76498 $1,085.27 $1,410.85 06100156 HB MRI ABDOMEN WO CONT ELASTOGRAPHY 74181 $6,190.68 $8,048.24 06100157 HB MRI GUIDANCE FOR TISSUE ABLATION 77022 $38,025.77 $49,437.76 06100158 HB MR ELASTOGRAPHY 76391 $10,582.64 $13,655.01 06100159 HB MRI BREAST W CAD WO/W CONT UNILAT 77048 $2,501.32 $3,145.14 06100160 HB MRI BREAST W CAD, W & W/O BILAT 77049 $2,488.87 $3,129.46 06100161 HB MRI UL PROC TBI 76498 $8,207.16 $10,670.38 06110003 HB MRI HEAD/BRAIN WO CONT 70551 $8,207.16 $10,670.38 06110004 HB MRI HEAD/BRAIN W CONT 70552 $10,326.04 $13,423.86 06110010 HB MRI HEAD/PITUITARY WO/W CNT 70553 $12,444.92 $16,179.49 06110012 HB MRI HEAD/BRAIN WO/W CONT 70553 $12,444.92 $16,179.49

Ancillary FY22 181 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 06110015 HB MRI BRAIN FUNCT W MD ASST 70555 $8,207.16 $10,669.33 06110017 HB MRI HEAD/BRAIN DURING OPEN INTRACRANIAL PROC 70557 $4,265.00 $5,544.71 06120001 HB MRI C-SPINE WO CONTRAST 72141 $6,387.14 $8,303.25 06120003 HB MRI T-SPINE WO CONTRAST 72146 $5,212.81 $6,776.66 06120005 HB MRI L-SPINE WO CONTRAST 72148 $6,387.14 $8,303.25 06120006 HB MRI L-SPINE WO/W CONT 72158 $10,213.08 $13,276.59 06120012 HB MRI C-SPINE W CONTRAST 72142 $8,118.88 $10,553.82 06120013 HB MRI T-SPINE W CONTRAST 72147 $6,387.14 $8,303.25 06120014 HB MRI L-SPINE W CONTRAST 72149 $8,652.14 $11,247.78 06120015 HB MRI C-SPINE WO/W CONT 72156 $11,993.93 $15,592.08 06120016 HB MRI T-SPINE WO/W CONT 72157 $11,993.93 $15,592.08 06150001 HB MR ANGIO NECK WO CONT W 3D 70547 $5,736.89 $7,458.50 06150002 HB MR ANGIO NECK W CONT W 3D 70548 $6,387.14 $8,303.25 06150003 HB MR ANGIO HEAD WO CONT W 3D 70544 $6,176.55 $8,030.58 06150004 HB MR ANGIO HEAD WO/W CONT W 3D 70546 $9,499.03 $12,348.74 06180001 HB MR ANGIO PELVIS WO/W CONT W 3D 72198 $7,994.16 $10,391.50 06180003 HB MR ANGIO ABDOMEN WO CONT W 3D 74185 $4,793.04 $6,230.94 06180004 HB MR ANGIO ABDOMEN WO/W CONT W 3D 74185 $6,494.23 $8,441.98 06180005 HB MR ANGIO CHEST W CONT W 3D 71555 $6,719.04 $8,733.32 06180006 HB MR ANGIO CHEST WO CONT W 3D 71555 $4,791.91 $6,229.48 06180008 HB MR ANGIO CHEST WO/W CONT W 3D 71555 $6,960.02 $9,048.06 06180011 HB MR ANGIO EXT LOW WO/W CONT W 3D 73725 $8,664.97 $11,265.57 06180024 HB MR ANGIO SPINE WO/W CONT 72159 $6,890.22 $8,956.31 06180027 HB MR ANGIO EXT UPP WO/W CN UN 73225 $6,594.81 $8,571.62 06180028 HB MR ANGIO EXT UPP WO CONT UN 73225 $5,981.66 $7,774.74 06210002 HB NEEDLE, MAMMOTOME MULTI-PROBE $1,965.88 06240003 HB G030064/S41 CVRS DEL SYS W/CLP $95,513.35 06240013 HB HEARTPOD IDE# G050018 $1.00 06240023 HB PARADYM BI-V ICD8770G090064 C1882 $122,036.86 06240027 HB G090216 PARTNERII STUDY DVC $132,648.76 06240054 HB STUDYREPNEUREDCOILG110066 $1.00 06240057 HB VERCISEDBSSTDYG120075/S005 $1.00 06240058 HB RSH SEPTAL OCCLDR(G070185) $38,428.23 06240059 HB MITRACLIP SYS COAPT G120024 $91,253.88 06240060 HB TRANSEPTAL SHEATH COAPT G120024 $20,631.31 06240061 HB COREVALVE (G120169) $158,702.40 06240070 HB PORTICO VLV G120263/A002 $96,830.51 06240071 HB DLSYS-PORTICO G120263/A002 $6,819.08 06240072 HB MICRA PPI (G130245) $51,578.28 06240073 HB MICRA INTRODUCER (G130245) $2,798.62 06240079 HB STENT, ABSORB STUDY(G120002) $1.00 06240080 HB CATH OCT (VISION G130159) $1.00

Ancillary FY22 182 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 06240081 HB SENTINEL EMB PROT SYS (G130276/S002) C1884 $1.00 06240085 HB LOTIS AORTIC VALVE(G140090/A001) $132,252.00 06240086 HB ENVOLUTR AORTIC VALVE (G120169) $165,250.80 06240088 HB VALIANT MONA LISA THORACIC STENT GRAFT STUDY IDE#G130027/S00 $88,596.00 06240089 HB ATRICURE DEEP PIVOTAL STUDY IDE#G120056/S014/A001 $10,935.69 06240093 HB RSH STENT ATLAS (G150006) C1876 $1.00 $1.00 06240095 HB HEARTMATEIII TAH G140113/S002 $628,345.73 06240098 HB HEARTMATE PUMP (G150079) $25,000.00 06240099 HB TRICUSPID GUIDE CATH (G150170) $1.00 06240100 HB WIRE DEL CATH SC (G150170) $1.00 06240101 HB WIRE DEL CATH MC (G150170) $1.00 06240102 HB CROSSING WIRE (G150170) $1.00 06240103 HB PLEDGET DEL CATH (G150170) $1.00 06240104 HB PLIC LOCK DEL CATH (G150170) $1.00 06240105 HB SUTURE CUTTER (G150170) $1.00 06240106 HB CROSSING WIRE CABLE (G150170) $1.00 06240107 HB VALLEYLAB FACEPLATE (G150170) $1.00 06240108 HB VALVE, AORTIC SAPIEN 3 (G150278) $30,000.00 06240109 HB VALVE, CARDIAQ (G140212) $30,000.00 06240110 HB LAA AMULET (G080150) $1.00 06240111 HB BONE SUPPORT CERAMENT-G BONE VOID FILLER FORTIFY STUDY IDE#G $8.89 06240112 HB CARBOCLEAR PEDICLE SCREW SYSTEM IDE#G150139/A001 $8.89 06240113 HB NOVOTTF-100M SYSTEM (G160089/A001) $1.00 06240114 HB MDOCK STUDY VALVE (G170152) $1.00 06240115 HB FLARE CATHETER (G160002) $10,069.05 06240116 HB FLARE ASP GUIDE CATH (G160002) $5,233.05 06240117 HB FLARE RETRACT ASP (G160002) $2,127.05 06240118 HB CLASP MVR GUIDE SHEATH (G170166) $1.00 06240119 HB CLASP MVR IMPLANT SYS (G170166) $1.00 06240120 HB CLASP MVR STABILIZER (G170166) $1.00 06240121 HB CLASP MVR TABLE (G170166) $1.00 06240122 HB TRILUMINATE CLIP DEL SYS (G170118) $1.00 06240123 HB TRILUMINATE STEERABLE GUIDE CATH (G170118) $1.00 06240124 HB P3 SAPIEN VALVE (G160259) $235,500.00 06240125 HB CARDIAMP SYSTEM (BB16057) $50,915.05 06240126 HB TOPS SYSTEM (G160168) $1.00 06240127 HB GORE TAG THORACIC BRANCH ENDOPROSTHESIS (TBE) (G130120/S026) $1.00 06240129 HB WATCHMAN PINNACLE FLX LAAC DEVICE (G150200) $1.00 06240130 HB VALVE, PASCAL CLASP IID (G170166) $247,300.00 06240131 HB VALVE, APOLLO MVR (G160020) $336,900.00 06240132 HB VALVE, CENTERA STUDY (G180045) $262,300.00 06240133 HB JENA VALVE (G150035) $1.00

Ancillary FY22 183 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 06240134 HB TENDYNE MITRAL VALVE (G140240/S034) $247,300.00 06240135 HB TRICINCH TRICUSPID VALVE SYS (G180151) $1.00 06240136 HB ACURATE NEO2 (G190051) VALVE-S $239,840.00 06240137 HB ACURATE NEO2 (G190051) VALVE-M $239,840.00 06240138 HB ACURATE NEO2 (G190051) VALVE-L $239,840.00 06240139 HB SAFARI2 WIRE LARGE CURVE (G190051) $1.00 06240140 HB SAFARI2 WIRE SMALL CURVE (G190051) $1.00 06240141 HB SAFARI2 WIRE X-SML CURVE (G190051) $1.00 06240142 HB LOTUS INTRODUCER SMALL (G190051) $1.00 06240143 HB ISLEEVE 14FR (G190051) $1.00 06240144 HB VALVE, CLASP TR EFS (G180266) $1.00 06240145 HB CLASP TR EFS (G180266) $1.00 06240146 HB SAPIEN3 ALTERRA ADAPTIVE PRESTENT(G170053) $1.00 06240147 HB EVOQUE TR EFS VALVE (G190289) $1.00 06240148 HB SHOCKWAVE CATHETER (K180454) $1.00 06240149 HB BONE GRAFT P-15L (G170300) $0.01 06240150 HB PORTICO NG VALVE (G120263) $220,460.00 06240151 HB POSEIDON STUDY (G140126) $1.00 06240152 HB TRI-CLIP TVR SYS (G233056) $266,100.00 06240153 HB CARMAT TOTAL ARTIFICIAL HEART (TAH) (G180184) $937,500.00 06240154 HB EVOQUE MR EOS (G140212) $1.00 06240155 HB POLARX BALLOON CATHETER (G190060) $25,595.71 06240156 HB POLARSHEATH STEERABLE SHEATH (G190060) $8,375.71 06240157 HB SMARTFREEZE CRYO-CABLE (G190060) $1,621.71 06240158 HB SMARTFREEZE CATH EXTN CABLE (G190060) $2,647.71 06240159 HB POLARMAP EP ELECTRICAL CABLE (G190060) $2,647.71 06240160 HB POLARMAP MAPPING CATHETER (G190060) $6,519.71 06360036 HB AXICABTAGENE CILOLEUCEL CAR+ VIABLE T CELLS Q2041 $1,332,873.29 06360037 HB BREXUCABTAGENE AUTOLEUCEL CAR+ VIABLE T CELLS Q2053 $1,263,387.10 06360038 HB TISAGENLECLEUCEL CAR+ VIABLE T CELLS Q2042 $1,263,387.10 06360039 HB LISOCABTAGENE MARALEUCEL CAR+ VIABLE T CELLS C9076 $1,420,887.10 06360040 HB IDECABTAGENE VICLEUCEL CAR+ VIABLE T CELLS J3490 $1,389,725.81 06810001 HB TRAUMA, LOW LEVEL RESPONSE G0390 $14,180.07 $14,180.07 06820001 HB TRAUMA, MID LEVEL RESPONSE G0390 $33,083.51 $33,083.51 06830001 HB TRAUMA, HIGH LEVEL RESPONSE G0390 $42,535.95 $42,535.95 07100005 HB HOURLY EXT RECOVERY $443.00 07100044 HB PACU - 1ST HOUR $5,702.31 07100047 HB PACU - EA ADDL MINUTE $91.35 07100050 HB PHASE I PACU 1ST HOUR $5,702.31 07100051 HB PHASE I PACU EA ADDL MIN $91.35 07100052 HB PHASE II PACU 1ST HOUR $1,405.35 07100053 HB PHASE II PACU EA ADDL MIN $22.85

Ancillary FY22 184 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 07100054 HB RECOVERY LABOR & DELIVERY $4,747.58 07200001 HB VAGINAL DELVRY-W/VBAC SUCCESS $20,162.17 07200002 HB C-SECTION W/FAILED VBAC $20,286.86 07200003 HB C-SECTION W/TUBAL LIGATION $20,008.17 07200004 HB BREECH VERSION ATTEMPT 59412 $17,494.01 07200005 HB L & D MINOR PROCEDURE $5,469.60 07200006 HB VAGINAL BIRTH W/HYSTERECTOMY $19,890.80 07200007 HB VAGINAL DELIVERY W/TUBAL LIGA $19,616.50 07200008 HB C-SECTION MULTIPLE BIRTHS $20,558.23 07200009 HB C-SECTION $19,736.79 07200010 HB VAGINAL MULTIPLE BIRTHS $20,433.56 07200011 HB ADDL PROC OR RETURN TO THE OR/MINOR $9,712.93 07200012 HB C-SECTION W/HYSTERECTOMY $22,003.10 07200013 HB ADDL PROC OR RETURN TO THE OR/MAJOR $12,905.48 07200015 HB VAGINAL DELIVERY 59409 $17,494.01 07200016 HB REMOVAL OF RETAINED PLACENTA 59414 $17,494.01 $22,742.21 07200019 HB VBAC/MULTIPLE BIRTHS $22,003.10 07200020 HB C-SEC-MULT BRTHS/W HYSTRCTMY $29,850.87 07200021 HB C-SEC MULT BRTHS W/TBL LIG $29,044.08 07200022 HB VAG DEL/MULT BRTH W/TBL LIG $26,403.72 07300002 HB ROUTINE ECG 93005 $837.24 $1,088.40 07300005 HB ECG RHYTHM STRIP 93041 $837.24 $1,088.40 07300006 HB PATIENT DEMAND EVENT RECOR 93270 $1,163.17 $1,512.12 07300007 HB PATIENT DEMAND ANALY & RPT 93271 $2,970.14 $3,861.16 07300008 HB ECG SIGNAL AVR HIGH GAIN TE 93278 $900.78 $1,148.83 07310001 HB ECG UP TO 48HRS RECORDING 93225 $867.18 $1,127.33 07310002 HB ECG UP TO 48HRS SCAN ANLYS RPT 93226 $1,048.34 $1,337.02 07310011 HB EXT REC >48HRS <7DAYS RECORDING 93242 $837.24 $1,088.40 07310012 HB EXT REC >7DAYS <15DAYS RECORDING 93246 $837.24 $1,088.40 07310013 HB EXT ECG REC >48HR <7DAYS SCAN ANAL W/ REP 93243 $867.18 $1,127.33 07310014 HB EXT REC >7DAYS <15DAYS SCAN ANAL W/ REP 93247 $867.18 $1,127.33 07320001 HB REMOTE 30 DAY ECG TECH SUPP 93229 $2,650.27 07400002 HB EEG EXT- MON ( 41-60 MIN) 95812 $3,204.04 $4,165.25 07400003 HB EEG EXTENDED MON > 61-119 MINUTES 95813 $3,204.04 $4,165.25 07400004 HB EEG AWAKE/DROWSY 95816 $3,204.04 $4,165.25 07400005 HB EEG (AWAKE & SLEEP) 95819 $3,204.04 $4,165.25 07400006 HB EEG IN COMA OR SLEEP ONLY 95822 $3,204.04 $4,165.25 07400007 HB ECI (BRAIN DEATH) STUDY 95824 $11,602.53 $15,083.92 07400012 HB EEG W/MED &/OR ACTIVTN W/MD 95954 $3,679.48 $4,783.32 07400013 HB WADA ( MEMORY DOMINANCE TEST) 95958 $14,163.75 $18,412.89 07400014 HB EEG DURING CEA SURGERY 95955 $4,501.39 $5,852.04 07400016 HB DIG/ANALYS/EPILEP/SPIKE/ANALYS 95957 $4,051.73 $5,267.21

Ancillary FY22 185 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 07400017 HB WADA ACT HEMISPHERIC FUNCT 95958 $14,163.75 $18,412.89 07400019 HB FUNCT/MOTOR/LANGUAG MAP/1ST HR 95961 $14,163.75 $18,412.89 07400020 HB FUNCT/MOTOR/LANG MAP ADD'L HR 95962 $4,642.42 $6,034.89 07400021 HB ECOG (ELECTROCORTICOGRAPHY) 95829 $27,244.02 $35,417.23 07400022 HB EEG CONT REC W/VIDEO BY TECH MIN 8 CHANNELS 95700 $3,204.04 07400023 HB EEG W/O VIDEO BY TECH 2-12 HR UNMONITORED 95705 $11,755.87 07400024 HB EEG W/O VIDEO BY TECH 2-12 HR INTERMITTENT MNTR 95706 $11,755.87 07400025 HB EEG WO VIDEO 2-12HR,CONTINUOUS R-T MNTR 95707 $11,755.87 07400026 HB EEG WO VIDEO EA INCR 12-26HR UNMONITORED 95708 $15,467.08 07400027 HB EEG WO VIDEO EA INCR 12-26HR INTMT MNTR 95709 $15,467.08 07400028 HB EEG WO VIDEO EA INCR 12-26HR CONT R-T MNTR 95710 $15,467.08 07400029 HB VEEG 2-12HR UNMONITORED 95711 $19,174.63 $24,927.01 07400030 HB VEEG 2-12 HR INTERMITTENT MONITORING 95712 $10,589.04 $13,765.75 07400031 HB VEEG 2-12HR CONTINUOUS R-T MONITORING 95713 $26,232.66 $34,102.46 07400032 HB VEEG EA INCR 12-26HR UNMONITORED 95714 $26,232.66 $34,102.46 07400033 HB VEEG EA INCR 12-26HR INTERMITTENT MNTR 95715 $14,163.75 $18,412.89 07400034 HB VEEG EA INCR 12-26HR CONT R-T MNTR 95716 $26,232.66 $34,102.46 07500004 HB GI PROCEDURE-EACH ADDL MINUTE $35.31 07500015 HB GI BEDSIDE PROC UP TO 1 HR $6,954.00 07500020 HB GI PROC LEVEL I- 1ST HR $8,985.83 07500021 HB GI PROC LEVEL II - 1ST HR $23,879.99 07500025 HB CANCELED PROC GI LEVEL 1 $2,605.89 07500026 HB CANCELED PROC GI LEVEL 2 $6,021.91 07500028 HB GI BEDSIDE PROC - MINOR $3,477.00 07610002 HB PC SUCTIONING 31720 $502.15 07610003 HB INJ C-SPINE STELLATE GANGLN 64510 $5,549.43 07610004 HB INJ T/L-SPINE SYMPATHETIC 64520 $5,549.43 07610005 HB CHRONIC PAIN CNTR PROCEDURES 1 $1,567.95 07610006 HB CHRONIC PAIN CNTR PROCEDURES 2 $5,581.98 07610008 HB CHRONIC PAIN CNTR PROCEDURES 4 $15,763.65 07610009 HB CHRONIC PAIN CNTR PROCEDURES 5 $23,511.24 07610010 HB CHRONIC PAIN CNTR PROCEDURES 3 $7,085.58 07610011 HB CANCELED PROCEDURE PAIN CENTER $1,388.75 07610012 HB CHRONIC PAIN CNTR PROCEDURES 6 $37,852.28 07620003 HB OBSERVATION, PER HOUR G0378 $443.00 07700001 HB SCREENING PAP CERV/VAG Q0091 $392.90 07710001 HB IMMUNIZATION ADM;1 VACCINE 90471 $319.77 $415.70 07710002 HB ADMIN INFLUENZA VACCINE 90471 $319.77 $415.70 07710003 HB ADMIN PNEUMOCOCCAL VACCINE 90471 $319.77 $415.70 07710006 HB VACCINE ADMIN, EA ADD'L 90472 $333.41 $433.43 07710009 HB IMMUNIZATION ADM ANY ROUTE 1ST VAC/TOX 90460 $328.59 $427.17 07710010 HB ADMIN IMMUN ADDL VAC/TOX(PEDS) 90461 $146.74 $190.76

Ancillary FY22 186 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 07710011 HB ADMIN HEPATITIS B VACCINE 90471 $319.77 $415.70 07710012 HB ADM SARSCOV2 30MCG/0.3ML 1ST 0001A $319.77 $415.70 07710013 HB ADM SARSCOV2 30MCG/0.3ML 2ND 0002A $319.77 $415.70 07710014 HB ADM SARSCOV2 100MCG/0.5ML1ST 0011A $319.77 $415.70 07710015 HB ADM SARSCOV2 100MCG/0.5ML2ND 0012A $319.77 $415.70 07710016 HB ADM SARSCOV2 VAC AD26 .5ML 0031A $319.77 $415.70 08010001 HB ACUTE HEMODIALYSIS G0257 $8,627.77 08010002 HB CRRT VENOUS HEMODIALYSIS 90945 $23,258.53 08020001 HB PERITONEAL DIALYSIS 90945 $23,258.53 08110002 HB ORGAN ACQ KIDNEY LIVE DONOR $344,891.13 08120002 HB ORGAN ACQ LIVER DEC DONOR $444,163.55 08120003 HB ORGAN ACQ HEART DEC DONOR $479,619.68 08120004 HB ORGAN ACQ LUNG BILA DEC DNR $690,371.61 08120005 HB ORGAN ACQ SNGL LUNG DEC DNR $690,371.61 08120006 HB ORGAN ACQ KIDNEY DEC DONOR $344,891.13 08120007 HB ORGAN ACQ PANCREAS $240,544.84 08120008 HB SYSTEM, OCS LUNG PERFUSION SINGLE $473,742.85 08120009 HB SYSTEM, OCS LUNG PERFUSION DOUBLE $551,889.85 08150001 HB T-CELL DEPLETION 38210 $5,802.20 08190002 HB ALLO PB STEM CELL APHERESIS BD 38205 $6,821.27 08190004 HB NMDP CT BLOOD SAMPLE 36415 $2,308.13 08190005 HB NMDP IDM TESTING AT CT $1,841.85 08190006 HB NMDP CUSTMZD(HR)HLA TS DNR $21,160.13 08190007 HB NMDP CNFIMTRY(CT)HLA TS DNR $21,160.13 08190008 HB NMDP HR C,HRDQ HLA CLS I,II $4,429.74 08190009 HB NMDP HR A,B,C,HR DP HLA CLS I,II $7,460.61 08190010 HB NMDP HR A,C, HR DQ HLA CLS I, II $6,972.53 08190011 HB NMDP PRECOLLECT BLD SAMPLE 36415 $2,308.13 08190012 HB NMDP PHYSICAL EXAM $10,584.74 08190013 HB NMDP MARROW COLLECTION 38230 $171,628.68 08190014 HB NMDP PBSC COLLECTION 38205 $270,335.31 08190018 HB NMDP CORD BLOOD COLLECTION 38230 $184,852.76 08190019 HB NMDP FORMAL SEARCH 99215 $7,127.02 08190020 HB NMDP WORK UP CANCELLATION 99215 $10,430.02 08190022 HB NMDP DONOR INFO SESSION 99205 $3,547.89 08190023 HB NMDP MNC APHERESIS COLLECTION 38205 $79,678.91 08210001 HB OUTPATIENT HEMODIALYSIS G0257 $8,627.77 08710001 HB LYMPHS CAR-T CELL HARVEST 0537T $6,424.93 08720001 HB LYMPHS PREP/TRNSPRT 0538T $5,318.55 08720002 HB LYMPHS PREP/TRNSPRT - FRESH 0538T $1,619.35 08730001 HB CAR-T CELL PREP/ADMINISTRATION 0539T $2,976.60 09000003 HB DIAG INTERVIEW EXAM 60 MINUTES 90791 $1,127.84

Ancillary FY22 187 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 09000004 HB DIAGNOSTIC INTERVIEW EXAM 90 90791 $1,409.80 09000009 HB PSYTX COMPLEX INTERACTIVE 90785 $483.89 09000010 HB PSYCH DIAGNOSTIC EVALUATION 90791 $704.90 09000011 HB PSYCH DIAG EVAL W/MED SRVCS 90792 $704.90 09000012 HB PSYCHOTHERAPY 30 MINUTES 90832 $845.88 09000013 HB PSYCHOTHERAPY W/E&M 30 MIN 90833 $1,105.95 09000014 HB PSYCHOTHERAPY 45 MINUTES 90834 $986.86 09000015 HB PSYCHOTHERAPY W/E&M 45 MIN 90836 $1,149.21 09000016 HB PSYCHOTHERAPY 60 MINUTES 90837 $1,127.84 09000017 HB PSYCHOTHERAPY W/E&M 60 MIN 90838 $1,149.21 09000018 HB PSYTX CRISIS INITIAL 60 MIN 90839 $1,127.84 09000019 HB PSYTX CRISIS EA ADDL 30 MIN 90840 $1,105.95 09000020 HB PHARMACOLOGIC MGMT W/PSYTX 90863 $907.28 09140017 HB ADAPT BEHAV TX TECH 1 PT EA 15 MIN 97153 $148.27 09140018 HB ADAPT BEHAV TX 1 PT EA 15 MIN 97155 $148.27 09140019 HB HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT 96156 $321.62 09140020 HB HEALTH BEHAVIOR INTERVENTION , 1ST 30 MIN 96158 $471.68 09140021 HB HEALTH BEHAVIOR INTERVENTION, EA ADDL 15 MIN 96159 $248.23 09150011 HB ADAPT BEHAV TX TECH MULT PTS EA 15 MIN 97154 $148.27 09150012 HB GRP ADAPT BEHAV TX GUID EA 15 MINS 97158 $148.27 09150013 HB GROUP THERAPY 90853 $235.83 09150014 HB HEALTH BEHAVIOR INTERVENTION, GROUP 1ST 30MIN 96164 $246.95 09150015 HB HEALTH BEHAVIOR INTERVENTION, GROUP EA ADDL 15MIN 96165 $129.97 09160007 HB FAM ADAPT BEHAV TX GUID EA 15 MIN 97156 $148.27 09160008 HB MULT FAM GRP ADAPT BEHAV TX EA 15 97157 $148.27 09160009 HB HEALTH BEHAVIOR INTERVENTION, FAMILY INITIAL 30MIN 96167 $471.68 09160010 HB HEALTH BEHAVIOR INTERVENTION, FAMILY EA ADDL 15MIN 96168 $248.23 09160011 HB HEALTH BEHAVIOR INTERVENTION, FAMILY WO PT, IST 30M 96170 $496.11 09160012 HB HEALTH BEHAVIOR INTERVENTION,FAMILY WO PT,EA ADDL 96171 $248.05 09180004 HB NEUROBHV STATUS EXAM W INT/RPT 96116 $3,204.04 09180010 HB DEVELOPEMENTAL TEST 1ST HR 96112 $3,204.04 09180011 HB DEVELOPEMENTAL TEST EA ADDL 30 MIN 96113 $1,297.91 09180012 HB NEUROBEHAVIORAL EXAM EA ADDL HR 96121 $64.81 09180013 HB PSYCHOLOGICAL TEST EVAL 1ST HR 96130 $3,204.04 09180014 HB PSYCHOLOGICAL TEST EVAL EA ADDL HR 96131 $1,297.91 09180015 HB NEUROPSYCH TEST EVAL 1ST HR 96132 $3,204.04 09180016 HB NEUROPSYCH TEST EVAL EA ADDL HR 96133 $1,297.91 09180017 HB PSYCH/NEUROPSYCH TEST 1ST 30 MIN 96136 $392.90 09180018 HB PSYCH/NEUROPSYCH TEST EA ADDL 30 MIN 96137 $134.76 09180019 HB PSYCH/NEUROPSYCH TECH 1ST 30 MIN 96138 $597.13 09180020 HB PSYCH/NEUROPSYCH TECH EA ADDL 30 MIN 96139 $134.76 09180021 HB PSYCH/NEUROPSYCH TEST AUTO RESULT 96146 $392.90

Ancillary FY22 188 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 09180022 HB BEHAV ID ASSMT EA 15 MIN 97151 $148.27 09180023 HB BEHAV ID ASSMT TECH EA 15 MIN 97152 $148.27 09200001 HB FETAL NON-STRESS TEST 59025 $1,417.90 09200002 HB BRAVO 48 HR PH STUDY 91035 $8,157.76 09200003 HB LACT/GLUC/FRUC HYDROGEN OR METHANE BREATH TEST 91065 $2,650.27 09200004 HB ANORECTAL MANOMETRY 91122 $3,391.93 09200005 HB PERIMETRY VFS LTD 92081 $837.24 09200006 HB PERIMETRY VFS INTMD 92082 $837.24 09200007 HB PERIMETRY VFS COMPR 92083 $867.18 09200008 HB BPM 24HR OR >,RECORD 93786 $867.18 $1,127.33 09200009 HB BPM 24HR OR >, SCAN ANAL W 93788 $867.18 $1,127.33 09200011 HB VNS - SIMPLE PROGRAMMING 95971 $1,060.75 $1,378.99 09200013 HB ANALYZE NEUROSTIM, SIMPLE 95971 $1,060.75 $1,378.99 09200014 HB GLUCOSE MONITORING CONT 95250 $929.49 $1,208.32 09200017 HB SCS ANALYSIS, COMPLEX 95972 $3,192.89 $4,150.77 09200020 HB NEEDLE EMG ANL/URTHRL SPHNCT 51785 $3,391.93 $4,409.52 09200021 HB UPR/LWR SSEPS 95938 $9,737.91 $12,659.26 09200022 HB C MOTOR EVOKED UPR&LWR LIMB 95939 $14,163.75 $18,412.89 09200023 HB AUTONOMIC NERV FUNC SUDOM 95923 $867.18 $1,127.33 09200028 HB FIBROSCAN 91200 $2,650.27 09200029 HB BIS XTRACELL FLUID ANALYSIS (L-DEX) 93702 $2,650.27 09200031 HB BIOELECTRICAL IMP ANALYSIS WHOLE BODY 0358T $392.90 09200032 HB CONT GLUC MONTR PAT PRVD EQUIP 95249 $837.24 $1,088.40 09200033 HB AUTONOMIC NERV FUNCTION TEST VASOMOTOR 95922 $867.18 $1,127.33 09200037 HB CRANIAL NEUROSTIM ANALYSIS SIMPLE 95976 $1,163.17 09200038 HB CRANIAL NEUROSTIM ANALYSIS COMPLEX 95977 $2,872.46 $3,854.28 09200039 HB NEUROSTIM ANALYSIS BRAIN 1ST 15 MIN 95983 $1,340.20 $1,742.26 09200040 HB NEUROSTIM ANALYSIS BRAIN EA ADDL 15 MIN 95984 $1,143.30 $1,486.43 09200041 HB OPSCPY EXTND RTA DRAWING & SCL DEPRSN I&R UNI/BI 92201 $837.24 09200042 HB OPSCPY EXTND OPTIC NRV/MACULA DRAWING I&R UNI/BI 92202 $837.24 09210011 HB VAS DUPLEX CAROTIDS BILAT 93880 $3,764.57 $4,893.94 09210012 HB VAS DUPLEX CAROTID LTD UNI 93882 $3,764.57 $4,893.94 09210013 HB VAS DUPLEX TRANSCRANIAL COM 93886 $3,764.57 $4,893.94 09210014 HB VAS DUPLEX TRANSCRANIAL LTD 93888 $1,561.68 $2,030.20 09210015 HB VAS DUPLEX ABI WO EX BILAT 93922 $867.18 $1,127.33 09210016 HB VAS DUPLEX THORACIC OUTLET 93923 $2,650.27 $3,445.35 09210017 HB VAS DUPLEX DIG FINGERS MULT 93923 $2,650.27 $3,445.35 09210018 HB VAS DUPLEX TCP02 MULT 93923 $2,650.27 $3,445.35 09210019 HB VAS DUPLEX ABI W EX BILAT 93923 $2,650.27 $3,445.35 09210020 HB VAS DUPLEX ARM SEGMENTAL 93923 $2,650.27 $3,445.35 09210021 HB VAS DUPLEX DIG TOES MULT 93923 $2,650.27 $3,445.35 09210022 HB VAS DUPLEX LEG GRAFT BILAT 93925 $3,764.57 $4,893.94

Ancillary FY22 189 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 09210023 HB VAS DUPLEX LEG ART BILAT 93925 $3,764.57 $4,893.94 09210024 HB VAS DUPLEX POPLITEAL ASM UN 93926 $2,900.28 $3,770.36 09210025 HB VAS DUPLEX LEG GRAFT UNILAT 93926 $2,900.28 $3,770.36 09210026 HB VAS DUPLEX LEG ART UNILAT 93926 $2,900.28 $3,770.36 09210027 HB VAS DUPLEX FEMORAL ANSM UNI 93926 $2,900.28 $3,770.36 09210028 HB VAS DUPLEX ARM ARTERY BILAT 93930 $3,764.57 $4,893.94 09210029 HB VAS DUPLEX ARM GRAFT BILAT 93930 $3,764.57 $4,893.94 09210031 HB VAS DUPLEX ARM ARTERY UNI 93931 $2,454.09 $3,190.30 09210032 HB VAS DUPLEX ARM GRAFT UNILAT 93931 $2,454.09 $3,190.30 09210033 HB VAS DUPLEX LEG VN SP/DP BIL 93970 $3,764.57 $4,893.94 09210034 HB VAS DUPLEX ARM VEIN BILAT 93970 $3,764.57 $4,893.94 09210035 HB VAS DUPLEX ARM VN SP/DP BIL 93970 $3,764.57 $4,893.94 09210036 HB VAS DUPLEX LEG VEIN DVT BIL 93970 $3,764.57 $4,893.94 09210037 HB VAS DUPLEX ARM VN SP/DP UNI 93971 $2,900.28 $3,770.36 09210038 HB VAS DUPLEX LEG VEIN DVT UNI 93971 $2,900.28 $3,770.36 09210039 HB VAS DUPLEX LEG VN SP/DP UNI 93971 $2,900.28 $3,770.36 09210040 HB VAS DUPLEX ARM VEIN UNILAT 93971 $2,900.28 $3,770.36 09210042 HB VAS DUPLEX RENAL/VISC ART 93975 $3,764.57 $4,893.94 09210043 HB US DUPLEX ABDOMEN 93975 $3,764.57 $4,893.94 09210044 HB VAS DUPLEX SMA/CELIAC ART 93975 $3,764.57 $4,893.94 09210046 HB DOPPLER, UTERINE ARTERY 93976 $3,437.96 $4,469.35 09210047 HB VAS DUPLEX REN/VISC ART LTD 93976 $3,764.57 $4,893.94 09210048 HB VAS DUPLEX RENAL TRANSPLANT 93976 $3,764.57 $4,893.94 09210049 HB VAS DUPLEX IVC/ILI VEIN COM 93978 $3,764.57 $4,893.94 09210050 HB VAS DUPLEX AOR/ILI ANSM COM 93978 $3,764.57 $4,893.94 09210051 HB VAS DUPLEX AOR/ILI ART COM 93978 $3,764.57 $4,893.94 09210054 HB VAS DUPLEX IVC/ILI VEIN LTD 93979 $2,454.09 $3,190.30 09210055 HB VAS DUPLEX AOR/ILI ANSM LTD 93979 $2,454.09 $3,190.30 09210056 HB VAS DUPLEX DIALYSIS ACCESS 93990 $2,900.28 $3,770.36 09210057 HB VAS DUPLEX EXT UPP/LOW BIL 93970 $3,437.96 $4,469.35 09210059 HB VAS LEG VARICOS VEIN UNI 93971 $2,900.28 $3,770.36 09210062 HB TCD, VASOREACTIVITY STUDY 93890 $2,900.28 $3,770.36 09210063 HB TCD, EMBOLI DETECT W/O INJ 93892 $2,900.28 $3,770.36 09210064 HB TCD, EMBOLI DETECT W/INJ 93893 $2,900.28 $3,770.36 09210067 HB DUPLEX SCAN ART IN & VEN OUT COMPL+J12 BIL 93985 $3,764.57 $4,893.94 09210068 HB DUPLEX SCAN ART IN & VEN OUT COMPL UNI 93986 $2,465.11 $3,204.65 09220001 HB EMG URETHA / ANUS 51784 $2,650.27 $3,445.35 09220002 HB EMG-3 EXTREMITIES 95863 $2,650.27 $3,445.35 09220003 HB EMG-4 EXTREMITIES 95864 $2,650.27 $3,445.35 09220004 HB NEEDLE EMG; CRANIAL NERVE (ONE 95867 $3,204.04 $4,165.25 09220005 HB NEEDLE EMG; CRANIAL NERVE (BOT 95868 $3,204.04 $4,165.25 09220006 HB NEEDLE EMG/THORACIC PARASPINAL 95869 $2,650.27 $3,445.35

Ancillary FY22 190 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 09220010 HB SSEP - UPPER EXTREMITIES 95925 $3,204.04 $4,165.25 09220011 HB SSEP - LOWER EXTREMITIES 95926 $3,204.04 $4,165.25 09220012 HB VEP - CHECKBOARD OR FLASH 95930 $3,204.04 $4,165.25 09220013 HB NCS - (BLINK) REFLEX 95933 $837.24 $1,088.40 09220015 HB NCS - REPET STIM 95937 $2,650.27 $3,445.35 09220016 HB EMG - 1 EXTREMITY 95860 $867.18 $1,127.33 09220017 HB EMG - 2 EXTREMITIES 95861 $867.18 $1,127.33 09220018 HB NEEDLE EMG; SINGLE FIBER 95872 $2,650.27 $3,445.35 09220019 HB MOTOR/SENSRY NRV COND W/FWA 95905 $597.13 $776.27 09220020 HB GUIDE NERV DESTR,NEEDLE EMG 95874 $473.02 $614.95 09220021 HB GUIDE NERV DESTR, ELEC STIM 95873 $473.02 $614.95 09220022 HB MUSCLE TEST LARYNX 95865 $867.18 $1,127.33 09220024 HB MUSCLE TST NONPRSPNL 1 EXTR 95870 $837.24 $1,088.40 09220027 HB MUSCLE TEST HEMIDIAPHRAGM 95866 $2,650.27 $3,445.35 09220028 HB MUSC TST DN W/NERV TST LIM 95885 $3,247.11 $4,221.28 09220029 HB MUSC TEST DN W/N TEST COMP 95886 $3,247.11 $4,221.28 09220030 HB MUSC TST DN W/N TST NONEXT 95887 $2,430.70 $3,159.95 09220031 HB NERVE CND TST 1-2 STUDIES 95907 $2,650.27 $3,445.35 09220032 HB NERVE CND TST 3-4 STUDIES 95908 $3,204.04 $4,165.25 09220033 HB NERVE CND TST 5-6 STUDIES 95909 $3,204.04 $4,165.25 09220034 HB NERVE CND TEST 7-8 STUDIES 95910 $3,204.04 $4,165.25 09220035 HB NERVE CND TEST 9-10 STUDIES 95911 $11,207.60 $14,569.91 09220036 HB NERVE CND TEST 11-12 STUDIES 95912 $12,491.08 $16,238.39 09220037 HB NERVE CND TEST 13/> STUDIES 95913 $15,727.87 $20,446.25 09220038 HB IONM IN OPERATNG ROOM 15 MIN 95940 $543.34 $706.33 09220039 HB IONM REMOTE/>1 PT OR PER HR 95941 $2,069.84 $2,690.81 09240001 HB PEDS - PERCUTAN.SKIN TESTS 95004 $1,342.57 09240002 HB SKIN TEST ID IMMED, PER TST 95018 $352.98 09240005 HB SKIN TEST ID IMED,NON-CHEMO 95018 $370.64 09240006 HB SKIN TEST ID IMMED, CHEMO 95018 $370.64 09240007 HB INGESTION CHALLENGE TEST 95076 $9,737.91 09240014 HB INGEST CHALLENGE ADDL 60 MN 95079 $1,306.60 09400001 HB THERAPEUTIC APHER WBC 36511 $8,014.20 09400002 HB THER APHER FOR RBC'S 36512 $8,014.20 09400003 HB THER APHER FOR PLTS 36513 $5,802.20 09400005 HB AMBUL PUMP REFILL /MAINT-CHEMO 96521 $1,452.43 09400006 HB AMBUL PUMP REFIL/MAINT-NONCHEM 96521 $1,426.03 09400007 HB THERAPEUTIC PHLEBOTOMY 99195 $867.18 09400012 HB NEG PRESS WND TX DME <=50 SQ CM 97605 $1,261.52 $1,639.97 09400015 HB HALO FH STUDY - THER APHERESIS W/HDL DELIP 0342T $15,932.45 09400016 HB LOW FREQUENCY NON-THERMAL US 97610 $1,261.52 09410001 HB RC THER RECREATION EVAL 97139 $1,970.54

Ancillary FY22 191 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 09420001 HB MED NUTR THPY 60 MIN 97802 $896.40 09420002 HB NUTRITION THERAPY (IND) EA 15 97802 $362.73 09420003 HB NUTRITION REASSES (IND) EA 15 97803 $308.86 09420004 HB NUTRITION THER (GRP V1) EA 30M 97804 $541.01 09420005 HB DIABETES TEACH, IND PER 30 MIN G0108 $770.52 09420006 HB DIABETES TEACH, GRP PER 30 MIN G0109 $701.67 09420009 HB GROUP MNT -30 MIN 97804 $541.01 09420012 HB CONT GLUC MNTR ANALYSIS I&R 95251 $937.82 $1,219.16 09420014 HB LACTATION CLASS S9443 $217.57 09420015 HB PT EDUCATION NOC GRP S9446 $525.25 09430001 HB CONT CARD EXERC # 93798 $1,255.85 09430002 HB CARD REHAB INIT EVAL # 93798 $1,255.85 09430003 HB CARDIAC REHAB; WO CONT ECG 93797 $1,255.85 09430004 HB PERIPHERAL ART DIS REHAB, PER SESSION 93668 $837.24 09480001 HB PULM REHAB WEXER 1 HR P/SES G0424 $837.24 09900501 HB STD GUEST TRAY $32.00 09900503 HB ADD-ON FOR DELUXE ROOM 8-NE $3,161.00 09900505 HB ADD-ON FOR DELUXE ROOM 8-SE $3,161.00 09900506 HB ADD-ON FOR DELUXE ROOM 8-SW $3,161.00 09900509 HB ADD-ON FOR DELUXE ROOM 8-NW $3,161.00 09900515 HB ELECTRONIC IMAGE TRANSMISSION $100.00 09900517 HB ADD-ON FOR SPECIAL DELUXE ROOM $527.00 99980001 HB CDSM APPLIED PATHWAYS, MEDICARE AUC G1000 $0.01 99980002 HB CDSM EVICORE, MEDICARE AUC G1001 $0.01 99980003 HB CDSM MEDCURRENT, MEDICARE AUC G1002 $0.01 99980004 HB CDSM MEDICALIS, MEDICARE AUC G1003 $0.01 99980005 HB CDSM NATIONAL DECISION SUPPORT, MEDICARE AUC G1004 $0.01 99980008 HB CDSM AIM SPECIALTY HEALTH, MEDICARE AUC G1007 $0.01 99980009 HB CDSM CRANBERRY PEAK, MEDICARE AUC G1008 $0.01 99980010 HB CDSM SAGE HMS, MEDICARE AUC G1009 $0.01 99980011 HB CDSM STANSON, MEDICARE AUC G1010 $0.01 99980012 HB CDSM NOT SPECIFIED, MEDICARE AUC G1011 $0.01 99980013 HB CDSM AGILEMD’S CLINICAL DECISION SUPPORT MECHANIS G1012 $0.01 99980014 HB CDSM EVIDENCECARE’S IMAGING ADVISOR G1013 $0.01 99980015 HB CDSM INVENIQA'S SEMANTIC ANSWERS IN MEDICINE G1014 $0.01 99980016 HB CDSM RELIANT MEDICAL GROUP G1015 $0.01 99980017 HB CDSM SPEED OF CARE G1016 $0.01 99980018 HB CDSM HEALTHHELP’S CLINICAL DECISION SUPPORT MECHA G1017 $0.01 99980019 HB CDSM INFINX G1018 $0.01 99980020 HB CDSM LOGICNETS AUC SOLUTION G1019 $0.01 99980021 HB CDSM CURBSIDE CLINICAL AUGMENTED WORKFLOW G1011 $0.01 99980022 HB CDSM E*HEALTHLINE G1011 $0.01

Ancillary FY22 192 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ Charge OP/ Default IP/ER Description HCPCS Code Price Price Code 99980023 HB CDSM INTERMOUNTAIN G1011 $0.01 99980024 HB CDSM PERSIVIA G1011 $0.01

Ancillary FY22 193 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

Charge Description Price Code 01200001 HB ROOM CHARGE 1:5 SEMI PRIV $10,615.00 01200002 HB ROOM CHG 1:5 OB PRIV DELX $10,615.00 01200003 HB ROOM CHG 1:5 OB DELX 1 ROOM $10,615.00 01200004 HB ROOM CHG 1:5 OB DELX 2 ROOMS $10,615.00 01200005 HB ROOM CHG 1:5 OB DELX 3 ROOMS $10,615.00 01200006 HB ROOM CHARGE 1:5 SEMI PRIV ** $10,615.00 01270001 HB ROOM CHARGE 1:1 ONC $46,930.00 01270002 HB ROOM CHARGE 1:2 ONC $34,585.00 01270003 HB ROOM CHARGE 1:3 ONC $14,515.00 01270004 HB ROOM CHARGE 1:4 ONC $13,114.00 01290001 HB ROOM CHARGE TRAUMA 1:5 MED/SURG $15,091.00 01530001 HB ROOM CHARGE TRAUMA 1:5 PEDS $15,774.00 01710001 HB ROOM CHARGE 1:8 NSY $4,287.00 01720001 HB ROOM CHARGE 1:4 NSY $5,565.00 01720003 HB ROOM CHARGE 1:4 NICU/PICU $22,030.00 01730002 HB ROOM CHARGE 1:3 NICU/PICU $26,388.00 01740001 HB ROOM CHARGE 2:1 NICU/PICU $59,911.00 01740002 HB ROOM CHARGE 1:1 NICU/PICU $46,486.00 01740003 HB ROOM CHARGE 1:2 NICU/PICU $38,430.00 02000001 HB ROOM CHARGE 2:1 ICU $53,857.00 02000002 HB ROOM CHARGE 1:1 ICU $42,608.00 02000003 HB ROOM CHARGE 1:2 ICU $31,396.00 02030001 HB ROOM CHARGE 1:3 STP DWN PED $13,177.00 02030002 HB ROOM CHARGE 1:4 STP DWN PED $11,343.00 02060001 HB ROOM CHARGE 1:3 STP DWN $13,177.00 02060003 HB ROOM CHARGE TRAUMA 1:3 & 1:4 $31,468.00 02060006 HB ROOM CHARGE 1:4 STP DWN $11,904.00 02060007 HB ROOM CHARGE 1:3 STP DWN ** $13,177.00 02060008 HB ROOM CHARGE 1:4 STP DWN ** $11,904.00 02080001 HB ROOM CHARGE TRAUMA 2:1 TO 1:2 $62,761.00 09900052 HB ROOM PRIVATE DELUX $3,161.00 09900053 HB ROOM OB DELUX 1 RM $5,643.00 09900054 HB ROOM OB DELUX 2 RM $6,580.00 09900055 HB ROOM OB DELUX 3 RM $7,987.00

Room and Board FY22 194 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 16 PHENYLEPHRINE HCL 10 % OP DROP 17478020605 $546.24 $546.24 5 mL 45 AMANTADINE HCL 50 MG/5 ML PO SOLN 00121064610 $167.00 $167.00 10 mL 76 AMANTADINE HCL 100 MG PO TABS 00832011100 $1,649.60 $1,649.60 100 Each 96 LOSARTAN 50 MG PO TABS 68084034701 $902.40 $902.40 100 Each 107 LORAZEPAM 4 MG/ML IJ SOLN J2060 00641604710 $167.00 $167.00 10 mL 111 ZIDOVUDINE 10 MG/ML PO SYRP 65862004824 $537.60 $537.60 240 mL 123 QUETIAPINE 25 MG PO TABS 16714045201 $167.00 $167.00 100 Each 154 TOLTERODINE 2 MG PO CP24 00009519002 $8,079.84 $8,079.84 90 Each 157 PENICILLIN V POTASSIUM 250 MG PO TABS 16714023401 $167.00 $167.00 100 Each 175 HYDROCORTISONE 5 MG PO TABS 00603389919 $263.20 $263.20 50 Each 188 CEFUROXIME SODIUM 750 MG IJ SOLR J0697 00143997922 $167.00 $167.00 1 Each 198 NAFCILLIN 1 GRAM IJ SOLR 00781312485 $167.00 $167.00 1 Each 256 PHENOBARBITAL 97.2 MG PO TABS 00603516821 $1,420.80 $1,420.80 100 Each 267 MITOMYCIN 20 MG IV SOLR J9280 55390025201 $1,362.40 $1,362.40 1 Each 311 OCTREOTIDE ACETATE 100 MCG/ML IJ SOLN J2354 63323037601 $167.00 $167.00 1 mL 348 AMOXICILLIN 500 MG PO CAPS 16714029903 $167.00 $167.00 100 Each 355 PRAMIPEXOLE 1 MG PO TABS 00597019061 $167.00 $167.00 100 Each 360 SODIUM CHLORIDE 5 % OP DROP 17478062312 $167.00 $167.00 15 mL 371 BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 IJ SOLN 00409175250 $167.00 $167.00 50 mL 405 CEFAZOLIN 1 GRAM IJ SOLR J0690 63323023710 $167.00 $167.00 1 Each 407 NEOMYCIN-COLIST-HC-THONZONIUM 3.3-3-10-0.5 MG/ML OT DRPS 63481042105 $3,385.76 $3,385.76 10 mL 415 OCTREOTIDE ACETATE 500 MCG/ML IJ SOLN J2354 25021045301 $521.98 $521.98 1 mL 428 NEVIRAPINE 50 MG/5 ML PO SUSP 00597004724 $2,926.08 $2,926.08 240 mL 432 METHOHEXITAL 500 MG IJ SOLR 42023010501 $1,103.68 $1,103.68 1 Each 439 AMINOCAPROIC ACID 500 MG PO TABS 49411005030 $9,610.08 $9,610.08 30 Each 445 RIVASTIGMINE TARTRATE 1.5 MG PO CAPS 63739057610 $859.20 $859.20 100 Each 450 LATANOPROST 0.005 % OP DROP 17478062512 $231.84 $231.84 2.5 mL 451 PEGASPARGASE 750 UNITS/ML IJ SOLN J9266 00944381001 $183,065.49 $183,065.49 5 mL 461 GANCICLOVIR SODIUM 500 MG IV SOLR J1570 42023017325 $745.68 $745.68 1 Each 482 PHENOBARBITAL SODIUM 65 MG/ML IJ SOLN J2560 00641047625 $288.88 $288.88 1 mL 486 CLINDAMYCIN PHOSPHATE 150 MG/ML IJ SOLN J3490 00009087026 $167.00 $167.00 300 mg 486 CLINDAMYCIN PHOSPHATE 150 MG/ML IJ SOLN J3490 00009090218 $167.00 $167.00 900 mg 486 CLINDAMYCIN PHOSPHATE 150 MG/ML IJ SOLN J3490 00009077526 $4,598.40 $4,598.40 600 mg 515 CHLORAMPHENICOL SOD SUCCINATE 1 GRAM IV SOLR J0720 63323001115 $386.88 $386.88 1 Each 535 DEXTROAMPHETAMINE-AMPHETAMINE 7.5 MG PO TABS 00555077502 $1,291.20 $1,291.20 100 Each 561 MANNITOL 25 % 25 % IV SOLN J2150 00409403101 $167.00 $167.00 50 mL 605 MONTELUKAST 5 MG PO CHEW 00781555592 $1,006.56 $1,006.56 90 Each 608 TROPICAMIDE 0.5 % OP DROP 17478010112 $167.00 $167.00 15 mL 614 PIOGLITAZONE 15 MG PO TABS 57237021930 $167.00 $167.00 30 Each 615 FUROSEMIDE 10 MG/ML IJ SOLN J1940 36000028225 $167.00 $167.00 2 mL 615 FUROSEMIDE 10 MG/ML IJ SOLN J1940 00409610210 $167.00 $167.00 10 mL 630 EPOETIN ALFA 2000 UNITS IJ SOLN J0885 55513012610 $305.99 $489.58 1 mL 631 FLUCONAZOLE 100 MG PO TABS 00904650061 $1,808.00 $1,808.00 100 Each 656 METHOCARBAMOL 500 MG PO TABS 63739016610 $167.00 $167.00 100 Each 667 MESALAMINE 4 GRAM/60 ML PR ENEM 45802009851 $167.00 $167.00 60 mL 681 POTASSIUM CHLORIDE IN 5 % DEX 20 MEQ/L IV SOLP J3480 00409790509 $167.00 $167.00 1000 mL 684 MITOMYCIN 40 MG IV SOLR J9280 55390025301 $2,477.92 $2,477.92 1 Each 697 CLOTRIMAZOLE 10 MG MM TROC 00574010777 $2,868.32 $2,868.32 70 Each 715 PENTOSAN POLYSULFATE SODIUM 100 MG PO CAPS 50458009801 $14,292.80 $14,292.80 100 Each 726 DEFEROXAMINE 2 GRAM IJ SOLR J0895 00078034751 $1,409.92 $1,409.92 4 Each 726 DEFEROXAMINE 2 GRAM IJ SOLR J0895 00409233725 $440.69 $440.69 1 Each 728 SILVER SULFADIAZINE 1 % TP CREA 61570013120 $167.00 $167.00 20 gram 728 SILVER SULFADIAZINE 1 % TP CREA 43598021055 $167.00 $167.00 50 gram 741 EPOETIN ALFA 4000 UNITS IJ SOLN J0885 55513014810 $611.99 $979.18 1 mL 755 DOXYCYCLINE MONOHYDRATE 25 MG/5 ML PO SUSR 00069097065 $616.32 $616.32 60 mL 762 PHENOBARBITAL 16.2 MG PO TABS 63739020010 $633.60 $633.60 100 Each 764 FENTANYL 50 MCG/HR TD PT72 00378912298 $919.68 $919.68 5 Each 791 DOXORUBICIN, PEG-LIPOSOMAL 2 MG/ML IV SUSP Q2050 47335005040 $20,322.45 $20,322.45 25 mL 791 DOXORUBICIN, PEG-LIPOSOMAL 2 MG/ML IV SUSP Q2050 47335004940 $14,451.20 $14,451.20 10 mL 794 ISOPROTERENOL HCL 0.2 MG/ML IJ SOLN J3490 00187433005 $1,972.16 $1,972.16 5 mL 866 THALIDOMIDE 50 MG PO CAPS 59572020514 $76,564.10 $76,564.10 28 Each 870 EPTIFIBATIDE 2 MG/ML IV SOLN J1327 00085117702 $3,411.20 $3,411.20 100 mL 870 EPTIFIBATIDE 2 MG/ML IV SOLN J1327 00085117701 $2,592.64 $2,592.64 10 mL 872 TERCONAZOLE 0.4 % VA CREA 51672130406 $537.12 $537.12 45 gram 888 PEGINTERFERON ALFA-2B 50 MCG/0.5 ML SC KIT 00085435301 $12,034.72 $12,034.72 1 Each 909 ACYCLOVIR 200 MG/5 ML PO SUSP 50383081016 $3,912.66 $3,912.66 473 mL 909 ACYCLOVIR 200 MG/5 ML PO SUSP 99999900302 $167.00 $167.00 10 mL 916 IVERMECTIN 3 MG PO TABS 00006003220 $1,387.84 $1,387.84 20 Each 926 DILTIAZEM HCL 5 MG/ML IV SOLN J3490 00409117101 $167.00 $167.00 5 mL 926 DILTIAZEM HCL 5 MG/ML IV SOLN J3490 55390056505 $167.00 $167.00 5 mL 930 CYCLOPHOSPHAMIDE 2 GRAM IV SOLR J9070 10019095701 $5,890.50 $5,890.50 1 Each 939 ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN J7608 00409330803 $167.00 $167.00 30 mL 939 ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN J7608 00517760425 $167.00 $167.00 4 mL 939 ACETYLCYSTEINE 200 MG/ML (20 %) MISC SOLN J7608 00517763003 $310.56 $310.56 30 mL 949 LIDOCAINE HCL 10 MG/ML (1 %) IJ SOLN J2001 63323020102 $167.00 $167.00 2 mL

Pharmacy FY22 MED IDs 195 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 949 LIDOCAINE HCL 10 MG/ML (1 %) IJ SOLN J2001 00143957701 $167.00 $167.00 50 mL 959 TUBERCULIN PPD 5 TUB. UNIT /0.1 ML ID SOLN 49281075222 $4,827.84 $4,827.84 5 mL 959 TUBERCULIN PPD 5 TUB. UNIT /0.1 ML ID SOLN 49281075221 $1,239.36 $1,239.36 1 mL 964 VALGANCICLOVIR 450 MG PO TABS 00004003822 $57,745.92 $57,745.92 60 Each 967 ANASTROZOLE 1 MG PO TABS 00310020130 $223.68 $223.68 30 Each 1007 HYDROXYUREA 500 MG PO CAPS 00555088202 $1,758.40 $1,758.40 100 Each 1010 NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OT SOLN 24208063110 $1,164.96 $1,164.96 10 mL 1014 METHOXSALEN 20 MCG/ML IJ SOLN 64067021601 $30,040.20 $30,040.20 10 mL 1036 BICALUTAMIDE 50 MG PO TABS 16714057102 $304.00 $304.00 100 Each 1069 ASPIRIN-DIPYRIDAMOLE 25-200 MG PO CM12 00597000160 $719.04 $719.04 60 Each 1084 ATORVASTATIN 80 MG PO TABS 00071015823 $205.92 $205.92 90 Each 1120 LEVONORGESTREL 20 MCG/24 HOURS (6 YRS) 52 MG IU IUD J7298 50419042301 $15,988.48 $15,988.48 1 Each 1155 ACETIC ACID 2 % OT SOLN 60432074115 $417.60 $417.60 15 mL 1167 AZELASTINE 0.05 % OP DROP 60505057804 $288.77 $288.77 6 mL 1172 NYSTATIN 100000 UNITS/ML PO SUSP 66689003750 $167.00 $167.00 5 mL 1202 VENLAFAXINE 37.5 MG PO CP24 00008083703 $499.20 $499.20 100 Each 1221 RIFAMPIN 600 MG IV SOLR J3490 00068059701 $2,663.04 $2,663.04 1 Each 1226 EPINEPHRINE HCL 1 MG/ML NA SOLN 42023010301 $1,861.20 $1,861.20 30 mL 1237 ALPHA-1 PROTEINASE INHIB.(HUM) 500 MG IV SOLR J0256 00944280201 $1,750.00 $2,800.00 1 Each 1258 DICYCLOMINE 10 MG/ML IM SOLN J0500 58914008052 $1,253.60 $1,253.60 2 mL 1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 69918090110 $4,661.76 $4,661.76 10 mL 1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 00409226501 $575.81 $575.81 1 mL 1296 DESMOPRESSIN 4 MCG/ML IJ SOLN J2597 00703505401 $4,071.36 $4,071.36 10 mL 1320 VENLAFAXINE 75 MG PO CP24 00904646961 $513.60 $513.60 100 Each 1343 BETAXOLOL 0.25 % OP DRPS 00065024610 $4,631.20 $4,631.20 10 mL 1387 COLISTIN (COLISTIMETHATE NA) 150 MG IJ SOLR J0770 00574085801 $417.44 $417.44 1 Each 1405 LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 IJ SOLN 63323048731 $167.00 $167.00 30 mL 1431 INTERFERON ALFA-2B 50 MILLION UNIT (1 ML) IJ SOLR J9214 00085435201 $12,889.53 $12,889.53 1 Each 1434 REPAGLINIDE 2 MG PO TABS 68084096725 $167.00 $167.00 30 Each 1460 NITROFURANTOIN MACROCRYSTAL 50 MG PO CAPS 47781030701 $1,504.00 $1,504.00 100 Each 1473 INTERFERON ALFA-2B 10 MILLION UNIT (1 ML) IJ SOLR J9214 00085435001 $4,582.88 $4,582.88 1 Each 1524 MITOTANE 500 MG PO TABS 00015308060 $7,152.00 $7,152.00 100 Each 1539 IODINE STRONG (LUGOLS) 5 % PO SOLN 00395277516 $1,210.88 $1,210.88 473 mL 1539 IODINE STRONG (LUGOLS) 5 % PO SOLN 48433023015 $439.94 $439.94 14 mL 1545 DOXYCYCLINE HYCLATE 100 MG PO CAPS 00143314250 $895.20 $895.20 50 Each 1546 ATOVAQUONE-PROGUANIL 62.5-25 MG PO TABS 68462040201 $2,006.40 $2,006.40 100 Each 1558 NEOMYCIN-BACITRACNZN-POLYMYXNB 3.5MG-400 UNIT- 5,000 UNIT/GRAM TP OINT 00713026831 $167.00 $167.00 28.4 gram 1567 ALPROSTADIL 500 MCG/ML IJ SOLN J0270 00703150102 $1,581.57 $1,581.57 1 mL 1576 TOBRAMYCIN SULFATE 10 MG/ML IJ SOLN J3260 63323030502 $167.00 $167.00 2 mL 1586 IMIGLUCERASE 400 UNITS IV SOLR J1786 58468466301 $13,599.68 $15,299.64 10 mL 1606 CEFUROXIME AXETIL 250 MG PO TABS 16714040002 $764.16 $764.16 60 Each 1610 PIPERACILLIN-TAZOBACTAM 40.5 GRAM IV SOLR J2543 00206885910 $930.24 $930.24 1 Each 1616 AMINO ACID (TROPHAMINE) INFUSION 10 % 10 % IV SOLP 00264934155 $568.00 $568.00 500 mL 1651 DEXRAZOXANE HCL 250 MG IV SOLR J1190 00013871762 $1,836.32 $1,836.32 1 Each 1665 ARGATROBAN 100 MG/ML IV SOLN J0883 00143967401 $3,252.96 $3,252.96 2.5 mL 1667 MICONAZOLE NITRATE 100 MG VA SUPP 00472173607 $167.00 $167.00 7 Each 1667 MICONAZOLE NITRATE 100 MG VA SUPP 49348083361 $167.00 $167.00 7 Each 1677 METOCLOPRAMIDE HCL 5 MG/ML IJ SOLN J2765 00409341401 $167.00 $167.00 2 mL 1697 LAMOTRIGINE 200 MG PO TABS 00173064460 $16,676.16 $16,676.16 60 Each 1714 SOMATROPIN 2 MG/0.25 ML SC SYRG J2941 00013265802 $17,309.00 $17,309.00 7 Each 1726 VENLAFAXINE 75 MG PO TABS 16714065801 $182.40 $182.40 100 Each 1733 POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN 00409729501 $203.28 $203.28 15 mL 1733 POTASSIUM PHOSPHATE M-/D-BASIC 3 MMOL/ML IV SOLN 63323008605 $167.60 $167.60 5 mL 1734 ATROPINE 1 % OP OINT 24208082555 $257.77 $257.77 3.5 gram 1736 LEUPROLIDE (3 MONTH) 11.25 MG IM SYKT J1950 00074366303 $37,327.32 $37,327.32 1 Each 1749 IPRATROPIUM-ALBUTEROL 0.5 MG-3 MG(2.5 MG BASE)/3 ML IN NEBU J7620 00487020101 $167.00 $167.00 3 mL 1764 LEUPROLIDE 3.75 MG IM SYKT J1950 00074364103 $12,442.32 $12,442.32 1 Each 1834 INSULIN GLARGINE 100 UNITS/ML SC SOLN J1815 00088222033 $1,268.64 $1,268.64 10 mL 1843 POTASSIUM CHLORID-D5-0.45%NACL 30 MEQ/L IV SOLP J3480 00409790309 $167.00 $167.00 1000 mL 1861 PILOCARPINE HCL 1 % OP DROP 61314020315 $1,176.00 $1,176.00 15 mL 1865 LORATADINE 5 MG/5 ML PO SOLN 99999900320 $167.00 $167.00 10 mL 1884 NIACIN 1000 MG PO TB24 65162032309 $745.92 $745.92 90 Each 1945 FLUCYTOSINE 500 MG PO CAPS 00187355510 $84,510.40 $84,510.40 100 Each 1956 PENTOSTATIN 10 MG IV SOLR J9268 00409080101 $17,627.22 $17,627.22 1 Each 1961 CEFEPIME 1 GRAM IJ SOLR J0692 60505083404 $167.00 $167.00 1 Each 1961 CEFEPIME 1 GRAM IJ SOLR J0692 63323032620 $167.00 $167.00 1 Each 1961 CEFEPIME 1 GRAM IJ SOLR J0692 25021012120 $167.00 $167.00 1 Each 1966 SULFASALAZINE 500 MG PO TABS 00591079601 $278.40 $278.40 100 Each 1974 FLUDARABINE 50 MG IV SOLR J9185 00703585401 $1,282.56 $1,282.56 1 Each 1977 CLONIDINE 0.1 MG/24 HR TD PTWK 00597003134 $937.60 $937.60 4 Each 2029 QUETIAPINE 300 MG PO TABS 16714045601 $283.20 $283.20 100 Each 2035 LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 IJ SOLN 00409318301 $167.00 $167.00 20 mL 2036 TOBRAMYCIN IN 0.225 % NACL 300 MG/5 ML IN NEBU J7682 00078049471 $1,954.16 $1,954.16 5 mL 2039 ERYTHROMYCIN 500 MG PO TABS 24338010413 $18,262.40 $18,262.40 100 Each 2052 CROMOLYN 5.2 MG/SPRAY (4 %) NA SPRY 57782039726 $167.00 $167.00 26 mL

Pharmacy FY22 MED IDs 196 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 2057 LOPINAVIR-RITONAVIR 400-100 MG/5 ML PO SOLN 00074395646 $7,636.48 $7,636.48 160 mL 2057 LOPINAVIR-RITONAVIR 400-100 MG/5 ML PO SOLN 99999777700 $238.40 $238.40 5 mL 2072 FAT EMULSION 20 % IV EMUL 00338051909 $192.00 $192.00 250 mL 2072 FAT EMULSION 20 % IV EMUL 00338051913 $224.00 $224.00 500 mL 2086 RIBAVIRIN 200 MG PO CAPS 68382026012 $1,670.59 $1,670.59 84 Each 2091 DEXTROAMPHETAMINE 15 MG PO CPSR 51862034690 $6,235.20 $6,235.20 90 Each 2112 LIDOCAINE 4 % TP PTMD 69993045006 $167.00 $167.00 1 Each 2125 LEUCOVORIN CALCIUM 25 MG PO TABS 51079058205 $3,280.96 $3,280.96 20 Each 2133 ENALAPRIL MALEATE 10 MG PO TABS 51079095220 $539.20 $539.20 100 Each 2164 ALBUTEROL SULFATE 2.5 MG /3 ML (0.083 %) IN NEBU J7613 00487950103 $167.00 $167.00 3 mL 2180 PROTAMINE 10 MG/ML IV SOLN J2720 63323022905 $167.00 $167.00 5 mL 2180 PROTAMINE 10 MG/ML IV SOLN J2720 63323022930 $424.40 $424.40 25 mL 2193 SUCCIMER 100 MG PO CAPS 55292020111 $32,977.60 $32,977.60 100 Each 2204 HYLAN G-F 20 16 MG/2 ML IX SYRG J7325 58468009001 $1,374.45 $1,374.45 2 mL 2210 REMIFENTANIL 2 MG IV SOLR J3490 63323072401 $1,470.48 $1,470.48 1 Each 2266 AMMONIUM LACTATE 12 % TP LOTN 00904598426 $167.00 $167.00 226 gram 2286 EPOPROSTENOL (GLYCINE) 0.5 MG IV SOLR J1325 00173051700 $373.76 $373.76 1 Each 2324 CARBAMIDE PEROXIDE 10 % MM SOLN 42037010476 $167.00 $167.00 60 mL 2338 POTASSIUM CHLORID-D5-0.45%NACL 40 MEQ/L IV SOLP J3480 00409790409 $167.00 $167.00 1000 mL 2348 DIVALPROEX 250 MG PO TBEC 62756079713 $904.00 $904.00 500 Each 2398 TRIAZOLAM 0.25 MG PO TABS 59762371809 $8,379.20 $8,379.20 100 Each 2406 APRACLONIDINE 0.5 % OP DROP 00065066505 $825.60 $825.60 5 mL 2412 LEVORPHANOL TARTRATE 2 MG PO TABS 42358010210 $66,366.40 $66,366.40 100 Each 2421 DEXTROAMPHETAMINE 5 MG PO TABS 00555095202 $2,236.80 $2,236.80 100 Each 2444 PHYTONADIONE (VITAMIN K1) 10 MG/ML IJ SOLN J3430 00409915801 $381.94 $381.94 1 mL 2446 LAMIVUDINE 100 MG PO TABS 00173066200 $1,243.20 $1,243.20 60 Each 2451 DIAZEPAM 5 MG/ML IJ SOLN J3360 00409321312 $558.56 $558.56 10 mL 2508 ENALAPRIL MALEATE 5 MG PO TABS 51079095120 $312.00 $312.00 100 Each 2523 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN J7643 00143968225 $167.00 $167.00 1 mL 2523 GLYCOPYRROLATE 0.2 MG/ML IJ SOLN J7643 00517460125 $191.09 $191.09 1 mL 2525 PHYTONADIONE (VITAMIN K1) 1 MG/0.5 ML IJ SOLN J3430 00409915701 $167.00 $167.00 .5 mL 2618 GOSERELIN 3.6 MG SC IMPL J9202 70720095036 $11,170.24 $11,170.24 1 Each 2629 INDOMETHACIN 50 MG PR SUPP 42211010243 $91,864.80 $91,864.80 30 Each 2659 CLARITHROMYCIN 250 MG PO TABS 00054003621 $3,590.40 $3,590.40 60 Each 2709 AMINO ACID (HEPATAMINE) INFUSION 8 % 8 % IV SOLP 00264937155 $1,664.00 $1,664.00 500 mL 2716 PHENOBARBITAL 20 MG/5 ML (4 MG/ML) PO ELIX 99999000980 $167.00 $167.00 5 mL 2720 MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) PO SOLN 99999900409 $167.00 $167.00 1 mL 2721 IOHEXOL 180 MG IODINE/ML IT SOLN Q9965 00407141120 $625.60 $625.60 20 mL 2729 VINBLASTINE 1 MG/ML IV SOLN J9360 63323027810 $559.52 $559.52 10 mL 2767 DANTROLENE 20 MG IV SOLR J3490 27505000367 $986.67 $986.67 1 Each 2791 OXYBUTYNIN CHLORIDE 10 MG PO TR24 00378661005 $3,728.00 $3,728.00 500 Each 2793 AZITHROMYCIN 250 MG PO TABS 59762306003 $524.80 $524.80 50 Each 2795 CLONIDINE 0.2 MG/24 HR TD PTWK 00597003234 $1,383.68 $1,383.68 4 Each 2808 FOSFOMYCIN TROMETHAMINE 3 GRAM PO PACK 00456430001 $1,361.12 $1,361.12 1 Each 2812 ALLOPURINOL SODIUM 500 MG IV SOLR J3490 67457018750 $20,972.25 $20,972.25 1 Each 2817 BENZOCAINE-MENTHOL 20-0.5 % TP AERO 16864068002 $167.00 $167.00 56 gram 2823 NITROGLYCERIN 0.3 MG SL SUBL 00071041724 $937.60 $937.60 100 Each 2834 LEVALBUTEROL HCL 0.63 MG IN NEBU J7614 00378968144 $167.00 $167.00 3 mL 2931 PRAVASTATIN 40 MG PO TABS 51079078220 $1,222.40 $1,222.40 100 Each 2941 FLOXURIDINE 0.5 GRAM IJ SOLR J9200 63323014507 $1,149.76 $1,149.76 1 Each 2956 DILTIAZEM HCL 180 MG PO CP24 62037059890 $1,255.68 $1,255.68 90 Each 2961 CHONDROITIN SULF-SOD HYALURON 3 %-4 %(0.5 ML) 1 % (0.55 ML) IO SYRG 08065183150 $1,416.48 $1,416.48 1.05 mL 3010 CITALOPRAM 10 MG/5 ML PO SOLN 00054006258 $952.32 $952.32 240 mL 3026 OFLOXACIN 0.3 % OP DROP 17478071310 $167.00 $167.00 5 mL 3049 CLORAZEPATE DIPOTASSIUM 3.75 MG PO TABS 00378003001 $1,483.20 $1,483.20 100 Each 3097 NYSTATIN 100000 UNIT/GRAM TP OINT 00168000730 $312.96 $312.96 30 gram 3103 CYCLOSPORINE MODIFIED 25 MG PO CAPS J7515 00093574065 $369.12 $369.12 30 Each 3122 ESTRAMUSTINE 140 MG PO CAPS 00013013202 $24,030.40 $24,030.40 100 Each 3142 ACETAZOLAMIDE 125 MG PO TABS 51672402201 $2,601.60 $2,601.60 100 Each 3146 METHADONE 10 MG/ML IJ SOLN J1230 99999900655 $578.56 $578.56 2 mL 3146 METHADONE 10 MG/ML IJ SOLN J1230 67457021720 $5,786.24 $5,786.24 20 mL 3186 LIOTHYRONINE 10 MCG/ML IV SOLN 39822015101 $5,145.12 $5,145.12 1 mL 3190 CHLOROPROCAINE 20 MG/ML (2 %) IJ SOLN J2400 63323047637 $259.20 $259.20 30 mL 3210 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG PO TABS 53489014501 $337.60 $337.60 100 Each 3235 AMPICILLIN 500 MG PO CAPS 00781214501 $616.00 $616.00 100 Each 3250 DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN Q9963 00270044540 $311.04 $311.04 120 mL 3250 DIATRIZOATE MEG-DIATRIZOAT SOD 66-10 % PO SOLN Q9963 00270044535 $3,898.05 $3,898.05 30 mL 3304 POTASSIUM ACETATE 2 MEQ/ML IV SOLN 00409818301 $167.00 $167.00 20 mL 3321 SODIUM ACETATE 2 MEQ/ML IV SOLN 00409729973 $167.00 $167.00 20 mL 3345 VALACYCLOVIR 1 GRAM PO TABS 59746032530 $520.80 $520.80 30 Each 3347 RITONAVIR 80 MG/ML PO SOLN 00074194063 $21,477.12 $21,477.12 240 mL 3372 ONABOTULINUMTOXINA 100 UNITS IJ SOLR J0585 00023114501 $6,010.00 $9,616.00 1 Each 3378 AMOXICILLIN-POT CLAVULANATE 600-42.9 MG/5 ML PO SUSR 00781613957 $336.00 $336.00 75 mL 3404 CLARITHROMYCIN 500 MG PO TABS 65862022660 $745.92 $745.92 60 Each 3435 AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5 ML PO SUSR 60432006575 $771.60 $771.60 75 mL

Pharmacy FY22 MED IDs 197 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 3435 AMOXICILLIN-POT CLAVULANATE 250-62.5 MG/5 ML PO SUSR 99999900122 $167.00 $167.00 1 mL 3443 ETHACRYNATE SODIUM 50 MG IV SOLR 25010021027 $13,955.36 $13,955.36 1 Each 3445 UREA 20 % TP CREA 00536110945 $167.00 $167.00 85 gram 3449 MICROFIBRIL. COLLAGEN HEMOSTAT TP POWD 53276101002 $2,089.39 $2,089.39 1 gram 3466 TOLTERODINE 4 MG PO CP24 00009519103 $51,400.00 $51,400.00 500 Each 3470 CEPHALEXIN 250 MG PO CAPS 00093314501 $196.80 $196.80 100 Each 3475 CHLORAMBUCIL 2 MG PO TABS 76388063525 $8,979.60 $8,979.60 25 Each 3493 HYDROCODONE-ACETAMINOPHEN 5-325 MG PO TABS 00406012362 $534.40 $534.40 100 Each 3504 SEVELAMER HCL 800 MG PO TABS 58468002101 $19,863.36 $19,863.36 180 Each 3509 CHLORPROMAZINE 100 MG PO TABS Q0161 51079051620 $11,476.80 $11,476.80 100 Each 3511 RIFAPENTINE 150 MG PO TABS 00088210224 $1,506.05 $1,506.05 24 Each 3566 MELPHALAN 2 MG PO TABS J8600 52609000105 $8,441.60 $8,441.60 50 Each 3571 MYCOPHENOLATE MOFETIL 250 MG PO CAPS J7517 00004025943 $6,712.00 $6,712.00 500 Each 3593 DAUNORUBICIN 5 MG/ML IV SOLN J9150 00703523313 $1,307.20 $1,307.20 4 mL 3596 DEFEROXAMINE 500 MG IJ SOLR J0895 00409233610 $167.00 $167.00 1 Each 3598 IMIPENEM-CILASTATIN 500 MG IV SOLR J0743 00409350701 $167.00 $167.00 1 Each 3598 IMIPENEM-CILASTATIN 500 MG IV SOLR J0743 00006351659 $167.00 $167.00 1 Each 3600 FLUCONAZOLE IN NACL (ISO-OSM) 400 MG/200 ML IV PGBK J1450 55390004601 $167.00 $167.00 200 mL 3605 HYDROCORTISONE 1 % TP OINT 00168002031 $167.00 $167.00 28.35 gram 3617 ENALAPRIL MALEATE 20 MG PO TABS 16714044501 $910.40 $910.40 100 Each 3629 PENICILLIN G POTASSIUM 5 MILLION UNIT IJ SOLR J2540 00049052083 $167.00 $167.00 1 Each 3689 ALUM, AMMONIUM (BULK) MISC POWD 00395004996 $167.00 $167.00 170 gram 3697 NALOXONE 0.4 MG/ML IJ SOLN J2310 00409121501 $167.00 $167.00 1 mL 3723 SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) IV SOLN 60267070550 $1,424.00 $1,424.00 12.5 gram 3757 TOLTERODINE 1 MG PO TABS 00093001006 $1,236.48 $1,236.48 60 Each 3764 EPINEPHRINE 0.15 MG/0.3 ML IJ ATIN J0171 49502050102 $8,985.76 $8,985.76 2 Each 3783 ACYCLOVIR SODIUM 50 MG/ML IV SOLN J0133 55150015520 $167.00 $167.00 20 mL 3783 ACYCLOVIR SODIUM 50 MG/ML IV SOLN J0133 55150015410 $167.00 $167.00 10 mL 3796 ERGOTAMINE-CAFFEINE 1-100 MG PO TABS 00781540501 $12,414.40 $12,414.40 100 Each 3798 PROMETHAZINE 25 MG PR SUPP J8498 00713052612 $1,744.51 $1,744.51 12 Each 3821 MAGNESIUM SULFATE 4 MEQ/ML (50 %) IJ SOLN J3475 51754100001 $167.00 $167.00 10 mL 3821 MAGNESIUM SULFATE 4 MEQ/ML (50 %) IJ SOLN J3475 63323064250 $200.80 $200.80 50 mL 3823 SODIUM BICARBONATE 325 MG PO TABS 00536104610 $224.00 $224.00 1000 Each 3850 HYDROCORTISONE 1 % TP LOTN 00394085932 $167.00 $167.00 114 gram 3861 ONDANSETRON HCL 8 MG PO TABS S0119 51079052520 $1,041.60 $1,041.60 100 Each 3865 ONDANSETRON HCL 2 MG/ML IV SOLN J2405 55390012101 $167.00 $167.00 20 mL 3873 METHACHOLINE CHLORIDE 100 MG IN SOLR 64281010006 $1,163.25 $1,163.25 1 Each 3881 AMIFOSTINE CRYSTALLINE 500 MG IV SOLR J0207 66220001703 $47,935.54 $47,935.54 3 Each 3901 METHADONE 10 MG PO TABS 00054855424 $521.60 $521.60 100 Each 3903 ERGOTAMINE-CAFFEINE 2-100 MG PR SUPP 75987009011 $27,648.38 $27,648.38 12 Each 3926 LORAZEPAM 2 MG/ML IJ SOLN J2060 00641604610 $167.00 $167.00 10 mL 3926 LORAZEPAM 2 MG/ML IJ SOLN J2060 00641604425 $167.00 $167.00 1 mL 3926 LORAZEPAM 2 MG/ML IJ SOLN J2060 76329826101 $167.00 $167.00 10 mL 3926 LORAZEPAM 2 MG/ML IJ SOLN J2060 76329826100 $167.00 $167.00 10 mL 3928 MINOCYCLINE 100 MG PO CAPS 65862021150 $358.40 $358.40 50 Each 3930 ALDESLEUKIN 22 MILLION UNIT IV SOLR J9015 65483011607 $39,290.22 $39,290.22 1 Each 3936 FLUCYTOSINE 250 MG PO CAPS 00187355410 $44,740.80 $44,740.80 100 Each 3939 SODIUM CHLORIDE 3 % IN NEBU J3490 00487900360 $167.00 $167.00 4 mL 3945 DILTIAZEM HCL 240 MG PO CP24 60687021711 $167.00 $167.00 1 Each 3945 DILTIAZEM HCL 240 MG PO CP24 60687021701 $913.60 $913.60 100 Each 3956 FLUCONAZOLE 200 MG PO TABS 16714069302 $2,232.00 $2,232.00 100 Each 4002 ETHANOLAMINE OLEATE 5 % IV SOLN J1430 67871479006 $6,375.74 $6,375.74 2 mL 4085 CEFEPIME 2 GRAM IJ SOLR J0692 60505068104 $167.00 $167.00 1 Each 4085 CEFEPIME 2 GRAM IJ SOLR J0692 25021012250 $167.00 $167.00 1 Each 4086 VENLAFAXINE 25 MG PO TABS 00093019901 $459.20 $459.20 100 Each 4092 IODIXANOL 320 MG IODINE/ML IV SOLN Q9967 00407222306 $1,718.50 $1,718.50 50 mL 4097 RISEDRONATE 5 MG PO TABS 00430047115 $1,118.40 $1,118.40 30 Each 4100 ATOVAQUONE-PROGUANIL 250-100 MG PO TABS 00173067502 $2,457.60 $2,457.60 24 Each 4129 HALOPERIDOL DECANOATE 100 MG/ML IM SOLN J1631 50458025414 $521.98 $521.98 1 mL 4187 ONDANSETRON HCL 4 MG PO TABS S0119 51079052420 $734.40 $734.40 100 Each 4191 LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 IJ SOLN 00409317701 $167.00 $167.00 50 mL 4210 HYDROMORPHONE 8 MG PO TABS 00406324901 $430.40 $430.40 100 Each 4220 THIOTEPA 15 MG IJ SOLR J9340 00143956501 $5,809.60 $5,809.60 1 Each 4232 METHYLPHENIDATE HCL 5 MG PO TABS 00406114201 $670.40 $670.40 100 Each 4262 DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NA SPRP 69918050105 $1,468.96 $1,468.96 5 mL 4271 DEXTROAMPHETAMINE-AMPHETAMINE 10 MG PO TABS 00555097202 $1,265.60 $1,265.60 100 Each 4299 CLONAZEPAM 0.5 MG PO TABS 51079088120 $167.00 $167.00 100 Each 4299 CLONAZEPAM 0.5 MG PO TABS 60687054401 $167.00 $167.00 100 Each 4315 CEFTRIAXONE 250 MG IJ SOLR J0696 00143985925 $167.00 $167.00 1 Each 4317 CIPROFLOXACIN 250 MG/5 ML PO SUMC 50419077701 $1,945.60 $1,945.60 100 mL 4327 ESTRADIOL 0.05 MG/24 HR TD PTWK 00378335099 $999.36 $999.36 4 Each 4386 CEFTAZIDIME 2 GRAM IJ SOLR J0713 00409508411 $167.00 $167.00 1 Each 4386 CEFTAZIDIME 2 GRAM IJ SOLR J0713 25021012850 $167.00 $167.00 1 Each 4402 NITROGLYCERIN 0.3 MG/HR TD PT24 00085331530 $17,561.76 $17,561.76 30 Each 4412 TACROLIMUS 5 MG PO CAPS J7507 00469065711 $15,161.60 $15,161.60 100 Each

Pharmacy FY22 MED IDs 198 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 4466 POTASSIUM CHLORID-D5-0.45%NACL 10 MEQ/L IV SOLP J3480 00409799309 $167.00 $167.00 1000 mL 4482 POTASSIUM CHLORIDE-D5-0.9%NACL 20 MEQ/L IV SOLP J3480 00409710709 $167.00 $167.00 1000 mL 4490 GENTIAN VIOLET 1 % TP SOLN 00395100392 $167.00 $167.00 59 mL 4497 DOXYCYCLINE HYCLATE 50 MG PO CAPS 53489011802 $302.40 $302.40 50 Each 4503 ENALAPRIL MALEATE 2.5 MG PO TABS 16714044201 $390.40 $390.40 100 Each 4507 BERACTANT IN 0.9 %SOD.CHLORIDE 25 MG/ML ITL SUSP 00074104004 $3,998.40 $3,998.40 4 mL 4517 FLUOROURACIL 5 % TP CREA 66530024940 $1,657.60 $1,657.60 40 gram 4533 BENZOYL PEROXIDE 5 % TP GEL 45802021601 $236.16 $236.16 90 gram 4533 BENZOYL PEROXIDE 5 % TP GEL 00536105556 $167.00 $167.00 42.5 gram 4544 CIPROFLOXACIN IN 5 % DEXTROSE 400 MG/200 ML IV PGBK J0744 00409477702 $167.00 $167.00 200 mL 4599 CEFOXITIN 1 GRAM IV SOLR J0694 60505075905 $167.00 $167.00 1 Each 4599 CEFOXITIN 1 GRAM IV SOLR J0694 25021010910 $167.00 $167.00 1 Each 4648 ETHACRYNIC ACID 25 MG PO TABS 25010021515 $3,355.20 $3,355.20 100 Each 4699 TRIAZOLAM 0.125 MG PO TABS 59762371709 $4,374.40 $4,374.40 100 Each 4714 PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2-0.1037 -0.0194 MG/5 ML PO ELIX 99999900145 $167.00 $167.00 5 mL 4754 CISATRACURIUM 10 MG/ML CONC. IV SOLN J3490 00703204503 $2,261.44 $2,261.44 20 mL 4758 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN J3490 00703950303 $167.00 $167.00 5 mL 4758 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN J3490 00703951403 $167.00 $167.00 10 mL 4758 SULFAMETHOXAZOLE-TRIMETHOPRIM 400-80 MG/5 ML IV SOLN J3490 00703952601 $561.12 $561.12 30 mL 4765 QUETIAPINE 200 MG PO TABS 16714045501 $225.60 $225.60 100 Each 4810 TERCONAZOLE 0.8 % VA CREA 51672130200 $368.00 $368.00 20 gram 4828 LIDOCAINE 4 % TP CREA 00496088230 $491.52 $491.52 30 gram 4835 SULFASALAZINE 500 MG PO TBEC 59762010401 $2,955.20 $2,955.20 100 Each 4842 GOSERELIN 10.8 MG SC IMPL J9202 70720095130 $18,849.78 $18,849.78 1 Each 4888 METRONIDAZOLE 250 MG PO TABS 00904145361 $483.20 $483.20 100 Each 4891 MICONAZOLE NITRATE 2 % VA CREA 49348053077 $167.00 $167.00 45 gram 4901 NIMODIPINE 30 MG PO CAPS 57664013564 $1,182.72 $1,182.72 30 Each 4939 CLONAZEPAM 1 MG PO TABS 51079088220 $167.00 $167.00 100 Each 4940 NIACIN 500 MG PO TB24 65162032109 $476.64 $476.64 90 Each 5006 NEVIRAPINE 200 MG PO TABS 00597004660 $167.00 $167.00 60 Each 5053 DOFETILIDE 250 MCG PO CAPS 00069581060 $3,155.52 $3,155.52 60 Each 5083 DOXORUBICIN 50 MG IV SOLR J9000 67457043650 $3,922.72 $3,922.72 1 Each 5148 PENTAMIDINE 300 MG IJ SOLR J7676 63323011310 $1,685.23 $1,685.23 1 Each 5157 ERYTHROMYCIN 500 MG PO TBEC 24338012613 $10,272.00 $10,272.00 100 Each 5159 FLUORESCEIN 500 MG/5 ML (10 %) IV SOLN 00065009265 $557.20 $557.20 5 mL 5171 PIMECROLIMUS 1 % TP CREA 00187510001 $4,459.68 $4,459.68 30 gram 5177 ASCORBIC ACID (VITAMIN C) 500 MG/ML IJ SOLN 67457011850 $3,624.00 $3,624.00 50 mL 5192 TRETINOIN (ANTINEOPLASTIC) 10 MG PO CAPS 00555080802 $27,825.60 $27,825.60 100 Each 5208 MOXIFLOXACIN 400 MG PO TABS 65862060330 $1,284.96 $1,284.96 30 Each 5311 CROMOLYN 20 MG/2 ML IN NEBU J7631 00172640649 $209.76 $209.76 2 mL 5312 PANTOPRAZOLE 40 MG IV SOLR C9113 00008092355 $167.00 $167.00 40 mg 5318 PERMETHRIN 5 % TP CREA 00472024260 $428.16 $428.16 60 gram 5332 ACETAZOLAMIDE 250 MG PO TABS 51672402301 $3,440.00 $3,440.00 100 Each 5335 PENICILLIN V POTASSIUM 250 MG/5 ML PO SOLR 00093412774 $167.00 $167.00 200 mL 5336 RIFABUTIN 150 MG PO CAPS 00013530117 $12,176.00 $12,176.00 100 Each 5368 CLINDAMYCIN HCL 150 MG PO CAPS 63304069201 $214.40 $214.40 100 Each 5380 VENLAFAXINE 150 MG PO CP24 00008083603 $568.00 $568.00 100 Each 5398 INSULIN NPH AND REGULAR HUMAN 100 UNIT/ML (70-30) SC SUSP J1815 00002871517 $167.00 $167.00 3 mL 5406 MONTELUKAST 4 MG PO CHEW 31722072790 $167.04 $167.04 90 Each 5443 TEMOZOLOMIDE 100 MG PO CAPS J8700 00093760141 $4,908.51 $4,908.51 14 Each 5455 ITRACONAZOLE 10 MG/ML PO SOLN 50458029515 $5,112.00 $5,112.00 150 mL 5464 DOFETILIDE 125 MCG PO CAPS 00069580060 $3,701.76 $3,701.76 60 Each 5468 TRAVOPROST 0.004 % OP DROP 00065026025 $2,892.96 $2,892.96 2.5 mL 5477 NYSTATIN 500000 UNITS PO TABS 53489040001 $1,566.40 $1,566.40 100 Each 5489 ADENOSINE (DIAGNOSTIC) 3 MG/ML IV SOLN J0153 00469087130 $696.00 $696.00 30 mL 5491 LEUCOVORIN CALCIUM 350 MG IJ SOLR J0640 00703514501 $200.96 $200.96 1 Each 5493 CARDIOPLEGIC SOLN 16 MEQ/L (= K+) PF SOLN 00409796905 $656.00 $656.00 1000 mL 5559 DILTIAZEM HCL 100 MG IV SOLR 00409435003 $167.00 $167.00 1 Each 5573 PROMETHAZINE-CODEINE 6.25-10 MG/5 ML PO SYRP 99999900466 $167.00 $167.00 5 mL 5602 TEMOZOLOMIDE 250 MG PO CAPS J8700 43975025705 $5,236.48 $5,236.48 5 Each 5612 OXYCODONE 5 MG/5 ML PO SOLN 66689040150 $167.00 $167.00 5 mL 5614 METRONIDAZOLE IN NACL (ISO-OS) 500 MG/100 ML IV PGBK 00264553532 $167.00 $167.00 100 mL 5620 METHYLERGONOVINE 0.2 MG PO TABS 43386014028 $22,446.14 $22,446.14 28 Each 5628 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG PO TABS 00378041501 $1,044.80 $1,044.80 100 Each 5652 VALSARTAN 80 MG PO TABS 60687012801 $446.40 $446.40 100 Each 5668 PARICALCITOL 5 MCG/ML IV SOLN J2501 00074165801 $167.00 $167.00 1 mL 5671 PIOGLITAZONE 45 MG PO TABS 00093727356 $208.32 $208.32 30 Each 5706 ETANERCEPT 25 MG (1 ML) SC SOLR J1438 58406042534 $44,503.36 $44,503.36 4 Each 5738 MIDAZOLAM 5 MG/ML IJ SOLN J2250 55390012605 $167.00 $167.00 5 mL 5738 MIDAZOLAM 5 MG/ML IJ SOLN J2250 00409259605 $167.00 $167.00 10 mL 5738 MIDAZOLAM 5 MG/ML IJ SOLN J2250 00409259653 $167.00 $167.00 10 mL 5738 MIDAZOLAM 5 MG/ML IJ SOLN J2250 55390012610 $167.00 $167.00 10 mL 5770 AMOXICILLIN-POT CLAVULANATE 250-125 MG PO TABS 00781187431 $2,123.04 $2,123.04 30 Each 5780 TETRAHYDROZOLINE 0.05 % OP DROP 00904633435 $167.00 $167.00 15 mL 5817 CODEINE SULFATE 15 MG PO TABS 00054024324 $1,048.00 $1,048.00 100 Each

Pharmacy FY22 MED IDs 199 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 5888 TOPIRAMATE 25 MG PO TABS 69097012215 $512.00 $512.00 1000 Each 5933 DIMERCAPROL 100 MG/ML IM SOLN J0470 17478052603 $2,342.11 $2,342.11 3 mL 5934 COSYNTROPIN 0.25 MG IJ SOLR J0834 00548590000 $1,566.61 $1,566.61 1 Each 5952 ROCURONIUM 10 MG/ML IV SOLN J3490 00409955849 $167.00 $167.00 5 mL 5983 METHYLPHENIDATE HCL 54 MG PO TR24 00591271830 $1,651.20 $1,651.20 30 Each 6010 VANCOMYCIN 5 GRAM IV SOLR J3370 00409650949 $262.72 $262.72 1 Each 6046 RISPERIDONE 0.25 MG PO TABS 50458030101 $193.60 $193.60 100 Each 6066 ERYTHROMYCIN 250 MG PO TBEC 24338012213 $7,681.60 $7,681.60 100 Each 6070 BIMATOPROST 0.03 % OP DROP 68180042901 $1,532.00 $1,532.00 2.5 mL 6070 BIMATOPROST 0.03 % OP DROP 68180042902 $2,230.40 $2,230.40 5 mL 6092 NIACIN 750 MG PO TB24 68180022201 $1,446.40 $1,446.40 100 Each 6094 DILTIAZEM HCL 360 MG PO CP24 00187079942 $5,896.80 $5,896.80 90 Each 6101 SULFACETAMIDE-PREDNISOLONE 10-0.2 % OP DRPS 11980002205 $2,392.16 $2,392.16 5 mL 6120 METRONIDAZOLE 500 MG PO TABS 42292000120 $806.40 $806.40 100 Each 6128 LIDOCAINE HCL 2 % MM JELL 17478071110 $167.00 $167.00 5 mL 6128 LIDOCAINE HCL 2 % MM JELL 17478071130 $1,306.56 $1,306.56 30 mL 6143 TROPICAMIDE 1 % OP DROP 17478010212 $167.00 $167.00 15 mL 6143 TROPICAMIDE 1 % OP DROP 61314035501 $167.00 $167.00 3 mL 6162 AZATHIOPRINE 50 MG PO TABS J7500 51079062006 $337.60 $337.60 50 Each 6170 FILGRASTIM 300 MCG IJ SOLN J1442 55513053010 $4,690.59 $4,690.59 1 mL 6198 HETASTARCH 6 % IN 0.9 % NACL 6 % IV SOLN 00264196510 $272.00 $272.00 500 mL 6230 SUCCINYLCHOLINE CHLORIDE 20 MG/ML IJ SOLN J0330 00409662902 $285.92 $285.92 10 mL 6253 FLUOCINONIDE 0.05 % TP OINT 00093026415 $844.08 $844.08 15 gram 6262 ACETAMINOPHEN-CODEINE 300-30 MG PO TABS 00406048462 $190.40 $190.40 100 Each 6279 CLOPIDOGREL 75 MG PO TABS 63653117103 $262.40 $262.40 100 Each 6329 CIPROFLOXACIN HCL 250 MG PO TABS 16714065102 $179.20 $179.20 100 Each 6349 BACLOFEN 500 MCG/ML IT SOLN J0476 70257056001 $2,960.00 $2,960.00 20 mL 6389 DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRP 00121063805 $167.00 $167.00 5 mL 6389 DEXTROMETHORPHAN-GUAIFENESIN 10-100 MG/5 ML PO SYRP 00121127600 $167.00 $167.00 10 mL 6431 MINERAL OIL-HYDROPHIL PETROLAT TP OINT 54868587000 $183.74 $183.74 396 gram 6431 MINERAL OIL-HYDROPHIL PETROLAT TP OINT 61924018416 $210.66 $210.66 454 gram 6446 LEVOFLOXACIN 250 MG PO TABS 65862053650 $283.20 $283.20 50 Each 6512 BACITRACIN ZINC 500 UNIT/GRAM TP OINT 49348015472 $167.00 $167.00 28.4 gram 6554 CAPECITABINE 500 MG PO TABS J8521 00004110150 $1,288.32 $1,288.32 120 Each 6569 EPOPROSTENOL (GLYCINE) 1.5 MG IV SOLR J1325 00173051900 $902.88 $902.88 1 Each 6571 ALBUMIN, HUMAN 5 % 5 % IV SOLP P9041 68516521402 $1,216.00 $1,216.00 500 mL 6571 ALBUMIN, HUMAN 5 % 5 % IV SOLP P9041 68516521405 $472.00 $472.00 50 mL 6571 ALBUMIN, HUMAN 5 % 5 % IV SOLP P9041 44206031025 $488.00 $488.00 250 mL 6574 TRIMETHOPRIM 100 MG PO TABS 43386033001 $286.40 $286.40 100 Each 6620 FONDAPARINUX 2.5 MG/0.5 ML SC SYRG J1652 67457058210 $167.00 $167.00 .5 mL 6635 STREPTOMYCIN 1 GRAM IM SOLR J3000 39822070602 $625.36 $625.36 1 Each 6661 DIVALPROEX 500 MG PO TBEC 62756079813 $1,816.00 $1,816.00 500 Each 6695 NICARDIPINE 25 MG/10 ML IV SOLN 67286081201 $233.60 $233.60 10 mL 6713 ENALAPRILAT 1.25 MG/ML IV SOLN 55390001010 $167.00 $167.00 1 mL 6714 VALACYCLOVIR 500 MG PO TABS 63739052510 $2,176.00 $2,176.00 100 Each 6725 METHOTREXATE SODIUM 25 MG/ML IJ SOLN J9250 63323012310 $385.28 $385.28 10 mL 6740 SULFADIAZINE 500 MG PO TABS 00185075701 $5,425.60 $5,425.60 100 Each 6747 CIPROFLOXACIN HCL 500 MG PO TABS 68084007001 $299.20 $299.20 100 Each 6776 CEFTRIAXONE 1 GRAM IV SOLR J0696 00409733304 $167.00 $167.00 1 Each 6778 MORPHINE 30 MG PO TBSR 00406833062 $1,761.60 $1,761.60 100 Each 6785 SULFAMETHOXAZOLE-TRIMETHOPRIM 800-160 MG PO TABS 00904272561 $230.40 $230.40 100 Each 6799 HYDROCODONE-ACETAMINOPHEN 10-325 MG PO TABS 00406012562 $592.00 $592.00 100 Each 6824 PROCAINAMIDE 100 MG/ML IJ SOLN J2690 00409190201 $881.44 $881.44 10 mL 6848 IOHEXOL 300 MG IODINE/ML IV SOLN Q9967 00407141361 $167.00 $167.00 50 mL 6862 INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) IJ SOLN J3490 00517037505 $2,132.64 $2,132.64 5 mL 6869 GRANISETRON HCL 1 MG PO TABS Q0166 00093748520 $1,062.40 $1,062.40 20 Each 6891 DIHYDROERGOTAMINE 1 MG/ML IJ SOLN J1110 00574085010 $1,860.96 $1,860.96 1 mL 6928 PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML IV SUSP Q9957 11994001101 $232.47 $232.47 1.5 mL 6969 VANCOMYCIN 1000 MG IV SOLR J3370 67457034001 $167.00 $167.00 1 Each 6983 CYCLOPHOSPHAMIDE 1 GRAM IV SOLR J9070 10019095601 $5,236.00 $5,236.00 1 Each 6990 DIGOXIN 250 MCG/ML (0.25 MG/ML) IJ SOLN J1160 00781305995 $167.00 $167.00 2 mL 6992 QUETIAPINE 100 MG PO TABS 16714045401 $167.00 $167.00 100 Each 7002 METHOCARBAMOL 100 MG/ML IJ SOLN J2800 00641610325 $167.00 $167.00 10 mL 7005 TESTOSTERONE 4 MG/24 HR TD PT24 52544007754 $306.18 $306.18 1 Each 7011 DEXAMETHASONE 1 MG/ML PO DROP 00054317644 $355.20 $355.20 30 mL 7029 AMANTADINE HCL 100 MG PO CAPS 68084061101 $2,406.40 $2,406.40 100 Each 7048 MORPHINE (PF) 1 MG/ML IJ SOLN J2274 00641601910 $167.00 $167.00 10 mL 7050 PRAZIQUANTEL 600 MG PO TABS 50419074701 $7,430.40 $7,430.40 6 Each 7052 RISPERIDONE 3 MG PO TABS 50458033001 $235.20 $235.20 100 Each 7084 COAGULATION FACTOR IX 1,000 (+/-) UNIT IV SOLR J7193 68516360202 $13,920.00 $13,920.00 1 Each 7122 TRIAMCINOLONE ACETONIDE 0.1 % TP CREA 00168000415 $167.00 $167.00 15 gram 7204 MAFENIDE ACETATE 85 MG/G TP CREA 51079062383 $7,221.31 $7,221.31 453.6 gram 7208 SINCALIDE 5 MCG IJ SOLR J2805 00270055615 $1,713.38 $1,713.38 1 Each 7228 PHYSOSTIGMINE SALICYLATE 1 MG/ML IJ SOLN 17478051002 $1,167.52 $1,167.52 2 mL 7236 KETOROLAC 30 MG/ML (1 ML) IJ SOLN J1885 00409379501 $167.00 $167.00 1 mL

Pharmacy FY22 MED IDs 200 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 7266 HYDRALAZINE 20 MG/ML IJ SOLN J0360 67457029101 $167.00 $167.00 1 mL 7276 BUTALBITAL-ACETAMINOPHEN-CAFF 50-325-40 MG PO TABS 00591336901 $838.40 $838.40 100 Each 7291 TRIMETHOBENZAMIDE 100 MG/ML IM SOLN J3250 42023011925 $580.61 $580.61 2 mL 7329 TEMAZEPAM 7.5 MG PO CAPS 00406991501 $4,492.80 $4,492.80 100 Each 7340 DIAZOXIDE 50 MG/ML PO SUSP 00575620030 $4,879.20 $4,879.20 30 mL 7359 ACYCLOVIR 800 MG PO TABS 31722077805 $1,304.00 $1,304.00 500 Each 7392 FERRIC SUBSULFATE 259 MG/G TP SOLN 59365606500 $167.00 $167.00 8 gram 7396 CEFOXITIN 2 GRAM IV SOLR J0694 60505076005 $167.00 $167.00 1 Each 7427 LIDOCAINE-PRILOCAINE 2.5-2.5 % TP CREA 50383066730 $347.04 $347.04 30 gram 7427 LIDOCAINE-PRILOCAINE 2.5-2.5 % TP CREA 00168035730 $635.04 $635.04 30 gram 7427 LIDOCAINE-PRILOCAINE 2.5-2.5 % TP CREA 00168035755 $167.00 $167.00 5 gram 7571 SELENIUM 200 MCG PO TABS 74312003201 $167.00 $167.00 100 Each 7583 MORPHINE 25 MG/ML IV SOLN J2270 00409113502 $167.00 $167.00 10 mL 7587 AZATHIOPRINE SODIUM 100 MG IJ SOLR J7501 00143956601 $3,288.48 $3,288.48 1 Each 7594 LAMOTRIGINE 25 MG PO TABS 00173063302 $20,393.60 $20,393.60 100 Each 7633 ROPIVACAINE (PF) 2 MG/ML (0.2 %) IJ SOLN J2795 63323028564 $720.00 $720.00 200 mL 7633 ROPIVACAINE (PF) 2 MG/ML (0.2 %) IJ SOLN J2795 63323028565 $360.00 $360.00 100 mL 7669 OXYCODONE 15 MG PO TABS 00406851501 $737.60 $737.60 100 Each 7682 PARICALCITOL 2 MCG/ML IV SOLN J2501 00074463701 $167.00 $167.00 1 mL 7713 ERYTHROMYCIN LACTOBIONATE 500 MG IV SOLR J1364 00409648201 $1,144.91 $1,144.91 1 Each 7725 POLIOVIRUS VACCINE 40-8-32 UNIT/0.5 ML IJ SUSP 90713 49281086010 $5,231.52 $5,231.52 5 mL 7734 HYDROCORTISONE ACETATE 25 MG PR SUPP 00574709012 $2,065.34 $2,065.34 12 Each 7734 HYDROCORTISONE ACETATE 25 MG PR SUPP 00713050324 $970.75 $970.75 24 Each 7743 POTASSIUM CHLORIDE 20 MEQ/15 ML PO LIQD 00121146515 $194.16 $194.16 15 mL 7743 POTASSIUM CHLORIDE 20 MEQ/15 ML PO LIQD 66689004850 $292.80 $292.80 30 mL 7769 NITROFURANTOIN 25 MG/5 ML PO SUSP 99999900327 $2,121.60 $2,121.60 20 mL 7804 IFOSFAMIDE 1 GRAM IV SOLR J9208 63323014210 $383.68 $383.68 1 Each 7823 DEXAMETHASONE SODIUM PHOSPHATE 0.1 % OP DROP 24208072002 $759.20 $759.20 5 mL 7826 PANTOPRAZOLE 20 MG PO TBEC 00093001198 $185.76 $185.76 90 Each 7852 PHENOXYBENZAMINE 10 MG PO CAPS 49884003801 $160,875.20 $160,875.20 100 Each 7854 SODIUM BICARBONATE 8.4 % IV SOLN 00409662502 $167.00 $167.00 50 mL 7854 SODIUM BICARBONATE 8.4 % IV SOLN 00409662525 $167.00 $167.00 50 mL 7855 PREDNISOLONE ACETATE 0.12 % OP DRPS 11980017405 $2,392.16 $2,392.16 5 mL 7855 PREDNISOLONE ACETATE 0.12 % OP DRPS 11980017410 $4,784.48 $4,784.48 10 mL 7861 KETOROLAC 0.5 % OP DROP 17478020919 $218.06 $218.06 3 mL 7868 BISOPROLOL FUMARATE 5 MG PO TABS 00185077130 $167.00 $167.00 1 tablet 7917 CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) IJ SOLN J9100 63323012020 $222.72 $222.72 20 mL 7935 MYCOPHENOLATE MOFETIL 500 MG PO TABS J7517 00004026001 $2,683.20 $2,683.20 100 Each 8027 POTASSIUM CHLORID-D5-0.45%NACL 20 MEQ/L IV SOLP J3480 00409790209 $167.00 $167.00 1000 mL 8028 CYCLOPENTOLATE 1 % OP DROP 24208073501 $178.24 $178.24 2 mL 8068 VECURONIUM BROMIDE 10 MG IV SOLR 41616093140 $167.00 $167.00 1 Each 8068 VECURONIUM BROMIDE 10 MG IV SOLR 55390003710 $167.00 $167.00 1 Each 8070 PRAMIPEXOLE 0.5 MG PO TABS 00597018561 $167.00 $167.00 100 Each 8080 RABIES IMMUNE GLOBULIN (PF) 150 UNITS/ML IM SOLN 90375 13533061810 $20,979.90 $20,979.90 10 mL 8090 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/GRAM-% TP OINT 51672127201 $744.24 $744.24 15 gram 8098 ALFENTANIL 500 MCG/ML IJ SOLN J3490 00409226605 $167.00 $167.00 5 mL 8114 DRONABINOL 2.5 MG PO CAPS Q0167 00051002121 $3,640.32 $3,640.32 60 Each 8117 AMINOCAPROIC ACID 250 MG/ML IV SOLN J3490 00409434673 $167.00 $167.00 20 mL 8121 METHYLPREDNISOLONE ACETATE 80 MG/ML IJ SUSP J1040 00009347503 $211.33 $211.33 1 mL 8143 LEUPROLIDE 11.25 MG IM KIT J1950 00074228203 $27,174.42 $27,174.42 1 Each 8154 DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SUSP 90700 58160081011 $306.70 $306.70 .5 mL 8178 PAROXETINE HCL 10 MG/5 ML PO SUSP 99999900345 $167.00 $167.00 5 mL 8180 CEFADROXIL 500 MG PO CAPS 57237009650 $444.00 $444.00 50 Each 8181 FLUCONAZOLE IN NACL (ISO-OSM) 200 MG/100 ML IV PGBK J1450 00409468823 $167.00 $167.00 100 mL 8191 METHYLPREDNISOLONE 2 MG PO TABS J7509 00009002001 $2,424.00 $2,424.00 100 Each 8203 CARMUSTINE 100 MG IV SOLR J9050 00015301260 $8,388.90 $8,388.90 1 Each 8226 RISPERIDONE 2 MG PO TABS 50458032001 $201.60 $201.60 100 Each 8235 POTASSIUM CHLORIDE IN WATER 10 MEQ/50 ML IV PGBK J3480 00409707514 $167.00 $167.00 50 mL 8244 TRIFLURIDINE 1 % OP DROP 61314004475 $2,648.04 $2,648.04 7.5 mL 8250 NITROGLYCERIN IN D5W 50 MG/250 ML (0.2 MG/ML) IV SOLN 00409148202 $167.00 $167.00 250 mL 8321 TACROLIMUS 5 MG/ML IV SOLN J7525 00469301601 $1,277.49 $1,277.49 1 mL 8352 CAFFEINE-SODIUM BENZOATE 250 MG/ML (125 MG/ML CAFFEINE) IJ SOLN 00517250210 $276.38 $276.38 2 mL 8360 FOLIC ACID 5 MG/ML IJ SOLN J3490 63323018410 $340.00 $340.00 10 mL 8366 MELPHALAN HCL 50 MG IV SOLR J9245 52609300100 $24,504.48 $24,504.48 1 Each 8387 METHYLERGONOVINE 0.2 MG/ML (1 ML) IJ SOLN J2210 00517074020 $262.96 $262.96 1 mL 8449 BETAMETHASONE ACET,SOD PHOS 6 MG/ML IJ SUSP J0702 00517072001 $506.24 $506.24 5 mL 8495 BENZOCAINE 20 % TP AERO 63736037882 $167.00 $167.00 57 gram 8500 OXYCODONE-ACETAMINOPHEN 5-325 MG PO TABS 00406051262 $385.60 $385.60 100 Each 8529 HYDROCORTISONE 2.5 % TP CRPE 65649040130 $388.32 $388.32 30 gram 8531 DIBUCAINE 1 % TP OINT 54162001101 $167.00 $167.00 28 gram 8575 LIDOCAINE-EPINEPHRINE 1 %-1:100,000 IJ SOLN 00409317801 $167.00 $167.00 20 mL 8575 LIDOCAINE-EPINEPHRINE 1 %-1:100,000 IJ SOLN 00409317803 $167.00 $167.00 50 mL 8622 ALBUMIN, HUMAN 25 % 25 % IV SOLP P9047 44206025110 $966.40 $966.40 100 mL 8622 ALBUMIN, HUMAN 25 % 25 % IV SOLP P9047 44206025105 $483.20 $483.20 50 mL 8622 ALBUMIN, HUMAN 25 % 25 % IV SOLP P9047 68516521605 $399.68 $399.68 20 mL

Pharmacy FY22 MED IDs 201 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 8631 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN J2515 76478050120 $12,267.84 $12,267.84 20 mL 8631 PENTOBARBITAL SODIUM 50 MG/ML IJ SOLN J2515 76478050150 $12,574.80 $12,574.80 50 mL 8639 TERBINAFINE HCL 250 MG PO TABS 16714079501 $167.00 $167.00 30 Each 8654 ALPRAZOLAM 0.5 MG PO TABS 00904585961 $640.00 $640.00 100 Each 8668 DEXTRAN 40 10 % IN 0.9 % NACL 10 % IV SOLP J7100 00409741903 $360.00 $360.00 500 mL 8669 RIFAMPIN 300 MG PO CAPS 51079089020 $1,550.40 $1,550.40 100 Each 8702 FLUPHENAZINE HCL 2.5 MG/ML IJ SOLN 63323028110 $1,341.44 $1,341.44 10 mL 8725 ENTACAPONE 200 MG PO TABS 00078032705 $11,500.80 $11,500.80 100 Each 8740 CEFTRIAXONE 1 GRAM IJ SOLR J0696 63323034610 $167.00 $167.00 1 Each 8740 CEFTRIAXONE 1 GRAM IJ SOLR J0696 00781320895 $167.00 $167.00 1 Each 8767 FENOLDOPAM 10 MG/ML IV SOLN 00409230402 $9,450.40 $9,450.40 2 mL 8791 THIAMINE HCL (VITAMIN B1) 100 MG/ML IJ SOLN J3411 63323001302 $167.00 $167.00 2 mL 8824 SODIUM CHLORIDE 5 % OP OINT 17478062235 $167.00 $167.00 3.5 gram 8857 SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SC SOLN J3030 00781317414 $167.00 $167.00 .5 mL 8862 PROGESTERONE 50 MG/ML IM OIL J2675 00591312879 $462.40 $462.40 10 mL 8908 STREPTOZOCIN 1 GRAM IV SOLR J9320 00703463601 $4,898,240.00 $4,898,240.00 1000 mg 8925 HYDROMORPHONE 2 MG PO TABS 00406324301 $167.00 $167.00 100 Each 8929 ALPRAZOLAM 0.25 MG PO TABS 67253090010 $167.00 $167.00 100 Each 8932 TRIPTORELIN PAMOATE 3.75 MG IM SUSR J3315 00023590204 $12,128.32 $12,128.32 1 Each 8944 CLINDAMYCIN PALMITATE HCL 75 MG/5 ML PO SOLR 00009076004 $395.20 $395.20 100 mL 8953 AMOBARBITAL 500 MG IJ SOLR J0300 00187430305 $10,932.48 $10,932.48 1 Each 8991 ALTEPLASE 100 MG IV SOLR J2997 50242008527 $73,825.38 $73,825.38 1 Each 8998 ZIPRASIDONE HCL 20 MG PO CAPS 68180033107 $1,193.28 $1,193.28 60 Each 9050 DOBUTAMINE IN D5W 500 MG/250 ML (2,000 MCG/ML) IV SOLP J1250 00409234732 $167.00 $167.00 250 mL 9067 ESMOLOL 100 MG/10 ML (10 MG/ML) IV SOLN 67457018210 $167.00 $167.00 10 mL 9085 ESTRADIOL 0.025 MG/24 HR TD PTWK 00378334999 $1,001.92 $1,001.92 4 Each 9087 PRAVASTATIN 80 MG PO TABS 60505132309 $273.60 $273.60 90 Each 9114 TOLTERODINE 2 MG PO TABS 00009454402 $6,896.64 $6,896.64 60 Each 9118 LEUCOVORIN CALCIUM 100 MG IJ SOLR J0640 00703514001 $167.00 $167.00 1 Each 9137 PREDNISOLONE ACETATE 1 % OP DRPS 11980018001 $167.00 $167.00 1 mL 9137 PREDNISOLONE ACETATE 1 % OP DRPS 61314063705 $660.00 $660.00 5 mL 9146 DIPHENHYDRAMINE HCL 50 MG/ML IJ SOLN J1200 00641037625 $167.00 $167.00 50 mg 9179 SUFENTANIL CITRATE 50 MCG/ML IV SOLN 17478005002 $167.00 $167.00 2 mL 9179 SUFENTANIL CITRATE 50 MCG/ML IV SOLN 00409338049 $167.00 $167.00 1 mL 9202 SIROLIMUS 1 MG/ML PO SOLN J7520 00008103006 $27,083.52 $27,083.52 60 mL 9231 ONDANSETRON HCL 4 MG/5 ML PO SOLN 68094076362 $190.40 $190.40 5 mL 9231 ONDANSETRON HCL 4 MG/5 ML PO SOLN 99999999996 $190.32 $190.32 5 mL 9245 LORAZEPAM 0.5 MG PO TABS 63739049910 $167.00 $167.00 100 Each 9252 METHOCARBAMOL 750 MG PO TABS 63739016710 $167.00 $167.00 100 Each 9252 METHOCARBAMOL 750 MG PO TABS 00603448628 $800.00 $800.00 500 Each 9268 PRAVASTATIN 10 MG PO TABS 60505016809 $345.60 $345.60 90 Each 9301 CALCIUM CHLORIDE 100 MG/ML (10 %) IV SOLN 00517271025 $167.00 $167.00 10 mL 9325 TEMAZEPAM 15 MG PO CAPS 51079041820 $167.00 $167.00 100 Each 9336 SODIUM NITRITE 30 MG/ML IV SOLN 60267031110 $1,424.00 $1,424.00 10 mL 9347 TOPOTECAN 4 MG IV SOLR J9351 16729015131 $644.64 $644.64 1 Each 9354 TRIAMCINOLONE ACETONIDE 0.1 % DT PSTE 51672126705 $961.44 $961.44 5 gram 9359 CEFAZOLIN IN DEXTROSE (ISO-OS) 1 GRAM/50 ML IV PGBK J0690 00264310311 $169.26 $169.26 1 Each 9360 ETOMIDATE 2 MG/ML IV SOLN 55390076210 $167.00 $167.00 10 mL 9360 ETOMIDATE 2 MG/ML IV SOLN 00409669501 $167.00 $167.00 10 mL 9418 MORPHINE 20 MG/5 ML (4 MG/ML) PO SOLN 00054023849 $193.60 $193.60 100 mL 9418 MORPHINE 20 MG/5 ML (4 MG/ML) PO SOLN 00054023863 $520.00 $520.00 500 mL 9466 FENTANYL 100 MCG/HR TD PT72 00591321472 $836.64 $836.64 5 Each 9469 PROMETHAZINE 12.5 MG PR SUPP J8498 00713053612 $1,744.51 $1,744.51 12 Each 9484 EXEMESTANE 25 MG PO TABS 00009766304 $764.64 $764.64 30 Each 9499 FAMCICLOVIR 500 MG PO TABS 00093811956 $494.40 $494.40 30 Each 9503 LEVOTHYROXINE 200 MCG IV SOLR 63323064710 $2,432.96 $2,432.96 1 Each 9514 POTASSIUM CHLORIDE IN WATER 40 MEQ/100 ML IV PGBK J3480 00409707726 $167.00 $167.00 100 mL 9526 LYMPHOCYTE,ANTI-THYMO IMM GLOB 50 MG/ML IV SOLN J7504 00009722402 $19,212.80 $19,212.80 5 mL 9541 SIROLIMUS 1 MG PO TABS J7520 00008104110 $47,395.20 $47,395.20 100 Each 9547 MORPHINE 10 MG/ML IJ SOLN J2270 63323045101 $167.00 $167.00 1 mL 9554 HYDROMORPHONE 2 MG/ML IJ SOLN J1170 00641012125 $167.00 $167.00 1 mL 9573 DACARBAZINE 200 MG IV SOLR J9130 63323012820 $167.00 $167.00 1 Each 9573 DACARBAZINE 200 MG IV SOLR J9130 00703507501 $244.80 $244.80 1 Each 9583 METHOTREXATE SODIUM 2.5 MG PO TABS J8610 00054855025 $3,268.80 $3,268.80 100 Each 9620 LIDOCAINE HCL 4 % (40 MG/ML) MM SOLN 00054350547 $596.80 $596.80 50 mL 9682 HOMATROPINE HBR 5 % OP DROP 54799043105 $551.20 $551.20 5 mL 9696 THIOGUANINE 40 MG PO TABS 76388088025 $9,330.00 $9,330.00 25 Each 9707 POTASSIUM CHLORIDE IN WATER 20 MEQ/100 ML IV PGBK J3480 00338070548 $167.00 $167.00 100 mL 9728 GENTAMICIN 0.3 % OP DROP 61314063305 $231.20 $231.20 5 mL 9766 OXYCODONE-ACETAMINOPHEN 10-325 MG PO TABS 00406052362 $2,825.60 $2,825.60 100 Each 9771 RIFAMPIN 150 MG PO CAPS 00185080101 $3,867.20 $3,867.20 100 Each 9784 AMPHOTERICIN B LIPID COMPLEX 5 MG/ML IV SUSP J0287 57665010141 $1,397.76 $1,397.76 20 mL 9785 REPAGLINIDE 0.5 MG PO TABS 65862067001 $352.00 $352.00 100 Each 9794 TAMSULOSIN 0.4 MG PO CAPS 00597005801 $633.60 $633.60 100 Each 9811 LINEZOLID 600 MG PO TABS 67877041984 $1,545.60 $1,545.60 30 Each

Pharmacy FY22 MED IDs 202 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 9866 LEVOTHYROXINE 500 MCG IV SOLR J3490 63323064810 $5,889.92 $5,889.92 1 Each 9879 HYDROCORTISONE-ACETIC ACID 1-2 % OT DROP 50383090110 $2,402.88 $2,402.88 10 mL 9977 DOXYCYCLINE HYCLATE 100 MG IV SOLR J3490 63323013011 $300.66 $300.66 1 Each 9978 AMPICILLIN-SULBACTAM 3 GRAM IJ SOLR J0295 00641611701 $167.00 $167.00 1 Each 10013 FLUPHENAZINE DECANOATE 25 MG/ML IJ SOLN J2680 63323027205 $2,311.04 $2,311.04 5 mL 10028 MORPHINE 100 MG PO TBSR 00406839062 $4,744.00 $4,744.00 100 Each 10046 AMOXICILLIN 250 MG/5 ML PO SUSR 00781604155 $167.00 $167.00 150 mL 10071 ETOPOSIDE 20 MG/ML IV SOLN J9181 00703565301 $167.00 $167.00 5 mL 10071 ETOPOSIDE 20 MG/ML IV SOLN J9181 00703565601 $566.40 $566.40 25 mL 10071 ETOPOSIDE 20 MG/ML IV SOLN J9181 16729011431 $167.00 $167.00 5 mL 10079 RISPERIDONE 1 MG/ML PO SOLN 50458059601 $228.96 $228.96 30 mL 10115 CISPLATIN 1 MG/ML IV SOLN J9060 63323010365 $249.60 $249.60 100 mL 10115 CISPLATIN 1 MG/ML IV SOLN J9060 00703574711 $193.60 $193.60 50 mL 10115 CISPLATIN 1 MG/ML IV SOLN J9060 00703574811 $387.20 $387.20 100 mL 10155 CIPROFLOXACIN HCL 0.3 % OP DROP 61314065605 $376.32 $376.32 5 mL 10155 CIPROFLOXACIN HCL 0.3 % OP DROP 61314065625 $199.04 $199.04 2.5 mL 10156 CALCITONIN (SALMON) 200 UNIT/ACTUATION NA SPRY 60505082306 $279.51 $279.51 3.7 mL 10163 TAMOXIFEN 10 MG PO TABS 63739026910 $585.60 $585.60 100 Each 10180 GEMCITABINE 200 MG IV SOLR J9201 47335015340 $167.00 $167.00 1 Each 10188 FLUCONAZOLE 10 MG/ML PO SUSR 59762502901 $241.36 $241.36 35 mL 10222 IMIQUIMOD 5 % TP CRPK 00168043224 $2,281.73 $2,281.73 24 Each 10254 BLEOMYCIN 15 UNITS IJ SOLR J9040 00703315401 $723.36 $723.36 1 Each 10292 PIPERACILLIN-TAZOBACTAM 3.375 GRAM IV SOLR J2543 00206885416 $167.00 $167.00 1 Each 10292 PIPERACILLIN-TAZOBACTAM 3.375 GRAM IV SOLR J2543 39822012503 $167.00 $167.00 1 Each 10301 SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) IV SOLN J3490 67457016302 $1,165.15 $1,165.15 2 mL 10304 SODIUM BICARBONATE 650 MG PO TABS 64980029410 $167.00 $167.00 1000 Each 10308 FOMEPIZOLE 1 G/ML IV SOLN J1451 00781318284 $13,757.76 $13,757.76 1.5 mL 10318 LORAZEPAM 2 MG PO TABS 00904600961 $167.00 $167.00 100 Each 10345 MORPHINE 60 MG PO TBSR 00406838062 $2,558.40 $2,558.40 100 Each 10346 DIAZEPAM 2 MG PO TABS 51079028420 $167.00 $167.00 100 Each 10355 PHENYTOIN SODIUM 50 MG/ML IV SOLN J1165 00641255545 $167.00 $167.00 5 mL 10355 PHENYTOIN SODIUM 50 MG/ML IV SOLN J1165 00641049325 $167.00 $167.00 2 mL 10372 SULFACETAMIDE SODIUM 10 % OP DROP 60758001805 $212.32 $212.32 5 mL 10372 SULFACETAMIDE SODIUM 10 % OP DROP 61314070101 $560.88 $560.88 15 mL 10387 DILTIAZEM HCL 300 MG PO CP24 00187079842 $78,353.28 $78,353.28 90 Each 10417 CLINDAMYCIN IN 5 % DEXTROSE 900 MG/50 ML IV PGBK J3490 00781329009 $167.00 $167.00 50 mL 10420 ETHAMBUTOL 400 MG PO TABS 68850001202 $1,163.20 $1,163.20 100 Each 10447 DIATRIZOATE MEGLUMINE 30 % UR SOLN Q9958 00270014957 $16,785.00 $16,785.00 300 mL 10471 SODIUM HYALURONATE 10 MG/ML IO SYRG 05047450858 $710.72 $710.72 .55 mL 10481 OXACILLIN 2 GRAM IJ SOLR J2700 55150012824 $167.00 $167.00 1 Each 10484 ACARBOSE 100 MG PO TABS 00054014225 $902.40 $902.40 100 Each 10528 BIVALIRUDIN 250 MG IV SOLR J0583 65293000101 $1,258.70 $1,258.70 1 Each 10535 TIMOLOL MALEATE 0.25 % OP DROP 61314022605 $167.00 $167.00 5 mL 10574 HOMEOPATHIC PRODUCTS TP OINT 8764710176 $272.00 $272.00 100 gram 10574 HOMEOPATHIC PRODUCTS TP OINT 62795700307 $167.00 $167.00 50 gram 10574 HOMEOPATHIC PRODUCTS TP OINT 62795700407 $167.00 $167.00 57 gram 10578 NALBUPHINE 10 MG/ML IJ SOLN J2300 00409146401 $449.12 $449.12 10 mL 10578 NALBUPHINE 10 MG/ML IJ SOLN J2300 00409146301 $167.00 $167.00 1 mL 10585 HYDROCORTISONE 1 % TP CREA 00168001516 $892.69 $892.69 453.6 gram 10585 HYDROCORTISONE 1 % TP CREA 00573283010 $167.00 $167.00 26 gram 10585 HYDROCORTISONE 1 % TP CREA 51672201301 $167.00 $167.00 14.2 gram 10585 HYDROCORTISONE 1 % TP CREA 00168015431 $167.00 $167.00 28.35 gram 10606 BELLADONNA ALKALOIDS-OPIUM 16.2-30 MG PR SUPP 00574704512 $3,931.39 $3,931.39 12 Each 10625 IFOSFAMIDE 3 GRAM IV SOLR J9208 10019092616 $1,267.68 $1,267.68 1 Each 10670 DOXORUBICIN 2 MG/ML IV SOLN J9000 00703504001 $2,099.20 $2,099.20 100 mL 10685 TRIAMCINOLONE ACETONIDE 40 MG/ML IJ SUSP J3301 00003029320 $708.48 $708.48 5 mL 10714 PHENYLEPHRINE HCL 1 % NA SPRY 00024135202 $167.00 $167.00 15 mL 10728 DORNASE ALFA 1 MG/ML IN SOLN J7639 50242010040 $1,713.88 $1,713.88 2.5 mL 10745 GRANISETRON HCL 1 MG/ML IV SOLN J1626 00143974501 $167.00 $167.00 4 mL 10745 GRANISETRON HCL 1 MG/ML IV SOLN J1626 00143974505 $167.00 $167.00 4 mL 10751 MIFEPRISTONE 200 MG PO TABS S0190 64875000101 $864.00 $864.00 1 Each 10760 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS 00406012462 $460.80 $460.80 100 Each 10780 IOHEXOL 240 MG IODINE/ML IV SOLN Q9966 00407141210 $314.06 $314.06 10 mL 10780 IOHEXOL 240 MG IODINE/ML IV SOLN Q9966 00407141220 $625.68 $625.68 20 mL 10790 DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NA SPRY 24208034205 $1,302.88 $1,302.88 5 mL 10814 CEPHALEXIN 500 MG PO CAPS 68180012202 $2,016.00 $2,016.00 500 Each 10851 COCAINE 4 % TP SOLN C9046 00527172874 $3,616.96 $3,616.96 4 mL 10876 PANTOPRAZOLE 40 MG PO TBEC 65862056090 $223.20 $223.20 90 Each 10877 METHYLPREDNISOLONE SODIUM SUCC 1000 MG IV SOLR J2930 00009069801 $655.20 $655.20 1 Each 10885 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OP OINT 00574402439 $223.27 $223.27 3.5 gram 10885 ERYTHROMYCIN 5 MG/GRAM (0.5 %) OP OINT 24208091019 $167.00 $167.00 1 gram 10891 VENLAFAXINE 37.5 MG PO TABS 00093738001 $478.40 $478.40 100 Each 10901 OXYTOCIN 10 UNITS/ML IJ SOLN J2590 63323001201 $167.00 $167.00 1 mL 10901 OXYTOCIN 10 UNITS/ML IJ SOLN J2590 63323001210 $167.00 $167.00 10 mL 10923 ACETAZOLAMIDE SODIUM 500 MG IJ SOLR J1120 00143950301 $365.44 $365.44 1 Each

Pharmacy FY22 MED IDs 203 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 10938 METHYLPREDNISOLONE ACETATE 40 MG/ML IJ SUSP J1030 00009307303 $167.00 $167.00 1 mL 10941 ACYCLOVIR 5 % TP OINT 00378870049 $2,237.28 $2,237.28 30 gram 10947 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML IJ SOLN J3420 00517003125 $167.00 $167.00 1 mL 10947 CYANOCOBALAMIN (VITAMIN B-12) 1000 MCG/ML IJ SOLN J3420 00517003225 $648.80 $648.80 10 mL 11009 OSELTAMIVIR 75 MG PO CAPS 00004080085 $2,265.12 $2,265.12 10 Each 11016 PYRIDOXINE (VITAMIN B6) 100 MG/ML IJ SOLN J3415 63323018001 $167.00 $167.00 1 mL 11037 TELMISARTAN 40 MG PO TABS 00591329345 $167.00 $167.00 1 Each 11042 FOSCARNET 24 MG/ML IV SOLN J1455 76310002425 $6,616.00 $6,616.00 250 mL 11075 FLUCONAZOLE 50 MG PO TABS 68462010130 $298.08 $298.08 30 Each 11099 ETHAMBUTOL 100 MG PO TABS 54879000101 $566.40 $566.40 100 Each 11112 CEPHALEXIN 250 MG/5 ML PO SUSR 00093417773 $188.80 $188.80 100 mL 11112 CEPHALEXIN 250 MG/5 ML PO SUSR 00093417774 $342.40 $342.40 200 mL 11121 TETRACAINE HCL (PF) 1 % (10 MG/ML) IJ SOLN J3490 17478004532 $1,132.54 $1,132.54 2 mL 11154 CONJUGATED ESTROGENS 0.625 MG/GRAM VA CREA 00046087221 $6,025.44 $6,025.44 30 gram 11186 LIDOCAINE HCL 5 MG/ML (0.5 %) IJ SOLN J2001 00409427501 $167.00 $167.00 50 mL 11212 LEUPROLIDE (3 MONTH) 22.5 MG IM SYKT J9217 00074334603 $44,480.79 $44,480.79 1 Each 11233 GEMCITABINE 1 GRAM IV SOLR J9201 00002750201 $246.08 $246.08 1 Each 11241 CROTALIDAE POLYVAL IMMUNE FAB IJ SOLR J0840 50633011012 $26,827.70 $26,827.70 1 Each 11281 FACTOR IX CPLX(PCC)NO4,3FACTOR 1,000 (+/-) UNIT IV SOLR J7194 68516320202 $18,880.00 $18,880.00 1 Each 11304 NEOMYCIN-POLYMYXIN B-DEXAMETH 3.5MG/ML-10,000 UNIT/ML-0.1 % OP DRPS 24208083060 $219.36 $219.36 5 mL 11331 AZTREONAM 2 GRAM IJ SOLR 63323040220 $806.38 $806.38 1 Each 11346 TOBRAMYCIN 0.3 % OP DROP 61314064305 $231.20 $231.20 5 mL 11352 TRIAMCINOLONE ACETONIDE 0.1 % TP OINT 00168000615 $167.00 $167.00 15 gram 11352 TRIAMCINOLONE ACETONIDE 0.1 % TP OINT 00168000680 $172.80 $172.80 80 gram 11352 TRIAMCINOLONE ACETONIDE 0.1 % TP OINT 00168000616 $370.14 $370.14 453.6 gram 11354 CISATRACURIUM 2 MG/ML IV SOLN 00074438010 $167.00 $167.00 10 mL 11354 CISATRACURIUM 2 MG/ML IV SOLN 00781315095 $167.00 $167.00 5 mL 11364 MYCOPHENOLATE MOFETIL 200 MG/ML PO SUSR J7517 00004026129 $16,064.00 $16,064.00 160 mL 11384 MINOCYCLINE 100 MG IV SOLR J2265 65293001410 $2,879.84 $2,879.84 1 Each 11390 NYSTATIN 100000 UNIT/GRAM TP CREA 00168005415 $167.00 $167.00 15 gram 11402 DIPYRIDAMOLE 5 MG/ML IV SOLN J1245 00641256941 $274.88 $274.88 10 mL 11435 HYDROCORTISONE-PRAMOXINE 1-1 % PR FOAM 00037682210 $2,096.96 $2,096.96 10 gram 11462 MITOMYCIN 5 MG IV SOLR J9280 16729011505 $762.56 $762.56 1 Each 11479 MITOXANTRONE 2 MG/ML IV CONC J9293 63323013210 $1,526.56 $1,526.56 10 mL 11489 CLOTRIMAZOLE-BETAMETHASONE 1-0.05 % TP CREA 51672404801 $251.52 $251.52 15 gram 11536 ADENOSINE 3 MG/ML IV SOLN J0153 67457085502 $167.00 $167.00 2 mL 11546 ISONIAZID 100 MG/ML IJ SOLN 00781305670 $4,148.32 $4,148.32 10 mL 11549 DEPACON 500 MG/5 ML (100 MG/ML) IV SOLN 00074156410 $167.00 $167.00 5 mL 11576 BOSENTAN 62.5 MG PO TABS 66215010106 $223,324.80 $223,324.80 60 Each 11655 CYCLOPENTOLATE 2 % OP DROP 00065039702 $535.20 $535.20 2 mL 11677 ATROPINE 0.1 MG/ML IJ SYRG J0461 00409491134 $167.00 $167.00 10 mL 11691 MEROPENEM 1 GRAM IV SOLR J2185 00310032130 $167.00 $167.00 1 Each 11704 INSULIN REGULAR HUMAN 100 UNITS/ML IJ SOLN J1815 00002821517 $167.00 $167.00 3 mL 11716 ALBENDAZOLE 200 MG PO TABS 69097023772 $2,043.20 $2,043.20 2 Each 11730 INFLIXIMAB 100 MG IV SOLR J1745 57894003001 $8,703.84 $9,791.82 1 Each 11761 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML PO SUSR 24338013213 $3,632.00 $3,632.00 100 mL 11761 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML PO SUSR 24338013402 $1,683.20 $1,683.20 100 mL 11761 ERYTHROMYCIN ETHYLSUCCINATE 200 MG/5 ML PO SUSR 24338013610 $2,960.00 $2,960.00 200 mL 11789 FLUOROMETHOLONE 0.1 % OP DRPS 60758088005 $1,059.68 $1,059.68 5 mL 11807 CEFAZOLIN 500 MG IJ SOLR J0690 63323023610 $167.00 $167.00 1 Each 11807 CEFAZOLIN 500 MG IJ SOLR J0690 00781345095 $167.00 $167.00 1 Each 11814 FENTANYL CITRATE (PF)-0.9%NACL 10 MCG/ML IV SOLN 71286207105 $884.00 $884.00 250 mL 11847 CLONAZEPAM 2 MG PO TABS 51079088320 $167.00 $167.00 100 Each 11888 CHLOROPROCAINE (PF) 30 MG/ML (3 %) IJ SOLN J2400 63323047827 $313.92 $313.92 20 mL 11900 POVIDONE-IODINE 5 % OP SOLN 00065041130 $167.00 $167.00 30 mL 11907 ISOSULFAN BLUE 1 % SC SOLN Q9968 63261025021 $14,917.60 $14,917.60 5 mL 11938 POLYMYXIN B SULF-TRIMETHOPRIM 10,000 UNIT- 1 MG/ML OP DROP 24208031510 $167.00 $167.00 10 mL 11983 CARBACHOL 0.01 % IO SOLN 00065002315 $204.91 $204.91 1.5 mL 11987 DIGOXIN 100 MCG/ML (0.1 MG/ML) IJ SOLN J1160 70515026210 $1,714.69 $1,714.69 1 mL 11994 TELMISARTAN 80 MG PO TABS 00591329445 $167.00 $167.00 1 Each 12002 CABERGOLINE 0.5 MG PO TABS 49884067314 $682.11 $682.11 8 Each 12009 METHYLPHENIDATE HCL 20 MG PO TBSR 00406147301 $4,568.00 $4,568.00 100 Each 12015 TRACE ELEMENTS CR-CU-MN-SE-ZN 4-400-100-20 -1000 MCG/ML IV SOLN 00517851025 $192.00 $192.00 10 mL 12053 AMPICILLIN SODIUM 500 MG IJ SOLR J0290 00409371801 $167.00 $167.00 1 Each 12060 IDARUBICIN 1 MG/ML IV SOLN J9211 00013257691 $688.64 $688.64 5 mL 12060 IDARUBICIN 1 MG/ML IV SOLN J9211 00013258691 $1,376.96 $1,376.96 10 mL 12061 METHOTREXATE SODIUM (PF) 1 GRAM IJ SOLR J9260 63323012250 $939.04 $939.04 1 Each 12070 DEXMEDETOMIDINE 100 MCG/ML IV SOLN J3490 00409163802 $167.00 $167.00 200 mcg 12070 DEXMEDETOMIDINE 100 MCG/ML IV SOLN J3490 44567060004 $298.11 $298.11 4 mL 12078 MESNA 100 MG/ML IV SOLN J9209 25021020111 $219.20 $219.20 10 mL 12100 IRON SUCROSE 100 MG IRON/5 ML IV SOLN J1756 00517234010 $307.60 $492.16 5 mL 12138 FLUTICASONE PROPIONATE 44 MCG/ACTUATION IN HFAA 00173071820 $1,336.36 $1,336.36 10.6 gram 12195 URSODIOL 250 MG PO TABS 58914078510 $992.00 $992.00 100 Each 12200 HYDROCORTISONE 100 MG/60 ML PR ENEM 00574202007 $316.80 $316.80 60 mL 12206 LOSARTAN 25 MG PO TABS 65862020190 $167.00 $167.00 90 Each

Pharmacy FY22 MED IDs 204 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 12239 BRIMONIDINE 0.2 % OP DROP 61314014305 $223.68 $223.68 5 mL 12255 DIGOXIN IMMUNE FAB 40 MG IV SOLR J1162 50633012011 $33,337.53 $33,337.53 1 Each 12268 EDETATE CALCIUM DISODIUM 200 MG/ML IJ SOLN J0600 99207024005 $86,167.20 $86,167.20 5 mL 12273 DIVALPROEX 125 MG PO TBEC 62756079688 $167.00 $167.00 100 Each 12275 OXYCODONE 5 MG PO CAPS 68462020401 $2,192.00 $2,192.00 100 Each 12301 EPINEPHRINE 0.1 MG/ML IJ SYRG J0171 00409492134 $167.00 $167.00 10 mL 12325 VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) IV SOLN 55390000710 $167.00 $167.00 5 mL 12352 POTASSIUM CHLORIDE IN LR-D5 20 MEQ/L IV SOLP J3480 00338081104 $167.00 $167.00 1000 mL 12446 INTERFERON ALFA-2B 10 MILLION UNIT/ML IJ SOLN J9214 00085113301 $14,749.59 $14,749.59 3.2 mL 12458 TOBRAMYCIN SULFATE 1.2 GRAM IJ SOLR J3260 39822041206 $1,473.97 $1,473.97 1 Each 12477 HYDROCORTISONE 20 MG PO TABS 59762007501 $726.40 $726.40 100 Each 12484 INSULIN NPH ISOPH U-100 HUMAN 100 UNITS/ML SC SUSP J1815 00002831517 $167.00 $167.00 3 mL 12503 CAPECITABINE 150 MG PO TABS J8520 00004110020 $12,131.52 $12,131.52 60 Each 12523 CLOTRIMAZOLE 1 % TP SOLN 51672203701 $456.80 $456.80 10 mL 12542 CASPOFUNGIN 70 MG IV SOLR J0637 00006382310 $5,232.96 $5,232.96 1 Each 12578 CHLORPROMAZINE 25 MG/ML IJ SOLN J3230 00641139735 $347.92 $347.92 1 mL 12578 CHLORPROMAZINE 25 MG/ML IJ SOLN J3230 00641139835 $398.66 $398.66 2 mL 12586 MECHLORETHAMINE 10 MG IJ SOLR J9230 55292091151 $19,821.44 $19,821.44 4 Each 12639 SALMETEROL 50 MCG/DOSE IN DSDV 00173052100 $3,035.04 $3,035.04 60 Each 12678 POTASSIUM CHLORIDE IN 0.9%NACL 20 MEQ/L IV SOLP J3480 00409711509 $167.00 $167.00 1000 mL 12686 OLANZAPINE 10 MG PO TBDL 00002445485 $747.36 $747.36 30 Each 12694 DINOPROSTONE 10 MG VA INSR 55566280001 $6,490.88 $6,490.88 1 Each 12729 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TP CREA 00168008115 $1,001.52 $1,001.52 15 gram 12729 NYSTATIN-TRIAMCINOLONE 100,000-0.1 UNIT/G-% TP CREA 00168008130 $438.72 $438.72 30 gram 12768 PRALIDOXIME 1 GRAM IJ SOLR J2730 60977014101 $7,758.05 $7,758.05 6 Each 12801 ZIDOVUDINE 300 MG PO TABS 65862002460 $352.32 $352.32 60 Each 12824 NITROGLYCERIN 400 MCG/SPRAY TL SPRY 45802021002 $3,146.11 $3,146.11 12 gram 12824 NITROGLYCERIN 400 MCG/SPRAY TL SPRY 45802021001 $1,615.82 $1,615.82 4.9 gram 12831 AMPICILLIN-SULBACTAM 1.5 GRAM IJ SOLR J0295 25021014220 $167.00 $167.00 1 Each 12861 TEMOZOLOMIDE 5 MG PO CAPS J8700 00093759941 $539.39 $539.39 14 Each 12863 CLADRIBINE 10 MG/10 ML IV SOLN J9065 63323014010 $1,815.36 $1,815.36 10 mL 12876 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN J3010 00409909335 $167.00 $167.00 5 mL 12876 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN J3010 00409909332 $167.00 $167.00 2 mL 12876 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN J3010 00641603001 $360.80 $360.80 50 mL 12876 FENTANYL CITRATE (PF) 50 MCG/ML IJ SOLN J3010 00409909345 $167.00 $167.00 5 mL 12975 PRAMIPEXOLE 0.125 MG PO TABS 00597018390 $167.00 $167.00 90 Each 12990 VENLAFAXINE 50 MG PO TABS 00093738101 $486.40 $486.40 100 Each 13030 CEFDINIR 125 MG/5 ML PO SUSR 16714039201 $384.96 $384.96 60 mL 13086 TRIAMCINOLONE ACETONIDE 0.025 % TP OINT 45802005435 $167.00 $167.00 15 gram 13136 AMPICILLIN SODIUM 2 GRAM IJ SOLR J0290 67457035210 $167.00 $167.00 1 Each 13147 IOHEXOL 350 MG IODINE/ML IV SOLN Q9967 00407141482 $475.30 $475.30 50 mL 13150 CLARITHROMYCIN 250 MG/5 ML PO SUSR 00781602352 $1,018.40 $1,018.40 50 mL 13178 POTASSIUM CHLORIDE-D5-0.2%NACL 20 MEQ/L IV SOLP J3480 00409790109 $167.00 $167.00 1000 mL 13181 MUPIROCIN CALCIUM 2 % TP CREA 00029152722 $2,272.80 $2,272.80 15 gram 13181 MUPIROCIN CALCIUM 2 % TP CREA 00029152725 $3,652.80 $3,652.80 30 gram 13189 LEUPROLIDE (4 MONTH) 30 MG IM SYKT J9217 00074368303 $59,307.84 $59,307.84 1 Each 13207 MILRINONE 1 MG/ML IV SOLN J2260 00143971010 $167.00 $167.00 10 mL 13207 MILRINONE 1 MG/ML IV SOLN J2260 55390001910 $167.00 $167.00 10 mL 13207 MILRINONE 1 MG/ML IV SOLN J2260 55390002010 $167.00 $167.00 20 mL 13209 RILUZOLE 50 MG PO TABS 60505328506 $2,362.56 $2,362.56 60 Each 13212 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP 99999900380 $167.00 $167.00 20 mL 13212 SULFAMETHOXAZOLE-TRIMETHOPRIM 200-40 MG/5 ML PO SUSP 99999900393 $167.00 $167.00 10 mL 13213 CALCITRIOL 1 MCG/ML IV SOLN J0636 17478093101 $167.00 $167.00 1 mL 13235 ACETIC ACID 0.25 % IR SOLN 00409614309 $167.00 $167.00 1000 mL 13240 AMPHOTERICIN B 50 MG IJ SOLR J0285 39822105505 $536.16 $536.16 1 Each 13248 MORPHINE 10 MG/5 ML PO SOLN 00054023749 $167.00 $167.00 100 mL 13248 MORPHINE 10 MG/5 ML PO SOLN 00054023763 $304.00 $304.00 500 mL 13248 MORPHINE 10 MG/5 ML PO SOLN 99999001240 $167.00 $167.00 5 mL 13271 ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) IO KIT 24208053920 $1,073.28 $1,073.28 1 Each 13276 KETAMINE 10 MG/ML IJ SOLN J3490 42023011310 $253.44 $253.44 20 mL 13290 VINCRISTINE 1 MG/ML IV SOLN J9370 61703030906 $167.00 $167.00 1 mL 13324 OXYBUTYNIN CHLORIDE 5 MG PO TR24 51079072220 $1,102.40 $1,102.40 100 Each 13327 DIAZEPAM 5 MG/ML PO CONC 00054318544 $448.32 $448.32 30 mL 13330 PRAMIPEXOLE 0.25 MG PO TABS 00597018461 $167.00 $167.00 100 Each 13351 MERCAPTOPURINE 50 MG PO TABS 00054458111 $708.80 $708.80 25 Each 13404 MOMETASONE 50 MCG/ACTUATION NA SPRY 00085128801 $1,874.49 $1,874.49 17 gram 13421 CHLOROTHIAZIDE SODIUM 500 MG IV SOLR J1205 63323065820 $633.76 $633.76 1 Each 13423 SELENIUM 40 MCG/ML IV SOLN 00517651025 $3,042.24 $3,042.24 10 mL 13426 BUDESONIDE 0.25 MG IN NBSP J7626 00186198804 $167.00 $167.00 2 mL 13443 CAFFEINE CITRATE 60 MG/3 ML (20 MG/ML) IV SOLN J0706 55150018703 $167.00 $167.00 3 mL 13446 TOBRAMYCIN 0.3 % OP OINT 00065064435 $3,196.82 $3,196.82 3.5 gram 13466 LIDOCAINE HCL 2 % MM SOLN 50383077517 $167.00 $167.00 15 mL 13568 ZINC CHLORIDE 1 MG/ML IV SOLN 00409409001 $206.88 $206.88 10 mL 13582 BUDESONIDE 0.5 MG IN NBSP J7626 00186198904 $167.00 $167.00 2 mL 13621 GENTAMICIN 0.1 % TP CREA 45802005635 $569.76 $569.76 15 gram

Pharmacy FY22 MED IDs 205 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 13631 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP DROP 00065035905 $750.72 $750.72 5 mL 13631 CYCLOPENTOLATE-PHENYLEPHRINE 0.2-1 % OP DROP 00065035902 $427.36 $427.36 2 mL 13633 CORTICORELIN OVINE TRIFLUTATE 100 MCG IV SOLR J0795 55566030201 $13,609.60 $13,609.60 1 Each 13642 BACLOFEN 2000 MCG/ML IT SOLN J0476 70257056302 $6,660.00 $6,660.00 20 mL 13700 VANCOMYCIN 500 MG IV SOLR J3370 00409433201 $167.00 $167.00 500 mg 13701 CHLORDIAZEPOXIDE-CLIDINIUM 5-2.5 MG PO CAPS 00187410010 $3,915.20 $3,915.20 100 Each 13709 TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN J3260 63323030602 $167.00 $167.00 80 mg 13709 TOBRAMYCIN SULFATE 40 MG/ML IJ SOLN J3260 67457047322 $495.36 $495.36 80 mg 13741 RALOXIFENE 60 MG PO TABS 60687026621 $2,411.04 $2,411.04 30 Each 13779 OCTREOTIDE ACETATE 200 MCG/ML IJ SOLN J2354 62756035040 $359.20 $359.20 5 mL 13816 STRONTIUM-89 CHLORIDE 1 MCI/ML IV SOLN A9600 17156052401 $87,771.45 $87,771.45 4 mL 13819 BENZTROPINE 1 MG/ML IJ SOLN J0515 17478001202 $683.94 $683.94 2 mL 13830 HALOPERIDOL DECANOATE 50 MG/ML IM SOLN J1631 10147092103 $293.28 $293.28 1 mL 13830 HALOPERIDOL DECANOATE 50 MG/ML IM SOLN J1631 50458025303 $293.28 $293.28 1 mL 13899 BUSULFAN 60 MG/10 ML IV SOLN J0594 59148007091 $414.18 $414.18 10 mL 13932 VERAPAMIL 2.5 MG/ML IV SOLN 00409114401 $167.00 $167.00 2 mL 13992 IMIPENEM-CILASTATIN 250 MG IV SOLR J0743 63323034925 $167.00 $167.00 1 Each 14028 DILTIAZEM HCL 120 MG PO CP24 62037059790 $367.20 $367.20 90 Each 14028 DILTIAZEM HCL 120 MG PO CP24 60687019501 $404.80 $404.80 100 Each 14038 FLUORESCEIN-PROPARACAINE 0.25-0.5 % OP DROP 54799050721 $549.60 $549.60 5 mL 14053 PRAMOXINE-CALAMINE 1-8 % TP LOTN 49348033736 $167.00 $167.00 177 mL 14083 PYRIDOSTIGMINE BROMIDE 180 MG PO TBSR 00187301330 $2,967.84 $2,967.84 30 Each 14113 LEUCOVORIN CALCIUM 5 MG PO TABS 00054449625 $880.00 $880.00 100 Each 14144 CIPROFLOXACIN HCL 0.3 % OP OINT 00065065435 $3,196.82 $3,196.82 3.5 gram 14172 HYDROCORTISONE 2.5 % TP CREA 00168008031 $167.00 $167.00 30 gram 14172 HYDROCORTISONE 2.5 % TP CREA 00168008016 $892.69 $892.69 453.6 gram 14183 AMOXICILLIN 250 MG PO CAPS 16714029801 $167.00 $167.00 100 Each 14186 ENOXAPARIN 150 MG/ML SC SYRG J1650 00703851023 $261.98 $261.98 1 mL 14192 EPOETIN ALFA 3000 UNITS IJ SOLN J0885 55513026710 $458.99 $734.38 1 mL 14195 CIDOFOVIR 75 MG/ML IV SOLN J0740 23155021631 $7,956.48 $7,956.48 5 mL 14243 MONTELUKAST 10 MG PO TABS 31722072690 $267.84 $267.84 90 Each 14266 CLINDAMYCIN PHOSPHATE 2 % VA CREA 59762500901 $1,296.00 $1,296.00 40 gram 14281 MORPHINE 15 MG PO TBSR 00406831562 $848.00 $848.00 100 Each 14309 CYCLOSPORINE MODIFIED 100 MG/ML PO SOLN J7502 00078027422 $7,317.60 $7,317.60 50 mL 14315 CODEINE-GUAIFENESIN 10-100 MG/5 ML PO LIQD 00121177505 $167.00 $167.00 5 mL 14315 CODEINE-GUAIFENESIN 10-100 MG/5 ML PO LIQD 50383008712 $167.00 $167.00 10 mL 14338 HALOPERIDOL LACTATE 5 MG/ML IJ SOLN J1630 63323047401 $167.00 $167.00 1 mL 14345 EFAVIRENZ 50 MG PO CAPS 00056047030 $1,219.68 $1,219.68 30 Each 14355 LAMIVUDINE 10 MG/ML PO SOLN 49702020548 $1,655.04 $1,655.04 240 mL 14359 ACETAMINOPHEN-CODEINE 300-60 MG PO TABS 00093035001 $417.60 $417.60 100 Each 14381 OXYCODONE-ACETAMINOPHEN 2.5-325 MG PO TABS 00603497821 $2,036.80 $2,036.80 100 Each 14447 AMPICILLIN SODIUM 1 GRAM IJ SOLR J0290 00781340495 $167.00 $167.00 1 Each 14460 KETAMINE 50 MG/ML IJ SOLN 99999001752 $167.00 $167.00 1 mL 14460 KETAMINE 50 MG/ML IJ SOLN 00143950810 $167.00 $167.00 10 mL 14524 FLUTICASONE PROPIONATE 220 MCG/ACTUATION IN HFAA 00173072020 $2,779.01 $2,779.01 12 gram 14572 LEUCOVORIN CALCIUM 500 MG IJ SOLR 63323071100 $671.04 $671.04 1 Each 14581 PRAVASTATIN 20 MG PO TABS 51079045820 $924.80 $924.80 100 Each 14595 CLONIDINE 0.3 MG/24 HR TD PTWK 00597003334 $1,632.51 $1,632.51 4 Each 14600 PENICILLIN G SODIUM 5 MILLION UNIT IJ SOLR J3490 00781615395 $584.80 $584.80 1 Each 14601 TOPIRAMATE 200 MG PO TABS 13668003460 $167.00 $167.00 60 Each 14615 TENOFOVIR DISOPROXIL FUMARATE 300 MG PO TABS 61958040101 $18,694.08 $18,694.08 30 Each 14633 PYRIDOSTIGMINE BROMIDE 5 MG/ML IJ SOLN 00781304095 $448.99 $448.99 2 mL 14642 QUINUPRISTIN-DALFOPRISTIN 500 MG IV SOLR J2770 61570026010 $5,212.13 $5,212.13 1 Each 14701 ACYCLOVIR 200 MG PO CAPS 00904578961 $174.40 $174.40 100 Each 14713 MUPIROCIN 2 % TP OINT 00168035222 $480.83 $480.83 22 gram 14718 SODIUM NITROPRUSSIDE 25 MG/ML IV SOLN J3490 00409302401 $354.40 $354.40 50 mg 14737 PENICILLIN G BENZATHINE 600000 UNITS/ML IM SYRG J0561 60793070010 $1,482.05 $1,482.05 1 mL 14784 TELMISARTAN 20 MG PO TABS 00591329245 $167.00 $167.00 1 Each 14785 ZOLPIDEM 5 MG PO TABS 51079072420 $187.20 $187.20 100 Each 14795 POTASSIUM CHLORIDE IN WATER 20 MEQ/50 ML IV PGBK J3480 00409707714 $167.00 $167.00 50 mL 14805 DACTINOMYCIN 0.5 MG IV SOLR J9120 55292081155 $35,978.88 $35,978.88 1 Each 14814 LIDOCAINE HCL 20 MG/ML (2 %) IJ SOLN J2001 00409427702 $167.00 $167.00 50 mL 14835 BUMETANIDE 0.25 MG/ML IJ SOLN J3490 55390050010 $167.00 $167.00 10 mL 14835 BUMETANIDE 0.25 MG/ML IJ SOLN J3490 00641600710 $167.00 $167.00 10 mL 14835 BUMETANIDE 0.25 MG/ML IJ SOLN J3490 00409141210 $167.00 $167.00 10 mL 14838 METHYLPREDNISOLONE SODIUM SUCC 500 MG IV SOLR J2930 00009075801 $352.00 $352.00 500 mg 14853 DEXRAZOXANE HCL 500 MG IV SOLR J1190 67457020850 $8,180.32 $8,180.32 1 Each 14857 ZIPRASIDONE HCL 40 MG PO CAPS 65862070360 $372.48 $372.48 60 Each 14862 PHENYLEPHRINE HCL 10 MG/ML IJ SOLN J2370 00641614225 $167.00 $167.00 1 mL 14862 PHENYLEPHRINE HCL 10 MG/ML IJ SOLN J2370 76014000410 $329.12 $329.12 5 mL 14881 ZINC SULFATE 5 MG/ML IV SOLN 00517810525 $654.56 $654.56 5 mL 14934 METHADONE 10 MG/ML PO CONC 9999995600 $167.00 $167.00 2 mL 14935 BASILIXIMAB 20 MG IV SOLR J0480 00078033184 $32,991.39 $32,991.39 1 Each 15014 HYDROCORTISONE 10 MG PO TABS 00603390021 $422.40 $422.40 100 Each 15037 GELATIN SPONGE,ABSORB-PORCINE 12-7 MM TP SPGE 00009031508 $982.80 $982.80 12 Each

Pharmacy FY22 MED IDs 206 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 15064 PHENOBARBITAL SODIUM 130 MG/ML IJ SOLN J2560 00641047725 $749.55 $749.55 1 mL 15082 LOTEPREDNOL ETABONATE 0.5 % OP DRPS 24208029905 $3,983.20 $3,983.20 5 mL 15106 CEFUROXIME SODIUM 1.5 GRAM IV SOLR J0697 00143997722 $167.00 $167.00 1 Each 15117 LEVOFLOXACIN 25 MG/ML IV SOLN J1956 17478010720 $5,968.00 $5,968.00 500 mg 15122 BETAXOLOL 0.5 % OP DROP 61314024503 $1,413.76 $1,413.76 10 mL 15123 OXYCODONE 30 MG PO TABS 00406853001 $737.60 $737.60 100 Each 15135 FAMOTIDINE 40 MG/5 ML (8 MG/ML) PO SUSP 68180015001 $1,380.00 $1,380.00 50 mL 15140 CYCLOSPORINE MODIFIED 100 MG PO CAPS J7502 00093574265 $1,967.04 $1,967.04 30 Each 15143 NYSTATIN 100000 UNIT/GRAM TP POWD 00574200815 $282.96 $282.96 15 gram 15182 LEVALBUTEROL HCL 1.25 MG IN NEBU J7614 76204090001 $167.00 $167.00 3 mL 15190 CODEINE SULFATE 30 MG PO TABS 00054024424 $1,281.60 $1,281.60 100 Each 15202 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN J1100 63323016505 $167.00 $167.00 5 mL 15202 DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML IJ SOLN J1100 63323016501 $167.00 $167.00 1 mL 15231 VANCOMYCIN 10 GRAM IV SOLR J3370 63323031461 $417.76 $417.76 1 Each 15232 LORAZEPAM 1 MG PO TABS 63739050010 $167.00 $167.00 100 Each 15272 AZTREONAM 1 GRAM IJ SOLR 63323040120 $403.12 $403.12 1 Each 15284 AZELASTINE 137 MCG (0.1 %) NA SPRA 60505083305 $167.00 $167.00 30 mL 15284 AZELASTINE 137 MCG (0.1 %) NA SPRA 42291015330 $167.00 $167.00 30 mL 15344 BUDESONIDE 3 MG PO CECX 00378715501 $6,636.80 $6,636.80 100 Each 15346 INSULIN LISPRO 100 UNITS/ML SC SOLN J1815 00002751001 $839.68 $839.68 10 mL 15395 EPINEPHRINE 0.3 MG/0.3 ML IJ ATIN J0171 49502050002 $8,985.76 $8,985.76 2 Each 15404 TRIAMCINOLONE ACETONIDE 0.1 % TP LOTN 60432056161 $258.24 $258.24 60 mL 15412 PHENYLEPHRINE HCL 2.5 % OP DROP 17478020102 $455.52 $455.52 2 mL 15427 FLUTICASONE PROPION-SALMETEROL 100-50 MCG/DOSE IN DSDV 00173069504 $1,040.93 $1,040.93 14 Each 15427 FLUTICASONE PROPION-SALMETEROL 100-50 MCG/DOSE IN DSDV 00173069500 $2,340.48 $2,340.48 60 Each 15452 TESTOSTERONE CYPIONATE 200 MG/ML IM OIL J1071 00009041701 $167.00 $167.00 1 mL 15455 MANNITOL 20 % 20 % IV SOLP 00409771503 $256.00 $256.00 500 mL 15464 HEPARIN (PORCINE) 20000 UNITS/ML IJ SOLN J1644 63323091501 $167.00 $167.00 1 mL 15481 CEFTAZIDIME 1 GRAM IJ SOLR J0713 00409508216 $167.00 $167.00 1 Each 15550 CYSTEINE (L-CYSTEINE) 50 MG/ML IV SOLN 00781894095 $1,081.28 $1,081.28 10 mL 15551 TRIAMCINOLONE ACETONIDE 10 MG/ML IJ SUSP J3301 00003049420 $180.32 $180.32 5 mL 15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312001 $167.00 $167.00 1 mL 15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312047 $167.00 $167.00 .25 mL 15570 CALCITRIOL 1 MCG/ML PO SOLN 0054312055 $167.00 $167.00 .5 mL 15570 CALCITRIOL 1 MCG/ML PO SOLN 6330424101 $167.00 $167.00 1 mL 15572 PROPOFOL 10 MG/ML IV EMUL J2704 63323026965 $167.00 $167.00 100 mL 15572 PROPOFOL 10 MG/ML IV EMUL J2704 63323026929 $167.00 $167.00 20 mL 15572 PROPOFOL 10 MG/ML IV EMUL J2704 63323026950 $167.00 $167.00 50 mL 15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 99999002391 $167.00 $167.00 6.25 mL 15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 99999900750 $167.00 $167.00 5 mL 15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 00069313019 $167.00 $167.00 22.5 mL 15600 AZITHROMYCIN 200 MG/5 ML PO SUSR 59762313001 $167.00 $167.00 22.5 mL 15630 CEFUROXIME AXETIL 500 MG PO TABS 64679092202 $2,056.32 $2,056.32 60 Each 15645 FENTANYL 25 MCG/HR TD PT72 00591319872 $167.00 $167.00 5 Each 15665 PACLITAXEL 6 MG/ML IV CONC J9267 61703034209 $167.00 $167.00 5 mL 15665 PACLITAXEL 6 MG/ML IV CONC J9267 61703034222 $369.00 $369.00 16.7 mL 15671 LEVOFLOXACIN 500 MG PO TABS 65862053750 $328.00 $328.00 50 Each 15699 OXYCODONE-ACETAMINOPHEN 7.5-325 MG PO TABS 00406052262 $2,390.40 $2,390.40 100 Each 15712 ANTITHROMBIN III (HUMAN) 500 (+/-) UNIT IV SOLR J7197 13533060320 $25,120.00 $25,120.00 1 Each 15728 SODIUM FERRIC GLUCONAT-SUCROSE 62.5 MG/5 ML IV SOLN J2916 00024279210 $474.24 $474.24 5 mL 15743 POLYMYXIN B SULFATE 500000 UNITS IJ SOLR 51991093917 $167.00 $167.00 1 Each 15751 PILOCARPINE HCL 4 % OP DROP 61314020615 $1,260.96 $1,260.96 15 mL 15757 AMIODARONE 50 MG/ML IV SOLN J0282 63323061603 $167.00 $167.00 3 mL 15757 AMIODARONE 50 MG/ML IV SOLN J0282 67457015309 $167.00 $167.00 9 mL 15760 CEFACLOR 250 MG/5 ML PO SUSR 16571007112 $8,604.00 $8,604.00 150 mL 15781 LEVOFLOXACIN 750 MG PO TABS 65862053820 $238.72 $238.72 20 Each 15785 LETROZOLE 2.5 MG PO TABS 00078024915 $167.00 $167.00 30 Each 15803 ZOLPIDEM 10 MG PO TABS 16714062201 $167.00 $167.00 100 Each 15809 DEXTROMETHORPHAN-GUAIFENESIN 30-600 MG PO TB12 63824005632 $167.00 $167.00 20 Each 15810 TOPIRAMATE 15 MG PO CPSP 00093733506 $969.60 $969.60 60 Each 15813 SCOPOLAMINE BASE 1 MG OVER 3 DAYS TD PT3D 00378647099 $964.03 $964.03 4 Each 15833 SODIUM PHOSPHATE 3 MMOL/ML IV SOLN 00409739172 $224.64 $224.64 15 mL 15860 NEOMYCIN 500 MG PO TABS 39822031005 $2,024.00 $2,024.00 100 Each 15863 ALUMINUM HYDROX-MAGNESIUM CARB 160-105 MG PO CHEW 00904536560 $167.00 $167.00 100 Each 15893 ALBUTEROL SULFATE 90 MCG/ACTUATION IN HFAA J3535 00173068220 $408.67 $408.67 18 gram 15893 ALBUTEROL SULFATE 90 MCG/ACTUATION IN HFAA J3535 00173068224 $167.00 $167.00 8 gram 15939 ABACAVIR 20 MG/ML PO SOLN 49702022248 $2,188.80 $2,188.80 240 mL 15966 MOXIFLOXACIN-SOD.CHLORIDE(ISO) 400 MG/250 ML IV PGBK J2280 67457032325 $656.00 $656.00 250 mL 15969 TIMOLOL MALEATE 0.5 % OP DROP 61314022705 $167.00 $167.00 5 mL 15969 TIMOLOL MALEATE 0.5 % OP DROP 64980051405 $167.00 $167.00 5 mL 15977 IPRATROPIUM BROMIDE 42 MCG (0.06 %) NA SPRY 24208039915 $272.16 $272.16 15 mL 15982 PILOCARPINE HCL 2 % OP DROP 61314020415 $1,202.64 $1,202.64 15 mL 15994 COLCHICINE 0.6 MG PO TABS 66993016502 $13,857.60 $13,857.60 100 Each 15996 KETOROLAC 60 MG/2 ML IM SOLN J1885 00409379601 $167.00 $167.00 2 mL 16057 BUTORPHANOL 1 MG/ML IJ SOLN J0595 00409162301 $167.00 $167.00 1 mL

Pharmacy FY22 MED IDs 207 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 16060 INDOMETHACIN SODIUM 1 MG IV SOLR 63323065903 $4,324.80 $4,324.80 1 Each 16066 MYCOPHENOLATE MOFETIL (HCL) 500 MG IV SOLR 00004029809 $1,030.61 $1,030.61 1 Each 16098 IBUTILIDE FUMARATE 0.1 MG/ML IV SOLN J1742 00009379401 $1,094.24 $1,094.24 10 mL 16145 PIOGLITAZONE 30 MG PO TABS 33342005510 $241.92 $241.92 90 Each 16165 OXANDROLONE 2.5 MG PO TABS 54396011111 $4,140.80 $4,140.80 100 Each 16221 OXACILLIN 1 GRAM IJ SOLR J2700 25021014610 $167.00 $167.00 1 Each 16239 KETOCONAZOLE 2 % TP CREA 00168009930 $621.60 $621.60 30 gram 16251 HYDROMORPHONE 4 MG PO TABS 00054026424 $276.80 $276.80 100 Each 16303 LABETALOL 5 MG/ML IV SOLN 17478042020 $372.80 $372.80 20 mL 16303 LABETALOL 5 MG/ML IV SOLN 00409226754 $167.00 $167.00 40 mL 16303 LABETALOL 5 MG/ML IV SOLN 00409226720 $167.00 $167.00 20 mL 16308 MORPHINE 15 MG PO TABS 00054023524 $1,102.40 $1,102.40 100 Each 16323 ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG IV SOLR J0256 00053720102 $4,300.00 $6,880.00 1 Each 16347 EFAVIRENZ 200 MG PO CAPS 00056047492 $14,624.64 $14,624.64 90 Each 16366 ANTI-THYMOCYTE GLOB (RABBIT) 25 MG IV SOLR J7511 58468008001 $10,300.80 $10,300.80 1 Each 16371 DICLOXACILLIN 250 MG PO CAPS 00093312301 $731.20 $731.20 100 Each 16382 DEXTRAN 40 10 % IN 5% DEXTROSE 10 % IV SOLP J7100 00409741803 $304.00 $304.00 500 mL 16419 PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2-0.1037 -0.0194 MG PO TABS 59212042510 $16,419.20 $16,419.20 100 Each 16424 PIPERACILLIN-TAZOBACTAM 2.25 GRAM IV SOLR J2543 00206885216 $167.00 $167.00 1 Each 16430 AMPHOTERICIN B LIPOSOME 50 MG IV SUSR J0289 00469305130 $1,332.96 $1,332.96 1 Each 16455 METHADONE 5 MG PO TABS 00054855324 $312.00 $312.00 100 Each 16461 PROPARACAINE 0.5 % OP DROP 17478026312 $523.44 $523.44 15 mL 16468 FENTANYL 75 MCG/HR TD PT72 00591321372 $823.68 $823.68 5 Each 16480 SARGRAMOSTIM 250 MCG IJ SOLR J2820 00024584305 $4,026.14 $4,026.14 1 Each 16506 ZIPRASIDONE HCL 60 MG PO CAPS 60505253006 $1,342.08 $1,342.08 60 Each 16510 LIDOCAINE-EPINEPHRINE 2 %-1:100,000 IJ SOLN 00409318203 $167.00 $167.00 50 mL 16562 ATROPINE 1 % OP DROP 17478021505 $765.44 $765.44 5 mL 16573 ONDANSETRON 4 MG PO TBDL S0119 00781523864 $167.00 $167.00 30 Each 16595 CEFDINIR 300 MG PO CAPS 16714039101 $482.40 $482.40 30 Each 16601 APRACLONIDINE 1 % OP DPET 00065066010 $9,924.48 $9,924.48 24 Each 16609 SODIUM CHLORIDE 0.9 % IN NEBU 00378698601 $167.00 $167.00 5 mL 16609 SODIUM CHLORIDE 0.9 % IN NEBU 00487930133 $167.00 $167.00 3 mL 16625 TOPIRAMATE 100 MG PO TABS 69097012412 $640.00 $640.00 500 Each 16638 OXYCODONE 20 MG/ML PO CONC 99999900408 $167.00 $167.00 1 mL 16653 DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN J1100 00641036721 $167.00 $167.00 1 mL 16653 DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML IJ SOLN J1100 63323051610 $167.00 $167.00 10 mL 16662 TEMOZOLOMIDE 20 MG PO CAPS J8700 00781269275 $1,199.52 $1,199.52 5 Each 16714 ALBUTEROL SULFATE 5 MG/ML IN NEBU J7611 50383074120 $704.00 $704.00 20 mL 16773 CEFOTETAN 2 GRAM IJ SOLR 63323038620 $272.03 $272.03 1 Each 16785 BENZOCAINE 20 % MM GEL 54162092629 $167.00 $167.00 29 gram 16785 BENZOCAINE 20 % MM GEL 10310028313 $167.00 $167.00 11.9 gram 16824 FLUTICASONE PROPIONATE 50 MCG/ACTUATION NA SPSN 60505084703 $167.00 $167.00 16 gram 16844 EPOETIN ALFA 10000 UNITS IJ SOLN J0885 59676031002 $1,345.11 $2,152.18 1 mL 16869 CLOTRIMAZOLE 1 % TP CREA 51672127506 $463.68 $463.68 45 gram 16869 CLOTRIMAZOLE 1 % TP CREA 00904782236 $167.00 $167.00 14.17 gram 16884 DIVALPROEX 125 MG PO CDRS 68084031301 $1,056.00 $1,056.00 100 Each 16899 CASPOFUNGIN 50 MG IV SOLR J0637 00006382210 $5,036.48 $5,036.48 1 Each 16919 HEPARIN (PORCINE) 5000 UNITS/ML IJ SOLN J1644 63323026201 $167.00 $167.00 1 mL 16931 ANAKINRA 100 MG/0.67 ML SC SYRG 66658023407 $2,594.22 $2,594.22 .67 mL 16947 LAMIVUDINE 150 MG PO TABS 60505325106 $3,355.20 $3,355.20 60 Each 16948 RITUXIMAB 10 MG/ML IV CONC J9312 50242005121 $9,395.20 $15,032.32 10 mL 16948 RITUXIMAB 10 MG/ML IV CONC J9312 50242005306 $37,580.80 $42,278.40 50 mL 16952 RISPERIDONE 1 MG PO TABS 50458059210 $195.20 $195.20 100 Each 16971 INDOCYANINE GREEN 25 MG IJ SOLR 17478070102 $1,699.12 $1,699.12 1 Each 16978 AZTREONAM IN DEXTROSE(ISO-OSM) 2 GRAM/50 ML IV PGBK 00003224011 $864.80 $864.80 50 mL 16979 ALTEPLASE 2 MG CATH SOLR J2997 99999900374 $2,282.72 $2,282.72 1 Each 16979 ALTEPLASE 2 MG CATH SOLR J2997 50242004164 $2,282.72 $2,282.72 1 Each 16980 NAPHAZOLINE-PHENIRAMINE 0.025-0.3 % OP DROP 00065008515 $167.00 $167.00 15 mL 16996 ITRACONAZOLE 100 MG PO CAPS 10147170003 $3,320.64 $3,320.64 30 Each 17023 TACROLIMUS 1 MG PO CAPS J7507 00469061711 $3,876.80 $3,876.80 100 Each 17032 DOFETILIDE 500 MCG PO CAPS 00069582043 $175.36 $175.36 40 Each 17037 INSULIN LISPRO PROTAMIN-LISPRO 100 UNIT/ML (75-25) SC SUSP J1815 00002751101 $839.68 $839.68 10 mL 17041 CORTICOTROPIN 80 UNITS/ML IJ GEL J0800 63004871001 $358,776.00 $358,776.00 5 mL 17117 MEDROXYPROGESTERONE 150 MG/ML IM SUSP J1050 00703680101 $1,216.00 $1,216.00 1 mL 17168 METRONIDAZOLE 0.75 % TP GEL 00168027545 $2,038.32 $2,038.32 45 gram 17181 PAPAVERINE 30 MG/ML IJ SOLN J2440 00517400225 $448.16 $448.16 2 mL 17206 CYCLOPHOSPHAMIDE 500 MG IV SOLR J9070 10019095501 $2,618.08 $2,618.08 1 Each 17250 BELLADONNA ALKALOIDS-OPIUM 16.2-60 MG PR SUPP 00574704012 $4,703.81 $4,703.81 12 Each 17261 LEUCOVORIN CALCIUM 200 MG IJ SOLR J0640 25021081530 $193.92 $193.92 1 Each 17279 PRAMIPEXOLE 1.5 MG PO TABS 00597019190 $167.00 $167.00 90 Each 17294 LAMOTRIGINE 100 MG PO TABS 00093046301 $203.20 $203.20 100 Each 17308 AZITHROMYCIN 600 MG PO TABS 50111078910 $1,082.40 $1,082.40 30 Each 17327 ESTRADIOL 0.1 MG/24 HR TD PTWK 00378335299 $1,006.40 $1,006.40 4 Each 17342 BLEOMYCIN 30 UNITS IJ SOLR J9040 61703032322 $887.36 $887.36 1 Each 17412 IRBESARTAN 300 MG PO TABS 00024585230 $3,742.08 $3,742.08 30 Each

Pharmacy FY22 MED IDs 208 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 17435 NOREPINEPHRINE BITARTRATE 1 MG/ML IV SOLN 55390000210 $167.00 $167.00 4 mL 17510 DEXTROAMPHETAMINE-AMPHETAMINE 5 MG PO TABS 13107006801 $556.80 $556.80 100 Each 17511 RIVASTIGMINE TARTRATE 3 MG PO CAPS 63739057710 $851.20 $851.20 100 Each 17527 PNEUMOCOCCAL 23-VAL PS VACCINE 25 MCG/0.5 ML IJ SOLN 90732 00006494300 $1,597.84 $1,597.84 .5 mL 17540 ELECTROLYTE-A IV SOLP 00338022104 $167.00 $167.00 1000 mL 17566 ETOPOSIDE 50 MG PO CAPS J8560 00378326694 $22,468.48 $22,468.48 20 Each 17578 RISPERIDONE 0.5 MG PO TABS 50458030201 $230.40 $230.40 100 Each 17580 ROPIVACAINE (PF) 7.5 MG/ML (0.75 %) IJ SOLN J2795 00409930221 $167.00 $167.00 20 mL 17582 IPRATROPIUM BROMIDE 0.02 % IN SOLN J7644 00487980125 $167.00 $167.00 2.5 mL 17621 GENTAMICIN 0.1 % TP OINT 45802004635 $523.92 $523.92 15 gram 17637 FLUTICASONE PROPIONATE 110 MCG/ACTUATION IN HFAA 00173071920 $1,789.15 $1,789.15 12 gram 17640 MORPHINE (PF) 0.5 MG/ML IJ SOLN J2274 00409381412 $167.00 $167.00 10 mL 17640 MORPHINE (PF) 0.5 MG/ML IJ SOLN J2274 00641602010 $167.00 $167.00 10 mL 17675 PREDNISOLONE 5 MG PO TABS J7510 23594050550 $11,518.40 $11,518.40 50 Each 17702 BISMUTH SUBGALLATE (BULK) MISC POWD 00406030402 $1,272.00 $1,272.00 500 gram 17731 ATOVAQUONE 750 MG/5 ML PO SUSP 00173054700 $445.04 $445.04 5 mL 17732 DIPHENOXYLATE-ATROPINE 2.5-0.025 MG/5 ML PO LIQD 99999900270 $167.00 $167.00 5 mL 17775 ERYTHROMYCIN 333 MG PO TBEC 24338012413 $9,712.00 $9,712.00 100 Each 17782 ZIDOVUDINE 100 MG PO CAPS 65862010701 $2,259.20 $2,259.20 100 Each 17819 ZIDOVUDINE 10 MG/ML IV SOLN J3485 49702021326 $435.20 $435.20 20 mL 17839 HYDROMORPHONE 1 MG/ML PO LIQD 99999900407 $167.00 $167.00 1 mL 17852 DOBUTAMINE IN D5W 1,000 MG/250 ML (4,000 MCG/ML) IV SOLP J1250 00409372432 $200.00 $200.00 250 mL 17881 DIAZEPAM 5 MG PO TABS 51079028520 $167.00 $167.00 100 Each 17891 SODIUM CHLORIDE 3 % 3 % IV SOLP J7131 00338005403 $167.00 $167.00 500 mL 17972 REPAGLINIDE 1 MG PO TABS 68084095425 $167.00 $167.00 30 Each 17976 AMOXICILLIN-POT CLAVULANATE 875-125 MG PO TABS 66685100101 $1,379.20 $1,379.20 100 Each 18012 TRIPTORELIN PAMOATE 11.25 MG IM SUSR J3315 00023590412 $20,466.54 $20,466.54 1 Each 18021 PHENOBARBITAL 32.4 MG PO TABS 63739020110 $500.80 $500.80 100 Each 18049 CONJUGATED ESTROGENS 25 MG IJ SOLR J1410 00046074905 $4,880.00 $4,880.00 1 Each 18055 ARSENIC TRIOXIDE 1 MG/ML IV SOLN J9017 14789060010 $1,536.16 $1,536.16 10 mL 18060 METHADONE 5 MG/5 ML PO SOLN 99999900321 $167.00 $167.00 1 mL 18063 DORZOLAMIDE 2 % OP DROP 00006351936 $1,130.40 $1,130.40 10 mL 18087 SODIUM CHLORIDE 4 MEQ/ML IV SOLP 63323018730 $167.00 $167.00 30 mL 18087 SODIUM CHLORIDE 4 MEQ/ML IV SOLP 00409114102 $167.00 $167.00 100 mL 18113 AMOXICILLIN-POT CLAVULANATE 500-125 MG PO TABS 00093227434 $420.80 $420.80 20 Each 18132 ARGININE HCL (L-ARGININE) 10 % IV SOLP 00009043601 $590.40 $590.40 300 mL 18156 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM OP OINT 17478023835 $167.00 $167.00 3.5 gram 18171 ARTIFICIAL TEARS(HYPROMELLOSE) 0.5 % OP DROP 00998040815 $397.20 $397.20 15 mL 18172 PROPRANOLOL 1 MG/ML IV SOLN J1800 63323060401 $167.00 $167.00 1 mL 18173 TACROLIMUS 0.5 MG PO CAPS J7507 00469060773 $1,852.80 $1,852.80 100 Each 18176 TESTOSTERONE 1 % (50 MG/5 GRAM) TD GLPK 00051845030 $318.32 $318.32 5 gram 18188 METOPROLOL TARTRATE 5 MG/5 ML IV SOLN 55390007310 $167.00 $167.00 5 mg 18193 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN J3490 00009085608 $4,685.89 $4,685.89 1 mL 18193 CARBOPROST TROMETHAMINE 250 MCG/ML IM SOLN J3490 43598069858 $3,830.10 $3,830.10 1 mL 18205 PORFIMER 75 MG IV SOLR J9600 76128015575 $189,360.00 $189,360.00 1 Each 18210 LEVOCARNITINE 200 MG/ML IV SOLN J1955 54482014701 $281.84 $281.84 5 mL 18211 KETAMINE 100 MG/ML IJ SOLN J3490 42023011510 $167.00 $167.00 5 mL 18219 MUPIROCIN CALCIUM 2 % NA OINT 00029152611 $167.00 $167.00 1 gram 18231 CLINDAMYCIN PHOSPHATE 1 % TP SOLN 45802056201 $223.68 $223.68 30 mL 18245 CLINDAMYCIN IN 5 % DEXTROSE 600 MG/50 ML IV PGBK J3490 00781328909 $167.00 $167.00 50 mL 18251 CYCLOPENTOLATE 0.5 % OP DROP 00065039515 $1,168.56 $1,168.56 15 mL 18253 BUSULFAN 2 MG PO TABS J8510 76388071325 $8,645.60 $8,645.60 25 Each 18259 PHYTONADIONE (VITAMIN K1) 5 MG PO TABS 00187170405 $74,038.40 $74,038.40 100 Each 18297 TOBRAMYCIN-DEXAMETHASONE 0.3-0.1 % OP DRPS 00065064725 $642.24 $642.24 2.5 mL 18305 OXYCODONE 5 MG PO TABS 00406055262 $678.40 $678.40 100 Each 18309 OLANZAPINE 5 MG PO TBDL 00002445385 $372.96 $372.96 30 Each 18313 MODAFINIL 100 MG PO TABS 68084062121 $4,675.20 $4,675.20 30 Each 18328 HYDROMORPHONE 3 MG PR SUPP 00574722406 $869.28 $869.28 6 Each 18342 VALSARTAN 160 MG PO TABS 00378581477 $596.16 $596.16 90 Each 18343 MIDAZOLAM 1 MG/ML IJ SOLN (PF) J2250 00641605701 $167.00 $167.00 2 mL 18343 MIDAZOLAM 1 MG/ML IJ SOLN (PF) J2250 00641605901 $167.00 $167.00 5 mL 18356 FLUMAZENIL 0.1 MG/ML IV SOLN J3490 00143978410 $167.00 $167.00 5 mL 18356 FLUMAZENIL 0.1 MG/ML IV SOLN J3490 63323042405 $167.00 $167.00 5 mL 18367 ABACAVIR 300 MG PO TABS 65862007360 $7,754.88 $7,754.88 60 Each 18415 NEOMYCIN-POLYMYXIN B-DEXAMETH 3.5 MG/G-10,000 UNIT/G-0.1 % OP OINT 24208079535 $236.94 $236.94 3.5 gram 18425 CALCITONIN (SALMON) 200 UNITS/ML IJ SOLN J0630 67457067502 $26,274.87 $26,274.87 2 mL 18429 NEOMYCIN-POLYMYXIN-HC 3.5-10,000-1 MG/ML-UNIT/ML-% OT DRPS 24208063562 $1,133.44 $1,133.44 10 mL 18436 LEVALBUTEROL HCL 0.31 MG IN NEBU J7614 76204070001 $167.00 $167.00 3 mL 18438 PEGFILGRASTIM 6 MG/0.6 ML SC SYRG J2505 55513019001 $37,750.05 $37,750.05 .6 mL 18442 CLINDAMYCIN PHOSPHATE 1 % TP LOTN 00168020360 $1,721.28 $1,721.28 60 mL 18492 CIPROFLOXACIN IN 5 % DEXTROSE 200 MG/100 ML IV PGBK J0744 00409477723 $167.00 $167.00 100 mL 18500 ERTAPENEM 1 GRAM IJ SOLR J1335 00006384371 $652.53 $652.53 1 Each 18851 INTERFERON BETA-1A (ALBUMIN) 44 MCG/0.5 ML SC SYRG Q3028 44087004403 $11,028.28 $11,028.28 .5 mL 18928 SUMATRIPTAN SUCCINATE 6 MG/0.5 ML SC PNIJ J3030 00781317207 $2,673.76 $2,673.76 1 mL 18963 PIPERACILLIN-TAZOBACTAM-DEXTRS 3.375 GRAM/50 ML IV PGBK J2543 00206886102 $167.00 $167.00 50 mL

Pharmacy FY22 MED IDs 209 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 19008 SODIUM HYPOCHLORITE 0.25 % MISC SOLN 00436093616 $167.00 $167.00 473 mL 19009 SODIUM HYPOCHLORITE 0.5 % MISC SOLN 00436094616 $167.00 $167.00 473 mL 19048 PAMIDRONATE 30 MG/10 ML (3 MG/ML) IV SOLN J2430 67457043010 $167.00 $167.00 10 mL 19049 PAMIDRONATE 90 MG/10 ML (9 MG/ML) IV SOLN J2430 67457044610 $418.40 $418.40 10 mL 19052 HYPROMELLOSE 2.5 % OP DROP 17478006412 $262.80 $262.80 15 mL 19263 ORAL WOUND CARE PRODUCTS MM GLPK 89141045602 $675.36 $675.36 15 mL 20265 ETHANOL (ETHYL ALCOHOL) 98 % IJ SOLN J3490 17478050305 $1,306.16 $1,306.16 5 mL 20400 SULFACETAMIDE-PREDNISOLONE 10 %-0.23 % (0.25 %) OP DROP 24208031705 $170.72 $170.72 5 mL 21183 OLMESARTAN 20 MG PO TABS 65597010330 $3,601.44 $3,601.44 30 Each 21200 FULVESTRANT 250 MG/5 ML IM SYRG J9395 00310072010 $14,459.12 $14,459.12 5 mL 21259 LEUPROLIDE 7.5 MG (1 MONTH) SC SYRG J9217 62935075375 $1,401.92 $1,401.92 1 Each 21264 RISEDRONATE 35 MG PO TABS 00430047207 $15,255.36 $15,255.36 12 Each 21294 HYDROMORPHONE 2 MG/ML IJ SYRG J1170 00409131230 $167.00 $167.00 1 mL 21301 TREPROSTINIL SODIUM 1 MG/ML IJ SOLN J3285 66302010101 $14,324.40 $14,324.40 20 mL 21302 TREPROSTINIL SODIUM 2.5 MG/ML IJ SOLN J3285 66302010201 $35,811.00 $35,811.00 20 mL 21303 TREPROSTINIL SODIUM 5 MG/ML IJ SOLN J3285 66302010501 $17,983.80 $17,983.80 20 mL 21304 TREPROSTINIL SODIUM 10 MG/ML IJ SOLN J3285 66302011001 $37,270.80 $37,270.80 20 mL 21308 ENOXAPARIN 30 MG/0.3 ML SC SYRG J1650 00075062430 $167.00 $167.00 .3 mL 21309 ENOXAPARIN 60 MG/0.6 ML SC SYRG J1650 00075062160 $167.00 $167.00 .6 mL 21310 ENOXAPARIN 80 MG/0.8 ML SC SYRG J1650 00075062280 $167.00 $167.00 .8 mL 21311 ENOXAPARIN 100 MG/ML SC SYRG J1650 00075062300 $167.00 $167.00 1 mL 21312 ENOXAPARIN 40 MG/0.4 ML SC SYRG J1650 00075062040 $167.00 $167.00 .4 mL 21432 DEXTROAMPHETAMINE-AMPHETAMINE 5 MG PO CP24 54092038101 $5,796.80 $5,796.80 100 Each 21560 VORICONAZOLE 50 MG PO TABS 00049317030 $2,903.04 $2,903.04 30 Each 21561 VORICONAZOLE 200 MG PO TABS 00049318030 $10,364.16 $10,364.16 30 Each 21562 VORICONAZOLE 200 MG IV SOLR J3465 00049319028 $440.64 $440.64 1 Each 22090 CALCIUM CHLORIDE 100 MG/ML (10 %) IV SYRG 00409492834 $167.00 $167.00 10 mL 22122 RABIES VACCINE, PCEC (PF) 2.5 UNITS IM SUSR 90675 58160096412 $5,021.44 $5,021.44 1 Each 22637 ZIPRASIDONE MESYLATE 20 MG/ML (FINAL CONC.) IM SOLR J3486 00049392020 $815.30 $815.30 1 Each 22680 DEXTROSE 50 % IN WATER (D50W) IV SYRG 00409490234 $167.00 $167.00 50 mL 22717 LINEZOLID IN DEXTROSE 5% 600 MG/300 ML IV PGBK J2020 00009514001 $326.40 $326.40 300 mL 22775 TROMETHAMINE 36 MG/ML (0.3 M) IV SOLN 00409159304 $3,632.00 $3,632.00 500 mL 22821 DIAZEPAM 5 MG/ML IJ SYRG J3360 00409127332 $354.94 $354.94 2 mL 22905 SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) IV SYRG 00409553434 $167.00 $167.00 10 mL 22906 SODIUM BICARBONATE 8.4 % (1 MEQ/ML) IV SYRG 00409663734 $167.00 $167.00 50 mL 22953 MORPHINE 10 MG/ML IJ SYRG J2270 76045000810 $167.00 $167.00 1 mL 22977 HYDROMORPHONE 1 MG/ML IJ SYRG J1170 00409128303 $167.00 $167.00 1 mL 22985 FILGRASTIM 300 MCG IJ SYRG J1442 55513092410 $4,971.76 $4,971.76 .5 mL 22988 ENOXAPARIN 120 MG/0.8 ML SC SYRG J1650 00703861023 $205.94 $205.94 .8 mL 22989 PENICILLIN G BENZATHINE 2400000 UNIT/4 ML IM SYRG J0561 60793070210 $5,260.86 $5,260.86 4 mL 22990 PENICILLIN G BENZATHINE 1200000 UNIT/2 ML IM SYRG J0561 60793070110 $2,567.14 $2,567.14 2 mL 23025 NALOXONE 0.4 MG/ML IJ SYRG J2310 00409178269 $219.23 $219.23 1 mL 23026 NALOXONE 1 MG/ML IJ SYRG J2310 76329336901 $312.45 $312.45 2 mL 23235 ESCITALOPRAM OXALATE 20 MG PO TABS 00456202001 $19,686.40 $19,686.40 100 Each 23248 VALSARTAN 40 MG PO TABS 00378580793 $167.00 $167.00 30 Each 23263 RASBURICASE 1.5 MG IV SOLR J2783 00024515010 $13,939.20 $13,939.20 1 Each 23319 LEUPROLIDE (3 MONTH) 22.5 MG SC SYRG J9217 62935022305 $4,205.60 $4,205.60 1 Each 23485 EPLERENONE 25 MG PO TABS 59762171001 $4,622.40 $4,622.40 100 Each 23528 METAXALONE 800 MG PO TABS 60793013601 $15,238.40 $15,238.40 100 Each 23576 PEGINTERFERON ALFA-2A 180 MCG/ML SC SOLN J3490 00004035009 $15,234.08 $15,234.08 1 mL 23664 EZETIMIBE 10 MG PO TABS 66582041428 $16,417.60 $16,417.60 100 Each 23725 KIT FOR YTTRIUM-90-IBRITUMOMAB 3.2 MG/2 ML IV KIT A9543 68152010303 $234,134.24 $234,134.24 1 Each 23732 MIDAZOLAM IN 0.9 % SOD CHLORID 1 MG/ML IV SOLN J7999 71286403505 $370.00 $370.00 125 mL 23757 BENZOCAINE 20 % MM SPRA 00283067902 $437.76 $437.76 57 gram 23797 ARIPIPRAZOLE 10 MG PO TABS 13668021830 $665.28 $665.28 30 Each 23798 ARIPIPRAZOLE 15 MG PO TABS 59148000913 $4,144.80 $4,144.80 30 Each 23850 ATOMOXETINE 10 MG PO CAPS 00002322730 $1,267.68 $1,267.68 30 Each 23853 ATOMOXETINE 40 MG PO CAPS 00002322930 $2,132.16 $2,132.16 30 Each 24410 ADALIMUMAB 40 MG/0.8 ML SC SYKT J0135 00074379902 $50,066.46 $50,066.46 2 Each 24442 ELETRIPTAN 40 MG PO TABS 00049234045 $6,132.29 $6,132.29 6 Each 24455 BUPRENORPHINE-NALOXONE 2-0.5 MG SL SUBL 65162041603 $828.48 $828.48 30 Each 24456 BUPRENORPHINE-NALOXONE 8-2 MG SL SUBL 65162041503 $994.08 $994.08 30 Each 24467 BUPRENORPHINE HCL 2 MG SL SUBL J0571 00054017613 $671.04 $671.04 30 Each 24468 BUPRENORPHINE HCL 8 MG SL SUBL J0574 00054017713 $631.68 $631.68 30 Each 24567 ESCITALOPRAM OXALATE 5 MG/5 ML PO SOLN 54838055170 $2,384.64 $2,384.64 240 mL 24567 ESCITALOPRAM OXALATE 5 MG/5 ML PO SOLN 99999900343 $167.00 $167.00 5 mL 24592 FILGRASTIM 480 MCG IJ SOLN J1442 55513054610 $7,469.16 $7,469.16 1.6 mL 24664 METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN J9250 00703367501 $167.00 $167.00 10 mL 24664 METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN J9250 00703367103 $167.00 $167.00 2 mL 24664 METHOTREXATE SODIUM (PF) 25 MG/ML IJ SOLN J9250 61703040841 $171.52 $171.52 40 mL 24719 CYCLOSPORINE 0.05 % OP DPET 00023916330 $4,582.56 $4,582.56 30 Each 24719 CYCLOSPORINE 0.05 % OP DPET 99999900428 $167.00 $167.00 .4 mL 24764 LEUPROLIDE (4 MONTH) 30 MG SC SYRG J9217 62935030330 $5,607.52 $5,607.52 1 Each 24802 THALIDOMIDE 100 MG PO CAPS 59572021015 $124,278.78 $124,278.78 28 Each 24803 SIROLIMUS 2 MG PO TABS J7520 00008104205 $32,161.60 $32,161.60 100 Each

Pharmacy FY22 MED IDs 210 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 24804 THALIDOMIDE 200 MG PO CAPS 59572022016 $141,495.87 $141,495.87 28 Each 24892 APREPITANT 80 MG PO CAPS J8501 00006046106 $10,218.72 $10,218.72 6 Each 24893 APREPITANT 125 MG PO CAPS J8501 00006046206 $16,454.11 $16,454.11 6 Each 25010 CLONAZEPAM 0.25 MG PO TBDL 49884030702 $601.92 $601.92 60 Each 25020 ZOLEDRONIC ACID 4 MG/5 ML IV SOLN J3489 55111068507 $180.80 $289.28 4 mg 25092 RISPERIDONE 0.5 MG PO TBDL 49884031191 $1,460.03 $1,460.03 28 Each 25093 RISPERIDONE 1 MG PO TBDL 59746002022 $396.03 $396.03 28 Each 25094 RISPERIDONE 2 MG PO TBDL 49884040191 $438.14 $438.14 28 Each 25100 MOXIFLOXACIN 0.5 % OP DROP 00065401303 $241.30 $241.30 3 mL 25114 MINOCYCLINE 100 MG PO TABS 49884051303 $2,384.00 $2,384.00 50 Each 25153 AGALSIDASE BETA 35 MG IV SOLR J0180 58468004001 $52,517.68 $59,082.39 1 Each 25217 BORTEZOMIB 3.5 MG IJ SOLR J9041 63020004901 $14,427.00 $14,427.00 1 Each 25307 LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK J1956 25021013282 $167.00 $167.00 100 mL 25308 LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK J1956 00143972024 $167.00 $167.00 150 mL 25309 LEVOFLOXACIN IN D5W 250 MG/50 ML IV PGBK J1956 25021013281 $167.00 $167.00 50 mL 25321 BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 IJ SOLN 00409904517 $167.00 $167.00 30 mL 25321 BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 IJ SOLN 63323046217 $167.00 $167.00 10 mL 25323 BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 IJ SOLN 00409904217 $167.00 $167.00 30 mL 25323 BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 IJ SOLN 00409174630 $167.00 $167.00 30 mL 25323 BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 IJ SOLN 63323046817 $167.00 $167.00 10 mL 25324 BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) IJ SOLN J3490 99999001846 $167.00 $167.00 10 mL 25324 BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) IJ SOLN J3490 99999001850 $167.00 $167.00 5 mL 25325 BUPIVACAINE (PF) 0.5 % (5 MG/ML) IJ SOLN J3490 00409116201 $167.00 $167.00 10 mL 25325 BUPIVACAINE (PF) 0.5 % (5 MG/ML) IJ SOLN J3490 99999001847 $167.00 $167.00 3 mL 25325 BUPIVACAINE (PF) 0.5 % (5 MG/ML) IJ SOLN J3490 99999001851 $167.00 $167.00 5 mL 25326 BUPIVACAINE (PF) 0.75 % IJ SOLN J3490 00409158229 $167.00 $167.00 30 mL 25326 BUPIVACAINE (PF) 0.75 % IJ SOLN J3490 00409158210 $167.00 $167.00 10 mL 25331 BUPIVACAINE-DEXTROSE-WATER(PF) 0.75 % (7.5 MG/ML) IJ SOLN 00409176102 $167.00 $167.00 2 mL 25384 MORPHINE (PF) 25 MG/ML IJ SOLN J2274 00641604001 $5,221.44 $5,221.44 20 mL 25390 POTASSIUM CHLORIDE-0.45 % NACL 20 MEQ/L IV SOLP J3480 00338070434 $167.00 $167.00 1000 mL 25404 POVIDONE-IODINE 10 % TP SOLN 52380190504 $167.00 $167.00 118 mL 25441 IMATINIB 100 MG PO TABS J8999 00078040134 $2,118.24 $2,118.24 90 Each 25463 PHENYLEPHRINE HCL 0.25 % NA SPRY 00024134803 $167.00 $167.00 15 mL 25468 PHENYLEPHRINE HCL 0.5 % NA SPRY 00024135301 $167.00 $167.00 15 mL 25469 PHENYLEPHRINE HCL 1 % NA DROP 49348019727 $167.00 $167.00 30 mL 25540 SODIUM CHLORIDE 0.65 % NA SPRA 49348035984 $167.00 $167.00 88 mL 25540 SODIUM CHLORIDE 0.65 % NA SPRA 00904386575 $167.00 $167.00 44 mL 25564 ATAZANAVIR 150 MG PO CAPS 00003362412 $21,822.72 $21,822.72 60 Each 25681 OMALIZUMAB 150 MG SC SOLR J2357 50242004062 $9,298.72 $10,461.06 1 Each 25758 LANSOPRAZOLE 30 MG PO TBLD 64764054411 $20,635.20 $20,635.20 100 Each 25819 EMTRICITABINE 200 MG PO CAPS 61958060101 $8,001.60 $8,001.60 30 Each 25827 BACITRACIN ZINC 500 UNIT/GRAM TP OIPK 00168011109 $292.61 $292.61 144 Each 25847 BACITRACIN-POLYMYXIN B 500-10,000 UNIT/GRAM TP PACK 69968006009 $426.24 $426.24 144 Each 25851 INHALATIONAL SPACING DEVICE MISC SPCR 00456315467 $542.40 $542.40 1 Each 26051 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN J3480 63323096730 $167.00 $167.00 30 mL 26051 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN J3480 00264194020 $308.00 $308.00 250 mL 26051 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN J3480 00409665106 $167.00 $167.00 10 mL 26051 POTASSIUM CHLORIDE 2 MEQ/ML IV SOLN J3480 00409665305 $167.00 $167.00 20 mL 26072 ARIPIPRAZOLE 5 MG PO TABS 65862066230 $3,744.48 $3,744.48 30 Each 26184 CIPROFLOXACIN-DEXAMETHASONE 0.3-0.1 % OT DRPS 00065853302 $3,714.84 $3,714.84 7.5 mL 26260 RIMABOTULINUMTOXINB 2500 UNIT/0.5 ML IM SOLN J0587 10454071010 $2,905.00 $4,648.00 .5 mL 26261 RIMABOTULINUMTOXINB 5000 UNITS/ML IM SOLN J0587 10454071110 $5,810.00 $9,296.00 1 mL 26267 PALONOSETRON 0.25 MG/5 ML IV SOLN J2469 62856079701 $167.00 $237.04 5 mL 26267 PALONOSETRON 0.25 MG/5 ML IV SOLN J2469 69097092735 $226.96 $226.96 5 mL 26268 ROSUVASTATIN 5 MG PO TABS 00310075590 $1,314.72 $1,314.72 90 Each 26269 ROSUVASTATIN 10 MG PO TABS 00310075190 $1,728.00 $1,728.00 90 Each 26270 ROSUVASTATIN 20 MG PO TABS 00310075290 $1,860.48 $1,860.48 90 Each 26271 ROSUVASTATIN 40 MG PO TABS 57237017190 $239.04 $239.04 90 Each 26317 AMINOPHYLLINE 250 MG/10 ML IV SOLN J0280 00409592101 $174.08 $174.08 10 mL 26318 AMINOPHYLLINE 500 MG/20 ML IV SOLN J0280 00409592201 $167.00 $167.00 20 mL 26359 EPINEPHRINE 1 MG/ML IJ SOLN J0171 42023016801 $2,535.36 $2,535.36 30 mL 26362 VARDENAFIL 2.5 MG PO TABS 00173082813 $7,452.96 $7,452.96 30 Each 26366 VARDENAFIL 20 MG PO TABS 00173083113 $23,043.84 $23,043.84 30 Each 26409 CARBOPLATIN 10 MG/ML IV SOLN J9045 61703033950 $675.36 $675.36 45 mL 26485 BUPROPION HCL 300 MG PO TB24 51079010903 $925.44 $925.44 30 Each 26486 BUPROPION HCL 150 MG PO TB24 00378200877 $1,118.88 $1,118.88 90 Each 27637 RISPERIDONE MICROSPHERES 25 MG/2 ML IM SSRR J2794 50458030611 $7,788.64 $7,788.64 1 Each 27638 RISPERIDONE MICROSPHERES 37.5 MG/2 ML IM SSRR J2794 50458030711 $11,683.52 $11,683.52 1 Each 27639 RISPERIDONE MICROSPHERES 50 MG/2 ML IM SSRR J2794 50458030811 $15,578.24 $15,578.24 1 Each 27683 GENTAMICIN IN NACL (ISO-OSM) 120 MG/100 ML IV PGBK J1580 00338050748 $167.00 $167.00 100 mL 27808 TADALAFIL 5 MG PO TABS 00002446230 $479.52 $479.52 30 Each 27810 TADALAFIL 20 MG PO TABS 00002446430 $31,094.88 $31,094.88 30 Each 27852 MEMANTINE 10 MG PO TABS 00456321063 $540.80 $540.80 100 Each 27855 MEMANTINE 5 MG PO TABS 00456320563 $620.80 $620.80 100 Each 27947 TETANUS-DIPHTHERIA TOXOIDS-TD 2-2 LF UNIT/0.5 ML IM SUSP 90714 13533013101 $325.95 $325.95 .5 mL

Pharmacy FY22 MED IDs 211 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 28051 ESCITALOPRAM OXALATE 5 MG PO TABS 00456200501 $18,043.20 $18,043.20 100 Each 28058 RIBAVIRIN 40 MG/ML PO SOLN 99999002247 $400.00 $400.00 100 mL 28284 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN 99999900653 $167.00 $167.00 10 mL 28284 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN 00121477210 $167.00 $167.00 10 mL 28284 HYDROCODONE-ACETAMINOPHEN 7.5-325 MG/15 ML PO SOLN 66689000550 $167.00 $167.00 10 mL 28290 PEMETREXED 500 MG IV SOLR J9305 00002762301 $31,649.85 $31,649.85 1 Each 28300 BACITRACIN ZINC-POLYMYXIN B 500-10,000 UNIT/GRAM TP OINT 00810079888 $167.00 $167.00 14.2 gram 28409 BEVACIZUMAB 25 MG/ML IV SOLN J9035 50242006101 $28,689.84 $28,689.84 16 mL 28409 BEVACIZUMAB 25 MG/ML IV SOLN J9035 50242006001 $12,751.04 $12,751.04 4 mL 28431 MYCOPHENOLATE SODIUM 180 MG PO TBEC J7518 00078038566 $10,218.24 $10,218.24 120 Each 28432 MYCOPHENOLATE SODIUM 360 MG PO TBEC J7518 00078038666 $12,197.76 $12,197.76 120 Each 28443 SODIUM HYALURONATE (VISCOSUP) 30 MG/2 ML IX SYRG J7324 59676036001 $870.00 $870.00 2 mL 30717 CINACALCET 30 MG PO TABS 55513007330 $1,021.44 $1,021.44 30 Each 30718 CINACALCET 60 MG PO TABS 55513007430 $4,995.84 $4,995.84 30 Each 30719 CINACALCET 90 MG PO TABS 55513007530 $5,816.16 $5,816.16 30 Each 30732 VORICONAZOLE 200 MG/5 ML (40 MG/ML) PO SUSR 00049316044 $6,338.40 $6,338.40 75 mL 30817 OLANZAPINE 10 MG IM SOLR J3490 00002759701 $706.88 $706.88 1 Each 31058 CLOZAPINE 100 MG PO TBDL 18860010401 $4,147.20 $4,147.20 48 Each 31059 CLOZAPINE 25 MG PO TBDL 18860010201 $1,417.73 $1,417.73 48 Each 31084 TERBUTALINE 1 MG/ML SC SOLN J3105 55390010110 $167.00 $167.00 1 mL 31177 ACETYLCYSTEINE 200 MG/ML (20 %) IV SOLN J0132 66220020730 $293.76 $293.76 30 mL 31245 FLUOCINONIDE-EMOLLIENT 0.05 % TP CREA 00093026315 $574.56 $574.56 15 gram 31276 AGALSIDASE BETA 5 MG IV SOLR J0180 58468004101 $9,376.60 $15,002.56 1 Each 31386 CHEMO DILUENT 1 (PF) 73-19-8-3 MG/10 ML IT SOLN J9175 55792000710 $15,024.00 $15,024.00 10 mL 31411 AZACITIDINE 100 MG IJ SOLR J9025 59572010201 $1,118.56 $1,118.56 1 Each 31575 METHYLPHENIDATE HCL 5 MG/5 ML PO SOLN 99999900347 $167.00 $167.00 5 mL 31606 RACEPINEPHRINE 2.25 % IN NEBU 00487590199 $167.00 $167.00 1 Each 31607 ALBUTEROL SULFATE 2.5 MG/0.5 ML IN NEBU J7611 00487990130 $167.00 $167.00 1 Each 31855 RIFAXIMIN 200 MG PO TABS 65649030103 $10,787.04 $10,787.04 30 Each 31954 NITROFURANTOIN 100 MG PO CAPS 51079034801 $167.00 $167.00 1 Each 31954 NITROFURANTOIN 100 MG PO CAPS 51079034820 $3,691.20 $3,691.20 100 Each 31954 NITROFURANTOIN 100 MG PO CAPS 68084044601 $3,691.20 $3,691.20 100 Each 32038 DOXERCALCIFEROL 0.5 MCG PO CAPS 00955172050 $3,279.20 $3,279.20 50 Each 32060 NITAZOXANIDE 500 MG PO TABS 67546011112 $60,236.16 $60,236.16 30 Each 32112 EMTRICITABINE-TENOFOVIR (TDF) 200-300 MG PO TABS 61958070101 $27,475.20 $27,475.20 30 Each 32120 DULOXETINE 20 MG PO CPDR 00002323560 $1,277.76 $1,277.76 60 Each 32121 DULOXETINE 30 MG PO CPDR 00904645361 $1,873.60 $1,873.60 100 Each 32122 DULOXETINE 60 MG PO CPDR 60505299703 $219.84 $219.84 30 Each 32429 CAPSAICIN 0.1 % TP CREA 41167075142 $167.00 $167.00 42.5 gram 32482 FLUDARABINE 50 MG/2 ML IV SOLN J9185 00703485211 $616.16 $616.16 2 mL 32633 MVI, PEDI NO.1 WITH VIT K 80 MG-400 UNIT- 200 MCG/5 ML IV SOLN 54643564601 $207.92 $207.92 5 mL 32635 VANCOMYCIN IN DEXTROSE 5 % 1 GRAM/200 ML IV PGBK J3370 00338355248 $460.80 $460.80 200 mL 32666 ETANERCEPT 50 MG/ML (1 ML) SC SYRG J1438 58406043504 $12,510.02 $12,510.02 .98 mL 32698 FENTANYL (PF)-BUPIVACAINE-NACL 2 MCG/ML- 0.0625 % IJ SOLN J7999 69374052525 $360.00 $360.00 250 mL 32711 NORFLURANE-PENTAFLUOROPROPANE TP SPRA 00386000803 $374.26 $374.26 103.5 mL 32711 NORFLURANE-PENTAFLUOROPROPANE TP SPRA 00386000404 $410.69 $410.69 103.5 mL 32773 LEVOFLOXACIN 250 MG/10 ML PO SOLN 50383028616 $7,856.64 $7,856.64 480 mL 32832 FONDAPARINUX 5 MG/0.4 ML SC SYRG J1652 67457058304 $477.57 $477.57 .4 mL 32833 FONDAPARINUX 10 MG/0.8 ML SC SYRG J1652 55111068110 $470.14 $470.14 .8 mL 32838 FONDAPARINUX 7.5 MG/0.6 ML SC SYRG J1652 55150023210 $415.78 $415.78 .6 mL 32851 ERLOTINIB 150 MG PO TABS 50242006401 $126,040.80 $126,040.80 30 Each 32853 ERLOTINIB 25 MG PO TABS J8999 50242006201 $40,571.04 $40,571.04 30 Each 32872 NATALIZUMAB 300 MG/15 ML IV SOLN J2323 64406000801 $59,711.88 $67,175.87 15 mL 32889 LANTHANUM 500 MG PO CHEW 54092025290 $16,116.48 $16,116.48 90 Each 32964 SOLIFENACIN 10 MG PO TABS 51248015101 $5,749.44 $5,749.44 30 Each 33033 PALIFERMIN 6.25 MG IV SOLR J2425 66658011206 $25,397.80 $25,397.80 1 Each 33050 ESZOPICLONE 2 MG PO TABS 63402019110 $376.00 $376.00 100 Each 33133 CLOFARABINE 20 MG/20 ML IV SOLN J9027 00024586001 $27,272.16 $27,272.16 20 mL 33171 OXYTOCIN IN 0.9 % SOD CHLORIDE 30 UNIT/500 ML IV SOLN 99999000985 $167.00 $167.00 500 mL 33224 ZICONOTIDE 100 MCG/ML IT SOLN J2278 18860072010 $14,991.84 $14,991.84 1 mL 33225 ZICONOTIDE 25 MCG/ML IT SOLN J2278 18860072310 $40,786.20 $40,786.20 20 mL 33242 TOBRAMYCIN-LOTEPRED 0.3-0.5 % OP DRPS 24208035805 $4,144.80 $4,144.80 5 mL 33253 MESALAMINE 1000 MG PR SUPP 58914050156 $17,326.56 $17,326.56 30 Each 33266 PACLITAXEL-PROTEIN BOUND 100 MG IV SUSR J9264 68817013450 $12,684.15 $12,684.15 1 Each 33486 LEUPROLIDE (6 MONTH) 45 MG SC SYRG J9217 62935045345 $8,411.20 $8,411.20 1 Each 33571 BACLOFEN 50 MCG/ML IT SOLN J0476 70257056255 $480.00 $480.00 1 mL 33700 LEVALBUTEROL TARTRATE 45 MCG/ACTUATION IN HFAA J3535 63402051001 $508.92 $508.92 15 gram 33739 IBANDRONATE 150 MG PO TABS 00004018682 $301.30 $301.30 3 Each 33770 ENTECAVIR 0.05 MG/ML PO SOLN 00003161412 $14,327.04 $14,327.04 210 mL 33771 ENTECAVIR 0.5 MG PO TABS 00003161112 $899.52 $899.52 30 Each 33809 ESOMEPRAZOLE SODIUM 40 MG INJECTION 00186604001 $665.87 $665.87 1 Each 33997 EXENATIDE 5 MCG/DOSE (250 MCG/ML) 1.2 ML SC PNIJ 00310651201 $11,252.16 $11,252.16 1.2 mL 33998 EXENATIDE 10 MCG/DOSE(250 MCG/ML) 2.4 ML SC PNIJ 00310652401 $11,252.16 $11,252.16 2.4 mL 34005 IPRATROPIUM BROMIDE 17 MCG/ACTUATION IN HFAA J3535 00597008717 $3,190.43 $3,190.43 12.9 gram 34041 FENTANYL 12 MCG/HR TD PT72 00378911998 $921.12 $921.12 5 Each

Pharmacy FY22 MED IDs 212 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 34103 OXALIPLATIN 50 MG/10 ML (5 MG/ML) IV SOLN J9263 61703036318 $615.20 $615.20 10 mL 34104 OXALIPLATIN 100 MG/20 ML IV SOLN J9263 25021023320 $715.84 $715.84 20 mL 34149 PARICALCITOL 1 MCG PO CAPS 00074431730 $647.52 $647.52 30 Each 34209 BUPRENORPHINE HCL 0.3 MG/ML IJ SOLN J0592 42023017905 $192.80 $192.80 1 mL 34214 SILDENAFIL (PULM.HYPERTENSION) 20 MG PO TABS 60687041621 $365.76 $365.76 30 Each 34232 PALIVIZUMAB 50 MG/0.5 ML IM SOLN 90378 60574411401 $14,158.98 $14,158.98 .5 mL 34233 PALIVIZUMAB 100 MG/ML IM SOLN 90378 60574411301 $26,736.12 $26,736.12 1 mL 34244 TIGECYCLINE 50 MG IV SOLR J3243 55150022810 $832.32 $832.32 1 Each 34312 SECRETIN (HUMAN) 16 MCG IV SOLR J2850 67066000501 $8,400.00 $8,400.00 1 Each 34332 MOMETASONE 220 MCG/ ACTUATION (14) IN AEPB 00085134106 $358.48 $358.48 1 Each 34352 MEGESTROL 625 MG/5 ML (125 MG/ML) PO SUSP 24979004113 $5,140.80 $5,140.80 150 mL 34375 LIDOCAINE-TETRACAINE 70-70 MG TP PTMH C9285 10885000210 $2,264.32 $2,264.32 10 Each 34541 ROPIVACAINE(PF)-0.9 % SODCHLOR 0.15 % EP SOLN J2795 99999002745 $167.00 $167.00 200 mL 34572 PREGABALIN 25 MG PO CAPS 00071101268 $694.08 $694.08 90 Each 34573 PREGABALIN 50 MG PO CAPS 00071101341 $1,124.80 $1,124.80 100 Each 34574 PREGABALIN 75 MG PO CAPS 00071101441 $728.00 $728.00 100 Each 34575 PREGABALIN 100 MG PO CAPS 00904700161 $1,252.80 $1,252.80 100 Each 34585 OPIUM TINCTURE 10 MG/ML (MORPHINE) PO TINC 99999900181 $167.00 $167.00 .6 mL 34653 INSULIN DETEMIR U-100 100 UNITS/ML SC SOLN J1815 00169368712 $3,593.28 $3,593.28 10 mL 34936 MEPERIDINE (PF) 50 MG/ML IJ SOLN J2175 00409125301 $167.00 $167.00 1 mL 34936 MEPERIDINE (PF) 50 MG/ML IJ SOLN J2175 00409125311 $167.00 $167.00 1 mL 34940 MEPERIDINE (PF) 25 MG/ML IJ SOLN J2175 00641605225 $167.00 $167.00 1 mL 34947 MEPERIDINE (PF) 100 MG/ML IJ SOLN J2175 00409125601 $167.00 $167.00 1 mL 34971 PANCURONIUM 1 MG/ML IV SOLN J3490 00409464601 $167.00 $167.00 10 mL 35153 LOPINAVIR-RITONAVIR 200-50 MG PO TABS 00074679922 $15,273.60 $15,273.60 120 Each 35164 NELARABINE 250 MG/50 ML IV SOLN J9261 00078068306 $10,967.20 $10,967.20 50 mL 35188 BCG LIVE 50 MG IS SUSR J9030 00052060202 $2,341.76 $2,341.76 1 Each 35244 PORACTANT ALFA 240 MG/3 ML ITL SUSP 10122051003 $13,246.42 $13,246.42 3 mL 35245 PORACTANT ALFA 120 MG/1.5 ML ITL SUSP 10122051001 $6,806.57 $6,806.57 1.5 mL 35270 DEFERASIROX 125 MG PO TBDP 00078046815 $20,269.44 $20,269.44 30 Each 35271 DEFERASIROX 250 MG PO TBDP 00078046915 $40,538.40 $40,538.40 30 Each 35272 DEFERASIROX 500 MG PO TBDP 00078047015 $81,075.36 $81,075.36 30 Each 35369 LANTHANUM 1000 MG PO CHEW 54092025490 $16,116.48 $16,116.48 90 Each 35370 LANTHANUM 750 MG PO CHEW 54092025390 $13,924.80 $13,924.80 90 Each 35500 SORAFENIB 200 MG PO TABS J8999 50419048858 $332,160.00 $332,160.00 120 Each 35507 EMOLLIENT COMBINATION NO.10 TP EMUL 58980096012 $234.72 $234.72 45 gram 35507 EMOLLIENT COMBINATION NO.10 TP EMUL 00187511090 $745.92 $745.92 90 gram 35538 ARIPIPRAZOLE 2 MG PO TABS 59148000613 $2,880.48 $2,880.48 30 Each 35558 LENALIDOMIDE 5 MG PO CAPS 59572040528 $357,210.11 $357,210.11 28 Each 35559 LENALIDOMIDE 10 MG PO CAPS 59572041028 $357,210.11 $357,210.11 28 Each 35590 ANTI-INHIBITOR COAGULANT CMPLX 1,750-3,250 UNIT IV SOLR J7198 64193042502 $44,000.00 $44,000.00 1 Each 35592 INSULIN GLULISINE U-100 100 UNITS/ML SC SOLN J1815 00088250033 $1,693.92 $1,693.92 10 mL 35688 IBANDRONATE 3 MG/3 ML IV SYRG J1740 25021082761 $1,938.72 $1,938.72 3 mL 35696 QUETIAPINE 50 MG PO TABS 16714045301 $167.00 $167.00 100 Each 35707 ILOPROST 10 MCG/ML IN NEBU Q4074 66215030200 $2,586.24 $2,586.24 1 mL 35715 ANTIHEMOPHILIC FACTOR-VWF 250-600 UNIT IV SOLR J7187 63833061502 $9,120.00 $9,120.00 1 Each 35716 ANTIHEMOPHILIC FACTOR-VWF 1,000-2,400 UNIT IV SOLR J7187 63833061702 $36,480.00 $36,480.00 1 Each 35717 ANTIHEMOPHILIC FACTOR-VWF 500-1,200 UNIT IV SOLR J7187 63833061602 $18,240.00 $18,240.00 1 Each 35720 HEPARIN (PORCINE) IN 5 % DEX 25,000 UNIT/250 ML(100 UNIT/ML) IV SOLP J1644 00409779362 $167.00 $167.00 250 mL 35721 HEPARIN, PORCINE (PF) 100 UNITS/ML IV SYRG J1642 08290306513 $167.00 $167.00 5 mL 35722 HEPARIN, PORCINE (PF) 10 UNITS/ML IV SYRG J1642 64253022233 $167.00 $167.00 3 mL 35729 SUNITINIB 12.5 MG PO CAPS 00069055038 $90,538.56 $90,538.56 28 Each 35730 SUNITINIB 25 MG PO CAPS 00069077038 $181,077.12 $181,077.12 28 Each 35731 SUNITINIB 50 MG PO CAPS 00069098038 $315,229.82 $315,229.82 28 Each 35739 HEPARIN, PORCINE (PF) 5000 UNIT/0.5 ML IJ SYRG J1644 00409131632 $167.00 $167.00 .5 mL 35749 RANOLAZINE 500 MG PO TB12 61958100301 $6,131.52 $6,131.52 60 Each 35772 LUBIPROSTONE 24 MCG PO CAPS 64764024060 $5,478.72 $5,478.72 60 Each 35944 OMEPRAZOLE-SODIUM BICARBONATE 40-1.1 MG-GRAM PO CAPS 68012010430 $49,316.64 $49,316.64 30 Each 35951 SELEGILINE 6 MG/24 HR TD PT24 49502090030 $27,510.24 $27,510.24 30 Each 35986 HYALURONIDASE, HUMAN RECOMB. 150 UNITS/ML IJ SOLN 18657011704 $595.41 $595.41 1 mL 36260 ALGLUCOSIDASE ALFA 50 MG IV SOLR J0221 58468016001 $8,406.40 $13,450.24 1 Each 36297 LIDOCAINE (PF) 40 MG/ML (4 %) IJ SOLN J2001 00409428301 $167.00 $167.00 5 mL 36299 LIDOCAINE (PF) 10 MG/ML (1 %) IJ SOLN J3490 55150016205 $167.00 $167.00 5 mL 36299 LIDOCAINE (PF) 10 MG/ML (1 %) IJ SOLN J3490 63323049237 $167.00 $167.00 30 mL 36299 LIDOCAINE (PF) 10 MG/ML (1 %) IJ SOLN J3490 63323049297 $167.00 $167.00 10 mL 36300 LIDOCAINE (PF) 20 MG/ML (2 %) IJ SOLN J2001 00409206605 $167.00 $167.00 5 mL 36300 LIDOCAINE (PF) 20 MG/ML (2 %) IJ SOLN J2001 00409428201 $167.00 $167.00 2 mL 36300 LIDOCAINE (PF) 20 MG/ML (2 %) IJ SOLN J2001 00409428202 $167.00 $167.00 10 mL 36302 LIDOCAINE (PF) 5 MG/ML (0.5 %) IJ SOLN J2001 00409427801 $167.00 $167.00 50 mL 36303 LIDOCAINE (PF) 20 MG/ML (2 %) IV SOLN J2001 63323020805 $167.00 $167.00 5 mL 36304 LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRG J2001 00409490334 $167.00 $167.00 5 mL 36311 LIDOCAINE IN 5 % DEXTROSE (PF) 4 MG/ML (0.4 %) IV SOLP J2001 00338040903 $167.00 $167.00 500 mL 36385 DECITABINE 50 MG IV SOLR J0894 62856060001 $1,715.04 $1,715.04 1 Each 36433 RASAGILINE 0.5 MG PO TABS 68546014256 $2,587.68 $2,587.68 30 Each 36435 RASAGILINE 1 MG PO TABS 47781013930 $5,075.52 $5,075.52 30 Each

Pharmacy FY22 MED IDs 213 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 36472 VARICELLA VIRUS VACC LIVE (PF) 1350 UNIT/0.5 ML SC SUSR 90716 00006482700 $2,166.21 $2,166.21 1 Each 36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516412 $167.00 $167.00 5 mL 36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516413 $548.24 $548.24 10 mL 36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516414 $1,212.60 $1,212.60 15 mL 36556 GADOBENATE DIMEGLUMINE 529 MG/ML (0.1MMOL/0.2ML) IV SOLN A9577 00270516415 $2,155.68 $2,155.68 20 mL 36560 IBUPROFEN LYSINE (PF) 20 MG/2 ML IV SOLN 39822103002 $3,970.72 $3,970.72 2 mL 36580 DARBEPOETIN ALFA IN POLYSORBAT 500 MCG/ML IJ SYRG J0881 55513003201 $31,166.46 $31,166.46 1 mL 36721 DASATINIB 20 MG PO TABS 00003052711 $125,450.88 $125,450.88 60 Each 36722 DASATINIB 50 MG PO TABS 00003052811 $250,900.80 $250,900.80 60 Each 36723 DASATINIB 70 MG PO TABS 00003052411 $250,900.80 $250,900.80 60 Each 36740 LENALIDOMIDE 15 MG PO CAPS 59572041521 $267,907.92 $267,907.92 21 Each 36741 LENALIDOMIDE 25 MG PO CAPS 59572042521 $267,907.92 $267,907.92 21 Each 36749 APREPITANT 40 MG PO CAPS J8501 00006046405 $5,836.96 $5,836.96 5 Each 36829 EFAVIRENZ-EMTRICITABIN-TENOFOV 600-200-300 MG PO TABS 15584010101 $44,662.08 $44,662.08 30 Each 36856 LIDOCAINE HCL 4 % LATR SOLN 00409469801 $340.80 $340.80 4 mL 36861 FENOFIBRATE NANOCRYSTALLIZED 48 MG PO TABS 16714073701 $1,651.68 $1,651.68 90 Each 36862 FENOFIBRATE NANOCRYSTALLIZED 145 MG PO TABS 16714073801 $4,006.08 $4,006.08 90 Each 36869 ADALIMUMAB 40 MG/0.8 ML SC PNKT J0135 00074433902 $50,066.46 $50,066.46 2 Each 36900 ETONOGESTREL 68 MG SD IMPL J7307 00052433001 $14,957.12 $14,957.12 1 Each 36914 IDURSULFASE 6 MG/3 ML IV SOLN J1743 54092070001 $25,086.65 $28,222.48 3 mL 36940 DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/0.4 ML IJ SYRG J0881 55513002801 $12,466.62 $12,466.62 .4 mL 36943 DARBEPOETIN ALFA IN POLYSORBAT 300 MCG/0.6 ML IJ SYRG J0881 55513011101 $18,699.84 $18,699.84 .6 mL 36951 DARBEPOETIN ALFA IN POLYSORBAT 100 MCG/0.5 ML IJ SYRG J0881 55513002501 $11,081.40 $11,081.40 .5 mL 37078 LEVETIRACETAM 500 MG/5 ML IV SOLN J1953 00409188602 $167.00 $167.00 5 mL 37107 DARBEPOETIN ALFA IN POLYSORBAT 200 MCG/ML IJ SOLN J0881 55513000601 $12,466.62 $12,466.62 1 mL 37248 SODIUM HYPOCHLORITE 0.125 % MISC SOLN 00436067216 $167.00 $167.00 473 mL 37273 POSACONAZOLE 200 MG/5 ML (40 MG/ML) PO SUSP 00085132801 $21,468.72 $21,468.72 105 mL 37284 PEG3350-SOD SUL-NACL-KCL-ASB-C 100-7.5-2.691 GRAM PO PWPK 65649020175 $1,771.04 $1,771.04 1 Each 37377 PERITON.DIALYSIS 8-4.25 % DEXT CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045908 $167.00 $167.00 2000 mL 37377 PERITON.DIALYSIS 8-4.25 % DEXT CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941045905 $167.00 $167.00 5000 mL 37399 PERITON.DIALYSIS 7-2.5 % DEXTR CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN J3490 00941045705 $167.00 $167.00 5000 mL 37399 PERITON.DIALYSIS 7-2.5 % DEXTR CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN J3490 00941045708 $167.00 $167.00 2000 mL 37422 SITAGLIPTIN 25 MG PO TABS 00006022128 $24,696.00 $24,696.00 100 Each 37424 SITAGLIPTIN 50 MG PO TABS 00006011228 $24,696.00 $24,696.00 100 Each 37425 SITAGLIPTIN 100 MG PO TABS 00006027728 $24,696.00 $24,696.00 100 Each 37462 ATAZANAVIR 300 MG PO CAPS 00003362212 $2,630.88 $2,630.88 30 Each 37480 PERIT.DIALYSIS 6-1.5 % DEXTROS CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941040907 $167.00 $167.00 5000 mL 37480 PERIT.DIALYSIS 6-1.5 % DEXTROS CA 2.5 MEQ/L- MG 0.5 MEQ/L IP SOLN 00941040906 $167.00 $167.00 2000 mL 37499 MICAFUNGIN 100 MG IV SOLR J2248 00469321110 $836.64 $836.64 1 Each 37523 ONDANSETRON HCL (PF) 4 MG/2 ML IJ SOLN J2405 00409475518 $167.00 $167.00 2 mL 37574 HEPARIN, PORCINE (PF) 1 UNITS/ML IV SYRG J1642 64253044430 $167.00 $167.00 10 mL 37574 HEPARIN, PORCINE (PF) 1 UNITS/ML IV SYRG J1642 99999900218 $167.00 $167.00 10 mL 37635 MORPHINE 20 MG PO CSRP 52544021160 $9,568.32 $9,568.32 60 Each 37726 PALIPERIDONE 3 MG PO TR24 50458055010 $16,144.00 $16,144.00 100 Each 37727 PALIPERIDONE 6 MG PO TR24 50458055101 $5,390.88 $5,390.88 30 Each 37728 PALIPERIDONE 9 MG PO TR24 50458055201 $6,931.20 $6,931.20 30 Each 37766 EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) IJ SOLN J0171 54288010310 $167.00 $167.00 1 mL 37767 GENTAMICIN IN NACL (ISO-OSM) 60 MG/50 ML IV PGBK J1580 00338050741 $167.00 $167.00 50 mL 37769 GENTAMICIN IN NACL (ISO-OSM) 80 MG/50 ML IV PGBK J1580 00338050941 $167.00 $167.00 50 mL 37772 GENTAMICIN IN NACL (ISO-OSM) 100 MG/100 ML IV PGBK J1580 00338050548 $167.00 $167.00 100 mL 37815 PRAMOXINE 1 % TP FOAM 00037682315 $1,092.24 $1,092.24 15 gram 37831 DEXAMETHASONE SODIUM PHOS (PF) 10 MG/ML IJ SOLN J1100 63323050601 $167.00 $167.00 1 mL 37860 OLOPATADINE 0.2 % OP DROP 00065027225 $167.00 $167.00 2.5 mL 37860 OLOPATADINE 0.2 % OP DROP 60505058604 $401.28 $401.28 2.5 mL 38060 HEPATITIS B IMMUNE GLOBULIN GREATR THAN 312 UNIT/ML IM SOLN 90371 59730420201 $2,191.52 $2,191.52 1 mL 38074 HEPATITIS B IMMUNE GLOBULIN GREATER THAN 1,560 UNIT/5 ML IM SOLN 90371 59730420301 $7,908.00 $7,908.00 5 mL 38081 LISDEXAMFETAMINE 30 MG PO CAPS 59417010310 $16,652.80 $16,652.80 100 Each 38083 LISDEXAMFETAMINE 70 MG PO CAPS 59417010710 $16,652.80 $16,652.80 100 Each 38088 ALISKIREN 300 MG PO TABS 70839030030 $4,602.72 $4,602.72 30 Each 38089 ALISKIREN 150 MG PO TABS 70839015030 $3,648.00 $3,648.00 30 Each 38265 THALIDOMIDE 150 MG PO CAPS 59572021513 $132,884.42 $132,884.42 28 Each 38312 ECULIZUMAB 300 MG/30 ML IV SOLN J1300 25682000101 $58,706.91 $58,706.91 30 mL 38399 TEMOZOLOMIDE 140 MG PO CAPS J8700 43975025514 $7,292.32 $7,292.32 14 Each 38400 TEMOZOLOMIDE 180 MG PO CAPS J8700 00093763941 $13,343.68 $13,343.68 14 Each 38551 ZOLEDRONIC ACID-MANNITOL-WATER 5 MG/100 ML IV PGBK J3489 00078043561 $475.00 $760.00 100 mL 38595 PEG 3350-ELECTROLYTES 236-22.74-6.74 -5.86 GRAM PO SOLR 52268010001 $167.00 $167.00 4000 mL 38613 RISPERIDONE MICROSPHERES 12.5 MG/2 ML IM SSRR J2794 50458030911 $3,894.56 $3,894.56 1 Each 38677 HEPATITIS B VIRUS VACC.REC(PF) 10 MCG/0.5 ML IM SYRG 90744 58160082043 $236.00 $236.00 .5 mL 38693 NEOMYCIN-POLYMYXIN-GRAMICIDIN 1.75 MG-10,000 UNIT-0.025MG/ML OP DROP 24208079062 $555.68 $555.68 10 mL 38804 BUDESONIDE-FORMOTEROL 160-4.5 MCG/ACTUATION IN HFAA 00186037028 $454.90 $454.90 6 gram 38811 VIT B1-B2-B3-B5-B6 100-2-100-2-2 MG/ML IJ SOLN 67457014630 $2,726.88 $2,726.88 30 mL 38863 HEPATITIS A VIRUS VACCINE (PF) 1440 UNITS IM SYRG 90632 58160082652 $964.54 $964.54 1 mL 39122 AMBRISENTAN 5 MG PO TABS 00378427093 $21,600.00 $21,600.00 30 Each 39123 AMBRISENTAN 10 MG PO TABS 00378427193 $21,600.00 $21,600.00 30 Each 39167 SAMARIUM SM 153 LEXIDRONAM 5550 MBQ/3 ML IV SOLN A9604 11994001601 $292,965.37 $292,965.37 3 mL

Pharmacy FY22 MED IDs 214 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 39283 HYDROMORPHONE (PF) 10 MG/ML IJ SOLN J1170 00703011003 $167.00 $167.00 1 mL 39283 HYDROMORPHONE (PF) 10 MG/ML IJ SOLN J1170 17478054005 $167.00 $167.00 5 mL 39283 HYDROMORPHONE (PF) 10 MG/ML IJ SOLN J1170 00703011303 $167.00 $167.00 5 mL 39284 TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST) IV SOLR J9330 00008117901 $37,297.80 $37,297.80 2.5 mL 39409 RIVASTIGMINE 4.6 MG/24 HOUR TD PT24 00078050115 $2,523.36 $2,523.36 30 Each 39410 RIVASTIGMINE 9.5 MG/24 HOUR TD PT24 00078050261 $167.00 $167.00 1 Each 39902 MARAVIROC 150 MG PO TABS 49702022318 $23,208.96 $23,208.96 60 Each 39907 MARAVIROC 300 MG PO TABS 49702022418 $23,208.96 $23,208.96 60 Each 39952 GENTAMICIN SULFATE (PED) (PF) 20 MG/2 ML IJ SOLN J1580 63323017302 $167.00 $167.00 2 mL 40154 HEPATITIS A VIRUS VACCINE (PF) 1440 UNITS IM SUSP 90632 58160082601 $964.54 $964.54 1 mL 40175 ANTIHEMOPHIL FVIII,FULL LENGTH 500 (+/-) UNIT IV SOLR 00026378335 $167.00 $167.00 1 Each 40176 ANTIHEMOPHIL FVIII,FULL LENGTH 1,000 (+/-) UNIT IV SOLR 00026378555 $167.00 $167.00 1 Each 40258 CARISOPRODOL 250 MG PO TABS 42543043401 $3,944.00 $3,944.00 100 Each 40298 THROMBIN (BOVINE) 5000 UNITS TP SPSY 60793070505 $680.32 $680.32 1 Each 40314 THROMBIN (BOVINE) 5000 UNITS TP SOLR 60793021505 $666.88 $666.88 1 Each 40435 LANREOTIDE 60 MG/0.2 ML SC SYRG J1930 15054106003 $50,175.00 $50,175.00 .2 mL 40436 LANREOTIDE 90 MG/0.3 ML SC SYRG J1930 15054109004 $69,831.00 $69,831.00 .3 mL 40436 LANREOTIDE 90 MG/0.3 ML SC SYRG J1930 15054109003 $66,825.00 $66,825.00 .3 mL 40437 LANREOTIDE 120 MG/0.5 ML SC SYRG J1930 15054112003 $78,804.00 $78,804.00 .5 mL 40480 OSELTAMIVIR 30 MG PO CAPS 00004080285 $2,078.08 $2,078.08 10 Each 40481 OSELTAMIVIR 45 MG PO CAPS 00004080185 $2,078.08 $2,078.08 10 Each 40498 RALTEGRAVIR 400 MG PO TABS 00006022761 $25,877.76 $25,877.76 60 Each 40529 IXABEPILONE 15 MG IV SOLR J9207 70020191001 $14,625.00 $14,625.00 1 Each 40530 IXABEPILONE 45 MG IV SOLR J9207 70020191101 $43,875.00 $43,875.00 1 Each 40536 FAMOTIDINE (PF) 20 MG/2 ML IV SOLN 63323073912 $167.00 $167.00 2 mL 40724 MAGNESIUM SULFATE IN WATER 4 GRAM/100 ML (4 %) IV PGBK J3475 00409672923 $167.00 $167.00 100 mL 40747 CEFOTETAN IN DEXTROSE, ISO-OSM 1 GRAM/50 ML IV PGBK 00264317311 $338.54 $338.54 1 Each 40748 CEFOTETAN IN DEXTROSE, ISO-OSM 2 GRAM/50 ML IV PGBK 00264317511 $476.06 $476.06 1 Each 40854 AMINO ACID (AMINOSYN NO.2) 10% 00409717217 $512.00 $512.00 2000 mL 40996 SEVELAMER CARBONATE 800 MG PO TABS 58468013001 $23,837.76 $23,837.76 270 Each 41003 DIPH,PERTUS(ACEL),TET PED (PF) 25-58-10 LF-MCG-LF/0.5ML IM SYRG 90700 58160081052 $306.70 $306.70 .5 mL 41017 INDIUM 111-PENTETREOTIDE 3-10 MCI/ML-MCG IV KIT A9572 00019905040 $25,722.19 $25,722.19 1 Each 41039 DICLOFENAC SODIUM 1 % TP GEL 76282066339 $167.00 $167.00 100 gram 41043 MAGNESIUM SULFATE IN D5W 1 G/100 ML IV PGBK J3475 00409672723 $167.00 $167.00 100 mL 41044 MAGNESIUM SULFATE IN WATER 20 GRAM/500 ML (4 %) IV SOLP J3475 00409672903 $167.00 $167.00 500 mL 41060 NEBIVOLOL 5 MG PO TABS 00456140563 $7,995.20 $7,995.20 100 Each 41061 NEBIVOLOL 2.5 MG PO TABS 00456140230 $2,355.36 $2,355.36 30 Each 41122 CLOPIDOGREL 300 MG PO TABS 55111067131 $5,120.16 $5,120.16 30 Each 41124 GRANISETRON HCL 1 MG/ML (1 ML) IV SOLN J1626 00703797103 $167.00 $167.00 1 mL 41126 PEMETREXED 100 MG IV SOLR J9305 00002764001 $11,253.28 $11,253.28 1 Each 41148 PARENTERAL AMINO ACID 10% NO.2 10 % IV SOLP 00409419103 $240.00 $240.00 500 mL 41158 HAEMOPH B POLY CONJ-TET TOX-PF 10 MCG/0.5 ML IM SOLR 90648 49281054503 $169.41 $169.41 1 Each 41173 PARENTERAL AMINO ACID 10% NO.6 10 % IV SOLP 00338064403 $167.00 $167.00 500 mL 41175 PARENTERAL AMINO ACID 10% NO.4 10 % IV SOLP 00264901055 $256.00 $256.00 1000 mL 41195 BARIUM SULFATE 0.1 % PO SUSP 32909094503 $5,832.00 $5,832.00 450 mL 41197 ETRAVIRINE 100 MG PO TABS 59676057001 $21,050.88 $21,050.88 120 Each 41290 IRINOTECAN 100 MG/5 ML IV SOLN J9206 00143970101 $182.08 $182.08 5 mL 41291 IRINOTECAN 40 MG/2 ML IV SOLN J9206 63323019302 $167.00 $167.00 2 mL 41291 IRINOTECAN 40 MG/2 ML IV SOLN J9206 00009752904 $353.76 $353.76 2 mL 41323 FOSPHENYTOIN 100 MG PE/2 ML IJ SOLN Q2009 00143978825 $167.00 $167.00 2 mL 41324 FOSPHENYTOIN 500 MG PE/10 ML IJ SOLN Q2009 00143978210 $222.40 $222.40 10 mL 41359 PARENT. AMINO ACID 8.5 % NO.2 8.5 % IV SOLP 00409418703 $167.00 $167.00 500 mL 41364 DIPH,PERTUS(ACEL),TET PED (PF) 15-10-5 LF-MCG-LF/0.5ML IM SUSP 90700 49281028610 $374.46 $374.46 .5 mL 41386 TETANUS AND DIPHTHER. TOX (PF) 5-2 LF UNIT/0.5 ML IM SYRG 90714 49281021515 $480.91 $480.91 .5 mL 41387 TETANUS AND DIPHTHER. TOX (PF) 5 LF UNIT- 2 LF UNIT/0.5ML IM SUSP 90714 49281021510 $480.91 $480.91 .5 mL 41388 DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SUSP 90715 49281040010 $631.25 $631.25 .5 mL 41424 DARUNAVIR ETHANOLATE 600 MG PO TABS 59676056201 $27,518.40 $27,518.40 60 Each 41578 EPIRUBICIN 50 MG/25 ML IV SOLN J9178 45963060868 $500.00 $500.00 25 mL 41592 BENDAMUSTINE 100 MG IV SOLR J9033 63459039120 $14,734.26 $14,734.26 1 Each 41623 MENING VAC A,C,Y,W135 DIP (PF) 4 MCG/0.5 ML IM SOLN 90734 49281058905 $2,003.20 $2,003.20 .5 mL 41635 AMINO ACID (PREMASOL) 10% NO.7 IV SOLP 00338113003 $336.00 $336.00 500 mL 41635 AMINO ACID (PREMASOL) 10% NO.7 IV SOLP 00338113004 $512.00 $512.00 1000 mL 41670 MEASLES,MUMPS,RUBELLA VACC(PF) 1,000-12,500 TCID50/0.5 ML SC SOLR 90707 00006468100 $11,705.28 $11,705.28 10 Each 41749 DIPH,PERTUSS(ACEL),TET VAC(PF) 2 LF-(2.5-5-3-5 MCG)-5LF/0.5 ML IM SYRG 90715 49281040015 $538.56 $538.56 .5 mL 41754 CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SC KIT J0717 50474070062 $22,498.56 $22,498.56 1 Each 41764 HEPATITIS B VIRUS VACC.REC(PF) 40 MCG/ML IM SUSP 90740 00006499200 $1,502.56 $1,502.56 1 mL 41766 HEPATITIS B VIRUS VACC.REC(PF) 5 MCG/0.5 ML IM SUSP 90744 00006498100 $291.86 $291.86 .5 mL 41843 TETANUS IMMUNE GLOBULIN (PF) 250 UNITS IM SYRG J1670 13533063402 $7,186.40 $7,186.40 1 Each 41938 METHYLNALTREXONE 12 MG/0.6 ML SC SOLN 65649055102 $2,006.08 $2,006.08 .6 mL 41976 REGADENOSON 0.4 MG/5 ML IV SYRG J2785 00469650189 $3,369.76 $3,369.76 5 mL 73589 NOREPINEPHRINE (LEVOPHED)(0.032MG/ML) 8 MG IN D5W 250 ML 99999900217 $200.00 $200.00 250 mL 73592 METHYLPREDNISOLONE SODIUM SUCC 2 MG IJ SOLR J2920 99999900220 $167.00 $167.00 2 Each 73642 HEPARIN INJECTION FOR DIALYSIS J1644 99999900254 $167.00 $167.00 10 mL 73652 LABETALOL 250 MG/50 ML (5 MG/ML) STRAIGHT DRUG IV SOLN 99999900668 $167.00 $167.00 50 mL 73654 MIDAZOLAM 125MG IN D5W 250ML (0.5 MG/ML) J2250 99999900260 $220.00 $220.00 250 mL

Pharmacy FY22 MED IDs 215 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 73656 CYTARABINE INJECTION 100 MG/ML J9100 99999900263 $167.00 $167.00 1 mL 73769 ONABOTULINUMTOXINA 200 UNITS IJ SOLR J0585 00023392102 $9,616.00 $10,818.00 1 Each 73838 TOCILIZUMAB 80 MG/4 ML (20 MG/ML) IV SOLN J3262 50242013501 $6,877.63 $6,877.63 4 mL 73839 TOCILIZUMAB 200 MG/10 ML (20 MG/ML) IV SOLN J3262 50242013601 $17,193.92 $17,193.92 10 mL 73840 TOCILIZUMAB 400 MG/20 ML (20 MG/ML) IV SOLN J3262 50242013701 $19,343.16 $19,343.16 20 mL 73852 METHYLPREDNISOLONE SOD SUC(PF) 40 MG/ML IJ SOLR J2920 00009003928 $167.00 $167.00 40 mg 73853 METHYLPREDNISOLONE SOD SUC(PF) 125 MG/2 ML IJ SOLR J2930 00009004722 $167.00 $167.00 125 mg 73854 METHYLPREDNISOLONE SOD SUC(PF) 500 MG/4 ML IV SOLR J2930 00009000302 $598.24 $598.24 1 Each 73855 METHYLPREDNISOLONE SOD SUC(PF) 1000 MG/8 ML IV SOLR J2930 00009001820 $777.92 $777.92 1 Each 73887 USTEKINUMAB 45 MG/0.5 ML SC SYRG J3357 57894006003 $101,467.17 $101,467.17 .5 mL 73888 USTEKINUMAB 90 MG/ML SC SYRG J3357 57894006103 $202,934.34 $202,934.34 1 mL 73896 VALGANCICLOVIR 50 MG/ML PO SOLR 00591257920 $11,934.21 $11,934.21 88 mL 74090 MENING VAC A,C,Y,W135 DIP (PF) 10-5 MCG/0.5 ML IM KIT 90734 58160095509 $7,740.32 $7,740.32 5 Each 74092 SILDENAFIL (PULM.HYPERTENSION) 10 MG/12.5 ML IV SOLN J3490 55150016613 $1,855.20 $1,855.20 12.5 mL 74134 VELAGLUCERASE ALFA 400 UNITS IV SOLR J3385 54092070104 $11,346.48 $12,764.79 1 Each 74136 PNEUMOC 13-VAL CONJ-DIP CR(PF) 0.5 ML IM SYRG 90670 00005197101 $3,159.65 $3,159.65 .5 mL 74264 ROMIDEPSIN 10 MG/2 ML IV SOLR J9315 00703312508 $28,787.85 $28,787.85 1 Each 74371 MORPHINE 1 MG/ML PCA CSMC J2270 71286204003 $170.40 $170.40 30 mL 74371 MORPHINE 1 MG/ML PCA CSMC J2270 99999900242 $170.40 $170.40 30 mL 74394 KIT PREP OF TC-99M-MEBROFENIN 45 MG IV SOLR A9537 45567045502 $10,042.50 $10,042.50 30 Each 74417 KIT PREP OF TC-99M-SOD PYROPH 12 MG IV SOLR A9538 45567006001 $1,261.75 $1,261.75 5 Each 74454 SIROLIMUS 0.5 MG PO TABS J7520 00008104010 $23,699.20 $23,699.20 100 Each 74461 TRIPTORELIN PAMOATE 22.5 MG IM SUSR J3315 00023590623 $40,933.17 $40,933.17 1 Each 74481 HYDROCORTISONE SOD SUCC (PF) 500 MG/4 ML IJ SOLR J1720 00009001612 $847.52 $847.52 1 Each 74483 HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML IJ SOLR J1720 00009001103 $226.24 $226.24 1 Each 74483 HYDROCORTISONE SOD SUCC (PF) 100 MG/2 ML IJ SOLR J1720 00009001104 $229.89 $229.89 1 Each 74528 RIFAXIMIN 550 MG PO TABS 65649030303 $41,123.52 $41,123.52 60 Each 74562 EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.5 MG PO TABS J7527 00078041420 $16,595.52 $16,595.52 60 Each 74563 EVEROLIMUS (IMMUNOSUPPRESSIVE) 0.25 MG PO TABS J7527 00078041720 $8,298.24 $8,298.24 60 Each 74619 SIPULEUCEL-T-LACTATED RINGERS 50 MILLION CELL/250 ML IV SUSP Q2043 30237890006 $583,650.00 $583,650.00 250 mL 74739 LACOSAMIDE 10 MG/ML PO SOLN 99999900342 $236.80 $236.80 10 mL 74773 DENOSUMAB 60 MG/ML SC SYRG J0897 55513071001 $10,098.32 $11,360.61 1 mL 74877 AMIKACIN 500 MG/2 ML IJ SOLN J0278 63323081502 $173.60 $173.60 2 mL 74906 PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG J7999 69374095710 $376.00 $376.00 10 mL 74933 CABAZITAXEL 10 MG/ML (FIRST DILUTION) IV SOLN J9043 00024582411 $99,720.18 $99,720.18 60 mg 74971 EVEROLIMUS (ANTINEOPLASTIC) 2.5 MG PO TABS J7527 00078059451 $124,324.03 $124,324.03 28 Each 75011 GLUCAGON 1 MG/ML IJ SOLR J1610 00597026010 $2,559.20 $2,559.20 1 Each 75158 CALCIUM GLUCONATE IN 0.9% NACL 2 G/100 ML IV SOLN J0610 99999001123 $272.00 $272.00 100 mL 75276 INCOBOTULINUMTOXINA 100 UNITS IM SOLR J0588 00259161001 $4,820.00 $7,712.00 1 Each 75277 INCOBOTULINUMTOXINA 50 UNITS IM SOLR J0588 00259160501 $2,530.00 $4,048.00 1 Each 75287 BUPRENORPHINE-NALOXONE 2-0.5 MG SL FILM J0572 12496120201 $167.00 $167.00 1 Each 75535 DOCETAXEL 20 MG/ML (1 ML) IV SOLN J9171 16729026763 $269.92 $269.92 1 mL 75536 DOCETAXEL 80 MG/4 ML (20 MG/ML) IV SOLN J9171 00075800404 $589.63 $589.63 4 mL 75580 KIT FOR TC 99M-SOD THIOSULFATE 2 MG MISC SOLR A9541 45567003001 $12,772.00 $12,772.00 5 Each 75596 DABIGATRAN ETEXILATE 150 MG PO CAPS 00597036082 $5,547.84 $5,547.84 60 Each 75600 KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR A9500 00019-9092-D0 $509.85 $509.85 10 mL 75600 KIT FOR TC 99M-SESTAMIBI NO.1 IV SOLR A9500 69945009240 $509.85 $509.85 10 mL 76251 LEVOLEUCOVORIN CALCIUM 50 MG IV SOLR J0641 68152010100 $177.12 $177.12 1 Each 76256 COAGULATION FACTOR VIIA RECOMB 1 MG (1,000 MCG) IV SOLR J7189 00169720101 $18,045.99 $18,045.99 1 Each 76257 COAGULATION FACTOR VIIA RECOMB 2 MG (2,000 MCG) IV SOLR J7189 00169720201 $36,091.98 $36,091.98 1 Each 76258 COAGULATION FACTOR VIIA RECOMB 5 MG (5,000 MCG) IV SOLR J7189 00169720501 $90,229.95 $90,229.95 1 Each 76259 MEPIVACAINE (PF) 20 MG/ML (2 %) IJ SOLN 00409106720 $167.00 $167.00 20 mL 76261 MEPIVACAINE (PF) 10 MG/ML (1 %) IJ SOLN J0670 00409103630 $167.00 $167.00 30 mL 76261 MEPIVACAINE (PF) 10 MG/ML (1 %) IJ SOLN J0670 99999001853 $167.00 $167.00 5 mL 76347 DIPH,PERTUS(ACEL),TET,POL (PF) 25 LF-58 MCG-10 LF/0.5 ML IM SUSP 90696 58160081211 $665.09 $665.09 .5 mL 76425 MILRINONE IN 5 % DEXTROSE 20 MG/100 ML (200 MCG/ML) IV PGBK J2260 00409277623 $235.20 $235.20 100 mL 76443 GADODIAMIDE 5 MMOL/10 ML (287 MG/ML) IV SOLN A9579 00407069010 $1,060.22 $1,060.22 10 mL 76459 FLUOROURACIL 500 MG/10 ML IV SOLN J9190 63323011710 $167.00 $167.00 10 mL 76460 FLUOROURACIL 1 GRAM/20 ML IV SOLN J9190 63323011720 $167.00 $167.00 20 mL 76461 FLUOROURACIL 2.5 GRAM/50 ML IV SOLN J9190 63323011751 $167.00 $167.00 50 mL 76462 FLUOROURACIL 5 G/100 ML IV SOLN J9190 63323011761 $232.00 $232.00 100 mL 76561 HEPARIN (PORCINE) IN NACL (PF) 1000 UNIT/500 ML IV SOLP J1644 00409762003 $167.00 $167.00 500 mL 76691 CYCLOSPORINE 250 MG/5 ML IV SOLN J7516 00078010901 $897.68 $897.68 5 mL 76828 ALVIMOPAN 12 MG PO CAPS 67919002010 $87,283.20 $87,283.20 30 Each 76830 VINORELBINE 50 MG/5 ML IV SOLN J9390 00703418301 $1,342.24 $1,342.24 5 mL 76832 GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) IV SOLN A9581 50419032005 $2,647.36 $2,647.36 10 mL 76835 ROMIPLOSTIM 500 MCG SC SOLR J2796 55513022201 $37,164.24 $37,164.24 1 Each 76836 ROMIPLOSTIM 250 MCG SC SOLR J2796 55513022101 $18,582.12 $18,582.12 1 Each 76857 DIMETHYL SULFOXIDE 50 % IS SOLN J1212 67457017750 $9,225.60 $9,225.60 50 mL 76877 LIDOCAINE HCL 2 % MM JELP 76329301305 $167.00 $167.00 10 mL 76889 VINCRISTINE 2 MG/2 ML IV SOLN J9370 61703030916 $167.00 $167.00 2 mL 76889 VINCRISTINE 2 MG/2 ML IV SOLN J9370 00703441211 $448.96 $448.96 2 mL 76890 PANITUMUMAB 100 MG/5 ML (20 MG/ML) IV SOLN J9303 55513095401 $11,397.87 $11,397.87 5 mL 76895 CLONIDINE (PF) 1,000 MCG/10 ML (100 MCG/ML) EP SOLN J0735 67457021810 $212.48 $212.48 10 mL 76896 CLONIDINE (PF) 5000 MCG/10 ML EP SOLN J0735 00517073101 $730.08 $730.08 10 mL

Pharmacy FY22 MED IDs 216 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 77052 DOXORUBICIN 50 MG/25 ML IV SOLN J9000 00069303220 $314.00 $314.00 25 mL 77053 DOXORUBICIN 10 MG/5 ML IV SOLN J9000 63323088305 $167.00 $167.00 5 mL 77054 DOXORUBICIN 20 MG/10 ML IV SOLN J9000 00069303120 $261.76 $261.76 10 mL 77119 BICARBONATE DIALYSIS SOLN NO.9 K (4 MEQ/L)-CA (2.5)-MG (1.5) HD SOLN 24571010506 $400.00 $400.00 5000 mL 77121 BICARB DIALY SOLN 11 WITHOUT K CA (2.5 MEQ/L) -MG (1.5 MEQ/L) HD SOLN 24571010806 $400.00 $400.00 5000 mL 77204 PERFLUTREN PROTEIN-A MICROSPHR 0.22 MG/ML IV SUSP Q9956 00407270703 $167.00 $167.00 3 mL 77278 INTERFERON BETA-1B 0.3 MG SC KIT J1830 00078056999 $6,643.89 $6,643.89 1 Each 77397 NICARDIPINE IN NACL (ISO-OS) 40 MG/200 ML (0.2 MG/ML) IV PGBK 10122032501 $1,088.00 $1,088.00 200 mL 78467 DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) IV SOLN J1250 00409234401 $167.00 $167.00 20 mL 78470 DOBUTAMINE IN D5W 250 MG/250 ML (1 MG/ML) IV SOLP J1250 00409234632 $167.00 $167.00 250 mL 78473 DOPAMINE 200 MG/5 ML (40 MG/ML) IV SOLN J1265 00409582001 $167.00 $167.00 5 mL 78475 DOPAMINE 400 MG/5 ML (80 MG/ML) IV SOLN J1265 00517190525 $167.00 $167.00 5 mL 78476 DOPAMINE 800 MG/10 ML (80 MG/ML) IV SOLN J1265 00409426501 $167.00 $167.00 10 mL 78477 DOPAMINE IN 5 % DEXTROSE 800 MG/250 ML (3,200 MCG/ML) IV SOLN J1265 00409781022 $167.00 $167.00 250 mL 78478 DOPAMINE IN 5 % DEXTROSE 400 MG/250 ML (1,600 MCG/ML) IV SOLN J1265 00409780922 $167.00 $167.00 250 mL 78487 CETUXIMAB 100 MG/50 ML IV SOLN J9055 66733094823 $10,138.40 $10,138.40 50 mL 78488 CETUXIMAB 200 MG/100 ML IV SOLN J9055 66733095823 $11,405.70 $11,405.70 100 mL 78615 PLERIXAFOR 24 MG/1.2 ML (20 MG/ML) SC SOLN J2562 00024586201 $79,699.23 $79,699.23 1.2 mL 78881 FEBUXOSTAT 40 MG PO TABS 64764091830 $4,921.92 $4,921.92 30 Each 78883 FEBUXOSTAT 80 MG PO TABS 64764067730 $4,921.92 $4,921.92 30 Each 78912 SILODOSIN 4 MG PO CAPS 59651009530 $509.76 $509.76 30 Each 78913 SILODOSIN 8 MG PO CAPS 59651009630 $347.04 $347.04 30 Each 79343 ARMODAFINIL 150 MG PO TABS 63459021530 $13,815.84 $13,815.84 30 Each 79344 ARMODAFINIL 50 MG PO TABS 63459020530 $4,591.68 $4,591.68 30 Each 79345 ARMODAFINIL 250 MG PO TABS 63459022530 $13,815.84 $13,815.84 30 Each 79352 TIROFIBAN-0.9% SODIUM CHLORIDE 12.5 MG/250 ML (50 MCG/ML) IV SOLN J3246 25208000202 $1,252.00 $1,252.00 250 mL 79353 NITROGLYCERIN 50 MG/10 ML (5 MG/ML) IV SOLN 00517481025 $174.72 $174.72 10 mL 79374 DEGARELIX 80 MG SC SOLR J9155 55566830301 $7,284.48 $7,284.48 1 Each 79382 DEGARELIX 120 MG SC SOLR J9155 55566840301 $22,731.04 $22,731.04 2 Each 79392 HYLAN G-F 20 48 MG/6 ML IX SYRG J7325 58468009003 $2,748.90 $2,748.90 6 mL 79426 LACOSAMIDE 50 MG PO TABS 00131247735 $8,907.84 $8,907.84 60 Each 79430 LACOSAMIDE 200 MG PO TABS 00131248060 $16,231.68 $16,231.68 60 Each 79488 TEMOZOLOMIDE 100 MG IV SOLR J9328 00085138101 $14,960.00 $14,960.00 1 Each 79537 CONIVAPTAN IN 5 % DEXTROSE 20 MG/100 ML IV SOLN 66220016010 $13,292.80 $13,292.80 100 mL 79622 EVEROLIMUS (ANTINEOPLASTIC) 5 MG PO TABS J7527 00078056651 $251,307.39 $251,307.39 28 Each 79623 EVEROLIMUS (ANTINEOPLASTIC) 10 MG PO TABS J7527 00078056751 $251,307.39 $251,307.39 28 Each 79804 LACOSAMIDE 200 MG/20 ML IV SOLN C9254 00131181067 $853.12 $853.12 20 mL 79860 GOLIMUMAB 50 MG/0.5 ML SC PNIJ J1602 57894007002 $41,972.31 $41,972.31 .5 mL 79862 GOLIMUMAB 100 MG/ML SC SYRG J1602 57894007001 $41,972.31 $41,972.31 .5 mL 80021 CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SC SYKT J0717 50474071079 $39,791.34 $39,791.34 1 Each 80085 TOLVAPTAN 15 MG PO TABS 59148002050 $82,815.36 $82,815.36 10 Each 80086 TOLVAPTAN 30 MG PO TABS 59148002150 $85,911.20 $85,911.20 10 Each 81014 CYTARABINE (PF) 100 MG/5 ML (20 MG/ML) IJ SOLN J9100 61703030538 $167.00 $167.00 5 mL 81046 VANCOMYCIN 750 MG IV SOLR J3370 00143935510 $167.00 $167.00 1 Each 81091 TAPENTADOL 50 MG PO TABS 69865021002 $11,459.20 $11,459.20 100 Each 81093 TAPENTADOL 100 MG PO TABS 69865023002 $17,844.80 $17,844.80 100 Each 81166 FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN Q0138 59338077501 $10,139.48 $16,223.17 17 mL 81205 DRONEDARONE 400 MG PO TABS 00024414210 $16,038.40 $16,038.40 100 Each 81234 PRASUGREL 5 MG PO TABS 00002512152 $5,476.22 $5,476.22 24 Each 81236 PRASUGREL 10 MG PO TABS 00002512377 $20,535.84 $20,535.84 90 Each 81294 LEVONORGESTREL 1.5 MG PO TABS 51285016288 $167.00 $167.00 1 Each 81462 SEVELAMER CARBONATE 0.8 GRAM PO PWPK 58468013202 $23,955.84 $23,955.84 90 Each 81463 SEVELAMER CARBONATE 2.4 GRAM PO PWPK 58468013102 $23,955.84 $23,955.84 90 Each 81472 TREPROSTINIL 1.74 MG/2.9 ML (0.6 MG/ML) IN NEBU J7686 99999977705 $12,936.55 $12,936.55 2.9 mL 81496 NEOSTIGMINE METHYLSULFATE 5 MG/5 ML (1 MG/ML) IV SYRG J7999 69374090205 $808.48 $808.48 5 mL 81533 ASENAPINE MALEATE 5 MG SL SUBL 00456240563 $29,832.00 $29,832.00 100 Each 81534 ASENAPINE MALEATE 10 MG SL SUBL 00456241060 $17,899.20 $17,899.20 60 Each 82920 ULIPRISTAL 30 MG PO TABS 50102091101 $533.12 $533.12 1 Each 82922 CEFTAROLINE FOSAMIL 400 MG IV SOLR J0712 00456040010 $2,843.01 $2,843.01 1 Each 82923 CEFTAROLINE FOSAMIL 600 MG IV SOLR J0712 00456060010 $2,843.01 $2,843.01 1 Each 82931 DABIGATRAN ETEXILATE 75 MG PO CAPS 00597035556 $5,547.84 $5,547.84 60 Each 82976 ABOBOTULINUMTOXINA 300 UNITS IM SOLR J0586 00299596230 $5,155.00 $8,248.00 1 Each 82995 ERIBULIN 1 MG/2 ML (0.5 MG/ML) IV SOLN J9179 62856038901 $10,926.00 $10,926.00 2 mL 83036 DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SC SOLN J0897 55513073001 $18,575.21 $20,897.11 1.7 mL 83125 IMMUNE GLOBUL G-GLY-IGA AVG 46 5 GRAM/50 ML (10 %) IJ SOLN J1561 13533080020 $4,988.00 $7,980.80 50 mL 83126 IMMUNE GLOBUL G-GLY-IGA AVG 46 10 GRAM/100 ML (10 %) IJ SOLN J1561 13533080071 $9,976.00 $15,961.60 100 mL 83127 IMMUNE GLOBUL G-GLY-IGA AVG 46 20 GRAM/200 ML (10 %) IJ SOLN J1561 13533080024 $19,952.00 $31,923.20 200 mL 83553 CHLOROPROCAINE (PF) 20 MG/ML (2 %) IJ SOLN J2400 63323047727 $298.88 $298.88 20 mL 83558 ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) IV SOLN J0131 43825010201 $167.00 $167.00 100 mL 83651 TETRACAINE HCL (PF) 0.5 % OP DROP 00065074114 $167.00 $167.00 4 mL 83739 CYTARABINE (PF) 20 MG/ML IJ SOLN J9100 61703030346 $277.60 $277.60 50 mL 83904 PRALATREXATE 20 MG/ML (1 ML) IV SOLN J9307 48818000101 $52,924.68 $52,924.68 1 mL 83905 PRALATREXATE 40 MG/2 ML (20 MG/ML) IV SOLN J9307 48818000102 $105,849.36 $105,849.36 2 mL 84066 ABOBOTULINUMTOXINA 500 UNITS IM SOLR J0586 15054050001 $8,590.00 $13,744.00 1 Each 84090 PERAMIVIR (PF) 200 MG/20 ML (10 MG/ML) IV SOLN J2547 61364018101 $15,200.00 $15,200.00 20 mL

Pharmacy FY22 MED IDs 217 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 84428 BENDAMUSTINE 25 MG IV SOLR J9033 63459039008 $7,756.16 $7,756.16 1 Each 84434 COLESEVELAM 3.75 GRAM PO PWPK 65597090230 $9,985.92 $9,985.92 30 Each 103469 HEPARIN, PORCINE (PF) 1000 UNIT/ML IJ SOLN (ADULT FLUSH) J1644 63323027602 $167.00 $167.00 2 mL 103574 BELIMUMAB 120 MG IV SOLR J0490 49401010101 $8,800.16 $8,800.16 1 Each 103575 BELIMUMAB 400 MG IV SOLR J0490 49401010201 $16,499.70 $16,499.70 1 Each 103730 IPILIMUMAB 50 MG/10 ML (5 MG/ML) IV SOLN J9228 00003232711 $68,525.37 $68,525.37 10 mL 103731 IPILIMUMAB 200 MG/40 ML (5 MG/ML) IV SOLN J9228 00003232822 $274,100.76 $274,100.76 40 mL 103822 GADOBUTROL 7.5 MMOL/7.5 ML (1 MMOL/ML) IV SOLN A9585 50419032511 $356.69 $356.69 7.5 mL 103823 GADOBUTROL 10 MMOL/10 ML (1 MMOL/ML) IV SOLN A9585 50419032512 $634.10 $634.10 10 mL 103824 GADOBUTROL 15 MMOL/15 ML (1 MMOL/ML) IV SOLN A9585 50419032513 $1,426.80 $1,426.80 15 mL 103849 PEGINTERFERON ALFA-2B 200 MCG SC KIT 00085434701 $16,611.66 $16,611.66 1 Each 103963 ROFLUMILAST 500 MCG PO TABS 00310009539 $3,545.60 $3,545.60 20 Each 103972 LINAGLIPTIN 5 MG PO TABS 00597014030 $5,647.20 $5,647.20 30 Each 103988 IOFLUPANE I 123 5 MCI/2.5 ML (185 MBQ/2.5ML) IV SOLN A9584 17156021001 $29,612.50 $29,612.50 2.5 mL 104222 RITONAVIR 100 MG PO TABS 00074333330 $3,835.20 $3,835.20 30 Each 104223 QUETIAPINE 25MG HALF-TAB = 12.5MG 99999900355 $167.00 $167.00 1 Each 104612 IRON SUCROSE 200 MG IRON/10 ML IV SOLN J1756 00517231005 $488.00 $780.80 200 mg 104614 LEUPROLIDE 7.5 MG IM SYKT J9217 00074364203 $14,826.96 $14,826.96 1 Each 104621 EPINEPHRINE 1 MG/ML (1 ML) IJ SOLN J0171 00409724101 $167.00 $167.00 1 mL 104677 RILPIVIRINE 25 MG PO TABS 59676027801 $18,160.80 $18,160.80 30 Each 104764 FIDAXOMICIN 200 MG PO TABS 52015008001 $63,564.16 $63,564.16 20 Each 104871 BELATACEPT 250 MG IV SOLR J0485 00003037113 $14,380.00 $14,380.00 250 mg 104927 RIVAROXABAN 10 MG PO TABS 50458058010 $167.00 $167.00 100 Each 104948 OFATUMUMAB 1000 MG/50 ML IV SOLN J9302 00078069061 $50,616.00 $50,616.00 50 mL 104974 OSELTAMIVIR 6 MG/ML PO SUSR 00004082205 $2,265.60 $2,265.60 60 mL 105071 CEFTAZIDIME IN D5W 2 GRAM/50 ML IV PGBK J0713 00264314511 $327.95 $327.95 1 Each 105072 TICAGRELOR 90 MG PO TABS 00186077739 $10,011.20 $10,011.20 100 Each 105162 KIT FOR OF PREP TC-99M-ALBUMIN 2.5 MG IV SOLR A9540 65174027030 $86,265.09 $86,265.09 30 Each 105180 ROPIVACAINE (PF) 5 MG/ML (0.5 %) IJ SOLN J2795 63323028620 $167.00 $167.00 20 mL 105180 ROPIVACAINE (PF) 5 MG/ML (0.5 %) IJ SOLN J2795 63323028631 $167.00 $167.00 30 mL 105180 ROPIVACAINE (PF) 5 MG/ML (0.5 %) IJ SOLN J2795 99999001852 $167.00 $167.00 5 mL 105271 LEUPROLIDE (PEDIATRIC 3 MONTH) 30 MG IM SYKT J1950 00074969403 $89,790.03 $89,790.03 1 Each 105273 LEUPROLIDE (PEDIATRIC 3 MONTH) 11.25 MG IM SYKT J1950 00074377903 $81,523.62 $81,523.62 1 Each 105290 KIT PREP TC 99M-PENTETIC ACID 20 MG IV SOLR A9539 65174028830 $63,925.92 $63,925.92 30 Each 105320 BRENTUXIMAB VEDOTIN 50 MG IV SOLR J9042 51144005001 $80,343.00 $80,343.00 1 Each 105340 ICATIBANT 30 MG/3 ML SC SYRG J1744 00093306634 $30,930.93 $30,930.93 3 mL 106214 KIT FOR PREP TC-99M-SUCCIMER 1 MG IV SOLR A9551 17156052501 $2,060.00 $2,060.00 1 Each 106243 EPOPROSTENOL 1.5 MG IV SOLR J1325 66215040201 $663.68 $663.68 1 Each 106245 PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) IJ SOLN J0780 00641613525 $167.00 $167.00 2 mL 106246 PEGINTERFERON ALFA-2A 180 MCG/0.5 ML SC SYRG 00004035230 $8,569.17 $8,569.17 1 Each 106252 HYDROXOCOBALAMIN 5 GRAM IV SOLR 11704037001 $350.72 $350.72 1 Each 106623 BUPIVACAINE LIPOSOME (PF) 1.3 % (13.3 MG/ML) LINF SUSP C9290 65250013310 $3,029.92 $3,029.92 10 mL 106626 GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) IV SOLN J9201 00409018101 $281.10 $281.10 26.3 mL 106648 TESTOSTERONE 2 MG/24 HOUR TD PT24 52544007654 $167.00 $167.00 1 Each 106665 RIVAROXABAN 15 MG PO TABS 50458057810 $167.00 $167.00 100 Each 106666 RIVAROXABAN 20 MG PO TABS 50458057910 $167.00 $167.00 100 Each 106719 LABETALOL 20 MG/4 ML (5 MG/ML) IV SYRG J7999 69374094604 $520.00 $520.00 4 mL 106772 TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) IV SOLN 00013111410 $167.00 $167.00 10 mL 106783 ASPARAGINASE (ERWINIA CHRYSAN) 10000 UNITS IJ SOLR J9019 57902024901 $36,277.56 $36,277.56 1 Each 106856 CLOBAZAM 10 MG PO TABS 67386031401 $35,974.40 $35,974.40 100 Each 106962 KIT PREP TC-99M-EXAMETAZIME 0.5 MG IV KIT A9521 17156002305 $20,712.99 $20,712.99 1 Each 106995 SODIUM IODIDE-123 3.7 MBQ (100 MICROCI) PO CAPS A9516 48815100101 $187.67 $187.67 1 Each 107001 IOBENGUANE SULFATE I-123 10 MCI/5 ML (370 MBQ/5 ML) IV SOLN A9582 17156023501 $26,880.68 $26,880.68 5 mL 107877 LEVETIRACETAM IN NACL (ISO-OS) 500 MG/100 ML IV PGBK J1953 70860060282 $167.00 $167.00 100 mL 108003 PENTETATE INDIUM DISOD. IN-111 1.5 MCI/1.5 ML IT SOLN A9548 17156025108 $13,653.78 $13,653.78 1.5 mL 108012 METHYLNALTREXONE 12 MG/0.6 ML SC SYRG J2212 65649055103 $2,006.06 $2,006.06 .6 mL 108016 METHYLNALTREXONE 8 MG/0.4 ML SC SYRG J2212 65649055204 $2,006.06 $2,006.06 .4 mL 108126 EVEROLIMUS (ANTINEOPLASTIC) 7.5 MG PO TABS J7527 00078062051 $251,307.39 $251,307.39 28 Each 108169 CEFAZOLIN IN DEXTROSE (ISO-OS) 2 GRAM/50 ML IV PGBK J0690 00264310511 $190.43 $190.43 1 Each 108192 ENFUVIRTIDE 90 MG SC SOLR J1324 00004038140 $53,473.92 $53,473.92 60 Each 108263 DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) PO SOLN 68094075062 $167.00 $167.00 5 mL 108862 C1 ESTERASE INHIBITOR 500 UNIT (10 ML) IV KIT J0597 63833082502 $24,157.89 $24,157.89 1 Each 109350 TALIGLUCERASE ALFA 200 UNITS IV SOLR J3060 00069010601 $8,068.40 $12,909.44 1 Each 109480 FLORBETAPIR F-18 10 MCI (370 MBQ) IV SOLN A9586 00002120001 $15,599.35 $15,599.35 1 Each 109607 PERTUZUMAB 420 MG/14 ML (30 MG/ML) IV SOLN J9306 50242014501 $49,771.39 $49,771.39 14 mL 110536 SODIUM IODIDE I-131 CAPSULE A9517 99999900479 $167.00 $167.00 1 Each 110542 RUBIDIUM CHLORIDE RB-82 A9555 00270009101 $1,189.19 $1,189.19 1 Each 110577 MVI, ADULT NO.4 WITH VIT K 3,300 UNIT- 150 MCG/10 ML IV SOLN 54643564901 $167.00 $167.00 10 mL 110766 CARFILZOMIB 60 MG IV SOLR J9047 76075010101 $23,209.65 $23,209.65 1 Each 110849 TETANUS,DIPHTHERIA TOX PED(PF) 5-25 LF UNIT/0.5 ML IM SUSP 49281022558 $895.36 $895.36 .5 mL 110946 ZIV-AFLIBERCEPT 100 MG/4 ML (25 MG/ML) IV SOLN J9400 00024584001 $12,800.00 $12,800.00 4 mL 111054 ELVITEG-COB-EMTRI-TENOFO DISOP 150-150-200-300 MG PO TABS 61958120101 $53,093.28 $53,093.28 30 Each 111103 LINACLOTIDE 145 MCG PO CAPS 00456120130 $6,965.28 $6,965.28 30 Each 111104 LINACLOTIDE 290 MCG PO CAPS 00456120230 $6,965.28 $6,965.28 30 Each 111144 RIVASTIGMINE 13.3 MG/24 HOUR TD PT24 00781731358 $201.60 $201.60 1 Each

Pharmacy FY22 MED IDs 218 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 111144 RIVASTIGMINE 13.3 MG/24 HOUR TD PT24 00781731331 $6,048.00 $6,048.00 30 Each 111205 EPOPROSTENOL 0.5 MG IV SOLR J1325 66215040301 $331.84 $331.84 1 Each 111324 HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) PO SYRP 00121481105 $167.00 $167.00 5 mL 111324 HYDROCODONE-HOMATROPINE 5-1.5 MG/5 ML (5 ML) PO SYRP 99999900135 $167.00 $167.00 5 mL 111550 MEGESTROL 400 MG/10 ML (10 ML) PO SUSP 66689002050 $167.00 $167.00 10 mL 111602 ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN 00121050405 $167.00 $167.00 5 mL 111602 ACETAMINOPHEN-CODEINE 120 MG-12 MG /5 ML (5 ML) PO SOLN 99999900386 $167.00 $167.00 5 mL 111657 DARUNAVIR ETHANOLATE 800 MG PO TABS 59676056630 $27,518.40 $27,518.40 30 Each 112770 FLUORODEOXYGLUCOSE (F-18) ISOTOPE (NUC MED) A9552 65857010010 $772.50 $772.50 5 mL 112771 SODIUM FLOURIDE (F-18) ISOTOPE (NUC MED) A9580 40028512300 $884.51 $884.51 1 Each 112772 GALLIUM (GA-67) CITRATE ISOTOPE (NUC MED) A9556 11994012109 $80,646.94 $80,646.94 9.9 mL 112772 GALLIUM (GA-67) CITRATE ISOTOPE (NUC MED) A9556 11994012106 $5,376.29 $5,376.29 1 Each 112774 BICISATE DIHYDROCHLORIDE (TC-99M) (NEUROLITE) ISOTOPE (NUC ME) A9557 11994000602 $7,197.43 $7,197.43 1 Each 112777 MEDRONATE (TC-99M MDP) ISOTOPE (NUC MED) A9503 00270387680 $770.85 $770.85 1 Each 112778 SODIUM PERTECHNETATE (TC-99M O4) ISOTOPE (NUC MED) A9512 99999900480 $167.00 $167.00 1 Each 112780 MICROSPHERES (Y-90 GLASS) (THERA-SPHERES) ISOTOPE (NUC MED) C2616 99999900481 $85,000.00 $85,000.00 1 Each 112781 MICROSPHERES (Y-90 RESIN) (SIR-SPHERES) ISOPTOPE (NUC MED) C2616 99999900482 $85,000.00 $85,000.00 1 Each 112909 APIXABAN 2.5 MG PO TABS 00003089331 $2,236.80 $2,236.80 100 Each 112998 HONEY 80 % TP GEL 09958003461 $167.00 $167.00 15 mL 113023 APIXABAN 5 MG PO TABS 00003089431 $2,236.80 $2,236.80 100 Each 113111 LEVONORGESTREL 14 MCG/24 HRS (3 YRS) 13.5 MG IU IUD J7301 50419042201 $13,313.12 $13,313.12 1 Each 113840 LABELED RED BLOOD CELLS (TC-99M RBC) (ULTRATAG) ISOTOPE (NUC MED) A9560 00019N068B0 $896.92 $896.92 1 kit 113955 ADO-TRASTUZUMAB EMTANSINE 100 MG IV SOLR J9354 50242008801 $29,667.96 $29,667.96 1 Each 113956 ADO-TRASTUZUMAB EMTANSINE 160 MG IV SOLR J9354 50242008701 $47,468.70 $47,468.70 1 Each 114065 HYALURONATE SOD, CROSS-LINKED 30 MG/3 ML IX SYRG J7326 87541030091 $4,590.00 $4,590.00 3 mL 114142 SOD BORATE-BORIC AC-NACL-WATER OP IRSL 00536122497 $167.00 $167.00 118 mL 114352 DEXMEDETOMIDINE IN 0.9 % NACL 200 MCG/50 ML (4 MCG/ML) IV SOLN 00409166050 $435.20 $435.20 50 mL 114354 DEXMEDETOMIDINE IN 0.9 % NACL 400 MCG/100 ML (4 MCG/ML) IV SOLN J3490 00143952510 $955.20 $955.20 100 mL 114407 LIPASE-PROTEASE-AMYLASE 36,000-114,000- 180,000 UNIT PO CPDR 00032301613 $15,921.60 $15,921.60 100 Each 115116 ADENOSINE IN 0.9% NACL 90 MG/90 ML INFUSION (CATH LAB USE) J0153 99999900544 $691.20 $691.20 90 mL 115120 HYDROMORPHONE 1 MG/ML PO LIQUID (DOSE >= 4 MG) 99999001194 $167.00 $167.00 4 mL 115127 TECHNETIUM (LYMPHOSEEK) TC 99M TILMANOCEPT A9520 52579160005 $2,559.55 $2,559.55 1 kit 115140 DIPHTH,PERTUS(ACELL),TETANUS 2.5-8-5 LF-MCG-LF/0.5ML IM SUSP 90715 58160084211 $537.12 $537.12 .5 mL 115146 SODIUM GLYCEROPHOSPHATE 1 MMOL/ML IV SOLN 63323024120 $171.20 $171.20 20 mL 115199 FLUTICASONE FUROATE-VILANTEROL 100-25 MCG/DOSE IN DSDV J3535 00173085914 $435.01 $435.01 28 Each 115242 RADIUM RA 223 DICHLORIDE 1,100 KBQ/ML(30 MICROCURIE/ML) IV SOLN A9606 50419020801 $337.74 $337.74 1 Each 115276 HYDROMORPHONE 0.5 MG/0.5 ML IJ SYRG J1170 00409128304 $167.00 $167.00 .5 mL 115363 NEOSTIGMINE METHYLSULFATE 1 MG/ML IV SOLN J2710 63323041510 $167.00 $167.00 10 mL 115413 NIMODIPINE 60 MG/20 ML PO SOLN 99999001225 $627.52 $627.52 10 mL 115413 NIMODIPINE 60 MG/20 ML PO SOLN 24338020020 $1,254.08 $1,254.08 20 mL 115541 DEXTROSE-SOD CITRATE-CITRIC AC 2.45-2.2 GRAM- 730 MG/100 ML MISC SOLN 99999002271 $167.00 $167.00 750 mL 115596 BUTALBITAL-ACETAMINOP-CAF-COD 50-300-40-30 MG PO CAPS 00591264101 $7,968.00 $7,968.00 100 Each 116015 BECLOMETHASONE DIPROPIONATE ORAL EMULSION 99999900600 $167.00 $167.00 120 mL 116040 VINCRISTINE SULFATE LIPOSOMAL 5 MG/31 ML(0.16 MG/ML) FINAL IV KIT J9371 20536032201 $140,961.24 $140,961.24 1 Each 116046 GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN A9575 00407294302 $167.00 $167.00 15 mL 116046 GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN A9575 00407294305 $167.00 $167.00 20 mL 116046 GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) IV SOLN A9575 00407294301 $167.00 $167.00 10 mL 116056 COPPER 380 SQUARE MM IU IUD J7300 51285020401 $14,152.00 $14,152.00 1 Each 116063 GOLIMUMAB 12.5 MG/ML IV SOLN J1602 57894035001 $16,762.61 $16,762.61 4 mL 116071 TACROLIMUS 0.5 MG PO CP24 J7508 00469064773 $433.92 $433.92 30 Each 116072 TACROLIMUS 1 MG PO CP24 J7508 00469067773 $868.32 $868.32 30 Each 116092 GOLIMUMAB 100 MG/ML SC PNIJ J3490 57894007102 $50,808.69 $50,808.69 1 mL 116111 FERRIC CARBOXYMALTOSE 50 IRON MG/ML IV SOLN J1439 00517065001 $8,534.55 $13,655.28 15 mL 116118 CLOBAZAM 2.5 MG/ML PO SUSP 99999900624 $287.68 $287.68 2 mL 116187 DOLUTEGRAVIR 50 MG PO TABS 49702022813 $28,584.96 $28,584.96 30 Each 116691 ASPIRIN ORAL SUSPENSION 1 MG/ML PEDIATRIC 99999900636 $167.00 $167.00 81 mL 116706 MIDAZOLAM (PF) 5 MG/ML IJ SOLN J2250 00409230801 $167.00 $167.00 1 mL 116707 MIDAZOLAM (PF) 1 MG/ML IJ SOLN J2250 00409230517 $167.00 $167.00 2 mL 116780 VORTIOXETINE 5 MG PO TABS 64764072030 $6,244.80 $6,244.80 30 Each 116781 VORTIOXETINE 10 MG PO TABS 64764073030 $6,244.80 $6,244.80 30 Each 116808 RIOCIGUAT 0.5 MG PO TABS 50419025091 $17,533.44 $17,533.44 9 Each 116809 RIOCIGUAT 1 MG PO TABS 50419025191 $16,539.84 $16,539.84 9 Each 116812 RIOCIGUAT 2.5 MG PO TABS 50419025401 $165,404.16 $165,404.16 90 Each 116883 MACITENTAN 10 MG PO TABS 66215050115 $91,190.40 $91,190.40 15 Each 116902 TOCILIZUMAB 162 MG/0.9 ML SC SYRG 50242013801 $16,047.52 $16,047.52 .9 mL 116926 OBINUTUZUMAB 1000 MG/40 ML IV SOLN J9301 50242007001 $61,638.84 $61,638.84 40 mL 116976 TBO-FILGRASTIM 300 MCG SC SYRG J1447 63459091011 $2,235.84 $2,235.84 .5 mL 116977 TBO-FILGRASTIM 480 MCG SC SYRG J1447 63459091211 $3,578.24 $3,578.24 .8 mL 117038 POSACONAZOLE 100 MG PO TBEC J8499 00085432402 $38,715.84 $38,715.84 60 Each 117397 METHOTREXATE (PF) 10 MG/0.4 ML SC ATIN 54436001004 $2,422.64 $2,422.64 .4 mL 117459 PERAMPANEL 2 MG PO TABS 62856027230 $7,948.80 $7,948.80 30 Each 117460 PERAMPANEL 4 MG PO TABS 62856027430 $15,704.16 $15,704.16 30 Each 117541 DAPAGLIFLOZIN 5 MG PO TABS 00310620530 $5,868.48 $5,868.48 30 Each 117542 DAPAGLIFLOZIN 10 MG PO TABS 00310621030 $5,868.48 $5,868.48 30 Each 117913 RAMUCIRUMAB 10 MG/ML IV SOLN J9308 00002767801 $55,424.25 $55,424.25 50 mL

Pharmacy FY22 MED IDs 219 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 117913 RAMUCIRUMAB 10 MG/ML IV SOLN J9308 00002766901 $11,084.85 $11,084.85 10 mL 117921 ETHIODIZED OIL 480 MG IODINE/ML IJ OIL A9698 67684190101 $24,480.00 $24,480.00 10 mL 117924 VEDOLIZUMAB 300 MG IV SOLR J3380 64764030020 $62,970.84 $62,970.84 1 Each 117930 CYCLOPHOSPHAMIDE 25 MG PO CAPS J8530 00054038225 $11,169.60 $11,169.60 100 Each 117931 CYCLOPHOSPHAMIDE 50 MG PO CAPS J8530 00054038325 $20,499.20 $20,499.20 100 Each 117933 POLIDOCANOL 1 % IV FOAM J3490 60635011801 $28,755.00 $28,755.00 45 mL 117944 UMECLIDINIUM-VILANTEROL 62.5-25 MCG/ACTUATION IN DSDV 00173086906 $443.07 $443.07 14 Each 118080 MORPHINE 2 MG/ML IV SYRG J2270 00409189001 $167.00 $167.00 1 mL 118081 MORPHINE 4 MG/ML IV SYRG J2270 00409189101 $167.00 $167.00 1 mL 118427 HUM PROTHROMBIN CPLX(PCC)4FACT 500 UNIT (400-620 UNIT) IV SOLR C9132 63833038602 $14,800.00 $14,800.00 1 Each 118616 HUM PROTHROMBIN CPLX(PCC)4FACT 1,000 UNIT (800-1240 UNIT) IV SOLR C9132 63833038702 $29,600.00 $29,600.00 1 Each 118876 EMPAGLIFLOZIN 25 MG PO TABS 00597015337 $5,364.00 $5,364.00 30 Each 118877 EMPAGLIFLOZIN 10 MG PO TABS 00597015237 $5,364.00 $5,364.00 30 Each 119944 GLATIRAMER 20 MG/ML SC SYRG J1595 68546031730 $3,536.51 $3,536.51 1 mL 119952 METHOTREXATE (PF) 15 MG/0.3 ML SC ATIN 59137052000 $1,838.12 $1,838.12 .3 mL 120220 COBICISTAT 150 MG PO TABS Z7610 61958140101 $3,778.08 $3,778.08 30 Each 120661 FERUMOXYTOL 510 MG/17 ML (30 MG/ML) IV SOLN (RADIANT USE) Q9953 99999001534 $5,323.32 $5,323.32 17 mL 120702 TIOTROPIUM BROMIDE 2.5 MCG/ACTUATION IN MIST J3535 00597010051 $216.26 $216.26 4 gram 120847 VASOPRESSIN 20 UNITS/ML IV SOLN J3490 42023016425 $3,157.73 $3,157.73 1 Each 120857 BUDESONIDE 2 MG/ACTUATION PR FOAM 65649065103 $5,257.43 $5,257.43 33.4 gram 120887 ALEMTUZUMAB 12 MG/1.2 ML IV SOLN (NON-ONCOLOGICAL USE) J0202 58468020001 $201,107.97 $201,107.97 1.2 mL 120946 BLINATUMOMAB 35 MCG IV KIT J9039 55513016001 $38,178.90 $38,178.90 1 Each 120962 HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SUSP 90651 00006411903 $3,297.63 $3,297.63 .5 mL 120963 HUMAN PAPILLOMAV VAC,9-VAL(PF) 0.5 ML IM SYRG 90651 00006412102 $3,461.95 $3,461.95 .5 mL 121230 MENINGOCOCCAL B VACCINE,4-COMP 50-50-50-25 MCG/0.5 ML IM SYRG 90620 58160097606 $2,370.51 $2,370.51 .5 mL 121236 OXYCODONE 10 MG PO TR12 00781570301 $5,568.00 $5,568.00 100 Each 121236 OXYCODONE 10 MG PO TR12 59011041020 $1,114.24 $1,114.24 20 Each 121236 OXYCODONE 10 MG PO TR12 59011041010 $5,425.60 $5,425.60 100 Each 121238 OXYCODONE 20 MG PO TR12 59011042020 $2,075.84 $2,075.84 20 Each 121238 OXYCODONE 20 MG PO TR12 59011042010 $10,120.00 $10,120.00 100 Each 121238 OXYCODONE 20 MG PO TR12 00781572601 $10,120.00 $10,120.00 100 Each 121240 OXYCODONE 40 MG PO TR12 59011044010 $17,331.20 $17,331.20 100 Each 121240 OXYCODONE 40 MG PO TR12 63629377401 $10,660.80 $10,660.80 60 Each 121240 OXYCODONE 40 MG PO TR12 63629377402 $15,991.20 $15,991.20 90 Each 121240 OXYCODONE 40 MG PO TR12 63629377403 $21,321.60 $21,321.60 120 Each 121240 OXYCODONE 40 MG PO TR12 00781576701 $17,331.20 $17,331.20 100 Each 121240 OXYCODONE 40 MG PO TR12 59011044020 $3,553.60 $3,553.60 20 Each 121242 OXYCODONE 80 MG PO TR12 59011048020 $6,203.84 $6,203.84 20 Each 121242 OXYCODONE 80 MG PO TR12 59011048010 $30,241.60 $30,241.60 100 Each 121242 OXYCODONE 80 MG PO TR12 00781578501 $30,241.60 $30,241.60 100 Each 121327 CEFTOLOZANE-TAZOBACTAM 1.5 GRAM IV SOLR J0695 67919003001 $1,867.41 $1,867.41 1 Each 121347 NIVOLUMAB 40 MG/4 ML IV SOLN J9299 00003377211 $10,018.73 $10,018.73 4 mL 121348 NIVOLUMAB 100 MG/10 ML IV SOLN J9299 00003377412 $25,046.82 $25,046.82 10 mL 121439 PEGFILGRASTIM 6 MG/0.6 ML SC OBISYRINGE J2505 55513019201 $37,750.05 $37,750.05 .6 mL 121472 PEMBROLIZUMAB 25 MG/ML IV SOLN J9271 00006302602 $44,414.64 $44,414.64 4 mL 121508 SECUKINUMAB 150 MG/ML SC PNIJ C9399 00078063968 $49,740.57 $49,740.57 1 mL 121532 PALBOCICLIB 125 MG PO CAPS 00069018921 $209,149.58 $209,149.58 21 Each 121945 IVABRADINE 5 MG PO TABS 55513080060 $7,256.64 $7,256.64 60 Each 121946 IVABRADINE 7.5 MG PO TABS 55513081060 $7,256.64 $7,256.64 60 Each 121950 OCTREOTIDE,MICROSPHERES 20 MG IM SSRR J2353 00078081881 $31,483.28 $35,418.69 1 Each 121951 OCTREOTIDE,MICROSPHERES 30 MG IM SSRR J2353 00078082581 $47,144.00 $53,037.00 1 Each 121952 OCTREOTIDE,MICROSPHERES 10 MG IM SSRR J2353 00078081181 $24,029.92 $27,033.66 1 Each 122035 CEFTAZIDIME-AVIBACTAM 2.5 GRAM IV SOLR J0714 00456270001 $5,738.08 $5,738.08 1 Each 122067 MENING A CONJ VACC,1 OF 2 (PF) 10 MCG /0.5 ML (FINAL) IM SOLR 90734 58160095801 $1,548.06 $1,548.06 1 Each 122080 ISAVUCONAZONIUM SULFATE 372 MG IV SOLR J1833 00469042099 $4,837.28 $4,837.28 1 Each 122083 ISAVUCONAZONIUM SULFATE 186 MG PO CAPS 00469052014 $19,899.04 $19,899.04 14 Each 122171 LEVONORGESTREL 20.1 MCG/24 HRS (6 YRS) 52 MG IU IUD J7297 00023585801 $13,521.60 $13,521.60 1 Each 122566 IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN 13533063504 $894.90 $1,431.84 2 mL 122566 IMMUNE GLOB G (IGG)-GLYCINE 15-18 % RANGE IM SOLN 13533063512 $4,088.80 $6,542.08 10 mL 122580 FLUTICASONE FUROATE-VILANTEROL 200-25 MCG/DOSE IN DSDV J3535 00173088214 $435.01 $435.01 28 Each 122590 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IV SOLN 59730650201 $6,650.00 $10,640.00 50 mL 122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270002 $908.00 $1,452.80 10 mL 122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270004 $4,540.00 $7,264.00 50 mL 122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270005 $9,080.00 $14,528.00 100 mL 122592 IMMUN GLOB G(IGG)-GLY-IGA OV50 10 % IJ SOLN J1569 00944270006 $14,528.00 $16,344.00 200 mL 122593 IMMUN GLOB G(IGG)-PRO-IGA 0-50 10 % IV SOLN J1459 44206043710 $6,919.00 $11,070.40 100 mL 122602 IMMUN GLOB G-GLY-GLUC-IGA 0-50 5 GRAM IV SOLR 00944265707 $6,385.30 $10,216.48 5 gram 122603 IMMUN GLOB G-GLY-GLUC-IGA 0-50 10 GRAM IV SOLR J1569 00944265804 $10,216.48 $11,493.54 1 Each 122923 CANGRELOR 50 MG IV SOLR C9460 10122062010 $10,656.45 $10,656.45 1 Each 122998 SACUBITRIL-VALSARTAN 24-26 MG PO TABS 00078065935 $14,344.00 $14,344.00 100 Each 122999 SACUBITRIL-VALSARTAN 49-51 MG PO TABS 00078077735 $14,344.00 $14,344.00 100 Each 123000 SACUBITRIL-VALSARTAN 97-103 MG PO TABS 00078069635 $14,344.00 $14,344.00 100 Each 123564 FILGRASTIM-SNDZ 480 MCG IJ SYRG Q5101 61314032601 $2,396.80 $2,396.80 .8 mL 123565 FILGRASTIM-SNDZ 300 MCG IJ SYRG Q5101 61314031801 $1,498.08 $1,498.08 .5 mL 123745 SULFUR HEXAFLUORIDE MICROSPHR 25 MG IV SUSR Q9950 00270709916 $185.85 $185.85 1 Each

Pharmacy FY22 MED IDs 220 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 123826 TICAGRELOR 60 MG PO TABS 00186077660 $6,007.68 $6,007.68 60 Each 124171 TRABECTEDIN 1 MG IV SOLR J9352 59676061001 $27,875.52 $27,875.52 1 Each 124173 INSULIN DEGLUDEC 100 UNIT/ML (3 ML) SC INPN 00169266015 $1,515.89 $1,515.89 3 mL 124174 INSULIN DEGLUDEC 200 UNIT/ML (3 ML) SC INPN 00169255013 $3,031.78 $3,031.78 3 mL 124331 MORPHINE 4 MG/ML IV SOLN J2270 00641612501 $167.00 $167.00 1 mL 124446 IDARUCIZUMAB 2.5 GRAM/50 ML IV SOLN J3590 00597019705 $19,160.55 $19,160.55 50 mL 124464 IRINOTECAN LIPOSOMAL 4.3 MG/ML IV DISP J9205 15054004301 $22,248.00 $22,248.00 10 mL 124485 TALIMOGENE LAHERPAREPVEC 10EXP6 (1 MILLION) PFU/ML IJ SUSP J9325 55513007801 $877.76 $877.76 1 mL 124486 TALIMOGENE LAHERPAREPVEC 10EXP8 (100 MILLION) PFU/ML IJ SUSP J9325 55513007901 $49,368.51 $49,368.51 1 mL 124522 MEPOLIZUMAB 100 MG SC SOLR J2182 00173088101 $25,835.13 $25,835.13 1 Each 124529 ELVITEG-COB-EMTRI-TENOF ALAFEN 150-150-200-10 MG PO TABS 61958190101 $50,613.12 $50,613.12 30 Each 124585 DARATUMUMAB 20 MG/ML IV SOLN J9145 57894050220 $20,858.40 $20,858.40 20 mL 125030 SUGAMMADEX 100 MG/ML IV SOLN J3490 00006542312 $1,639.52 $1,639.52 2 mL 125036 GENTAMICIN IN NACL (ISO-OSM) 160 MG/100 ML IV PGBK J1580 99999990001 $167.00 $167.00 100 mL 125039 HYDROXYPROGESTERONE CAP(PPRES) 250 MG/ML IM OIL 64011024301 $26,937.00 $26,937.00 5 mL 125129 ELOTUZUMAB 300 MG IV SOLR J9176 00003229111 $17,739.81 $17,739.81 1 Each 125130 ELOTUZUMAB 400 MG IV SOLR J9176 00003452211 $23,652.99 $23,652.99 1 Each 125167 BENDAMUSTINE 25 MG/ML IV SOLN J9034 63459034804 $14,734.26 $14,734.26 4 mL 125227 SELEXIPAG 200 MCG PO TABS 66215060206 $207,734.40 $207,734.40 60 Each 125228 SELEXIPAG 400 MCG PO TABS 66215060406 $307,968.00 $307,968.00 60 Each 125229 SELEXIPAG 600 MCG PO TABS 66215060606 $323,059.20 $323,059.20 60 Each 125230 SELEXIPAG 800 MCG PO TABS 66215060806 $338,572.80 $338,572.80 60 Each 125234 SELEXIPAG 1600 MCG PO TABS 66215061606 $323,059.20 $323,059.20 60 Each 125904 HYALURONATE,MOD.,NON-CROSSLINK 24 MG/3 ML IX SYRG J7322 89122049663 $6,300.00 $6,300.00 3 mL 126048 INCOBOTULINUMTOXINA 200 UNITS IM SOLR J0588 00259162001 $9,640.00 $15,424.00 1 Each 126722 BRIVARACETAM 10 MG/ML PO SOLN 99999002174 $167.00 $167.00 2.5 mL 126724 BRIVARACETAM 25 MG PO TABS Z7610 50474047066 $18,116.16 $18,116.16 60 Each 126780 RESLIZUMAB 10 MG/ML IV SOLN J2786 59310061031 $15,216.00 $15,216.00 10 mL 126839 EMTRICITABINE-TENOFOVIR ALAFEN 200-25 MG PO TABS 61958200201 $28,793.76 $28,793.76 30 Each 126848 HYDROMORPHONE (PF)-0.9 % NACL 30 MG/30 ML (1 MG/ML) IV SPCA J7999 71286201201 $234.24 $234.24 30 mL 127054 ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) IV SOLN J9022 50242091701 $85,228.74 $85,228.74 20 mL 127441 AZATHIOPRINE ORAL SUSPENSION 50 MG/ML J7500 99999001272 $202.56 $202.56 30 mL 127442 DILTIAZEM ORAL SUSPENSION 12 MG/ML 99999001276 $167.00 $167.00 100 mL 127475 TADALAFIL (PULM. HYPERTENSION) 20 MG PO TABS 00378697693 $663.84 $663.84 30 Each 127510 EPHEDRINE SULFATE 50 MG/ML IV SOLN 76014000530 $167.00 $167.00 1 mL 127526 VANCOMYCIN IN 0.9 % SODIUM CHL 750 MG/150 ML IV PGBK J3370 00338358201 $167.00 $167.00 150 mL 127562 MESALAMINE 400 MG PO CDTI 00023585318 $10,414.08 $10,414.08 180 Each 128085 SOD,POT CHLOR-MAG-SOD,POT PHOS 800-40-20-8.75- 6.25 MG/100 ML IR IRSL 00338019004 $167.00 $167.00 1000 mL 128096 FAT EMULSION 20% (SMOFLIPID) ADULT 63323082074 $320.00 $320.00 250 mL 128102 METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) IV SOLN Q9968 00517037401 $3,081.12 $3,081.12 10 mL 128136 METHYLNALTREXONE 150 MG PO TABS 65649015090 $30,091.68 $30,091.68 90 Each 128205 THALLOUS CHLORIDE TL-201 74 MBQ/ML (2 MCI/ML) IV SOLN A9505 11994042726 $167.00 $167.00 1 Each 128651 USTEKINUMAB 130 MG/26 ML IV SOLN J3358 57894005427 $15,822.85 $15,822.85 26 mL 128668 HYDROMORPHONE 1 MG/ML IJ SOLN J1170 00409255201 $167.00 $167.00 1 mL 128671 INFLIXIMAB-DYYB 100 MG IV SOLR Q5103 00069080901 $7,644.00 $7,644.00 1 Each 128700 LEVONORGESTREL 17.5 MCG/24 HRS (5 YRS) 19.5 MG IU IUD J7296 50419042401 $15,988.48 $15,988.48 1 Each 128837 OLARATUMAB 10 MG/ML IV SOLN J9285 00002892601 $22,380.30 $22,380.30 50 mL 129158 SODIUM HYALURONATE (VISCOSUP) 10 MG/ML(MW 2.4 -3.6 MILLION) IX SYRG J7323 55566410001 $1,512.81 $1,512.81 2 mL 129165 MELPHALAN HCL-BETADEX SBES 50 MG IV SOLR J9246 68152010900 $9,647.28 $9,647.28 1 Each 129166 IMM GLOB G (IGG)-SORB-IGA 0-50 10 % IV SOLN 61953000501 $4,428.00 $7,084.80 50 mL 129189 TENOFOVIR ALAFENAMIDE 25 MG PO TABS 61958230101 $18,326.88 $18,326.88 30 Each 129316 NUSINERSEN (PF) 12 MG/5 ML IT SOLN J2326 64406005801 $500,000.00 $500,000.00 5 mL 130577 AVELUMAB 20 MG/ML IV SOLN J9023 44087353501 $26,707.20 $26,707.20 10 mL 130591 OCRELIZUMAB 30 MG/ML IV SOLN J2350 50242015001 $150,637.50 $150,637.50 10 mL 131258 LETERMOVIR 240 MG PO TABS 00006307502 $101,127.04 $101,127.04 28 Each 131412 LU-177 DOTATATE (LUTATHERA) ISOTOPE (NUC MED) A9513 99999911111 $192,865.80 $192,865.80 25 mL 131493 SARILUMAB 200 MG/1.14 ML SC SYRG J3590 00024591001 $15,338.74 $15,338.74 1.14 mL 131569 RITUXIMAB-HYALURONIDASE,HUMAN 1400 MG/11.7 ML (120 MG/ML) SC SOLN J9311 50242010801 $52,612.65 $59,189.24 11.7 mL 131584 DURVALUMAB 50 MG/ML IV SOLN J9173 00310450012 $14,284.80 $14,284.80 2.4 mL 131584 DURVALUMAB 50 MG/ML IV SOLN J9173 00310461150 $33,479.82 $33,479.82 10 mL 131629 EDARAVONE 30 MG/100 ML IV SOLN J1301 70510217101 $9,219.20 $9,219.20 100 mL 131760 RITUXIMAB-HYALURONIDASE,HUMAN 1600 MG/13.4 ML (120 MG/ML) SC SOLN J9311 50242010901 $60,128.70 $67,644.78 13.4 mL 132409 ARSENIC TRIOXIDE 2 MG/ML IV SOLN J9017 63459060106 $5,219.81 $5,219.81 6 mL 132800 SPIRONOLACTONE 25 MG/5 ML PO SUSP 46287002004 $3,864.74 $3,864.74 118 mL 132827 DAUNORUBICIN-CYTARABINE LIPOS 44-100 MG IV SOLR J9153 68727074501 $76,217.76 $76,217.76 1 Each 132843 INOTUZUMAB OZOGAMICIN 0.9 MG (0.25 MG/ML INITIAL) IV SOLR J9229 00008010001 $181,227.69 $181,227.69 .9 mg 132886 GEMTUZUMAB OZOGAMICIN 4.5 MG (1 MG/ML INITIAL CONC) IV SOLR J9203 00008451001 $79,468.83 $79,468.83 1 Each 133065 BECLOMETHASONE DIPROPIONATE 40 MCG/ACTUATION IN HFAB J3535 59310030240 $1,444.65 $1,444.65 10.6 gram 133074 MEROPENEM-VABORBACTAM 2 GRAM IV SOLR J2186 70842012006 $2,524.72 $2,524.72 1 Each 133081 COPANLISIB 60 MG IV SOLR J9057 50419038501 $42,822.00 $42,822.00 1 Each 133185 TRIAMCINOLONE ACETONIDE 32 MG IX SSRR J3304 70801000301 $9,120.00 $9,120.00 1 Each 133245 VARICELLA-ZOSTER GE-AS01B (PF) 50 MCG/0.5 ML IM SUSR 90750 58160081912 $2,367.98 $2,367.98 1 Each 133635 NIVOLUMAB 240 MG/24 ML IV SOLN J9299 00003373413 $60,112.37 $60,112.37 24 mL 133641 ALPHA-1 PROTEINASE INHIB.(HUM) 1000 MG (+/-)/20 ML IV SOLN J0256 13533070501 $3,821.60 $6,114.56 1 Each 133859 ANGIOTENSIN II 2.5 MG/ML IV SOLN C9399 68547050102 $13,500.00 $13,500.00 1 mL

Pharmacy FY22 MED IDs 221 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 133949 BICTEGRAV-EMTRICIT-TENOFOV ALA 50-200-25 MG PO TABS 61958250101 $50,613.12 $50,613.12 30 Each 134117 TENECTEPLASE 50 MG IV SOLR J3101 50242012047 $54,517.05 $54,517.05 1 Each 134118 ESMOLOL IN STERILE WATER 2,500 MG/250 ML (10 MG/ML) IV SOLP J3490 44567081110 $1,760.00 $1,760.00 250 mL 134119 ESMOLOL IN STERILE WATER 2,000 MG/100 ML (20 MG/ML) IV SOLP 44567081210 $1,908.80 $1,908.80 100 mL 134253 STERILE TALC 4 GRAM PL SUSR J3490 62327044404 $2,384.00 $2,384.00 1 Each 134510 IRON DEXTRAN 50 MG/ML IJ SOLN J1750 52544093102 $457.22 $457.22 2 mL 134559 RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLN 90375 13533031805 $20,979.45 $20,979.45 5 mL 134559 RABIES IMMUNE GLOBULIN (PF) 300 UNITS/ML IM SOLN 90375 13533031801 $7,459.36 $7,459.36 1 mL 134878 DAPTOMYCIN 350 MG IV SOLR J0878 70594005301 $313.12 $313.12 1 Each 134879 BARICITINIB 2 MG PO TABS C9399 00002418230 $35,470.56 $35,470.56 30 Each 134885 SARILUMAB 150 MG/1.14 ML SC PNIJ J3590 00024592001 $15,338.74 $15,338.74 1.14 mL 134886 SARILUMAB 200 MG/1.14 ML SC PNIJ J3590 00024592201 $15,338.74 $15,338.74 1.14 mL 134907 EPOETIN ALFA-EPBX 2000 UNITS/ML IJ SOLN Q5106 00069130510 $175.92 $281.47 1 mL 134908 EPOETIN ALFA-EPBX 3000 UNITS IJ SOLN Q5106 00069130610 $263.88 $422.21 1 mL 134909 EPOETIN ALFA-EPBX 4000 UNITS IJ SOLN Q5106 00069130710 $351.84 $562.94 1 mL 134910 EPOETIN ALFA-EPBX 10000 UNITS IJ SOLN Q5106 00069130810 $879.62 $1,407.39 1 mL 135229 CARFILZOMIB 10 MG IV SOLR J9047 76075010301 $6,876.96 $6,876.96 1 Each 135244 SODIUM ZIRCONIUM CYCLOSILICATE 5 GRAM PO PWPK 00310110539 $658.42 $658.42 11 Each 135246 SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM PO PWPK 00310111039 $658.42 $658.42 11 Each 135306 DARUNAVIR-COBI-EMTRI-TENOF ALA 800-150-200-10 MG PO TABS 59676080030 $60,620.64 $60,620.64 30 Each 135554 GLYCOPYRROLATE (PF) 0.2 MG/ML IJ SOLN J7643 51754600001 $167.00 $167.00 1 mL 135562 AMINO ACID 15% NO.5 15 % IV SOLP 00338050206 $768.00 $768.00 2000 mL 135681 IOHEXOL 12 MG IODINE/ML PO SOLN A9698 00407141612 $167.00 $167.00 500 mL 135879 EVEROLIMUS (IMMUNOSUPPRESSIVE) 1 MG PO TABS J7527 00078042220 $33,191.04 $33,191.04 60 Each 135886 AMINOLEVULINIC ACID HCL 30 MG/ML PO SOLR 71469023101 $25,101.00 $25,101.00 1 Each 135895 RIVAROXABAN 2.5 MG PO TABS 50458057710 $4,363.20 $4,363.20 100 Each 135932 ANTIVENIN CROTALIDAE (EQUINE) IJ SOLR 66621079002 $10,233.63 $10,233.63 1 Each 136003 CEMIPLIMAB-RWLC 50 MG/ML IV SOLN J9119 61755000801 $83,128.50 $83,128.50 7 mL 136071 BALSAM PERU-CASTOR OIL TP OINT 58980078021 $417.60 $417.60 60 gram 136919 ETHYL ALCOHOL 99 % IA SOLN J3490 54288010515 $12,229.12 $12,229.12 5 mL 136926 CALCIUM GLUC IN NACL, ISO-OSM 1 GRAM/50 ML IV SOLN 44567062024 $167.00 $167.00 50 mL 136931 DEXTROSE-SOD CITRATE-CITRIC AC 2.45-2.2 GRAM- 800 MG/100 ML MISC SOLN 14537096775 $167.00 $167.00 750 mL 136959 FACTOR XA,INACTIVATED-ZHZO 200 MG IV SOLR J7169 69853010201 $46,781.01 $46,781.01 1 Each 136994 ARGININE-LYSINE IN 0.9 % NACL 25-25 MG/ML IV SOLN J7999 69374098810 $720.00 $720.00 1000 mL 137088 PRUCALOPRIDE 1 MG PO TABS 54092054601 $6,902.40 $6,902.40 30 Each 137091 PRUCALOPRIDE 2 MG PO TABS 54092054701 $6,902.40 $6,902.40 30 Each 137338 ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) IV SOLN J9022 50242091801 $59,659.99 $59,659.99 14 mL 137514 TRASTUZUMAB-HYALURONIDASE-OYSK 600 MG-10,000 UNIT/5 ML SC SOLN J9356 50242007701 $42,077.16 $42,077.16 5 mL 137554 ROMOSOZUMAB-AQQG 210MG/2.34ML ( 105MG/1.17MLX2) SC SYRG J3111 55513088002 $8,697.06 $8,697.06 1.17 mL 137819 SELENIUM 60 MCG/ML IV SOLN 00517656025 $3,042.40 $3,042.40 10 mL 138215 BEVACIZUMAB-AWWB 25 MG/ML IV SOLN Q5107 55513020701 $23,538.96 $23,538.96 16 mL 138215 BEVACIZUMAB-AWWB 25 MG/ML IV SOLN Q5107 55513020601 $10,461.76 $10,461.76 4 mL 138219 CALCIUM GLUC IN NACL, ISO-OSM 2 G/100 ML IV SOLN J0610 44567062124 $268.80 $268.80 100 mL 138242 TRASTUZUMAB-ANNS 420 MG IV SOLR Q5117 55513013201 $32,119.02 $32,119.02 1 Each 138287 AMLODIPINE BENZOATE 1 MG/ML PO SUSP 52652500101 $7,634.40 $7,634.40 150 mL 138755 ANTI-INHIBITOR COAGULANT CMPLX 700-1,300 UNIT IV SOLR J7198 64193042402 $28,640.00 $28,640.00 1 Each 138758 INSULIN REGULAR IN 0.9 % NACL 100 UNIT/100 ML (1 UNIT/ML) IV SOLN J3490 00338012612 $252.80 $252.80 100 mL 138969 BACLOFEN 5 MG/5 ML PO SOLN 69528030116 $12,176.91 $12,176.91 473 mL 139145 TRASTUZUMAB-ANNS 150 MG IV SOLR Q5117 55513014101 $11,471.13 $11,471.13 1 Each 139149 BARICITINIB 1 MG PO TABS C9399 99999977700 $18,120.00 $18,120.00 30 Each 139414 BEVACIZUMAB-BVZR 25 MG/ML IV SOLN Q5118 00069031501 $8,304.32 $8,304.32 4 mL 139414 BEVACIZUMAB-BVZR 25 MG/ML IV SOLN Q5118 00069034201 $18,684.86 $18,684.86 16 mL 139497 ROMIPLOSTIM 125 MCG SC SOLR J2796 55513022301 $16,517.60 $16,517.60 1 Each 139883 COVID-19 VACC,MRNA(MODERNA)-PF 100 MCG/0.5 ML IM SUSP 91301 80777027310 $167.00 $167.00 5 mL 139884 COVID-19 VACC,MRNA(PFIZER)(PF) 30 MCG/0.3 ML IM SUSR 91300 59267100001 $167.00 $167.00 1.8 mL 139946 RITUXIMAB-PVVR 10 MG/ML IV SOLN Q5119 00069024901 $26,206.20 $26,206.20 50 mL 139946 RITUXIMAB-PVVR 10 MG/ML IV SOLN Q5119 00069023801 $9,317.76 $9,317.76 10 mL 140035 TEPROTUMUMAB-TRBW 500 MG IV SOLR J3241 75987013015 $134,100.00 $134,100.00 1 Each 140179 TRASTUZUMAB-QYYP 420 MG IV SOLR Q5116 00069030501 $21,996.09 $21,996.09 1 Each 140183 CEFIDEROCOL 1 GRAM IV SOLR J0693 59630026601 $2,734.16 $2,734.16 1 Each 140374 CASIRIVIMAB (REGN10933) 120 MG/ML IV SOLN Q0243 61755002601 $167.00 $167.00 2.5 mL 140374 CASIRIVIMAB (REGN10933) 120 MG/ML IV SOLN Q0243 61755002401 $167.00 $167.00 11.1 mL 140375 IMDEVIMAB (REGN10987) 120 MG/ML IV SOLN Q0243 61755002701 $167.00 $167.00 2.5 mL 140375 IMDEVIMAB (REGN10987) 120 MG/ML IV SOLN Q0243 61755002501 $167.00 $167.00 11.1 mL 140404 TERIPARATIDE 20 MCG/DOSE (620MCG/2.48ML) SC PNIJ 00002840001 $31,690.89 $31,690.89 2.4 mL 140433 EPTINEZUMAB-JJMR 100 MG/ML IV SOLN J3032 67386013051 $13,455.00 $13,455.00 1 mL 140775 SACITUZUMAB GOVITECAN-HZIY 180 MG IV SOLR J9317 55135013201 $18,655.92 $18,655.92 1 Each 140780 MITOMYCIN 40 MG INPY KIT J9281 72493010140 $96,192.00 $96,192.00 1 Each 140925 NIMODIPINE 30 MG/5 ML PO SYRG 24338023012 $646.56 $646.56 5 mL 140935 DARATUMUMAB-HYALURONIDASE-FIHJ 1,800 MG-30,000 UNIT/15 ML SC SOLN J9144 57894050301 $71,080.20 $71,080.20 15 mL 140977 REMDESIVIR 100 MG/20 ML (5 MG/ML) IV SOLN J3490 61958290201 $8,320.00 $8,320.00 20 mL 141164 FLU VACC QS2020-21 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 58160088541 $208.78 $208.78 .5 mL 141164 FLU VACC QS2020-21 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 58160088552 $208.78 $208.78 .5 mL 141164 FLU VACC QS2020-21 6MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 49281042050 $265.31 $265.31 .5 mL 141167 REMDESIVIR 100 MG IV SOLR J3490 61958290101 $8,320.00 $8,320.00 1 Each

Pharmacy FY22 MED IDs 222 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 141179 FLU VACC QS2020-21(65YR UP)-PF 240 MCG/0.7 ML IM SYRG 90662 49281012088 $745.37 $745.37 .7 mL 141179 FLU VACC QS2020-21(65YR UP)-PF 240 MCG/0.7 ML IM SYRG 90662 49281012065 $745.37 $745.37 .7 mL 141226 FLU VAC QS2020-21 36MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 33332032002 $229.94 $229.94 .5 mL 141226 FLU VAC QS2020-21 36MOS UP(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90686 33332032001 $229.94 $229.94 .5 mL 141230 FLU VAC QS 2020-21(6-35MO)(PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRG 90685 33332022020 $229.94 $229.94 .25 mL 141230 FLU VAC QS 2020-21(6-35MO)(PF) 30 MCG (7.5 MCG X 4)/0.25 ML IM SYRG 90685 33332022021 $229.94 $229.94 .25 mL 141263 FLU VAC QS 2020(4 YR UP)CD(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90674 70461032004 $283.17 $283.17 .5 mL 141263 FLU VAC QS 2020(4 YR UP)CD(PF) 60 MCG (15 MCG X 4)/0.5 ML IM SYRG 90674 70461032003 $283.17 $283.17 .5 mL 141360 PERTUZUMAB-TRASTUZUMAB-HY-ZZXF 1,200 MG-600MG- 30000 UNIT/15ML SC SOLN J9316 50242024501 $114,362.96 $114,362.96 15 mL 141361 PERTUZUMAB-TRASTUZUMAB-HY-ZZXF 600 MG-600 MG- 20000 UNIT/10ML SC SOLN J9316 50242026001 $76,239.00 $76,239.00 10 mL 141644 MIDAZOLAM IN NACL,ISO-OSMO(PF) 1 MG/ML IV SOLN J7999 69374031410 $352.00 $352.00 100 mL 141887 BELANTAMAB MAFODOTIN-BLMF 100 MG IV SOLR J9037 00173089601 $74,493.00 $74,493.00 1 Each 142130 COPPER CU-64 DOTATATE 148 MBQ/4 ML (4 MCI/4 ML) IV SOLN A9597 69945006401 $19,055.00 $19,055.00 4 mL 142622 BAMLANIVIMAB 700 MG/20 ML (35 MG/ML) IV SOLN Q0239 00002791001 $167.00 $167.00 20 mL 142679 FLUOROESTRADIOL F-18 148 MBQ/ML TO 3,700 MBQ/ML IV SOLN A9591 72874000101 $20,285.85 $20,285.85 1 Each 143063 COVID-19 VAC,AD26(JANSSEN)-PF 0.5 ML IM SUSP 91303 59676058005 $167.00 $167.00 2.5 mL 143502 ETESEVIMAB 700 MG/20 ML (35 MG/ML) IV SOLN Q0245 00002795001 $167.00 $167.00 20 mL 145446 ARTESUNATE 110 MG IV SOLR C9399 73607000111 $89,640.00 $89,640.00 2 Each 145485 THYROTROPIN ALFA 0.9 MG IM SOLR 58468003002 $31,950.54 $31,950.54 1 Each 146100 FLORBETABEN F-18 8.1 MCI (300 MBQ) IV SOLN 54828000130 $14,420.00 $14,420.00 1 Each 200001 AMIODARONE IV INFUSION (1 MG/ML) J0282 99999900423 $167.00 $167.00 500 mL 200005 PROCAINAMIDE 2500MG IN D5W 250ML 99999900514 $2,200.00 $2,200.00 250 mL 400009 AZITHROMYCIN 500 MG IV J0290 63323039810 $167.00 $167.00 1 Each 400022 CARDIOPLEGIC SOLUTION WITH GLUTAMATE/ASPARTATE IRRIGATION 99999900396 $2,144.00 $2,144.00 1000 mL 400026 HYDROMORPHONE 1MG/ML PCA CSMC J1170 99999900382 $211.20 $211.20 30 mL 400061 CALCIUM GLUCONATE IVPB 1 G J0610 99999900162 $167.00 $167.00 50 mL 400093 VANILLA TPN PICU/NICU 250 ML 99999900406 $420.00 $420.00 250 mL 400279 HEPARIN, PORCINE (PF) 1000 UNIT/ML IJ SOLN FOR INTRACATHETER J1644 99999900420 $167.00 $167.00 10 mL 400282 CEFAZOLIN IVPB 2 G J0690 99999900109 $167.00 $167.00 1 Each 400290 SODIUM CHLORIDE 3% IV PEDIATRIC 99999900203 $167.00 $167.00 1 mL 400309 HYDROMORPHONE PCA HIGH DOSE 99999900383 $167.00 $167.00 30 mL 400311 PHENOBARBITAL ORAL SOLUTION 4 MG/ML FOR NICU 99999900140 $167.00 $167.00 1 mL 400312 CHLORAL HYDRATE ORAL SOLUTION 100 MG/ML FOR NICU 99999900141 $167.00 $167.00 1 mL 400318 OXYTOCIN CONTINUOUS INFUSION (0.06 UNITS/ML) J2590 99999900362 $167.00 $167.00 250 mL 400338 LOSARTAN 25 MG HALF-TAB = 12.5 MG 99999900426 $167.00 $167.00 1 Each 400350 METHACHOLINE 50 MG IN 0.9% NACL WITH 0.4% PHENOL 2 ML (25 MG/ML) (TEST SOLUTION A) 999990020654 $559.20 $559.20 1 Each 400351 METHACHOLINE 25 MG IN 0.9% NACL WITH 0.4% PHENOL 2.5 ML (10 MG/ML) (TEST SOLUTION B) 999990020655 $279.68 $279.68 1 Each 400352 METHACHOLINE 22.5 MG IN 0.9% NACL WITH 0.4% PHENOL 9 ML (2.5 MG/ML ) (TEST SOLUTION C) 999990020656 $251.68 $251.68 1 Each 400353 METHACHOLINE 2.5 MG IN 0.9% NACL WITH 0.4% PHENOL 10 ML (0.25 MG/ML ) (TEST SOLUTION D) 999990020657 $167.00 $167.00 1 Each 400449 LEVOTHYROXINE 100 MCG IV SOLR 6332364907 $1,253.76 $1,253.76 1 Each 400457 DEXTROSE 25% - PEDIATRIC 99999900474 $167.00 $167.00 1 Each 400473 INSULIN REGULAR 1 UNIT/ML BOLUS PEDIATRIC 99999-9002-04 $167.00 $167.00 1 mL 400474 PENICILLIN 0.5MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900443 $167.00 $167.00 50 mL 400475 PENICILLIN 5 MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900444 $167.00 $167.00 50 mL 400476 PENICILLIN 50 MG/ML FOR CHALLENGE/DESENSITIZATION ORAL SUSP 99999900445 $167.00 $167.00 50 mL 400480 METOPROLOL (LOPRESSOR) ORAL SUSPENSION 10MG/ML 99999900440 $448.00 $448.00 100 mL 400493 DIETHYLENE TRIAMINE PENTAACETIC ACID (TC-99M DTPA) ISOTOPE (NUC MED) N A9567 99999900478 $2,130.86 $2,130.86 30 Each 400500 AMPHETAMINE-DEXTROAMPHETAMINE 5 MG PO HALF-TAB = 2.5 MG CS0040050001 $167.00 $167.00 1 Each 400502 ALPRAZOLAM 0.25 MG HALF-TAB = 0.125 MG CS0040050201 $167.00 $167.00 1 Each 400505 AZATHIOPRINE 50 MG HALF-TAB = 25 MG CS0040050501 $167.00 $167.00 1 Each 400509 CAPECITABINE 150 MG HALF-TAB = 75 MG J8520 CS0040050901 $167.00 $167.00 1 Each 400527 LORAZEPAM 0.5 HALF-TAB = 0.25 MG 99999900353 $167.00 $167.00 1 Each 400529 MERCAPTOPURINE 50 MG HALF-TAB = 25 MG CS0040052901 $167.00 $167.00 1 Each 400531 METHYLPHENIDATE 5 MG HALF-TAB = 2.5 MG CS0040053101 $167.00 $167.00 1 Each 400533 MODAFINIL 100 MG HALF-TAB = 50 MG CS0040053301 $167.00 $167.00 1 Each 400534 PHYTONADIONE 5 MG HALF-TAB = 2.5 MG CS0040053401 $473.97 $473.97 1 Each 400545 ZOLPIDEM 5 MG HALF-TAB = 2.5 MG CS0040054501 $167.00 $167.00 1 Each 400551 ALBUTEROL 90 MCG/ACTUATION IN AERO - PEDIATRIC 00085113201 $594.16 $594.16 6.7 gram 400554 PANTOPRAZOLE ORAL SUSPENSION 2 MG/ML 99999900434 $167.00 $167.00 10 mL 400554 PANTOPRAZOLE ORAL SUSPENSION 2 MG/ML 99999900436 $167.00 $167.00 20 mL 400560 CARVEDILOL (COREG) ORAL SUSPENSION 99999900437 $167.00 $167.00 100 mL 400563 IOHEXOL 300 MG IODINE/ML IV SOLN (RADIANT USE) Q9967 00407141351 $435.60 $435.60 50 mL 400563 IOHEXOL 300 MG IODINE/ML IV SOLN (RADIANT USE) Q9967 00407141360 $1,581.60 $1,581.60 100 mL 400565 PENICILLIN G POTASSIUM 3 MILLION UNITS IN 0.9% NACL 50ML J2540 99999900483 $352.00 $352.00 50 mL 400568 TRANEXAMIC ACID (CYCLOKAPRON) (100MG/ML) 5000MG IN 50ML (STRAIGHT DRU) 99999900670 $584.00 $584.00 50 mL 400588 PEMBROLIZUMAB (STUDY DRUG) - CHEMO VIAL (PRL: BPT-201) 99999001801 $150.00 $150.00 4 mL 400641 TECHNETIUM TETROFOSMIN (TC-99M) (MYOVIEW) ISOTOPE (NUC MED) A9502 17156002630 $9,084.60 $9,084.60 5 Each 400642 TECHNETIUM MERTIATIDE (TC-99M) (MAG3) ISOTOPE (NUC MED) A9562 00019N096BO $2,846.82 $2,846.82 10 mL 400645 FOSAPREPITANT (EMEND) VIAL-TO-BAG VIAL J1453 67457088910 $335.52 $671.04 1 Each 400646 POTASSIUM CHLORIDE 10 MEQ/100 ML IV PGBK (BMT PROTOCOL) J3480 00409707426 $167.00 $167.00 100 mL 400650 LIDOCAINE (PF) 10 MG/ML (1 %) IJ SOLN (30 CC-OB USE) J2001 00409427902 $167.00 $167.00 30 mL 400652 PHENOL 5% IN OLIVE OIL 99999900554 $167.00 $167.00 30 mL 400653 BACLOFEN (LIORESAL) ORAL SUSPENSION 10 MG/ML PEDIATRIC 99999900563 $830.40 $830.40 30 mL 400654 DAPSONE ORAL SUSPENSION 2 MG/ML PEDIATRIC 99999900564 $167.00 $167.00 30 mL 400655 HYDRALAZINE ORAL SUSPENSION 4 MG/ML PEDIATRIC 99999900565 $167.00 $167.00 30 mL

Pharmacy FY22 MED IDs 223 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 400656 LAMOTRIGINE (LAMICTAL) ORAL SUSPENSION 1 MG/ML PEDIATRIC 99999900566 $167.00 $167.00 30 mL 400657 RIFABUTIN (MYCOBUTIN) ORAL SUSPENSION 20 MG/ML PEDIATRIC 99999900567 $753.60 $753.60 30 mL 400658 ZONISAMIDE (ZONEGRAN) ORAL SUSPENSION 10 MG/ML PEDIATRIC (IP ORDERING ONLY) 99999900568 $167.00 $167.00 30 mL 400659 FINASTERIDE (PROSCAR) ORAL SUSPENSION 99999900569 $167.00 $167.00 30 mL 400664 CLOPIDOGREL ORAL SUSPENSION 5 MG/ML PEDIATRIC (IP ORDERING ONLY) 99999900579 $167.00 $167.00 90 mL 400665 ANTITHYMOCYTE GLOBULIN (EQUINE) (ATGAM) SKIN TEST J7504 99999900578 $167.00 $167.00 .1 mL 400717 HIV POST EXPOSURE PROPHYLAXIS KIT 99999900169 $4,758.34 $4,758.34 1 Each 400723 CLONAZEPAM 0.1 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900306 $167.00 $167.00 10 mL 400723 CLONAZEPAM 0.1 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900173 $167.00 $167.00 1 mL 400724 LORAZEPAM 1 MG/ML ORAL SUSPENSION 99999900174 $167.00 $167.00 1 mL 400732 DAKINS SOLUTION FULL STRENGTH 99999900186 $320.00 $320.00 1000 mL 400733 DAKINS SOLUTION 1/2 STRENGTH 99999-9001-83 $320.00 $320.00 1000 mL 400740 FENTANYL 10 MCG/ML NS 250 ML PYXIS J3010 99999900195 $884.00 $884.00 250 mL 400742 FENTANYL (SUBLIMAZE) CONTINUOUS INFUSION (STRAIGHT DRUG) J3010 99999900671 $167.00 $167.00 50 mL 400783 LEVOTHYROXINE (SYNTHROID) ORAL SUSPENSION 25 MCG/ML 99999900350 $624.00 $624.00 60 mL 400784 TOPIRAMATE (TOPAMAX) ORAL SUSPENSION PEDIATRIC 6 MG/ML (IP ORDERING ONLY) 99999900351 $167.00 $167.00 100 mL 400801 METHOCARBAMOL 500 MG PO HALF-TAB = 250 MG 99999900613 $167.00 $167.00 1 Each 400815 RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG)/2 ML IJ SYRG FOR OB J2791 99999900696 $901.56 $901.56 2 mL 400827 MAGNESIUM SULFATE L&D LOADING DOSE 6 GRAM/100 ML 99999000881 $167.00 $167.00 100 mL 400846 HEPARIN IN 0.45% NACL 25000 UNITS/250ML FOR CRRT NX STAGE PUMP J1644 00409765062 $167.00 $167.00 250 mL 400852 VANILLA TPN WITH HEPARIN NICU 99999001466 $420.54 $420.54 250 mL 400876 PHENOBARBITAL ORAL SOLUTION 8 MG/2 ML FOR NICU 99999001809 $167.00 $167.00 2 mL 400919 LEUCOVORIN CALCIUM 5 MG PO HALF-TAB = 2.5 MG 99999002601 $167.00 $167.00 1 Each 400966 BACLOFEN (LIORESAL) ORAL SUSPENSION 5 MG/ML 65628010102 $894.72 $894.72 60 mL 401003 KETAMINE 10 MG/ML PO SOLN 99999002113 $167.00 $167.00 5 mL 409195 OLAPARIB (STUDY DRUG) 50MG CHEMO CAPSULE - (PRL: D0810C00042) 99999900491 $10.00 $10.00 1 capsule 409286 PASIREOTIDE (STUDY DRUG) INJECTION - (PRL: SOM230B2412) 99999900588 $75.00 $75.00 40 mg 409286 PASIREOTIDE (STUDY DRUG) INJECTION - (PRL: SOM230B2412) 99999001161 $75.00 $75.00 60 mg 409379 SGN-LIV1A (STUDY DRUG) CHEMO VIAL - (PRL: SGNLVA-001) 99999900676 $150.00 $150.00 40 mg 409410 BRENTUXIMAB (STUDY DRUG) VIAL - (PRL: COG ANHL12P1) 99999900767 $150.00 $150.00 50 mg 409543 PT2385 (STUDY DRUG) 200 MG CHEMO TABLET - (PRL: PT2385-101) 99999000876 $30.00 $30.00 1 tablet 409563 BLINATUMOMAB (STUDY DRUG) PEDS 24 CHEMO VIAL-(PRL:AALL1331) 99999000895 $30.00 $30.00 38.5 mcg 409609 LUPRON DEPOT (LEUPROLIDE ACETATE, 3 MONTH)(STUDY DRUG) 22.5 MG SYRINGE - (PRL: MDV3100-13) 99999001058 $30.00 $30.00 1 kit 409612 ENZALUTAMIDE OR PLACEBO (STUDY DRUG) 40 MG CAPSULE - (PRL: MDV3100-13) 99999001060 $30.00 $30.00 120 capsule 409613 ENZALUTAMIDE (OPEN-LABEL) (STUDY DRUG) 40 MG CAPSULE - (PRL: MDV3100-13) 99999001061 $30.00 $30.00 120 capsule 409646 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE - (PRL: PR-30-5020-C) 99999001103 $50.00 $50.00 93 capsule 409660 HEPARIN (PORCINE) IN NACL (PF) 1000 UNITS/500ML FOR ECMO FLUSH IV SOLP 99999001111 $167.00 $167.00 500 mL 409667 MERCAPTOPURINE (PURINETHOL) ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999001122 $167.00 $167.00 1 mL 409701 PEMBROLIZUMAB (STUDY DRUG) VIAL - (PRL: IIT2015-13-WALSH-PEMCIGEM) 99999001154 $150.00 $150.00 50 mg 409701 PEMBROLIZUMAB (STUDY DRUG) VIAL - (PRL: IIT2015-13-WALSH-PEMCIGEM) 99999001155 $150.00 $150.00 100 mg 409726 LEUPROLIDE DEPOT (ELIGARD) (STUDY DRUG) INJECTION - (IRB# 40227) 99999001184 $30.00 $30.00 1 Syringe 409744 PEMBROLIZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: MK3475-158) 99999001202 $150.00 $150.00 4 mL 409755 ASTX660 (STUDY DRUG) 30 MG CAPSULE - (PRL: ASTX660-01) 99999001208 $50.00 $50.00 14 Each 409756 ASTX660 (STUDY DRUG) 180 MG CAPSULE - (PRL: ASTX660-01) 99999001209 $50.00 $50.00 14 Each 409759 AZD9291 OR PLACEBO (STUDY DRUG) 80 MG TABLET - (PRL: D5164C00001) 99999001212 $50.00 $50.00 80 mg 409760 AZD9291 OR PLACEBO (STUDY DRUG) 40 MG TABLET - (PRL: D5164C00001) 99999001213 $50.00 $50.00 40 mg 409771 SDX-7320 (STUDY DRUG) - (PRL: SDX-101 ) SYRINGE #1 99999001227 $30.00 $30.00 1 mL 409774 BICALUTAMIDE OR PLACEBO (STUDY DRUG) 50 MG CAPSULE (PRL: 56021927PCR3003) 99999001231 $30.00 $30.00 30 capsule 409890 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE (PRL: 3000-PN162-01-001) 99999001263 $30.00 $30.00 72 capsule 409915 AVELUMAB (STUDY DRUG) VIAL - (PRL: B9991003) 99999001273 $150.00 $150.00 200 mg 409917 NIVOLUMAB OR PLACEBO (STUDY DRUG) VIAL (PRL: CA209-548) 99999001275 $150.00 $150.00 100 mg 410042 FUROSEMIDE (LASIX) 1000MG IN 100ML (STRAIGHT DRUG) INFUSION J1940 99999900669 $167.00 $167.00 100 mL 410043 BUMETANIDE (BUMEX) 25MG IN 100ML (STRAIGHT DRUG) INFUSION 99999900561 $304.00 $304.00 100 mL 410068 EPINEPHRINE IN D5W 4MG/250ML IV PREMIX 99999900258 $480.00 $480.00 250 mL 410104 RGX-104 (STUDY DRUG) 40 MG CAPSULE (PRL: RGX-104) 99999001477 $30.00 $30.00 30 capsule 410130 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2015-18-MITA-MK3475) 99999001484 $150.00 $150.00 100 mg 410133 HYDROXYCHLOROQUINE 200 MG/8 ML ORAL SUSPENSION 99999002386 $167.00 $167.00 8 mL 410135 HYDROMORPHONE IN D5W 50 MG/250 ML (0.2 MG/ML) PREMIX IV PGBK 99999002399 $167.00 $167.00 250 mL 411068 EPINEPHRINE IN D5W 8 MG/250ML (0.032 MG/ML)IV PREMIX 99999900395 $920.00 $920.00 250 mL 411069 EPINEPHRINE IN D5W 3 MG/100 ML (0.03 MG/ML) IV PREMIX 99999001971 $372.80 $372.80 100 mL 411072 SUFENTANIL CITRATE IN 0.9% NACL 100 MCG/250 ML IV SOLP 99999002411 $167.00 $167.00 250 mL 500037 METHOTREXATE INTRAMUSCULAR 99999900274 $167.00 $167.00 2 mL 500047 THIOTEPA CHEMO IV PUSH J9340 99999900196 $5,809.68 $5,809.68 15 mg 500060 HEPARIN FOR NICU ARTERIAL LINE INFUSION 99999900401 $167.00 $167.00 100 mL 500068 LIDOCAINE 1% (BUFFERED) INJ. SOLUTION J2001 99999900197 $167.00 $167.00 1 mL 500073 MMX ORAL SUSPENSION (IP ORDERING ONLY) 99999900375 $167.00 $167.00 120 mL 500092 VANCOMYCIN ORAL SOLUTION 25 MG/ML 99999900335 $167.00 $167.00 5 mL 500092 VANCOMYCIN ORAL SOLUTION 25 MG/ML 99999900390 $167.00 $167.00 10 mL 500125 CAFFEINE CITRATE 20 MG/ML ORAL SOLUTION PEDIATRIC 99999900133 $167.00 $167.00 1 mL 500133 AMIKACIN 25 % FOR INHALATION 99999900469 $167.00 $167.00 4 mL 500137 GENTAMICIN 4 % NEBULIZER SOLUTION 99999900152 $167.00 $167.00 1 mL 500138 PENTAMIDINE NEBULIZER SOLUTION J2545 99999900153 $167.00 $167.00 1 mL 500140 MEDICINAL LEECH 99999900155 $242.40 $242.40 1 Each 500142 VANCOMYCIN ENEMA 99999900370 $262.72 $262.72 1 enema 500143 HEPARIN 500 UNITS PICU PRESSURE LINE INFUSION (PT WT 10KG OR GREATER) 99999900402 $167.00 $167.00 500 mL

Pharmacy FY22 MED IDs 224 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 500149 MORPHINE INJECTION - PEDS < 1 YEAR J2250 99999900161 $167.00 $167.00 2 mL 500151 HEPARIN 20,000 UNITS/20 ML SYRINGE FOR CRRT DIALYSIS J1644 99999900394 $167.00 $167.00 20 mL 500152 FLUCONAZOLE 2 MG/ML IN NS IV PEDIATRIC 99999900163 $167.00 $167.00 1 mL 500153 METRONIDAZOLE 5 MG/ML IV PEDIATRIC 99999900164 $167.00 $167.00 1 mL 500154 LINEZOLID 2 MG/ML IV PEDIATRIC 99999900165 $167.00 $167.00 1 mL 500155 LEVOFLOXACIN 5 MG/ML IV PEDIATRIC J1956 99999900166 $167.00 $167.00 1 mL 500165 FENTANYL 10 MCG/ML IV PEDIATRIC J3010 99999900253 $167.00 $167.00 1 mL 500167 ENOXAPARIN 100 MG/ML IV PEDIATRIC J1650 99999900167 $178.30 $178.30 1 mL 500177 CEFTRIAXONE IVPB VIAL 1 GRAM/50 ML VIAL-TO-BAG IVPB J0696 00781320885 $167.00 $167.00 1 Each 500181 MEROPENEM 500 MG/50 ML VIAL-TO-BAG IVPB J2185 00310032520 $167.00 $167.00 1 Each 500183 OXACILLIN IVPB VIAL 1 G VIAL-TO-BAG J2700 00781309985 $167.00 $167.00 1 Each 500184 OXACILLIN IVPB VIAL 2 G VIAL-TO-BAG J2700 00781310180 $167.00 $167.00 1 Each 500188 PIPERACILLIN-TAZOBACTAM VIAL 4.5 G VIAL-TO-BAG IVPB J2543 00206885516 $167.00 $167.00 1 Each 500193 CEFOTETAN 1 G/50 ML VIAL-TO-BAG IVPB 63323038510 $167.00 $167.00 1 Each 500195 FAT EMULSION 20 % IV PEDS 99999900172 $167.00 $167.00 25 mL 500203 METRONIDAZOLE IN NACL (ISO-OS) 250 MG/50 ML IVPB 99999900206 $167.00 $167.00 50 mL 500222 HEPARIN FLUSH INFUSION FOR THROMBOLYSIS (5 UNITS/ML) IV SOLN J1644 99999900577 $167.00 $167.00 1000 mL 500329 CEFTRIAXONE 2 GRAM/50 ML VIAL-TO-BAG IVPB J0696 00409733503 $167.00 $167.00 1 Each 500356 DEXAMETHASONE (DECADRON) 10MG/50ML VIAL-TO-BAG J1100 99999001479 $167.00 $167.00 1 Each 500363 IRON SUCROSE 100 MG/100 ML VIAL-TO-BAG IVPB J1756 99999001650 $307.59 $492.14 1 Each 500364 IRON SUCROSE 200 MG/100 ML VIAL-TO-BAG IVPB J1756 99999001651 $596.70 $954.72 1 Each 500365 MIDAZOLAM 250 MG/50 ML (5 MG/ML) ADULT STRAIGHT DRUG IV SOLUTION 99999001701 $167.00 $167.00 50 mL 500500 FERRIC CARBOXYMALTOSE 750MG/250ML VIAL-TO-BAG IVPB J1439 99999002225 $8,534.50 $13,655.20 1 Each 500670 HEPARIN 20,000 UNITS/20 ML SYRINGE FOR BM HARVEST (INTRAPROCEDURE) J1644 99999002185 $167.00 $167.00 20 mL 501143 POTASSIUM CHLORIDE 10 MEQ/100ML IN 0.9% NACL PGBK J3480 99999001764 $167.00 $167.00 100 mL 501144 POTASSIUM CHLORIDE 10 MEQ/100ML IN D5W PGBK J3480 99999001765 $167.00 $167.00 100 mL 501151 CEFAZOLIN IN 0.9% NACL 2 GRAM/50 ML IV PGBK J0690 99999001811 $167.00 $167.00 1 Each 501152 GENTAMICIN 80 MG/50ML VIAL-TO-BAG IVPB J1580 99999001812 $167.00 $167.00 1 Each 501166 PHENOBARBITAL 10 MG/ML IV IN NS PEDIATRIC 99999900364 $167.00 $167.00 1 mL 509012 SODIUM BICARBONATE (STRAIGHT DRUG) IV INFUSION 99999900433 $167.00 $167.00 50 mL 509015 MMX ORAL SUSPENSION (CC) 99999-900438 $167.00 $167.00 10 mL 509029 HEPARIN 1000UNIT/ML 1ML VIAL FOR PORT FLUSH J1644 63323054001 $167.00 $167.00 1 mL 509031 CARFILZOMIB CHEMO VIAL J9047 99999900439 $16,757.55 $16,757.55 30 mL 509034 LIDOCAINE 10 MG/ML (1 %) IJ SOLN (CC) J2001 63323048527 $167.00 $167.00 20 mL 509034 LIDOCAINE 10 MG/ML (1 %) IJ SOLN (CC) J2001 00409427602 $167.00 $167.00 50 mL 509043 LIDOCAINE 4 % TP CREA CC 00496088206 $167.00 $167.00 5 gram 510005 MAGIC MOUTHWASH (IP ORDERING ONLY) 99999900376 $167.00 $167.00 120 mL 520001 FORTIFIED TOBRAMYCIN 14 MG/ML OP DROPS 99999900036 $167.00 $167.00 7 mL 520002 FORTIFIED GENTAMICIN 14 MG/ML OP DROPS 99999900037 $278.88 $278.88 7 mL 520003 FORTIFIED VANCOMYCIN 50 MG/ML OP DROPS 99999900038 $167.00 $167.00 10 mL 520004 FORTIFIED CEFAZOLIN 33 MG/ML OP DROPS 99999900039 $167.00 $167.00 15 mL 520009 AMPHOTERICIN SWISH & SWALLOW 0.1 MG/ML 99999900044 $307.20 $307.20 120 mL 520012 MODIFIED STANFORD'S STOMATITIS ORAL SUSPENSION (IP ORDERING ONLY) 99999900050 $252.80 $252.80 100 mL 520014 ATENOLOL ORAL SUSPENSION 2 MG/ML 99999900052 $167.00 $167.00 100 mL 520015 CAPTOPRIL ORAL SUSPENSION 1 MG/ML 99999900053 $167.00 $167.00 1 mL 520017 ENALAPRIL ORAL SUSPENSION 1 MG/ML (IP ORDERING ONLY) 99999900056 $167.00 $167.00 1 mL 520018 HYDROCORTISONE ORAL SUSPENSION 2 MG/ML (IP ORDERING ONLY) 99999900055 $167.00 $167.00 1 mL 520019 METOLAZONE ORAL SUSPENSION 1 MG/ML 99999900057 $167.00 $167.00 1 mL 520020 METRONIDAZOLE ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999900058 $167.00 $167.00 1 mL 520021 NIFEDIPINE ORAL SUSPENSION 4 MG/ML (IP ORDERING ONLY) 99999900326 $167.00 $167.00 30 mL 520022 URSODIOL ORAL SUSPENSION 50 MG/ML (IP ORDERING ONLY) 99999001192 $167.00 $167.00 5 mL 520023 HYDROXYUREA ORAL SUSPENSION 50 MG/ML 99999900309 $167.00 $167.00 30 mL 520024 POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION 99999900065 $167.00 $167.00 1 mL 520024 POTASSIUM CHLORIDE 2 MEQ/ML ORAL SOLUTION 99999900066 $167.00 $167.00 3 mL 520025 SPIRONOLACTONE 5 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900336 $167.00 $167.00 5 mL 520026 ACETAZOLAMIDE 25 MG/ML ORAL SUSPENSION 99999900301 $168.00 $168.00 50 mL 520027 SILDENAFIL 2.5 MG/ML ORAL SUSPENSION (IP ORDERING ONLY) 99999900334 $167.00 $167.00 4 mL 520028 RIFAMPIN ORAL SUSPENSION 25 MG/ML (IP ORDERING ONLY) 99999900079 $167.00 $167.00 1 mL 520029 SODIUM CHLORIDE ORAL SOLUTION 4 MEQ/ML 99999900082 $167.00 $167.00 .5 mL 520029 SODIUM CHLORIDE ORAL SOLUTION 4 MEQ/ML 99999900083 $167.00 $167.00 1 mL 520034 MODIFIED DANIELS SOLUTION 99999900089 $1,958.40 $1,958.40 240 mL 520035 ARGININE ORAL SOLUTION 10 % (0.475 MEQ/ML) 99999900090 $167.00 $167.00 1 mL 520036 CALCIUM GLUCONATE ORAL SOLUTION 100 MG/ML 99999900091 $167.00 $167.00 1 mL 520037 DEXAMETHASONE 4 MG/ML ORAL SOLUTION 99999900092 $167.00 $167.00 1 mL 520039 KANAMYCIN ORAL SOLUTION 333 MG/ML 99999900094 $167.00 $167.00 1 mL 520042 SODIUM PHOSPHATE ORAL SOLUTION 4 MEQ/ML (3 MMOL/ML) 99999900097 $167.00 $167.00 1 mL 520044 GENTAMICIN NEBULIZER SOLUTION 40 MG/ML 99999900099 $167.00 $167.00 2 mL 520045 TOBRAMYCIN NEBULIZER SOLUTION 40 MG/ML J3260 99999900100 $167.00 $167.00 2 mL 520046 HYDROXYUREA ORAL SUSPENSION 100 MG/ML (IP ORDERING ONLY) 99999900308 $230.40 $230.40 240 mL 520047 MORPHINE ORAL SOLUTION 1 MG/ML PEDIATRIC 99999900102 $167.00 $167.00 1 mL 520050 LEVOFLOXACIN ORAL SUSPENSION 50 MG/ML 99999900105 $167.00 $167.00 1 mL 520052 AMIODARONE ORAL SUSPENSION 5 MG/ML 99999900107 $167.00 $167.00 120 mL 520053 LABETALOL ORAL SUSPENSION 10 MG/ML 99999900108 $167.00 $167.00 1 mL 520057 RIFAMPIN (RIFADIN) ORAL SUSPENSION 10MG/ML PEDIATRIC 99999900419 $167.00 $167.00 1 mL 520061 TACROLIMUS ORAL SUSPENSION 1 MG/ML (IP ORDERING ONLY) 99999900611 $1,084.80 $1,084.80 60 mL

Pharmacy FY22 MED IDs 225 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 520062 MESNA 100 MG/ML ORAL SOLN 99999001095 $167.00 $167.00 10 mL 520064 CLONIDINE ORAL SUSPENSION 10 MCG/ML 99999001340 $167.00 $167.00 200 mL 520101 F-18 FLUCICLOVINE A9588 69932001030 $25,461.60 $25,461.60 10 millicurie 522058 HEPARIN INJECTION FOR APHERESIS 1000 UNIT/ML J1644 63323054011 $167.00 $167.00 10 mL 530011 KETOROLAC 30 MG/ML IV PEDIATRIC J1885 99999900201 $167.00 $167.00 1 mL 530018 CLINDAMYCIN IVPB PEDIATRIC 99999900215 $167.00 $167.00 1 mL 530036 METOCLOPRAMIDE 5 MG/ML IV PEDIATRIC 99999900113 $167.00 $167.00 1 mL 530037 HYDROCORTISONE 50 MG/ML IV PUSH PEDIATRIC J1720 99999900114 $167.00 $167.00 1 mL 531014 MIDAZOLAM 2 MG/ML PO SYRP < 1 ML 99999900324 $167.00 $167.00 5 mL 531032 PENTOXIFYLLINE 20 MG/ML ORAL SOLUTION 99999002269 $167.00 $167.00 200 mL 800037 AMINOCAPROIC ACID 5G/20 ML (0.25 G/ML) STRAIGHT DRUG IV SOLN 99999900548 $167.00 $167.00 20 mL 800040 ACETIC ACID 4% TOPICAL SOLN INTRAPROCEDURE 99999900549 $307.20 $307.20 120 mL 800071 GENTAMICIN (MIX WITH GELFOAM) FOR INTRAPROCEDURE J1580 00409120703 $167.00 $167.00 2 mL 800087 BUPIVACAINE 0.25% INFUSION (ANES-INTRAPROCEDURE) J3490 55150016710 $167.00 $167.00 10 mL 800087 BUPIVACAINE 0.25% INFUSION (ANES-INTRAPROCEDURE) J3490 63323046437 $167.00 $167.00 30 mL 800087 BUPIVACAINE 0.25% INFUSION (ANES-INTRAPROCEDURE) J3490 00409115901 $167.00 $167.00 10 mL 800088 BUPIVACAINE 0.5% INFUSION (ANES-INTRAPROCEDURE) 00409116202 $167.00 $167.00 30 mL 800093 LIDOCAINE OINTMENT 5% (MIX WITH GELFOAM) INTRAPROCEDURE 00168020437 $3,579.16 $3,579.16 35.44 gram 800093 LIDOCAINE OINTMENT 5% (MIX WITH GELFOAM) INTRAPROCEDURE 51672300803 $1,133.60 $1,133.60 50 gram 800111 SUFENTANIL - BUPIVACAINE PF 0.25% EPI EPIDURAL (L&D ANES-INTRAPROCEDURE) 99999001607 $330.00 $330.00 1 Each 800116 NITROGLYCERIN 100 MCG/ML INJECTION FOR INTRAPROCEDURE 99999001687 $167.00 $167.00 10 mL 800121 ADENOSINE (ADENOCARD) 100 MCG/ML INJECTION FOR INTRAPROCEDURE J0153 99999001217 $167.00 $167.00 50 mL 800122 VERAPAMIL (ISOPTIN) 100 MCG/ML INJECTION FOR INTRAPROCEDURE 99999001218 $167.00 $167.00 10 mL 800126 VANCOMYCIN 500 MG IN 200 ML 0.9% NACL POCKET IRRIGATION FOR INTRAPROCEDURE J3370 99999001254 $167.00 $167.00 200 mL 800127 GENTAMICIN 80 MG IN 200 ML 0.9% NACL POCKET IRRIGATION FOR INTRAPROCEDURE J1580 99999001255 $167.00 $167.00 200 mL 800132 ACETYLCHOLINE 0.182 MCG/ML (ACH 10-6) INJECTION FOR INTRAPROCEDURE 99999001306 $167.00 $167.00 1 Each 800160 HEPARIN SOLUTION 5 UNITS/ML FOR INSTRUMENT WASH/RINSE FOR INTRAPROCEDURE (IR ONLY) J1644 99999001999 $167.00 $167.00 1000 mL 800163 HEPARIN SOLUTION 2.5 UNITS/ML FOR INSTRUMENT WASH/RINSE FOR INTRAPROCEDURE (IR ONLY) J1644 99999002527 $167.00 $167.00 1000 mL 800173 SUFENTANIL 0.4 MCG/ML-BUPIVACAINE 0.04%-EPINEPRHINE 1:400,000 (L&D) WALKING EPIDURAL J3490 99999002575 $284.00 $284.00 250 mL 802321 ALTEPLASE 25 MG/25 ML (1 MG/ML) STRAIGHT DRUG IV INFUSION J2997 99999900673 $18,456.75 $18,456.75 25 mL 802781 ARGATROBAN IN NACL (ISO-OS) 50 MG/50 ML (1 MG/ML) IV SOLN J0883 42367020307 $3,385.60 $3,385.60 50 mL 802787 LORAZEPAM 100 MG/50 ML (2 MG/ML) IV SOLN STRAIGHT DRUG 99999900430 $360.00 $360.00 50 mL 802796 LORAZEPAM 120 MG/30 ML (4 MG/ML) IV SOLN STRAIGHT DRUG J2060 99999900429 $753.60 $753.60 30 mL 802810 MIDAZOLAM PF 10 MG/10 ML (1 MG/ML) STRAIGHT DRUG IV SOLN 99999900470 $167.00 $167.00 10 mL 802811 MIDAZOLAM PF 25 MG/25 ML (1 MG/ML) STRAIGHT DRUG IV SOLN 99999900471 $167.00 $167.00 25 mL 802812 MIDAZOLAM PF 50 MG/50 ML (1MG/ML) STRAIGHT DRUG IV SOLN 99999900472 $240.00 $240.00 50 mL 802815 FENTANYL 2500 MCG/50 ML (50 MCG/ML) STRAIGHT DRUG IV SOLN 99999900473 $167.00 $167.00 50 mL 802832 MIDAZOLAM 250 MG/50 ML (5 MG/ML) PEDS STRAIGHT DRUG IV SOLUTION 99999900847 $167.00 $167.00 50 mL 802848 MORPHINE (PF) 1 MG/ML IJ SOLN J2274 99999000898 $504.00 $504.00 50 mL 803835 FUROSEMIDE (LASIX) 500 MG IN 50 ML (STRAIGHT DRUG) IV INFUSION J1940 99999900848 $167.00 $167.00 50 mL 803847 FENTANYL 150 MCG/3 ML (50 MCG/ML) STRAIGHT DRUG IV SOLN 99999002262 $167.00 $167.00 3 mL 803852 FUROSEMIDE (LASIX) 30 MG IN 3 ML (STRAIGHT DRUG) IV INFUSION J1940 99999002264 $167.00 $167.00 3 mL 803868 MIDAZOLAM PF 3 MG/3 ML (1 MG/ML) STRAIGHT DRUG IV SOLN 99999002266 $167.00 $167.00 3 mL 803869 MIDAZOLAM 15 MG/3 ML (5 MG/ML) PEDS STRAIGHT DRUG IV SOLUTION 99999002267 $167.00 $167.00 3 mL 803879 SILDENAFIL (ANTIHYPERTENSIVE) 2.4 MG/3 ML (0.8 MG/ML) STRAIGHT DRUG IV SOLN J3490 99999002268 $468.48 $468.48 3 mL 909005 ETHIODIZED OIL 48% IJ OIL 99999900513 $17,504.00 $17,504.00 10 mL 1000020 CEDIRANIB (STUDY DRUG) 15 MG TABLET- (PRL: D8488C00001) 99999001509 $30.00 $30.00 30 tablet 1000021 OLAPARIB (STUDY DRUG) 100 MG TABLET- (PRL: D8488C00001) 99999001511 $30.00 $30.00 32 tablet 1000022 CEDIRANIB (STUDY DRUG) 20 MG TABLET- (PRL: D8488C00001) 99999001510 $30.00 $30.00 30 tablet 1000023 OLAPARIB (STUDY DRUG) 150 MG TABLET- (PRL: D8488C00001) 99999001512 $30.00 $30.00 32 tablet 1000053 PALBOCICLIB (STUDY DRUG) 75 MG CAPSULE- (PRL: AFT-05 PALLAS) 99999001584 $30.00 $30.00 21 capsule 1000054 PALBOCICLIB (STUDY DRUG) 100 MG CAPSULE- (PRL: AFT-05 PALLAS) 99999001585 $30.00 $30.00 21 capsule 1000055 PALBOCICLIB (STUDY DRUG) 125 MG CAPSULE- (PRL: AFT-05 PALLAS) 99999001586 $30.00 $30.00 21 capsule 1000096 ALXN1210 (STUDY DRUG) IN 0.9% NACL VIAL (PRL: ALXN1210-PNH-301) J1300 99999001644 $75.00 $75.00 300 mg 1000099 XILONIX (STUDY DRUG) IN 0.9% NACL VIAL (PRL: IIT2016-07-HENDIFAR-ONFX) 99999001646 $150.00 $150.00 800 mg 1000125 DURVALUMAB (STUDY DRUG) VIAL (PRL: IIT2016-01-TULI-DURVARAD) 99999001684 $150.00 $150.00 500 mg 1000141 EDO-S101 (STUDY DRUG) VIAL (PRL: EDO-S101-1002) 99999001695 $150.00 $150.00 100 mL 1000143 P-32 ONCOSIL (ONCOPA-1 STUDY DRUG) ISOTOPE NUC MED - (IRB #49148) 99999001678 $1.00 $1.00 1 Each 1000161 MINNELIDE (STUDY DRUG) 0.25 MG CAPSULE (PRL: MINNELIDE 101) 99999001702 $30.00 $30.00 25 capsule 1000162 MINNELIDE (STUDY DRUG) 0.5 MG CAPSULE (PRL: MINNELIDE 101) 99999001703 $30.00 $30.00 45 capsule 1000172 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2017-07-HO-PEMBRORT) 99999001717 $150.00 $150.00 4 mL 1000187 TRC105 (STUDY DRUG) VIAL (PRL: IIT2016-16-POSADAS-TRC105) 99999001730 $150.00 $150.00 100 mg 1000187 TRC105 (STUDY DRUG) VIAL (PRL: IIT2016-16-POSADAS-TRC105) 99999001731 $150.00 $150.00 400 mg 1000191 PF-06804103 (STUDY DRUG) VIAL (PRL: C0541001) 99999001732 $150.00 $150.00 40 mg 1000193 DSP-7888 (STUDY DRUG) INTRADERMAL SYRINGE (PRL: BBI-DSP7888-201G) 99999001740 $200.00 $200.00 3 mL 1000196 PALBOCICLIB (STUDY DRUG) 125 MG CAPSULE - (PRL: TAPUR) 99999001734 $75.00 $75.00 21 capsule 1000197 PALBOCICLIB (STUDY DRUG) 75 MG CAPSULE - (PRL: TAPUR) 99999001735 $75.00 $75.00 21 capsule 1000198 PALBOCICLIB (STUDY DRUG) 100 MG CAPSULE - (PRL: TAPUR) 99999001736 $75.00 $75.00 21 capsule 1000202 SUNITINIB MALATE (STUDY DRUG) 50 MG CAPSULE - (PRL: TAPUR) 99999001741 $75.00 $75.00 28 capsule 1000203 SUNITINIB MALATE (STUDY DRUG) 37.5 MG CAPSULE - (PRL: TAPUR) 99999001742 $75.00 $75.00 28 capsule 1000204 SUNITINIB MALATE (STUDY DRUG) 25 MG CAPSULE - (PRL: TAPUR) 99999001743 $75.00 $75.00 28 capsule 1000205 SUNITINIB MALATE (STUDY DRUG) 12.5 MG CAPSULE - (PRL: TAPUR) 99999001744 $75.00 $75.00 28 capsule 1000218 TISLELIZUMAB BGB-A317 (STUDY DRUG) VIAL (PRL: BGB-A317/BGB-290) 99999900477 $150.00 $150.00 100 mg 1000236 TRASTUZUMAB (STUDY DRUG) VIAL - (PRL: TAPUR) 99999001759 $75.00 $75.00 150 mg 1000238 PERTUZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999001760 $75.00 $75.00 420 mg

Pharmacy FY22 MED IDs 226 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 1000245 COBIMETINIB (STUDY DRUG) 20 MG TABLET (PRL: CO39611) 99999001771 $30.00 $30.00 63 tablet 1000246 IPATASERTIB (STUDY DRUG) 100 MG TABLET (PRL: CO39611) 99999001772 $30.00 $30.00 7 tablet 1000251 SGN-LIV1A (STUDY DRUG) VIAL (PRL: SGNLVA-002) 99999001776 $150.00 $150.00 40 mg 1000253 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: SGNLVA-002) 99999001778 $150.00 $150.00 100 mg 1000255 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: UCDCC258) 99999001777 $150.00 $150.00 1200 mg 1000257 MCLA-128 (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001779 $150.00 $150.00 100 mg 1000259 TRASTUZUMAB (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001780 $150.00 $150.00 150 mL 1000261 VINORELBINE (STUDY DRUG) VIAL (PRL: MCLA-128-CL02) 99999001781 $150.00 $150.00 50 mg 1000264 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: CO39611) 99999001782 $150.00 $150.00 1200 mg 1000266 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: CO39611) 99999001783 $150.00 $150.00 400 mg 1000276 ABEMACICLIB (STUDY DRUG) 50 MG CAPSULE (PRL: I3Y-MC-JPCF) 99999001820 $30.00 $30.00 60 capsule 1000277 RX108 (STUDY DRUG) 0.1 MG/ML VIAL (PRL: NP-102) 99999001821 $150.00 $150.00 5 mL 1000300 MELPHALAN/HDS (STUDY DRUG) VIAL (PRL: PHP-ICC-203) 99999001835 $150.00 $150.00 50 mg 1000307 CALCIUM CHLORIDE 300 MG IN 0.9% NACL 100 ML FOR THERA APHERESIS 99999001849 $167.00 $167.00 100 mL 1000318 BENDAMUSTINE (STUDY DRUG) VIAL (PRL: IIT2017-03-MERIN-HA) 99999001859 $150.00 $150.00 100 mg 1000325 DURVALUMAB (STUDY DRUG) VIAL (PRL: D419CC00002) 99999001862 $150.00 $150.00 500 mg 1000327 TREMELIMUMAB (STUDY DRUG) VIAL - (PRL: D419CC00002) 99999001865 $150.00 $150.00 400 mg 1000329 XMAB20717 (STUDY DRUG) VIAL (PRL: XMAB20717-01) 99999001870 $150.00 $150.00 100 mg 1000331 CB-839 OR PLACEBO (STUDY DRUG) 200 MG TABLET (PRL: CX-839-008) 99999001869 $30.00 $30.00 250 tablet 1000332 SELINEXOR OR PLACEBO (STUDY DRUG) 20 MG TABLET (PRL: KCP-330-020) 99999001867 $30.00 $30.00 12 tablet 1000333 SELINEXOR (OPEN-LABEL) (STUDY DRUG) 20 MG TABLET (PRL: KCP-330-020) 99999001868 $30.00 $30.00 12 tablet 1000338 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: BIG16-05/AFT-27/WO39391) 99999001871 $150.00 $150.00 1200 mg 1000343 XMAB18087 (STUDY DRUG) VIAL (PRL: XMAB18087-01) 99999001876 $150.00 $150.00 1000 mcg 1000344 SORAFENIB (STUDY DRUG) 200 MG TABLET (PRL: D419CC00002) 99999001875 $75.00 $75.00 120 tablet 1000353 FPA150-001 (STUDY DRUG) IN 0.9% NACL VIAL (PRL: FPA150-001) 99999001877 $150.00 $150.00 100 mg 1000400 ENTINOSTAT (STUDY DRUG) 5 MG TABLET (PRL: CO39611) 99999001907 $30.00 $30.00 3 tablet 1000401 ENTINOSTAT (STUDY DRUG) 1 MG TABLET (PRL: CO39611) 99999001908 $30.00 $30.00 9 tablet 1000409 F-18 CP-18, DIAGNOSTIC, PER STUDY DOSE, UP TO 15 MILLICURIES 99999001933 $150.00 $150.00 1 Each 1000529 BOSUTINIB (STUDY DRUG) 500 MG TABLET - (PRL: TAPUR) 99999001993 $75.00 $75.00 30 tablet 1000530 AXITINIB (STUDY DRUG) 5 MG TABLET - (PRL: TAPUR) 99999001995 $75.00 $75.00 60 tablet 1000532 CRIZOTINIB (STUDY DRUG) 200 MG CAPSULE - (PRL: TAPUR) 99999001997 $75.00 $75.00 60 capsule 1000533 CRIZOTINIB (STUDY DRUG) 250 MG CAPSULE - (PRL: TAPUR) 99999001998 $75.00 $75.00 60 capsule 1000534 DASATINIB (STUDY DRUG) 50 MG TABLET - (PRL: TAPUR) 99999002000 $75.00 $75.00 60 tablet 1000536 ERLOTINIB (STUDY DRUG) 100 MG TABLET - (PRL: TAPUR) 99999002002 $75.00 $75.00 30 tablet 1000537 ERLOTINIB (STUDY DRUG) 150 MG TABLET - (PRL: TAPUR) 99999002003 $75.00 $75.00 30 tablet 1000538 VISMODEGIB (STUDY DRUG) 150 MG CAPSULE - (PRL: TAPUR) 99999002004 $75.00 $75.00 28 capsule 1000539 CETUXIMAB (STUDY DRUG) CHEMO IVPB - (PRL: TAPUR) 99999002014 $75.00 $75.00 200 mg 1000539 CETUXIMAB (STUDY DRUG) CHEMO IVPB - (PRL: TAPUR) 99999002013 $75.00 $75.00 100 mg 1000540 PEMBROLIZUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999002006 $75.00 $75.00 100 mg 1000542 REGORAFENIB (STUDY DRUG) 40 MG TABLET - (PRL: TAPUR) 99999002007 $75.00 $75.00 84 tablet 1000543 NIVOLUMAB (STUDY DRUG) CHEMO VIAL - (PRL: TAPUR) 99999002010 $75.00 $75.00 100 mg 1000577 PAMIPARIB BGB-290 (STUDY DRUG) 20 MG CAPSULE (PRL: BGB-A317/BGB-290) 99999900605 $30.00 $30.00 30 capsule 1000595 PT2977 (STUDY DRUG) 40 MG TABLET (IRB# 54237) 99999002033 $30.00 $30.00 90 tablet 1000597 RGX-104 (STUDY DRUG) 80 MG CAPSULE (PRL: RGX-104-001) 99999001792 $30.00 $30.00 30 capsule 1000611 SELICRELUMAB (RO7009789) SYRINGE #1 (STUDY DRUG) (PRL: BP29889) 99999002036 $150.00 $150.00 20 mg 1000615 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: BP29889) 99999002040 $150.00 $150.00 400 mg 1000615 BEVACIZUMAB (STUDY DRUG) VIAL (PRL: BP29889) 99999002041 $150.00 $150.00 100 mg 1000669 TEMSIROLIMUS (STUDY DRUG) VIAL - (PRL:TAPUR) 99999002072 $75.00 $75.00 25 mg 1000670 PEMBROLIZUMAB OR PLACEBO (STUDY DRUG) CHEMO VIAL (PRL: MK3475-789) 99999002067 $150.00 $150.00 100 mg 1000672 PEMBROLIZUMAB (OPEN-LABEL) (STUDY DRUG) CHEMO VIAL (PRL: MK3475-789) 99999002071 $150.00 $150.00 100 mg 1000674 JNJ-61186372 (STUDY DRUG) CHEMO VIAL (PRL: 61186372EDI1001) 99999002074 $150.00 $150.00 150 mg 1000676 NIVOLUMAB (STUDY DRUG) VIAL (PRL: IIT2018-01-MCARTHUR-IPI) 99999002077 $150.00 $150.00 100 mg 1000678 IPILIMUMAB (STUDY DRUG) VIAL (PRL: IIT2018-01-MCARTHUR-IPI) 99999002078 $150.00 $150.00 200 mg 1000680 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: ACT15377) 99999002075 $150.00 $150.00 20 mL 1000685 RGX-202-01 (STUDY DRUG) 200 MG CAPSULE (IRB# 55176) 99999002080 $75.00 $75.00 60 capsule 1000686 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2018-04-MCARTHUR-NEOHP) 99999002079 $150.00 $150.00 100 mg 1000698 SULOPENEM/PLACEBO (IT001-303 STUDY DRUG) VIAL (IRB# 55070) 99999002092 $150.00 $150.00 1 Each 1000700 ERTAPENEM/PLACEBO (IT001-303 STUDY DRUG) VIAL (IRB# 55070) 99999002093 $150.00 $150.00 1 Each 1000706 TSR-042 OR PLACEBO (STUDY DRUG) VIAL (PRL: 3000-03-005) 99999002098 $150.00 $150.00 500 mg 1000708 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE (PRL: 3000-03-005) 99999002099 $30.00 $30.00 72 capsule 1000730 IPILIMUMAB (STUDY DRUG) 200 MG VIAL (PRL: RGX-104-001) 99999002117 $150.00 $150.00 200 mg 1000733 GZ17-6.02 (STUDY DRUG) 300 MG CAPSULE (PRL: GZ17-6.02-CT-101) 99999002119 $75.00 $75.00 100 capsule 1000736 BI 754091 (STUDY DRUG) VIAL (PRL: 1381-1) 99999002122 $150.00 $150.00 300 mg 1000761 RGX-202-01 (STUDY DRUG) 400 MG TABLET (PRL: RGX-202-001) 99999002138 $75.00 $75.00 60 tablet 1000768 ASTX029 (STUDY DRUG) 40 MG TABLET (PRL: ASTX029-01) 99999002143 $50.00 $50.00 21 tablet 1000769 ASTX029 (STUDY DRUG) 120 MG TABLET (PRL: ASTX029-01) 99999002144 $50.00 $50.00 21 tablet 1000782 PALONOSETRON (STUDY DRUG) INJECTION (PRL: EDO-S101-1002) 99999002150 $30.00 $30.00 .25 mg 1000785 BB2121 (STUDY DRUG) IV IN CRYOBAG (PRL: BB2121-MM-003) 99999002151 $200.00 $200.00 1 Each 1000787 FLUDARABINE (STUDY DRUG) CHEMO VIAL (PRL: BB2121-MM-003) 99999002153 $150.00 $150.00 2 mL 1000789 CYCLOPHOSPHAMIDE (STUDY DRUG) CHEMO VIAL (PRL: BB2121-MM-003) 99999002154 $150.00 $150.00 1000 mg 1000806 IN-111 LABELED AUTOLOGOUS WHITE BLOOD CELLS, DIAGNOSTIC, PER STUDY DOSE A9570 99999002164 $19,728.57 $19,728.57 1 kit 1000808 CYCLOPHOSPHAMIDE (STUDY DRUG) 50 MG CAPSULE (PRL: P1719-SUR-Z11) 99999002166 $75.00 $75.00 14 capsule 1000820 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: P1719-SUR-Z11) 99999002181 $150.00 $150.00 4 mL 1000822 DPX-SURVIVAC (STUDY DRUG) SYRINGE (PRL: P1719-SUR-Z11) 99999002182 $150.00 $150.00 1 Each 1000826 (AB154) DOMVANALIMAB (STUDY DRUG) IN 0.9% NACL VIAL (PRL: AB154CSP0001) 99999002187 $150.00 $150.00 80 mg

Pharmacy FY22 MED IDs 227 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 1000828 (AB122) ZIMBERELIMAB (STUDY DRUG) IN 0.9% NACL VIAL (PRL: AB154CSP0001) 99999002188 $150.00 $150.00 120 mg 1000830 RO6958688 (CIBISATAMAB) (STUDY DRUG) VIAL (PRL: CO40939) 99999002189 $150.00 $150.00 2 mL 1000832 TOCILIZUMAB (STUDY DRUG) 200 MG/10 ML VIAL (PRL: CO40939) 99999002190 $75.00 $75.00 10 mL 1000834 ATEZOLIZUMAB (STUDY DRUG) 1,200 MG/20 ML VIAL (PRL: CO40939) 99999002191 $150.00 $150.00 20 mL 1000836 OBINUTUZUMAB (STUDY DRUG) 1000 MG/40 ML VIAL (PRL: CO40939) 99999002192 $150.00 $150.00 40 mL 1000838 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: FPA150-001) 99999002196 $150.00 $150.00 100 mg 1000846 OLAPARIB (STUDY DRUG) 150 MG TABLET (PRL: MK-7339-002) 99999002200 $30.00 $30.00 32 tablet 1000847 OLAPARIB (STUDY DRUG) 100 MG TABLET (PRL: MK-7339-002) 99999002201 $30.00 $30.00 32 tablet 1000861 ATEZOLIZUMAB (STUDY DRUG) 60 MG/ML VIAL (PRL: XL184-021) 999990021111 $150.00 $150.00 14 mL 1000861 ATEZOLIZUMAB (STUDY DRUG) 60 MG/ML VIAL (PRL: XL184-021) 999990021110 $150.00 $150.00 20 mL 1000863 CABOZANTINIB (STUDY DRUG) 20 MG TABLET (PRL: XL 184-021) 999990021112 $30.00 $30.00 30 tablet 1000864 CABOZANTINIB (STUDY DRUG) 60 MG TABLET (PRL: XL 184-021) 999990021113 $30.00 $30.00 30 tablet 1000879 RX108 (STUDY DRUG) 0.5 MG/ML VIAL (PRL: NP-102) 99999002230 $150.00 $150.00 4 mL 1000882 PEMBROLIZUMAB OR PLACEBO (STUDY DRUG) VIAL (PRL: MK3475-756) 99999002232 $150.00 $150.00 100 mg 1000884 NKTR-214 (STUDY DRUG) VIAL (PRL: 17-214-09) 99999002233 $150.00 $150.00 1 mg 1000886 NIVOLUMAB (STUDY DRUG) VIAL (PRL: 17-214-09) 99999002234 $150.00 $150.00 100 mg 1000905 COPANLISIB (STUDY DRUG) 60 MG/4 ML VIAL (PRL: 19769) 99999002252 $150.00 $150.00 4 mL 1000916 LENVATINIB (STUDY DRUG) 4 MG CAPSULE (PRL: MK-7902-005) 99999002259 $50.00 $50.00 25 capsule 1000917 LENVATINIB (STUDY DRUG) 10 MG CAPSULE (PRL: MK-7902-005) 99999002260 $50.00 $50.00 25 capsule 1000918 PEMBROLIZUMAB (STUDY DRUG) VIAL (IRB# 55738) 99999002261 $150.00 $150.00 4 mL 1000923 CART-TNMUC1 (STUDY DRUG) IV IN CRYOBAG (PRL: CART-TNMUC1-01) 99999002270 $150.00 $150.00 10 mL 1000924 ASTX295 (STUDY DRUG) 15 MG TABLET (PRL: ASTX295-01) 99999002272 $50.00 $50.00 28 tablet 1000925 ASTX295 (STUDY DRUG) 60 MG TABLET (PRL: ASTX295-01) 99999002273 $50.00 $50.00 28 tablet 1000926 GRN-1201 + GM-CSF (STUDY DRUG) INTRADERMAL INJECTION (PRL: GRN-1201-002) - SYRINGE #1 99999002274 $150.00 $150.00 10 mg 1000931 OBT076 (STUDY DRUG) 50 MG/10 ML VIAL (PRL: OBT076-001) 99999002279 $150.00 $150.00 10 mL 1000934 HSPPC-96 OR PLACEBO (STUDY DRUG) INTRADERMAL INJECTION (PRL - 17C0034-BTTC) 99999002282 $200.00 $200.00 .4 mL 1000935 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL - 17C0034-BTTC) 99999002283 $150.00 $150.00 100 mg 1000937 MT-5111 (STUDY DRUG) 5 MCG/ML SYRINGE (PRL: MT-5111-001) 99999002284 $200.00 $200.00 1 Each 1000938 MT-5111 (STUDY DRUG) 10 MCG/ML SYRINGE (PRL: MT-5111-001) 99999002285 $200.00 $200.00 1 Each 1000939 MT-5111 (STUDY DRUG) 1 MG/ML VIAL (PRL: MT-5111-001) 99999002286 $150.00 $150.00 1 mL 1000942 CDX-301 (STUDY DRUG) 2,500 MCG/ML SC SOLN (PRL: PICI0033) 99999002288 $75.00 $75.00 1 mL 1000945 ABBV-155 (STUDY DRUG) VIAL (PRL: M16-573) 99999002400 $150.00 $150.00 100 mg 1000947 INO-5151 (STUDY DRUG) 3 MG/ML IM SOLN (PRL: PICI0033 COHORT C) 99999002290 $75.00 $75.00 3.3 mg 1000948 NIVOLUMAB (STUDY DRUG) 100 MG/10 ML IV SOLN (PRL: PICI0033) 99999002291 $150.00 $150.00 10 mL 1000950 PACLITAXEL (STUDY DRUG) VIAL (PRL: M16-573) 99999002401 $150.00 $150.00 100 mg 1000952 DOCETAXEL (STUDY DRUG) VIAL (PRL: M16-573) 999999002402 $150.00 $150.00 80 mg 1000988 ASTX660 (STUDY DRUG) 90 MG CAPSULE - (PRL: ASTX660-01) 99999002324 $50.00 $50.00 14 capsule 1001001 CEMIPLIMAB-RWLC (STUDY DRUG) 50 MG/ML VIAL (PRL: ATI001-204) 99999002335 $150.00 $150.00 7 mL 1001010 BALIXAFORTIDE (STUDY DRUG) VIAL (PRL: POL6326-009) 99999002344 $150.00 $150.00 385 mg 1001012 ERIBULIN (STUDY DRUG) IVP (PRL: POL6326-009) 99999002345 $150.00 $150.00 1 mg 1001014 ENZASTAURIN OR PLACEBO (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002349 $50.00 $50.00 9 tablet 1001014 ENZASTAURIN OR PLACEBO (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002348 $50.00 $50.00 96 tablet 1001015 ENZASTAURIN (OPEN-LABEL) (STUDY DRUG) 125 MG TABLET (PRL: DB102-02) 99999002350 $50.00 $50.00 96 tablet 1001034 RGX-202-01 (STUDY DRUG) 600 MG TABLET (PRL: RGX-202-001) 99999002367 $75.00 $75.00 60 tablet 1001037 VE800 (STUDY DRUG) 400 MG CAPSULE (PRL: VE800-001) 99999002368 $75.00 $75.00 5 capsule 1001038 NIVOLUMAB (STUDY DRUG) VIAL (PRL: VE800-001) 99999002369 $150.00 $150.00 240 mg 1001040 GEFITINIB (STUDY DRUG) 250 MG TABLET (PRL: D6186C00001) 99999002372 $50.00 $50.00 30 tablet 1001041 SAVOLITINIB (STUDY DRUG) 100 MG TABLET (PRL: D6186C00001) 99999002373 $50.00 $50.00 24 tablet 1001042 SAVOLITINIB (STUDY DRUG) 200 MG TABLET (PRL: D6186C00001) 99999002374 $50.00 $50.00 24 tablet 1001043 OSIMERTINIB (STUDY DRUG) 40 MG TABLET (PRL: D6186C00001) 99999002375 $50.00 $50.00 35 tablet 1001044 OSIMERTINIB (STUDY DRUG) 80 MG TABLET (PRL: D6186C00001) 99999002376 $50.00 $50.00 35 tablet 1001047 DURVALUMAB (STUDY DRUG) 500 MG/10 ML VIAL (PRL - D6186C00001) 99999002377 $150.00 $150.00 10 mL 1001049 NECITUMUMAB (STUDY DRUG) 800 MG/50 ML VIAL (PRL - D6186C00001) 99999002378 $150.00 $150.00 50 mL 1001051 CARBOPLATIN (STUDY DRUG) 10 MG/ML IV SOLN (PRL - D6186C00001) J9045 99999002379 $150.00 $150.00 60 mL 1001053 PEMETREXED (STUDY DRUG) 500 MG IV SOLR (PRL - D6186C00001) J9305 99999002380 $150.00 $150.00 20 mL 1001055 NIVOLUMAB OR PLACEBO (STUDY DRUG) 10 MG/ML IV SOLN (PRL: CA209-914) 99999002381 $150.00 $150.00 24 mL 1001057 IPILIMUMAB OR PLACEBO (STUDY DRUG) 5 MG/ML IV SOLN (PRL: CA209-914) 99999002382 $150.00 $150.00 40 mL 1001059 NGM120 (OPEN-LABEL) (STUDY DRUG) SYRINGE (PRL: 18-0402) 99999002383 $75.00 $75.00 100 mg 1001060 NGM120 OR PLACEBO (STUDY DRUG) SYRINGE (PRL: 18-0402) 99999002384 $75.00 $75.00 100 mg 1001062 JNJ-73841937 (LAZERTINIB) (STUDY DRUG) 80 MG TABLET (PRL: 61186372EDI1001) 99999002385 $50.00 $50.00 98 tablet 1001067 SB 11285 (STUDY DRUG) 2 MG VIAL (PRL: SPB-11285-ONC-101) 99999002390 $200.00 $200.00 2 mg 1001079 AVASOPASEM MANGANESE (GC4419) OR PLACEBO (STUDY DRUG) 9 MG/ML IV SOLN (PRL: GTI-4419-301) 99999002395 $75.00 $75.00 90 mL 1001100 LNS8801 (STUDY DRUG) 125 MG TABLET (PRL: LNS-101) 99999002419 $50.00 $50.00 30 tablet 1001117 BA3021 (STUDY DRUG) VIAL (PRL: BA3021-001) 99999002430 $150.00 $150.00 5 mL 1001119 PEGFILGRASTIM (STUDY DRUG) INJECTION (PRL: BA3021-001) 99999002431 $50.00 $50.00 .6 mL 1001120 BA3011 (STUDY DRUG) VIAL (PRL: BA3011-001) 99999002432 $150.00 $150.00 5 mL 1001123 MELPHALAN (STUDY DRUG) 5 MG/ML IV SOLN (PRL: PHP-OCM-301A) 99999002436 $150.00 $150.00 10 mL 1001126 PEGFILGRASTIM (STUDY DRUG) INJECTION SYRINGE (PRL: PHP-OCM-301A) 99999002437 $50.00 $50.00 .6 mL 1001127 ENZALUTAMIDE (STUDY DRUG) 40 MG CAPSULE (PRL: RTOG 3506) 99999002435 $50.00 $50.00 124 capsule 1001146 ALKS4230 (STUDY DRUG) 5 MG/ML SUBQ SOLN (PRL: ALKS4230-001) 99999002450 $75.00 $75.00 10 mg 1001147 ALKS4230 (STUDY DRUG) 15 MG/ML SUBQ SOLN (PRL: ALKS4230-001) 99999002451 $75.00 $75.00 30 mg 1001148 PEMBROLIZUMAB (STUDY DRUG) 25 MG/ML IV SOLN (PRL: ALKS4230-001) 99999002452 $150.00 $150.00 4 mL 1001160 PALBOCICLIB (STUDY DRUG) 125 MG CAPSULE (PRL: C0541001) 99999002458 $50.00 $50.00 23 capsule 1001161 PALBOCICLIB (STUDY DRUG) 100 MG CAPSULE (PRL: C0541001) 99999002459 $50.00 $50.00 23 capsule 1001162 PALBOCICLIB (STUDY DRUG) 75 MG CAPSULE (PRL: C0541001) 99999002460 $50.00 $50.00 23 capsule

Pharmacy FY22 MED IDs 228 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 1001164 TUCATINIB (STUDY DRUG) 50 MG TABLET (PRL: ACCRU-GI-1617-SGNTUC017) 99999002462 $50.00 $50.00 50 tablet 1001165 TRASTUZUMAB (STUDY DRUG) 150 MG IV SOLN (PRL: ACCRU-GI-1617-SGNTUC017) 99999002463 $150.00 $150.00 150 mg 1001167 PANCRELIPASE (STUDY DRUG) 21,000 UNIT CAPSULE (PRL: IIT2018-29-HENDIFAR-PNCX3) 99999002464 $50.00 $50.00 100 capsule 1001178 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: J2I-MC-JZMA) 99999002473 $150.00 $150.00 4 mL 1001181 LY3475070 (STUDY DRUG) 100 MG CAPSULE (PRL: J2I-MC-JZMA) 99999002475 $50.00 $50.00 24 capsule 1001184 APALUTAMIDE OR PLACEBO (STUDY DRUG) 60 MG TABLET (PRL:56021927PCR3011) 99999002478 $50.00 $50.00 120 tablet 1001185 ISB 1302 (STUDY DRUG) (DOSE 100,000 NG) (PRL: ISB 1302-103) VIAL 99999002480 $150.00 $150.00 110000 ng 1001195 AB122 (STUDY DRUG) VIAL (PRL: AB154CSP0002) 99999002485 $150.00 $150.00 4 mL 1001197 AB154 (STUDY DRUG) VIAL (PRL: AB154CSP0002) 99999002486 $150.00 $150.00 4 mL 1001199 AB928 (STUDY DRUG) 25 MG CAPSULE (PRL: AB154CSP0002) 99999002487 $50.00 $50.00 30 capsule 1001201 DSP-7888 (STUDY DRUG) INTRADERMAL INJECTION #1 (PRL: BBI-DSP-7888-102CI) 99999002488 $200.00 $200.00 .1 mL 1001203 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: BBI-DSP-7888-102CI) 99999002490 $150.00 $150.00 4 mL 1001214 AVID200 (STUDY DRUG) (PRL: MPN-RC118) VIAL 99999002500 $75.00 $75.00 50 mL 1001214 AVID200 (STUDY DRUG) (PRL: MPN-RC118) VIAL 99999002499 $75.00 $75.00 10 mL 1001223 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: SBP-11285-ONC-101) 99999002511 $150.00 $150.00 20 mL 1001248 PALBOCICILB (STUDY DRUG) 125 MG CAPSULE (PRL: EIIT2020-MCARTHUR-TDM1) 99999002528 $50.00 $50.00 14 capsule 1001249 PALBOCICILB (STUDY DRUG) 100 MG CAPSULE (PRL: EIIT2020-MCARTHUR-TDM1) 99999002529 $50.00 $50.00 14 capsule 1001250 PALBOCICILB (STUDY DRUG) 75 MG CAPSULE (PRL: EIIT2020-MCARTHUR-TDM1) 99999002530 $50.00 $50.00 14 capsule 1001256 ASTX295 (STUDY DRUG) 200 MG TABLET (PRL: ASTX295-01) 99999002536 $50.00 $50.00 28 tablet 1001257 OLAPARIB (STUDY DRUG) 150 MG TABLET (PRL: D6018C00004) 99999002537 $50.00 $50.00 32 tablet 1001258 OLAPARIB (STUDY DRUG) 100 MG TABLET (PRL: D6018C00004) 99999002538 $50.00 $50.00 32 tablet 1001259 OLAPARIB OR PLACEBO (STUDY DRUG) 150 MG TABLET (PRL: D6018C00004) 99999002539 $50.00 $50.00 32 tablet 1001260 CERALASERTIB (STUDY DRUG) 80 MG TABLET (PRL: D6018C00004) 99999002540 $50.00 $50.00 18 tablet 1001262 OLAPARIB OR PLACEBO (STUDY DRUG) 100 MG TABLET (PRL: D6018C00004) 99999002542 $50.00 $50.00 32 tablet 1001267 POLY-ICLC (STUDY DRUG) (HILTONOL) INTRAMUSCULAR SYRINGE (PRL: PICI0033) 99999002547 $75.00 $75.00 1 mL 1001268 SM-88 (STUDY DRUG) 230 MG CAPSULE (PRL: PRECISIONPROMISE) 99999002548 $50.00 $50.00 30 capsule 1001269 METHOXSALEN (STUDY DRUG) 10 MG CAPSULE (PRL: PRECISIONPROMISE) 99999002549 $50.00 $50.00 50 capsule 1001270 PHENYTOIN (STUDY DRUG) 50 MG TABLET (PRL: PRECISIONPROMISE) 99999002550 $50.00 $50.00 100 tablet 1001271 SIROLIMUS (STUDY DRUG) 0.5 MG TABLET (PRL: PRECISIONPROMISE) 99999002551 $50.00 $50.00 100 tablet 1001273 SQZ-PBMC-HPV (STUDY DRUG) IV SYRINGE (PRL: SQZ-PBMC-HPV-101) 99999002552 $200.00 $200.00 5 mL 1001275 ATEZOLIZUMAB (STUDY DRUG) VIAL (PRL: SQZ-PBMZ-HPV-101) 99999002554 $150.00 $150.00 20 mL 1001279 ME-401 (STUDY DRUG) 60 MG CAPSULE (PRL: ME-401-003) 99999002557 $50.00 $50.00 7 capsule 1001279 ME-401 (STUDY DRUG) 60 MG CAPSULE (PRL: ME-401-003) 99999002558 $50.00 $50.00 28 capsule 1001290 BNT411 (STUDY DRUG) (FOR DOSE GREATER THAN 63 MCG) VIAL (PRL: BNT411-01) 99999002564 $200.00 $200.00 14 mL 1001292 BNT411 (STUDY DRUG) (FOR DOSE LESS THAN OR EQUAL TO 63 MCG) VIAL (PRL: BNT411-01) 99999002565 $200.00 $200.00 14 mL 1001304 ZZ06 (STUDY DRUG) VIAL (PRL: 8379643) 99999002570 $150.00 $150.00 10 mg 1001306 LAZERTINIB (STUDY DRUG) 80 MG TABLET (PRL: 73841937NSC1001) 99999002571 $50.00 $50.00 93 tablet 1001308 JNJ-61186372 (STUDY DRUG) VIAL (PRL: 73841937NSC1001) 99999002572 $150.00 $150.00 7 mL 1001310 CAPIVASERTIB OR PLACEBO (STUDY DRUG) 200 MG TABLET (PRL: D3614C00001) 99999002576 $50.00 $50.00 60 tablet 1001311 CAPIVASERTIB OR PLACEBO (STUDY DRUG) 160 MG TABLET (PRL: D3614C00001) 99999002577 $50.00 $50.00 60 tablet 1001318 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: LNS-101) 99999002585 $150.00 $150.00 4 mL 1001321 SIMVASTATIN (STUDY DRUG) 40 MG TABLET (PRL: IIT2020-03-RIMEL-STOV) 99999002586 $50.00 $50.00 90 tablet 1001332 ALECTINIB (STUDY DRUG) 150 MG CAPSULE (PRL: ML41591) 99999002597 $50.00 $50.00 260 capsule 1001333 VEMURAFENIB (STUDY DRUG) 240 MG TABLETS (PRL: ML41591) 99999002598 $50.00 $50.00 120 tablet 1001334 ENTRECTINIB (STUDY DRUG) 200 MG CAPSULE (PRL: ML41591) 99999002599 $50.00 $50.00 30 capsule 1001335 COBIMETINIB (STUDY DRUG) 20 MG TABLET (PRL: ML41591) 99999002600 $50.00 $50.00 63 tablet 1001348 TTX-030 (STUDY DRUG) VIAL (PRL: TTX-030-002) 99999002614 $150.00 $150.00 6.7 mL 1001353 BUDIGALIMAB (STUDY DRUG) VIAL (PRL: TTX-030-002) 99999002615 $150.00 $150.00 100 mg 1001362 TELAGLENASTAT OR PLACEBO (STUDY DRUG) 200 MG TABLET (PRL: CX-839-014) 99999002619 $50.00 $50.00 4 bottle 1001363 SERIBANTUMAB (STUDY DRUG) VIAL (PRL: ELV-CAP001-01) 99999002621 $150.00 $150.00 10 mL 1001363 SERIBANTUMAB (STUDY DRUG) VIAL (PRL: ELV-CAP001-01) 99999002620 $150.00 $150.00 40 mL 1001366 PATRITUMAB DERUXTECAN (STUDY DRUG) VIAL (PRL: U31402-A-U201) 99999002624 $150.00 $150.00 100 mg 1001379 NIVOLUMAB (STUDY DRUG) VIAL (PRL: BA3011-001) 99999002629 $150.00 $150.00 24 mL 1001381 ION251 (STUDY DRUG) VIAL (PRL: ION251-CS1) 99999002642 $150.00 $150.00 2 mL 1001384 DURVALUMAB OR PLACEBO (STUDY DRUG) VIAL (PRL: D910LC00001) 99999002632 $150.00 $150.00 10 mL 1001386 PF-07248144 (STUDY DRUG) 0.5 MG TABLET (PRL: C4551001) 99999002633 $50.00 $50.00 30 tablet 1001387 PF-07248144 (STUDY DRUG) 5 MG TABLET (PRL: C4551001) 99999002634 $50.00 $50.00 30 tablet 1001388 PF-07248144 (STUDY DRUG) 25 MG TABLET (PRL: C4551001) 99999002635 $50.00 $50.00 30 tablet 1001389 PF-07248144 (STUDY DRUG) 100 MG TABLET (PRL: C4551001) 99999002636 $50.00 $50.00 30 tablet 1001390 PALBOCICLIB (STUDY DRUG) 125 MG TABLET (PRL: C4551001) 99999002637 $50.00 $50.00 21 tablet 1001391 PALBOCICLIB (STUDY DRUG) 100 MG TABLET (PRL: C4551001) 99999002638 $50.00 $50.00 21 tablet 1001392 PALBOCICLIB (STUDY DRUG) 75 MG TABLET (PRL: C4551001) 99999002639 $50.00 $50.00 21 tablet 1001393 LETROZOLE (STUDY DRUG) 2.5 MG TABLET (PRL: C4551001) 99999002640 $50.00 $50.00 30 tablet 1001394 FULVESTRANT (STUDY DRUG) INTRAMUSCULAR INJECTION (PRL: C4551001) 99999002641 $50.00 $50.00 250 mg 1001397 ROZANOLIXIZUMAB OR PLACEBO (STUDY DRUG) SUBCUTANEOUS SYRINGE (PRL: TP0006) 99999002645 $150.00 $150.00 6 mL 1001403 MENINGOCOCCAL GROUP B VACCINE (TRUMENBA, MENB-4C) (STUDY DRUG) SYRINGE (PRL: TP0006) 90621 00005010001 $2,346.66 $2,346.66 .5 mL 1001411 OSIMERTINIB (STUDY DRUG) 80 MG TABLET (PRL: D5169C00001) 99999003005 $50.00 $50.00 25 tablet 1001412 OSIMERTINIB (STUDY DRUG) 40 MG TABLET (PRL: D5169C00001) 99999003006 $50.00 $50.00 25 Each 1001413 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL:SGN22E-002) 99999003007 $150.00 $150.00 4 mL 1001415 ENFORTUMAB VEDOTIN (STUDY DRUG) VIAL (PRL:SGN22E-002) 99999003008 $150.00 $150.00 3 mL 1001421 PACLITAXEL (STUDY DRUG) VIAL (PRL: D3614C00001) 99999003010 $150.00 $150.00 100 mg 1001436 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: SGN35-033) 99999002662 $150.00 $150.00 4 mL 1001438 BRENTUXIMAB VEDOTIN (STUDY DRUG) VIAL (PRL: SGN35-033) 99999002663 $150.00 $150.00 50 mg 1001440 PANITUMUMAB (STUDY DRUG) VIAL (PRL: ACCRU-GI-1623) 99999002664 $150.00 $150.00 20 mL

Pharmacy FY22 MED IDs 229 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 1001440 PANITUMUMAB (STUDY DRUG) VIAL (PRL: ACCRU-GI-1623) 99999002665 $150.00 $150.00 5 mL 1001450 DS-7300A (STUDY DRUG) VIAL (PRL: DS7300-A-J101) 99999002669 $150.00 $150.00 100 mg 1001455 LENVATINIB (STUDY DRUG) 10 MG CAPSULE (PRL: MK-6482-011) 99999003016 $50.00 $50.00 25 capsule 1001457 MK-6482 (STUDY DRUG) 40 MG TABLET (PRL: MK-6482-011) 99999003018 $50.00 $50.00 90 tablet 1001458 GEMCITABINE (STUDY DRUG) VIAL (PRL: GCT3013-02) 99999003019 $150.00 $150.00 10 mL 1001459 BINIMETINIB (STUDY DRUG) 15 MG TABLET (PRL: ACCRU-GI-1907) 99999002671 $50.00 $50.00 180 tablet 1001461 OXALIPLATIN (STUDY DRUG) VIAL (PRL: GCT3013-02) 99999003020 $150.00 $150.00 20 mL 1001463 EPCORITAMAB (STUDY DRUG) SUBCUTANEOUS SYRINGE 0.16 MG DOSE (PRL: GCT3013-0) 99999003021 $150.00 $150.00 1 mL 1001464 EPCORITAMAB (STUDY DRUG) SUBCUTANEOUS SYRINGE 0.8 MG DOSE (PRL: GCT3013-0) 99999003022 $150.00 $150.00 1 mL 1001465 EPCORITAMAB (STUDY DRUG) SUBCUTANEOUS SYRINGE 24 MG DOSE (PRL: GCT3013-0) 99999003023 $150.00 $150.00 1 mL 1001466 EPCORITAMAB (STUDY DRUG) SUBCUTANEOUS SYRINGE 48 MG DOSE (PRL: GCT3013-02) 99999003024 $150.00 $150.00 1 mL 1001468 ENCORAFENIB (STUDY DRUG) 75 MG CAPSULE (PRL: ACCRU-GI-1907) 99999002672 $50.00 $50.00 90 capsule 1001469 APL-101 (STUDY DRUG) 100 MG CAPSULE (PRL: APL-101-01) 99999002673 $50.00 $50.00 60 capsule 1001482 L-GLUTAMINE (STUDY DRUG) 5 GRAMS ORAL POWDER (PRL: IIT2020-02-GONG-GLUTAPANC) 99999002684 $50.00 $50.00 5 gram 1001483 TELATINIB (STUDY DRUG) 300 MG TABLET (PRL: IIT2020-11-HENDIFAR-TELAT) 99999002685 $50.00 $50.00 48 tablet 1001495 ADAVOSERTIB (STUDY DRUG) 100 MG CAPSULE (PRL: D601HC00002) 99999002694 $50.00 $50.00 10 capsule 1001499 AZD9291 (OPEN-LABEL) (STUDY DRUG) 80 MG TABLET (PRL: D5164C00001) 99999002696 $50.00 $50.00 35 tablet 1001506 TALAZOPARIB (TEST)(STUDY DRUG) 1 MG CAPSULE (PRL: C3441037) 99999002727 $50.00 $50.00 30 capsule 1001507 TALAZOPARIB (REFERENCE)(STUDY DRUG) 1 MG CAPSULE (PRL: C3441037) 99999002726 $50.00 $50.00 30 capsule 1001508 TALAZOPARIB (REFERENCE)(STUDY DRUG) 0.25 MG CAPSULE (PRL: C3441037) 99999002728 $50.00 $50.00 30 capsule 1001510 KB-0742 (STUDY DRUG) 20 MG CAPSULE (PRL: KB-0742-1001) 99999002703 $50.00 $50.00 15 capsule 1001511 KB-0742 (STUDY DRUG) 50 MG CAPSULE (PRL: KB-0742-1001) 99999002704 $50.00 $50.00 15 capsule 1001512 PALBOCICLIB (STUDY DRUG) 125 MG TABLET (PRL: EIIT2020-BASHO-DARE) 99999002705 $50.00 $50.00 21 tablet 1001513 PALBOCICLIB (STUDY DRUG) 100 MG TABLET (PRL: EIIT2020-BASHO-DARE) 99999002706 $50.00 $50.00 21 tablet 1001514 PALBOCICLIB (STUDY DRUG) 75 MG TABLET (PRL: EIIT2020-BASHO-DARE) 99999002707 $50.00 $50.00 21 tablet 1001515 FULVESTRANT (STUDY DRUG) INTRAMUSCULAR INJECTION (PRL: EIIT2020-BASHO-DARE) 99999002708 $50.00 $50.00 250 mg 1001516 INCB106385 (STUDY DRUG) 10 MG TABLET (PRL: INCB106385-102) 99999002709 $50.00 $50.00 35 tablet 1001517 INCMGA00012 (STUDY DRUG) VIAL (PRL: INCB106385-102) 99999002710 $150.00 $150.00 20 mL 1001522 NIVOLUMAB (STUDY DRUG) VIAL (PRL: SQZ-PBMC-HPV-101) 99999002712 $150.00 $150.00 24 mL 1001523 IPILIMUMAB (STUDY DRUG) VIAL (PRL: SQZ-PBMC-HPV-101) 99999002713 $150.00 $150.00 40 mL 1001529 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: EIIT2020-MCARTHUR-CBCV) 99999002719 $150.00 $150.00 4 mL 1001540 NIRAPARIB (STUDY DRUG) 100 MG CAPSULE (PRL: 213409) 99999002729 $50.00 $50.00 93 capsule 1001541 FLUDARABINE (STUDY DRUG) CHEMO VIAL (PRL: CRSP-ONC-001) 99999002730 $150.00 $150.00 2 mL 1001545 CYCLOPHOSPHAMIDE (STUDY DRUG) CHEMO VIAL (PRL: CRSP-ONC-001) 99999002734 $150.00 $150.00 50 mL 1001548 TUCATINIB (STUDY DRUG) 50 MG TABLET (PRL: IIT2019-21-BASHO-TOPAZ) 99999002721 $50.00 $50.00 50 tablet 1001559 NIVOLUMAB (STUDY DRUG) VIAL (PRL: BA3021-001) 99999002739 $150.00 $150.00 24 mL 1001562 DEFACTINIB (STUDY DRUG) 200 MG TABLET (PRL: EIIT2020-OSIPOV-PEMDEF) 99999002742 $50.00 $50.00 64 tablet 1001563 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: EIIT2020-OSIPOV-PEMDEF) 99999002743 $150.00 $150.00 4 mL 1001565 PEMBROLIZUMAB (STUDY DRUG) VIAL (PRL: IIT2019-21-BASHO-TOPAZ) 99999002744 $150.00 $150.00 4 mL 1001606 CDX-301 (STUDY DRUG) SUBCUTANEOUS VIAL (PRL: EIIT2020-MCARTHUR-CBCV) 99999002718 $75.00 $75.00 1 mL 1001607 GC4711 OR PLACEBO (STUDY DRUG) VIAL (PRL: GTI-4711-201) 99999002771 $75.00 $75.00 120 mg 1001609 REGORAFENIB (STUDY DRUG) 40 MG TABLET (PRL: GCAR-7213) 99999002772 $50.00 $50.00 30 tablet 1001612 AMV564 (STUDY DRUG) SUBCUTANEOUS SYRINGE (PRL: AMV564-301) 99999002777 $75.00 $75.00 .4 mL 1001613 AMV564 (STUDY DRUG) 50 MCG PREFILLED SYRINGE (PRL: AMV564-301) 99999002778 $50.00 $50.00 .2 mL 1001614 AMV564 (STUDY DRUG) 15 MCG PREFILLED SYRINGE (PRL: AMV564-301) 99999002779 $50.00 $50.00 .2 mL 1001628 ENZASTAURIN OR PLACEBO (STUDY DRUG) 125 MG TABLET (PRL: DB102-01) 99999002785 $50.00 $50.00 128 tablet 4088577 SODIUM BICARBONATE 4.2% NEBULIZER SOLUTION J3490 00409555502 $167.00 $167.00 5 mL 4089713 PHENTOLAMINE SUBCUT INJ PEDIATRIC (RN TO PREP) J2760 00143956410 $6,316.42 $6,316.42 1 Each 40838681 HEPATITIS B VIRUS VACC.REC(PF) 20 MCG/ML IM SUSP (RESTRICTED) 90740 58160082101 $642.53 $642.53 1 mL 40895160 CALCIUM GLUCONATE 1G VIAL-TO-BAG IVPB J0610 63323031110 $167.00 $167.00 1000 mg 408122998 SACUBITRIL-VALSARTAN 24-26 MG HALF-TAB = 12-13 MG 99999002786 $167.00 $167.00 1 Each 408200000 AMIODARONE 150MG-D5W 150ML CSHS J0282 99999900424 $167.00 $167.00 150 mL 408400007 MODIFIED HOPP'S STOMATITIS ORAL SUSPENSION 99999900425 $167.00 $167.00 100 mL 408400077 ALTEPLASE IV INFUSION J2997 50242004406 $36,912.69 $36,912.69 1 Each 408909015 IOHEXOL 350 MG IODINE/ML PO SOLN **FOR INPATIENT USE** Q9967 00407141489 $167.00 $167.00 50 mL 408909027 PENICILLIN G POTASSIUM INJ FOR DESENSITIZATION J2540 99999002296 $167.00 $167.00 1 Each 408909030 ROPIVACAINE 0.2% IN 0.9% NACL 500 ML FOR PERIPHERAL NERVE CATETHER J2795 69374098750 $800.00 $800.00 500 mL 408999001 LEUPROLIDE 1 MG/0.2ML FOR PEDS STIM TEST J9218 00781400332 $10,142.23 $10,142.23 2.8 mL 408999002 GALLIUM DOTATATE (GA-68)(NETSPOT) ISOTOPE (NUC MED) A9587 69488000140 $97,335.00 $97,335.00 5.4 millicurie 4080000012 VANCOMYCIN 750 MG/250 ML IVPB J3370 99999900366 $167.00 $167.00 1 Each 4080000110 MAGNESIUM SULFATE 50 % (4 MEQ/ML) IJ SOLN J3475 63323006402 $167.00 $167.00 2 mL 4080100012 VANCOMYCIN 1250 MG/250 ML PREMIX IVPB J3370 99999900367 $167.00 $167.00 250 mL 4080200012 VANCOMYCIN 1500 MG/300 ML IVPB J3370 99999900368 $167.00 $167.00 1 Each 4080210007 CEFTRIAXONE IVPB VIAL 250 MG/50 ML VIAL-TO-BAG IVPB J0696 00781320685 $167.00 $167.00 1 Each 4084040008 HEPARIN BOLUS FOR APHERESIS 10000 UNITS/10 ML 99999001144 $167.00 $167.00 10 mL 4084040010 CEFOXITIN 2 GRAM/50 ML VIAL-TO-BAG IVPB J0694 63323034225 $190.00 $190.00 1 Each 4084040023 HEPARIN (PORCINE) IN NACL 500 UNITS/500ML NS FOR CONGENITAL HEART ECMO FLUSH IV SOLP 99999001207 $167.00 $167.00 500 mL 4084040025 SILDENAFIL 2.5 MG/ML ORAL SUSPENSION (DOSE > 10 MG) (IP ORDERING ONLY) 99999900078 $167.00 $167.00 8 mL 4084040027 METHADONE 5 MG/5 ML PO SOLN (2.5MG

Pharmacy FY22 MED IDs 230 of 231 Cedars-Sinai Medical Center AB-1045 Chargemaster Submission Prices Effective July 1, 2021

CPT/ OP/Default ERx Charge Charge Code Description HCPCS NDC IP/ED Price Price Quantity Code 4087770030 HEPARIN (PORCINE) IN NACL 1000 UNITS/500ML NS FOR CONGENITAL HEART ECMO FLUSH FROM BAG 9999907700 $167.00 $167.00 500 mL 4087771292 TRASTUZUMAB 150 MG IV SOLR J9355 50242013201 $14,025.78 $14,025.78 1 Each

Pharmacy FY22 MED IDs 231 of 231