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Montana Healthcare Programs Fee Schedule APC Services July 1, 2018 APC Code APC Description APC Begin Dt APC Status Ind APC Relative Wt APC Payment 00701 SR89 STRONTIUM 7/1/2018 K 29.6046 $1,464.24 00726 DEXRAZOXANE HCL INJECTION 7/1/2018 K 4.6385 $229.42 00731 SARGRAMOSTIM INJECTION 7/1/2018 K 0.6986 $34.55 00736 AMPHOTERICIN B LIPOSOME INJ 4/1/2018 K 0.9428 $46.63 00738 RASBURICASE 7/1/2018 K 5.3280 $263.52 00747 CHLOROTHIAZIDE SODIUM INJ 1/1/2018 D 0.0000 $0.00 00751 MECHLORETHAMINE HCL INJ 7/1/2018 K 6.3286 $313.01 00752 DACTINOMYCIN INJECTION 7/1/2018 K 30.8734 $1,527.00 00759 NALTREXONE, DEPOT FORM 4/1/2018 K 0.0640 $3.17 00800 LEUPROLIDE ACETATE 7/1/2018 K 23.4760 $1,161.12 00802 ETOPOSIDE ORAL 7/1/2018 K 1.4865 $73.52 00807 ALDESLEUKIN INJECTION 4/1/2018 K 81.1649 $4,014.42 00809 BCG LIVE INTRAVESICAL VAC 7/1/2018 K 2.7089 $133.98 00810 GOSERELIN ACETATE IMPLANT 7/1/2018 K 9.1710 $453.60 00812 CARMUSTINE INJECTION 7/1/2018 K 76.9157 $3,804.25 00820 DAUNORUBICIN INJECTION 7/1/2018 K 0.8297 $41.04 00821 DAUNORUBICIN CITRATE INJ 1/1/2018 D 0.0000 $0.00 00823 DOCETAXEL INJECTION 7/1/2018 K 0.0356 $1.76 00825 NELARABINE INJECTION 7/1/2018 K 2.9835 $147.56 00827 FLOXURIDINE INJECTION 1/1/2018 D 0.0000 $0.00 00831 IFOSFAMIDE INJECTION 1/1/2018 D 0.0000 $0.00 00832 IDARUBICIN HCL INJECTION 7/1/2018 K 0.6952 $34.38 00836 ALFA-2B INJ 7/1/2018 K 0.6743 $33.35 00838 INTERFERON GAMMA 1-B INJ 4/1/2018 K 135.9756 $6,725.35 00840 INJ MELPHALAN HYDROCHL 7/1/2018 K 20.7106 $1,024.35 00843 PEGASPARGASE INJECTION 7/1/2018 K 294.7993 $14,580.77 00844 PENTOSTATIN INJECTION 7/1/2018 K 39.3298 $1,945.25 00849 INJECTION 7/1/2018 K 17.9525 $887.93 00850 STREPTOZOCIN INJECTION 7/1/2018 K 6.7469 $333.70 00851 THIOTEPA INJECTION 7/1/2018 K 15.4111 $762.23 00856 PORFIMER SODIUM INJECTION 4/1/2018 K 416.1970 $20,585.10 00858 INJ 7/1/2018 K 0.4369 $21.61 00864 MITOXANTRONE HYDROCHL 7/1/2018 K 0.5860 $28.98 00868 ORAL APREPITANT 7/1/2018 K 0.1469 $7.27 00873 HYALGAN SUPARTZ VISCO-3 DOSE 7/1/2018 K 1.6314 $80.69 00874 SYNVISC OR SYNVISC-ONE 7/1/2018 K 0.2295 $11.35 00875 EUFLEXXA INJ PER DOSE 7/1/2018 K 2.8192 $139.44 00877 ORTHOVISC INJ PER DOSE 7/1/2018 K 2.7526 $136.14 00887 PARENTERAL 7/1/2018 K 4.5167 $223.40 00890 LYMPHOCYTE IMMUNE GLOBULIN 7/1/2018 K 41.3167 $2,043.52 00901 ALPHA 1 PROTEINASE INHIBITOR 7/1/2018 K 0.0886 $4.38 00902 INJECTION,ONABOTULINUMTOXINA 7/1/2018 K 0.1208 $5.97 00903 CYTOMEGALOVIRUS IMM IV /VIAL 4/1/2018 K 22.1464 $1,095.36 00910 INTERFERON BETA-1B / .25 MG 7/1/2018 K 7.6338 $377.57 00913 GANCICLOVIR LONG ACT IMPLANT 1/1/2018 D 0.0000 $0.00

Please see cover page for a complete description of information contained in the fee schedules. Page 1 Montana Healthcare Programs Fee Schedule APC Services July 1, 2018

00925 FACTOR VIII 7/1/2018 K 0.0220 $1.09 00927 FACTOR VIII RECOMBINANT 7/1/2018 K 0.0269 $1.33 00928 FACTOR IX COMPLEX 7/1/2018 K 0.0280 $1.38 00929 ANTI-INHIBITOR 7/1/2018 K 0.0419 $2.07 00931 FACTOR IX NON-RECOMBINANT 7/1/2018 K 0.0223 $1.10 00932 FACTOR IX RECOMBINANT NOS 7/1/2018 K 0.0296 $1.46 00943 OCTAGAM INJECTION 7/1/2018 K 0.6504 $32.17 00944 GAMMAGARD LIQUID INJECTION 7/1/2018 K 0.9916 $49.04 00946 HEPAGAM B IM INJECTION 7/1/2018 K 1.3315 $65.86 00947 FLEBOGAMMA INJECTION 7/1/2018 K 0.7075 $34.99 00948 GAMUNEX-C/GAMMAKED 7/1/2018 K 0.8082 $39.97 00961 ALBUMIN (HUMAN),5%, 50ML 7/1/2018 K 0.2314 $11.45 00963 ALBUMIN (HUMAN), 5%, 250 ML 4/1/2018 K 1.0733 $53.09 00964 ALBUMIN (HUMAN), 25%, 20 ML 7/1/2018 K 0.4411 $21.82 00965 ALBUMIN (HUMAN), 25%, 50ML 7/1/2018 K 1.0481 $51.84 01015 INJECTION GLATIRAMER ACETATE 7/1/2018 K 4.0324 $199.44 01052 INJECTION, VORICONAZOLE 7/1/2018 K 0.0381 $1.88 01064 I131 IODIDE CAP, RX 7/1/2018 K 0.3919 $19.38 01083 INJECTION 4/1/2018 K 25.3232 $1,252.49 01086 TEMOZOLOMIDE 1/1/2018 D 0.0000 $0.00 01138 HEPAGAM B INTRAVENOUS, INJ 7/1/2018 K 1.3315 $65.86 01139 PROTEIN C CONCENTRATE 7/1/2018 K 0.3008 $14.88 01142 SUPPRELIN LA IMPLANT 7/1/2018 K 597.0822 $29,531.69 01150 I131 IODIDE SOL, RX 7/1/2018 K 0.2330 $11.52 01166 CYTARABINE LIPOSOME INJ 4/1/2018 K 12.3247 $609.58 01168 INJ, 7/1/2018 K 1.4469 $71.56 01178 BUSULFAN INJECTION 7/1/2018 K 0.3976 $19.67 01203 VERTEPORFIN INJECTION 4/1/2018 K 0.2130 $10.53 01207 OCTREOTIDE INJECTION, DEPOT 7/1/2018 K 3.9038 $193.08 01213 ANTIHEMOPHILIC VIII/VWF COMP 4/1/2018 K 0.0194 $0.96 01214 INJ IVIG PRIVIGEN 500 MG 7/1/2018 K 0.7781 $38.48 01232 MITOMYCIN INJECTION 7/1/2018 K 2.8259 $139.77 01235 VALRUBICIN INJECTION 7/1/2018 K 24.5011 $1,211.82 01236 LEVOLEUCOVORIN INJECTION 7/1/2018 K 0.0046 $0.23 01237 INJ IRON DEXTRAN 7/1/2018 K 0.2681 $13.26 01238 TOPOTECAN ORAL 7/1/2018 K 2.0371 $100.75 01253 TRIAMCINOLONE A INJ PRS-FREE 7/1/2018 K 0.0757 $3.74 01263 ANTITHROMBIN III INJECTION 7/1/2018 K 0.0723 $3.58 01268 XYNTHA INJ 7/1/2018 K 0.0245 $1.21 01274 EDETATE CALCIUM DISODIUM INJ 4/1/2018 K 109.7280 $5,427.15 01280 CORTICOTROPIN INJECTION 7/1/2018 K 78.2625 $3,870.86 01281 BEVACIZUMAB INJECTION 7/1/2018 K 0.0387 $1.91 01289 ABOBOTULINUMTOXINA 7/1/2018 K 0.1652 $8.17 01291 INJECTION 7/1/2018 K 0.4725 $23.37 01295 SM 153 LEXIDRONAM 7/1/2018 K 271.3852 $13,422.71 01296 DEGARELIX INJECTION 7/1/2018 K 0.0717 $3.55

Please see cover page for a complete description of information contained in the fee schedules. Page 2 Montana Healthcare Programs Fee Schedule APC Services July 1, 2018

01297 FERUMOXYTOL, NON-ESRD 7/1/2018 K 0.0188 $0.93 01311 CANAKINUMAB INJECTION 7/1/2018 K 2.1677 $107.21 01312 HIZENTRA INJECTION 7/1/2018 K 0.1932 $9.56 01327 IMIGLUCERASE INJECTION 7/1/2018 K 0.8107 $40.10 01331 OLANZAPINE LONG-ACTING INJ 1/1/2018 D 0.0000 $0.00 01332 ANTITHROMBIN RECOMBINANT 1/1/2018 D 0.0000 $0.00 01338 METHYL AMINOLEVULINATE, TOP 1/1/2018 D 0.0000 $0.00 01340 COLLAGENASE, CLOST HIST INJ 7/1/2018 K 0.8532 $42.20 01341 AMOBARBITAL 125 MG INJ 4/1/2018 K 4.5900 $227.02 01352 WILATE INJECTION 7/1/2018 K 0.0202 $1.00 01353 INJECTION 7/1/2018 K 0.8555 $42.31 01361 ENFUVIRTIDE INJECTION 1/1/2018 D 0.0000 $0.00 01408 CYCLOPHOSPHAMIDE 100 MG INJ 7/1/2018 K 0.8204 $40.58 01413 LUMIZYME INJECTION 7/1/2018 K 3.1934 $157.95 01415 GLASSIA INJECTION 7/1/2018 K 0.0929 $4.59 01416 FACTOR XIII ANTI-HEM FACTOR 7/1/2018 K 0.1611 $7.97 01417 GEL-ONE 7/1/2018 K 9.9903 $494.12 01420 INJECTION 7/1/2018 K 18.9798 $938.74 01421 IMPORTED LIPODOX INJ 4/1/2018 K 9.9722 $493.23 01424 NABILONE ORAL 1/1/2018 D 0.0000 $0.00 01426 ERIBULIN MESYLATE INJECTION 7/1/2018 K 2.2161 $109.61 01431 CENTRUROIDES IMMUNE F(AB) 7/1/2018 K 90.0824 $4,455.48 01433 CALCITONIN SALMON INJECTION 7/1/2018 K 51.1162 $2,528.21 01440 INJ DESMOPRESSIN ACETATE 7/1/2018 K 0.2531 $12.52 01442 NON-HEU TC-99M ADD-ON/DOSE 7/1/2018 K 0.1961 $9.70 01443 ICATIBANT INJECTION 7/1/2018 K 7.1537 $353.82 01446 VISUALIZATION ADJUNCT 7/1/2018 K 0.1075 $5.32 01457 TOTAZOLINE HCL INJECTION 1/1/2018 D 0.0000 $0.00 01458 PHENTOLAINE MESYLATE INJ 7/1/2018 K 7.6873 $380.21 01460 INTERFERON ALFA-2A INJ 1/1/2018 D 0.0000 $0.00 01464 FACTOR VIII (PORCINE) 1/1/2018 D 0.0000 $0.00 01466 INJ, VINCRISTINE SUL LIP 1MG 4/1/2018 K 55.0589 $2,723.21 01467 FACTOR IX RECOMBINAN RIXUBIS 7/1/2018 K 0.0265 $1.31 01468 INJ ARIPIPRAZOLE EXT REL 1MG 7/1/2018 K 0.1027 $5.08 01469 INJ FILGRASTIM EXCL BIOSIMIL 4/1/2018 K 0.0200 $0.99 01471 INJECTION, PERTUZUMAB, 1 MG 7/1/2018 K 0.2316 $11.45 01472 INJ BETA INTERFERON IM 1 MCG 7/1/2018 K 1.0626 $52.56 01474 INJ 1MG 7/1/2018 K 0.1574 $7.79 01475 FOR IV USE 1MG 7/1/2018 K 0.4766 $23.57 01476 INJ 7/1/2018 K 1.2326 $60.96 01478 HUMAN FIBRINOGEN CONC INJ 7/1/2018 K 0.0228 $1.13 01480 ELOSULFASE ALFA, INJECTION 7/1/2018 K 4.5605 $225.56 01482 DARBEPOETIN ALFA, ESRD USE 7/1/2018 K 0.0753 $3.72 01484 PENTAZOCINE INJECTION 4/1/2018 K 2.1258 $105.14 01485 FERUMOXYTOL, ESRD USE 7/1/2018 K 0.0188 $0.93 01486 FACTOR IX FC FUSION RECOMB 7/1/2018 K 0.0587 $2.90

Please see cover page for a complete description of information contained in the fee schedules. Page 3 Montana Healthcare Programs Fee Schedule APC Services July 1, 2018

01488 INJECTION, RAMUCIRUMAB 7/1/2018 K 1.1311 $55.94 01489 INJECTION, 7/1/2018 K 0.3849 $19.04 01490 INJ PEMBROLIZUMAB 7/1/2018 K 0.9527 $47.12 01491 NEW TECHNOLOGY - LEVEL 1A ($0-$10) 7/1/2018 S 0.0981 $4.85 01492 NEW TECHNOLOGY - LEVEL 1B ($11-$20) 7/1/2018 S 0.3040 $15.04 01493 NEW TECHNOLOGY - LEVEL 1C ($21-$30) 7/1/2018 S 0.5002 $24.74 01494 NEW TECHNOLOGY - LEVEL 1D ($31-$40) 7/1/2018 S 0.6963 $34.44 01495 NEW TECHNOLOGY - LEVEL 1E ($41-$50) 7/1/2018 S 0.8924 $44.14 01496 NEW TECHNOLOGY - LEVEL 1A ($0-$10) 7/1/2018 T 0.0981 $4.85 01497 NEW TECHNOLOGY - LEVEL 1B ($11-$20) 7/1/2018 T 0.3040 $15.04 01498 NEW TECHNOLOGY - LEVEL 1C ($21-$30) 7/1/2018 T 0.5002 $24.74 01499 NEW TECHNOLOGY - LEVEL 1D ($31-$40) 7/1/2018 T 0.6963 $34.44 01500 NEW TECHNOLOGY - LEVEL 1E ($41-$50) 7/1/2018 T 0.8924 $44.14 01502 NEW TECHNOLOGY - LEVEL 2 ($51 - $100) 7/1/2018 S 1.4808 $73.24 01503 NEW TECHNOLOGY - LEVEL 3 ($101 - $200) 7/1/2018 S 2.9519 $146.00 01504 NEW TECHNOLOGY - LEVEL 4 ($201 - $300) 4/1/2018 S 4.9133 $243.01 01505 NEW TECHNOLOGY - LEVEL 5 ($301 - $400) 4/1/2018 S 6.8746 $340.02 01506 NEW TECHNOLOGY - LEVEL 6 ($401 - $500) 4/1/2018 S 8.8360 $437.03 01507 NEW TECHNOLOGY - LEVEL 7 ($501 - $600) 4/1/2018 S 10.7974 $534.04 01508 NEW TECHNOLOGY - LEVEL 8 ($601 - $700) 4/1/2018 S 12.7588 $631.05 01509 NEW TECHNOLOGY - LEVEL 9 ($701 - $800) 4/1/2018 S 14.7202 $728.06 01510 NEW TECHNOLOGY - LEVEL 10 ($801 - $900) 4/1/2018 S 16.6816 $825.07 01511 NEW TECHNOLOGY - LEVEL 11 ($901 - $1000) 4/1/2018 S 18.6429 $922.08 01512 NEW TECHNOLOGY - LEVEL 12 ($1001 - $1100) 4/1/2018 S 20.6043 $1,019.09 01513 NEW TECHNOLOGY - LEVEL 13 ($1101 - $1200) 4/1/2018 S 22.5657 $1,116.10 01514 NEW TECHNOLOGY - LEVEL 14 ($1201- $1300) 4/1/2018 S 24.5271 $1,213.11 01515 NEW TECHNOLOGY - LEVEL 15 ($1301 - $1400) 4/1/2018 S 26.4885 $1,310.12 01516 NEW TECHNOLOGY - LEVEL 16 ($1401 - $1500) 4/1/2018 S 28.4499 $1,407.13 01517 NEW TECHNOLOGY - LEVEL 17 ($1501-$1600) 4/1/2018 S 30.4112 $1,504.14 01518 NEW TECHNOLOGY - LEVEL 18 ($1601-$1700) 4/1/2018 S 32.3726 $1,601.15 01519 NEW TECHNOLOGY - LEVEL 19 ($1701-$1800) 4/1/2018 S 34.3340 $1,698.16 01520 NEW TECHNOLOGY - LEVEL 20 ($1801-$1900) 4/1/2018 S 36.2954 $1,795.17 01521 NEW TECHNOLOGY - LEVEL 21 ($1901-$2000) 4/1/2018 S 38.2568 $1,892.18 01522 NEW TECHNOLOGY - LEVEL 22 ($2001-$2500) 4/1/2018 S 44.1409 $2,183.21 01523 NEW TECHNOLOGY - LEVEL 23 ($2501-$3000) 4/1/2018 S 53.9478 $2,668.26 01524 NEW TECHNOLOGY - LEVEL 24 ($3001-$3500) 4/1/2018 S 63.7548 $3,153.31 01525 NEW TECHNOLOGY - LEVEL 25 ($3501-$4000) 4/1/2018 S 73.5617 $3,638.36 01526 NEW TECHNOLOGY - LEVEL 26 ($4001-$4500) 4/1/2018 S 83.3686 $4,123.41 01527 NEW TECHNOLOGY - LEVEL 27 ($4501-$5000) 4/1/2018 S 93.1755 $4,608.46 01528 NEW TECHNOLOGY - LEVEL 28 ($5001-$5500) 4/1/2018 S 102.9824 $5,093.51 01529 NEW TECHNOLOGY - LEVEL 29 ($5501-$6000) 4/1/2018 S 112.7893 $5,578.56 01530 NEW TECHNOLOGY - LEVEL 30 ($6001-$6500) 4/1/2018 S 122.5962 $6,063.61 01531 NEW TECHNOLOGY - LEVEL 31 ($6501-$7000) 4/1/2018 S 132.4032 $6,548.66 01532 NEW TECHNOLOGY - LEVEL 32 ($7001-$7500) 4/1/2018 S 142.2101 $7,033.71 01533 NEW TECHNOLOGY - LEVEL 33 ($7501-$8000) 4/1/2018 S 152.0170 $7,518.76 01534 NEW TECHNOLOGY - LEVEL 34 ($8001-$8500) 4/1/2018 S 161.8239 $8,003.81

Please see cover page for a complete description of information contained in the fee schedules. Page 4 Montana Healthcare Programs Fee Schedule APC Services July 1, 2018

01535 NEW TECHNOLOGY - LEVEL 35 ($8501-$9000) 4/1/2018 S 171.6308 $8,488.86 01536 NEW TECHNOLOGY - LEVEL 36 ($9001-$9500) 4/1/2018 S 181.4377 $8,973.91 01537 NEW TECHNOLOGY - LEVEL 37 ($9501-$10000) 4/1/2018 S 191.2446 $9,458.96 01539 NEW TECHNOLOGY - LEVEL 2 ($51 - $100) 7/1/2018 T 1.4808 $73.24 01540 NEW TECHNOLOGY - LEVEL 3 ($101 - $200) 7/1/2018 T 2.9519 $146.00 01541 NEW TECHNOLOGY - LEVEL 4 ($201 - $300) 4/1/2018 T 4.9133 $243.01 01542 NEW TECHNOLOGY - LEVEL 5 ($301 - $400) 4/1/2018 T 6.8746 $340.02 01543 NEW TECHNOLOGY - LEVEL 6 ($401 - $500) 4/1/2018 T 8.8360 $437.03 01544 NEW TECHNOLOGY - LEVEL 7 ($501 - $600) 4/1/2018 T 10.7974 $534.04 01545 NEW TECHNOLOGY - LEVEL 8 ($601 - $700) 4/1/2018 T 12.7588 $631.05 01546 NEW TECHNOLOGY - LEVEL 9 ($701 - $800) 4/1/2018 T 14.7202 $728.06 01547 NEW TECHNOLOGY - LEVEL 10 ($801 - $900) 4/1/2018 T 16.6816 $825.07 01548 NEW TECHNOLOGY - LEVEL 11 ($901 - $1000) 4/1/2018 T 18.6429 $922.08 01549 NEW TECHNOLOGY - LEVEL 12 ($1001 - $1100) 4/1/2018 T 20.6043 $1,019.09 01550 NEW TECHNOLOGY - LEVEL 13 ($1101 - $1200) 4/1/2018 T 22.5657 $1,116.10 01551 NEW TECHNOLOGY - LEVEL 14 ($1201- $1300) 4/1/2018 T 24.5271 $1,213.11 01552 NEW TECHNOLOGY - LEVEL 15 ($1301 - $1400) 4/1/2018 T 26.4885 $1,310.12 01553 NEW TECHNOLOGY - LEVEL 16 ($1401 - $1500) 4/1/2018 T 28.4499 $1,407.13 01554 NEW TECHNOLOGY - LEVEL 17 ($1501-$1600) 4/1/2018 T 30.4112 $1,504.14 01555 NEW TECHNOLOGY - LEVEL 18 ($1601-$1700) 4/1/2018 T 32.3726 $1,601.15 01556 NEW TECHNOLOGY - LEVEL 19 ($1701-$1800) 4/1/2018 T 34.3340 $1,698.16 01557 NEW TECHNOLOGY - LEVEL 20 ($1801-$1900) 4/1/2018 T 36.2954 $1,795.17 01558 NEW TECHNOLOGY - LEVEL 21 ($1901-$2000) 4/1/2018 T 38.2568 $1,892.18 01559 NEW TECHNOLOGY - LEVEL 22 ($2001-$2500) 4/1/2018 T 44.1409 $2,183.21 01560 NEW TECHNOLOGY - LEVEL 23 ($2501-$3000) 4/1/2018 T 53.9478 $2,668.26 01561 NEW TECHNOLOGY - LEVEL 24 ($3001-$3500) 4/1/2018 T 63.7548 $3,153.31 01562 NEW TECHNOLOGY - LEVEL 25 ($3501-$4000) 4/1/2018 T 73.5617 $3,638.36 01563 NEW TECHNOLOGY - LEVEL 26 ($4001-$4500) 4/1/2018 T 83.3686 $4,123.41 01564 NEW TECHNOLOGY - LEVEL 27 ($4501-$5000) 4/1/2018 T 93.1755 $4,608.46 01565 NEW TECHNOLOGY - LEVEL 28 ($5001-$5500) 4/1/2018 T 102.9824 $5,093.51 01566 NEW TECHNOLOGY - LEVEL 29 ($5501-$6000) 4/1/2018 T 112.7893 $5,578.56 01567 NEW TECHNOLOGY - LEVEL 30 ($6001-$6500) 4/1/2018 T 122.5962 $6,063.61 01568 NEW TECHNOLOGY - LEVEL 31 ($6501-$7000) 4/1/2018 T 132.4032 $6,548.66 01569 NEW TECHNOLOGY - LEVEL 32 ($7001-$7500) 4/1/2018 T 142.2101 $7,033.71 01570 NEW TECHNOLOGY - LEVEL 33 ($7501-$8000) 4/1/2018 T 152.0170 $7,518.76 01571 NEW TECHNOLOGY - LEVEL 34 ($8001-$8500) 4/1/2018 T 161.8239 $8,003.81 01572 NEW TECHNOLOGY - LEVEL 35 ($8501-$9000) 4/1/2018 T 171.6308 $8,488.86 01573 NEW TECHNOLOGY - LEVEL 36 ($9001-$9500) 4/1/2018 T 181.4377 $8,973.91 01574 NEW TECHNOLOGY - LEVEL 37 ($9501-$10000) 4/1/2018 T 191.2446 $9,458.96 01575 NEW TECHNOLOGY - LEVEL 38 ($10,001-$15,000) 4/1/2018 S 245.1827 $12,126.74 01576 NEW TECHNOLOGY - LEVEL 39 ($15,001-$20,000) 4/1/2018 S 343.2518 $16,977.23 01577 NEW TECHNOLOGY - LEVEL 40 ($20,001-$25,000) 4/1/2018 S 441.3210 $21,827.74 01578 NEW TECHNOLOGY - LEVEL 41 ($25,001-$30,000) 4/1/2018 S 539.3901 $26,678.23 01579 NEW TECHNOLOGY - LEVEL 42 ($30,001-$40,000) 4/1/2018 S 686.4938 $33,953.98 01580 NEW TECHNOLOGY - LEVEL 43 ($40,001-$50,000) 4/1/2018 S 882.6321 $43,654.98 01581 NEW TECHNOLOGY - LEVEL 44 ($50,001-$60,000) 4/1/2018 S 1078.7704 $53,355.98

Please see cover page for a complete description of information contained in the fee schedules. Page 5 Montana Healthcare Programs Fee Schedule APC Services July 1, 2018

01582 NEW TECHNOLOGY - LEVEL 45 ($60,001-$70,000) 4/1/2018 S 1274.9087 $63,056.98 01583 NEW TECHNOLOGY - LEVEL 46 ($70,001-$80,000) 4/1/2018 S 1471.0470 $72,757.98 01584 NEW TECHNOLOGY - LEVEL 47 ($80,001-$90,000) 4/1/2018 S 1667.1853 $82,458.98 01585 NEW TECHNOLOGY - LEVEL 48 ($90,001-$100,000) 4/1/2018 S 1863.3236 $92,159.99 01589 NEW TECHNOLOGY - LEVEL 38 ($10,001-$15,000) 4/1/2018 T 245.1827 $12,126.74 01590 NEW TECHNOLOGY - LEVEL 39 ($15,001-$20,000) 4/1/2018 T 343.2518 $16,977.23 01591 NEW TECHNOLOGY - LEVEL 40 ($20,001-$25,000) 4/1/2018 T 441.3210 $21,827.74 01592 NEW TECHNOLOGY - LEVEL 41 ($25,001-$30,000) 4/1/2018 T 539.3901 $26,678.23 01593 NEW TECHNOLOGY - LEVEL 42 ($30,001-$40,000) 4/1/2018 T 686.4938 $33,953.98 01594 NEW TECHNOLOGY - LEVEL 43 ($40,001-$50,000) 4/1/2018 T 882.6321 $43,654.98 01595 NEW TECHNOLOGY - LEVEL 44 ($50,001-$60,000) 4/1/2018 T 1078.7704 $53,355.98 01596 NEW TECHNOLOGY - LEVEL 45 ($60,001-$70,000) 4/1/2018 T 1274.9087 $63,056.98 01597 NEW TECHNOLOGY - LEVEL 46 ($70,001-$80,000) 4/1/2018 T 1471.0470 $72,757.98 01598 NEW TECHNOLOGY - LEVEL 47 ($80,001-$90,000) 4/1/2018 T 1667.1853 $82,458.98 01599 NEW TECHNOLOGY - LEVEL 48 ($90,001-$100,000) 4/1/2018 T 1863.3236 $92,159.99 01605 ABCIXIMAB INJECTION 1/1/2018 D 0.0000 $0.00 01607 EPTIFIBATIDE INJECTION 7/1/2018 K 0.3624 $17.92 01608 INJECTION 4/1/2018 K 12.6615 $626.24 01609 RHO(D) IMMUNE GLOBULIN H, SD 7/1/2018 K 0.5358 $26.50 01612 , PARENTERAL 1/1/2018 D 0.0000 $0.00 01613 TRASTUZUMAB INJECTION 7/1/2018 K 2.0345 $100.63 01630 HEP B IG, IM 7/1/2018 K 2.2971 $113.61 01631 BACLOFEN INTRATHECAL TRIAL 7/1/2018 K 1.1649 $57.62 01633 1/1/2018 D 0.0000 $0.00 01643 Y90 IBRITUMOMAB, RX 7/1/2018 K 946.7512 $46,826.31 01656 FACTOR VIII FC FUSION RECOMB 7/1/2018 K 0.0394 $1.95 01657 PURAPLY OR PURAPLY AM 1/1/2018 D 0.0000 $0.00 01658 INJECTION, BELINOSTAT, 10MG 7/1/2018 K 0.7307 $36.14 01660 INJECTION, ORITAVANCIN 7/1/2018 K 0.5024 $24.85 01661 GEN, NEURO, HF, RECHG BAT 1/1/2018 D 0.0000 $0.00 01662 INJ TEDIZOLID PHOSPHATE 7/1/2018 K 0.0282 $1.39 01663 INJ, PHENYLEPHRINE KETOROLAC 1/1/2018 D 0.0000 $0.00 01664 FLORBETAPIR F18 1/1/2018 D 0.0000 $0.00 01666 TETRACYCLIN INJECTION 1/1/2018 D 0.0000 $0.00 01669 ERYTHRO LACTOBIONATE /500 MG 7/1/2018 K 1.5469 $76.51 01670 TETANUS IMMUNE GLOBULIN INJ 7/1/2018 K 6.1279 $303.09 01675 P32 NA PHOSPHATE 4/1/2018 K 5.0211 $248.34 01676 P32 CHROMIC PHOSPHATE 1/1/2018 D 0.0000 $0.00 01683 7/1/2018 K 71.7083 $3,546.69 01684 CORTICORELIN OVINE TRIFLUTAL 4/1/2018 K 0.1688 $8.35 01685 DARBEPOETIN ALFA, NON-ESRD 7/1/2018 K 0.0753 $3.72 01686 EPOETIN ALFA, NON-ESRD 7/1/2018 K 0.2567 $12.70 01687 DIGOXIN IMMUNE FAB (OVINE) 7/1/2018 K 68.8874 $3,407.17 01688 ETHANOLAMINE OLEATE 4/1/2018 K 8.7105 $430.82 01689 FOMEPIZOLE 7/1/2018 K 0.1113 $5.50 01690 HEMIN 7/1/2018 K 0.4520 $22.36

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01693 LEPIRUDIN 1/1/2018 D 0.0000 $0.00 01694 ZICONOTIDE INJECTION 7/1/2018 K 0.1487 $7.35 01695 NESIRITIDE INJECTION 7/1/2018 K 1.4382 $71.13 01696 PALIFERMIN INJECTION 7/1/2018 K 0.3989 $19.73 01697 PEGAPTANIB SODIUM INJECTION 7/1/2018 K 14.0801 $696.40 01700 INJ SECRETIN SYNTHETIC HUMAN 7/1/2018 K 0.6822 $33.74 01701 TREPROSTINIL INJECTION 7/1/2018 K 1.2011 $59.41 01704 HUMATE-P, INJ 4/1/2018 K 0.0221 $1.09 01705 FACTOR VIIA 7/1/2018 K 0.0406 $2.01 01709 AZACITIDINE INJECTION 7/1/2018 K 0.0296 $1.46 01710 CLOFARABINE INJECTION 7/1/2018 K 2.3583 $116.64 01711 VANTAS IMPLANT 7/1/2018 K 67.7134 $3,349.10 01712 PACLITAXEL PROTEIN BOUND 7/1/2018 K 0.2202 $10.89 01738 OXALIPLATIN 1/1/2018 D 0.0000 $0.00 01739 PEGADEMASE BOVINE, 25 IU 7/1/2018 K 7.2171 $356.96 01741 UROFOLLITROPIN, 75 IU 1/1/2018 D 0.0000 $0.00 01743 NANDROLONE DECANOATE 50 MG 4/1/2018 K 1.4236 $70.41 01745 RADIUM RA223 DICHLORIDE THER 7/1/2018 K 2.6205 $129.61 01746 FACTOR XIII RECOMB A-SUBUNIT 7/1/2018 K 0.2920 $14.44 01747 MONOVISC INJ PER DOSE 7/1/2018 K 15.6236 $772.74 01748 INJ TBO FILGRASTIM 1 MICROG 7/1/2018 K 0.0116 $0.57 01761 ROLAPITANT, ORAL, 1MG 7/1/2018 K 0.0436 $2.16 01809 INJECTION, 7/1/2018 K 36.1537 $1,788.16 01822 INJECTION, ZARXIO 7/1/2018 G 0.0128 $0.63 01823 INJECTION, DALBAVANCIN 7/1/2018 K 0.2875 $14.22 01824 CEFTAROLINE FOSAMIL INJ 7/1/2018 K 0.0568 $2.81 01825 CEFTAZIDIME AND AVIBACTAM 7/1/2018 K 1.6472 $81.47 01826 HYQVIA 100MG IMMUNEGLOBULIN 7/1/2018 K 0.2851 $14.10 01827 FACTOR VIII RECOMB OBIZUR 7/1/2018 K 0.0487 $2.41 01828 CARBIDOPA LEVODOPA ENT 100ML 7/1/2018 K 0.0429 $2.12 01829 PENICILLIN G BENZATHINE INJ 7/1/2018 K 0.2734 $13.52 01832 DIMETHYL SULFOXIDE 50% 50 ML 7/1/2018 K 10.4258 $515.66 01836 PENICILLIN G PROCAINE INJ 1/1/2018 D 0.0000 $0.00 01838 UROKINASE 250,000 IU INJ 1/1/2018 D 0.0000 $0.00 01839 ORAL BUSULFAN 1/1/2018 D 0.0000 $0.00 01842 LEUPROLIDE ACETATE IMPLANT 1/1/2018 D 0.0000 $0.00 01844 FACTOR VIII PEGYLATED RECOMB 7/1/2018 G 0.0349 $1.73 01845 TACROL ENVARSUS EX REL ORAL 7/1/2018 G 0.0246 $1.22 01846 FACTOR VIII NUWIQ RECOMB 1IU 7/1/2018 G 0.0289 $1.43 01847 INJECTION, INFLECTRA 7/1/2018 G 1.2745 $63.04 01848 ARTISS FIBRIN SEALANT 7/1/2018 K 2.4399 $120.68 01849 FOSCARNET SODIUM INJECTION 4/1/2018 K 1.6136 $79.81 01850 GAMMA GLOBULIN 1 CC INJ 7/1/2018 K 0.7548 $37.33 01851 GAMMA GLOBULIN > 10 CC INJ 7/1/2018 K 7.5476 $373.30 01852 INTERFERON BETA-1A INJ 4/1/2018 K 11.8546 $586.33 01853 MINOCYCLINE HYDROCHLORIDE 7/1/2018 K 0.0321 $1.59

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01854 PENTOBARBITAL SODIUM INJ 7/1/2018 K 0.9650 $47.73 01855 PRALIDOXIME CHLORIDE INJ 1/1/2018 D 0.0000 $0.00 01856 FACTOR VIII RECOMB NOVOEIGHT 7/1/2018 K 0.0261 $1.29 01857 INJ, FACTOR X, (HUMAN), 1IU 7/1/2018 K 0.1406 $6.95 01858 LEUPROLIDE ACETATE INJECITON 7/1/2018 K 0.6511 $32.20 01859 ARGATROBAN NONESRD USE 1MG 7/1/2018 K 0.0258 $1.28 01860 MONOCLONAL 4/1/2018 K 0.1334 $6.60 01861 INJ., BENDEKA 1 MG 7/1/2018 G 0.4598 $22.74 01862 GELSYN-3 INJECTION 0.1 MG 7/1/2018 G 0.0427 $2.11 01863 INJ DICLOFENAC SODIUM 0.5MG 4/1/2018 K 0.0044 $0.22 01901 NEW TECHNOLOGY - LEVEL 49 ($100,001-$115,000) 4/1/2018 S 2108.4965 $104,286.24 01902 NEW TECHNOLOGY - LEVEL 49 ($100,001-$115,000) 4/1/2018 T 2108.4965 $104,286.24 01903 NEW TECHNOLOGY - LEVEL 50 ($115,001-$130,000) 4/1/2018 S 2402.7039 $118,837.73 01904 NEW TECHNOLOGY - LEVEL 50 ($115,001-$130,000) 4/1/2018 T 2402.7039 $118,837.73 01905 NEW TECHNOLOGY - LEVEL 51 ($130,001-$145,000) 4/1/2018 S 2696.9113 $133,389.23 01906 NEW TECHNOLOGY - LEVEL 51 ($130,001-$145,000) 4/1/2018 T 2696.9113 $133,389.23 01907 NEW TECHNOLOGY - LEVEL 52 ($145,001-$160,000) 4/1/2018 S 2991.1188 $147,940.74 01908 NEW TECHNOLOGY - LEVEL 52 ($145,001-$160,000) 4/1/2018 T 2991.1188 $147,940.74 02613 LUNG BX PLUG W/DEL SYS 1/1/2018 D 0.0000 $0.00 02616 BRACHYTX, NON-STR,YTTRIUM-90 1/1/2018 U 212.5946 $10,514.93 02623 CATH, TRANSLUMIN, DRUG-COAT 1/1/2018 D 0.0000 $0.00 02632 IODINE I-125 SODIUM IODIDE 1/1/2018 U 0.3389 $16.76 02634 BRACHYTX, NON-STR, HA, I-125 1/1/2018 U 1.4963 $74.01 02635 BRACHYTX, NON-STR, HA, P-103 1/1/2018 U 0.3299 $16.32 02636 BRACHY LINEAR, NON-STR,P-103 1/1/2018 U 0.3444 $17.03 02638 BRACHYTX, STRANDED, I-125 1/1/2018 U 0.4417 $21.85 02639 BRACHYTX, NON-STRANDED,I-125 1/1/2018 U 0.4408 $21.80 02640 BRACHYTX, STRANDED, P-103 1/1/2018 U 1.0011 $49.51 02641 BRACHYTX, NON-STRANDED,P-103 1/1/2018 U 0.8173 $40.42 02642 BRACHYTX, STRANDED, C-131 1/1/2018 U 1.1177 $55.28 02643 BRACHYTX, NON-STRANDED,C-131 1/1/2018 U 1.1115 $54.97 02644 BRACHYTX CESIUM-131 CHLORIDE 1/1/2018 U 1.3364 $66.10 02645 BRACHYTX, NON-STR, GOLD-198 1/1/2018 U 1.5592 $77.12 02646 BRACHYTX, NON-STR, HDR IR-192 1/1/2018 U 3.7462 $185.29 02647 BRACHYTX, NS, NON-HDRIR-192 1/1/2018 U 0.2436 $12.05 02648 BRACHYTX PLANAR, P-103 7/1/2018 U 0.0920 $4.55 02698 BRACHYTX, STRANDED, NOS 1/1/2018 U 0.4417 $21.85 02699 BRACHYTX, NON-STRANDED, NOS 1/1/2018 U 0.2436 $12.05 02731 IMMUNE GLOBULIN, POWDER 7/1/2018 K 0.8121 $40.17 02770 QUINUPRISTIN/DALFOPRISTIN 7/1/2018 K 8.2102 $406.08 03041 BIVALIRUDIN 1/1/2018 D 0.0000 $0.00 04001 ECHO GUIDANCE RADIOTHERAPY 7/1/2018 S 0.4660 $23.05 04002 STEREOSCOPIC X-RAY GUIDANCE 7/1/2018 S 1.1296 $55.87 04003 RADIATION TREATMENT DELIVERY, MEV <= 5; SIMPLE 7/1/2018 S 3.9679 $196.25 04004 RADIATION TREATMENT DELIVERY, 6-10 MEV; SIMPLE 4/1/2018 S 2.9440 $145.61 04005 RADIATION TREATMENT DELIVERY, 11-19 MEV; SIMPLE 4/1/2018 S 2.9370 $145.26

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04006 RADIATION TREATMENT DELIVERY, MEV>=20; SIMPLE 4/1/2018 S 2.9440 $145.61 04007 RADIATION TREATMENT DELIVERY, MEV<=5; INTERMEDIATE 4/1/2018 S 5.9589 $294.73 04008 RADIATION TREATMENT DELIVERY, 6-10 MEV; INTERMEDIATE 4/1/2018 S 4.0738 $201.49 04009 RADIATION TREATMENT DELIVERY, 11-19 MEV; INTERMEDIATE 4/1/2018 S 4.0597 $200.79 04010 RADIATION TREATMENT DELIVERY, MEV >=20; INTERMEDIATE 7/1/2018 S 4.0314 $199.39 04011 RADIATION TREATMENT DELIVERY, MEV<=5; COMPLEX 4/1/2018 S 5.6623 $280.06 04012 RADIATION TREATMENT DELIVERY, 6-10 MEV; COMPLEX 4/1/2018 S 5.3869 $266.44 04013 RADIATION TREATMENT DELIVERY, 11-19 MEV; COMPLEX 4/1/2018 S 5.3869 $266.44 04014 RADIATION TREATMENT DELIVERY, MEV >=20; COMPLEX 4/1/2018 S 5.3940 $266.79 04015 RADIATION TX DELIVERY IMRT 4/1/2018 S 7.0320 $347.80 04016 DELIVERY COMP IMRT 4/1/2018 S 7.0108 $346.75 05012 CLINIC VISITS AND RELATED SERVICES 3/1/2018 M 0.0000 $0.00 05021 LEVEL 1 TYPE A ED VISITS 1/1/2018 V 1.4458 $71.51 05022 LEVEL 2 TYPE A ED VISITS 1/1/2018 V 1.4458 $71.51 05023 LEVEL 3 TYPE A ED VISITS 1/1/2018 V 2.7863 $137.81 05024 LEVEL 4 TYPE A ED VISITS 1/1/2018 V 4.5212 $223.62 05025 LEVEL 5 TYPE A ED VISITS 1/1/2018 V 6.6235 $327.60 05041 CRITICAL CARE 1/1/2018 S 9.3295 $461.44 05045 TRAUMA RESPONSE WITH CRITICAL CARE 1/1/2018 S 12.1773 $602.29 05051 LEVEL 1 SKIN PROCEDURES 1/1/2018 T 2.1485 $106.26 05052 LEVEL 2 SKIN PROCEDURES 1/1/2018 T 3.9524 $195.49 05053 LEVEL 3 SKIN PROCEDURES 1/1/2018 T 6.2084 $307.07 05054 LEVEL 4 SKIN PROCEDURES 1/1/2018 T 19.9454 $986.50 05055 LEVEL 5 SKIN PROCEDURES 1/1/2018 T 34.4687 $1,704.82 05061 HYPERBARIC OXYGEN 1/1/2018 S 1.4519 $71.81 05071 LEVEL 1 EXCISION/ BIOPSY/ INCISION AND DRAINAGE 1/1/2018 T 7.2848 $360.31 05072 LEVEL 2 EXCISION/ BIOPSY/ INCISION AND DRAINAGE 1/1/2018 T 17.1427 $847.88 05073 LEVEL 3 EXCISION/ BIOPSY/ INCISION AND DRAINAGE 1/1/2018 T 29.5649 $1,462.28 05091 LEVEL 1 BREAST/LYMPHATIC SURGERY AND RELATED PROCEDURES 1/1/2018 T 34.6895 $1,715.74 05092 LEVEL 2 BREAST/LYMPHATIC SURGERY AND RELATED PROCEDURES 1/1/2018 T 61.1918 $3,026.55 05093 LEVEL 3 BREAST/LYMPHATIC SURGERY AND RELATED PROCEDURES 1/1/2018 T 93.9484 $4,646.69 05094 LEVEL 4 BREAST/LYMPHATIC SURGERY AND RELATED PROCEDURES 1/1/2018 T 144.8261 $7,163.10 05101 LEVEL 1 STRAPPING AND CAST APPLICATION 1/1/2018 T 1.7221 $85.18 05102 LEVEL 2 STRAPPING AND CAST APPLICATION 1/1/2018 T 3.0174 $149.24 05111 LEVEL 1 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 2.7329 $135.17 05112 LEVEL 2 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 17.1669 $849.07 05113 LEVEL 3 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 33.6389 $1,663.78 05114 LEVEL 4 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 71.2959 $3,526.30 05115 LEVEL 5 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 128.7314 $6,367.06 05116 LEVEL 6 MUSCULOSKELETAL PROCEDURES 1/1/2018 T 195.4703 $9,667.96 05151 LEVEL 1 AIRWAY ENDOSCOPY 1/1/2018 T 1.9975 $98.80 05152 LEVEL 2 AIRWAY ENDOSCOPY 1/1/2018 T 4.7748 $236.16 05153 LEVEL 3 AIRWAY ENDOSCOPY 1/1/2018 T 16.8333 $832.58 05154 LEVEL 4 AIRWAY ENDOSCOPY 1/1/2018 T 33.2745 $1,645.76 05155 LEVEL 5 AIRWAY ENDOSCOPY 1/1/2018 T 61.8568 $3,059.44 05161 LEVEL 1 ENT PROCEDURES 1/1/2018 T 2.2699 $112.27

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05162 LEVEL 2 ENT PROCEDURES 1/1/2018 T 5.8481 $289.25 05163 LEVEL 3 ENT PROCEDURES 1/1/2018 T 14.4740 $715.88 05164 LEVEL 4 ENT PROCEDURES 1/1/2018 T 27.9650 $1,383.15 05165 LEVEL 5 ENT PROCEDURES 1/1/2018 T 55.1756 $2,728.99 05166 COCHLEAR IMPLANT PROCEDURE 1/1/2018 T 414.5681 $20,504.54 05181 LEVEL 1 VASCULAR PROCEDURES 1/1/2018 T 7.7900 $385.29 05182 LEVEL 2 VASCULAR PROCEDURES 1/1/2018 T 12.5002 $618.26 05183 LEVEL 3 VASCULAR PROCEDURES 1/1/2018 T 31.6997 $1,567.87 05184 LEVEL 4 VASCULAR PROCEDURES 1/1/2018 T 54.2367 $2,682.55 05191 LEVEL 1 ENDOVASCULAR PROCEDURES 1/1/2018 T 35.7801 $1,769.68 05192 LEVEL 2 ENDOVASCULAR PROCEDURES 1/1/2018 T 64.6651 $3,198.34 05193 LEVEL 3 ENDOVASCULAR PROCEDURES 1/1/2018 T 133.6596 $6,610.80 05194 LEVEL 4 ENDOVASCULAR PROCEDURES 1/1/2018 T 203.7285 $10,076.41 05200 IMPLANTATION WIRELESS PA PRESSURE MONITOR 1/1/2018 T 414.9317 $20,522.52 05211 LEVEL 1 ELECTROPHYSIOLOGIC PROCEDURES 1/1/2018 T 11.5629 $571.90 05212 LEVEL 2 ELECTROPHYSIOLOGIC PROCEDURES 1/1/2018 T 67.5812 $3,342.57 05213 LEVEL 3 ELECTROPHYSIOLOGIC PROCEDURES 1/1/2018 T 235.4663 $11,646.16 05221 LEVEL1 PACEMAKER AND SIMILAR PROCEDURES 1/1/2018 T 36.4712 $1,803.87 05222 LEVEL 2 PACEMAKER AND SIMILAR PROCEDURES 1/1/2018 T 93.7356 $4,636.16 05223 LEVEL 3 PACEMAKER AND SIMILAR PROCEDURES 1/1/2018 T 123.9635 $6,131.23 05224 LEVEL 4 PACEMAKER AND SIMILAR PROCEDURES 1/1/2018 T 223.6322 $11,060.85 05231 LEVEL 1 ICD AND SIMILAR PROCEDURES 1/1/2018 T 281.1756 $13,906.95 05232 LEVEL 2 ICD AND SIMILAR PROCEDURES 1/1/2018 T 393.7399 $19,474.38 05241 LEVEL 1 BLOOD PRODUCT EXCHANGE AND RELATED SERVICES 1/1/2018 S 4.7697 $235.91 05242 LEVEL 2 BLOOD PRODUCT EXCHANGE AND RELATED SERVICES 1/1/2018 S 15.5367 $768.45 05243 LEVEL 3 BLOOD PRODUCT EXCHANGE AND RELATED SERVICES 1/1/2018 S 47.0536 $2,327.27 05244 LEVEL 4 BLOOD PRODUCT EXCHANGE AND RELATED SERVICES 1/1/2018 S 387.1435 $19,148.12 05301 LEVEL 1 UPPER GI PROCEDURES 1/1/2018 T 9.4548 $467.63 05302 LEVEL 2 UPPER GI PROCEDURES 1/1/2018 T 18.1519 $897.79 05303 LEVEL 3 UPPER GI PROCEDURES 1/1/2018 T 34.8879 $1,725.56 05311 LEVEL 1 LOWER GI PROCEDURES 1/1/2018 T 9.0287 $446.56 05312 LEVEL 2 LOWER GI PROCEDURES 1/1/2018 T 11.9079 $588.96 05313 LEVEL 3 LOWER GI PROCEDURES 1/1/2018 T 29.4475 $1,456.47 05331 COMPLEX GI PROCEDURES 1/1/2018 T 54.6012 $2,700.58 05341 ABDOMINAL/PERITONEAL/BILIARY AND RELATED PROCEDURES 1/1/2018 T 37.0207 $1,831.04 05361 LEVEL 1 LAPAROSCOPY AND RELATED SERVICES 1/1/2018 T 57.0818 $2,823.27 05362 LEVEL 2 LAPAROSCOPY AND RELATED SERVICES 1/1/2018 T 96.5896 $4,777.32 05371 LEVEL 1 UROLOGY AND RELATED SERVICES 1/1/2018 T 2.9189 $144.37 05372 LEVEL 2 UROLOGY AND RELATED SERVICES 1/1/2018 T 7.1926 $355.75 05373 LEVEL 3 UROLOGY AND RELATED SERVICES 1/1/2018 T 21.5637 $1,066.54 05374 LEVEL 4 UROLOGY AND RELATED SERVICES 1/1/2018 T 34.2942 $1,696.19 05375 LEVEL 5 UROLOGY AND RELATED SERVICES 1/1/2018 T 47.1289 $2,331.00 05376 LEVEL 6 UROLOGY AND RELATED SERVICES 1/1/2018 T 96.6003 $4,777.85 05377 LEVEL 7 UROLOGY AND RELATED SERVICES 1/1/2018 T 199.6264 $9,873.52 05401 DIALYSIS 1/1/2018 S 7.6051 $376.15 05411 LEVEL 1 GYNECOLOGIC PROCEDURES 1/1/2018 T 2.0436 $101.08

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05412 LEVEL 2 GYNECOLOGIC PROCEDURES 1/1/2018 T 3.4125 $168.78 05413 LEVEL 3 GYNECOLOGIC PROCEDURES 1/1/2018 T 7.3198 $362.04 05414 LEVEL 4 GYNECOLOGIC PROCEDURES 1/1/2018 T 28.9024 $1,429.51 05415 LEVEL 5 GYNECOLOGIC PROCEDURES 1/1/2018 T 52.2891 $2,586.22 05416 LEVEL 6 GYNECOLOGIC PROCEDURES 1/1/2018 T 79.9552 $3,954.58 05431 LEVEL 1 NERVE PROCEDURES 1/1/2018 T 20.4805 $1,012.97 05432 LEVEL 2 NERVE PROCEDURES 1/1/2018 T 58.8483 $2,910.64 05441 LEVEL 1 NERVE INJECTIONS 1/1/2018 T 3.1118 $153.91 05442 LEVEL 2 NERVE INJECTIONS 1/1/2018 T 6.9101 $341.77 05443 LEVEL 3 NERVE INJECTIONS 1/1/2018 T 8.5480 $422.78 05461 LEVEL 1 NEUROSTIMULATOR AND RELATED PROCEDURES 1/1/2018 T 36.6165 $1,811.05 05462 LEVEL 2 NEUROSTIMULATOR AND RELATED PROCEDURES 1/1/2018 T 77.0081 $3,808.82 05463 LEVEL 3 NEUROSTIMULATOR AND RELATED PROCEDURES 1/1/2018 T 233.5939 $11,553.55 05464 LEVEL 4 NEUROSTIMULATOR AND RELATED PROCEDURES 1/1/2018 T 354.6949 $17,543.21 05471 IMPLANTATION OF DRUG INFUSION DEVICE 1/1/2018 T 209.0747 $10,340.83 05481 LASER EYE PROCEDURES 1/1/2018 T 6.2055 $306.92 05491 LEVEL 1 INTRAOCULAR PROCEDURES 1/1/2018 T 24.4301 $1,208.31 05492 LEVEL 2 INTRAOCULAR PROCEDURES 1/1/2018 T 45.9173 $2,271.07 05493 LEVEL 3 INTRAOCULAR PROCEDURES 1/1/2018 T 116.8305 $5,778.44 05494 LEVEL 4 INTRAOCULAR PROCEDURES 1/1/2018 T 121.2219 $5,995.64 05495 LEVEL 5 INTRAOCULAR PROCEDURES 1/1/2018 T 223.3238 $11,045.60 05501 LEVEL 1 EXTRAOCULAR, REPAIR, AND PLASTIC EYE PROCEDURES 1/1/2018 T 3.4038 $168.35 05502 LEVEL 2 EXTRAOCULAR, REPAIR, AND PLASTIC EYE PROCEDURES 1/1/2018 T 10.2799 $508.44 05503 LEVEL 3 EXTRAOCULAR, REPAIR, AND PLASTIC EYE PROCEDURES 1/1/2018 T 23.0346 $1,139.29 05504 LEVEL 4 EXTRAOCULAR, REPAIR, AND PLASTIC EYE PROCEDURES 1/1/2018 T 37.5346 $1,856.46 05521 LEVEL 1 IMAGING WITHOUT CONTRAST 1/1/2018 S 0.7900 $39.07 05522 LEVEL 2 IMAGING WITHOUT CONTRAST 1/1/2018 S 1.4556 $71.99 05523 LEVEL 3 IMAGING WITHOUT CONTRAST 1/1/2018 S 2.9543 $146.12 05524 LEVEL 4 IMAGING WITHOUT CONTRAST 1/1/2018 S 6.1892 $306.12 05571 LEVEL 1 IMAGING WITH CONTRAST 1/1/2018 S 3.2140 $158.96 05572 LEVEL 2 IMAGING WITH CONTRAST 1/1/2018 S 5.8036 $287.05 05573 LEVEL 3 IMAGING WITH CONTRAST 1/1/2018 S 8.6713 $428.88 05591 LEVEL 1 NUCLEAR MEDICINE AND RELATED SERVICES 1/1/2018 S 4.4438 $219.79 05592 LEVEL 2 NUCLEAR MEDICINE AND RELATED SERVICES 1/1/2018 S 5.7618 $284.98 05593 LEVEL 3 NUCLEAR MEDICINE AND RELATED SERVICES 1/1/2018 S 15.2943 $756.46 05594 LEVEL 4 NUCLEAR MEDICINE AND RELATED SERVICES 1/1/2018 S 17.5138 $866.23 05611 LEVEL 1 THERAPEUTIC RADIATION TREATMENT PREPARATION 1/1/2018 S 1.5941 $78.84 05612 LEVEL 2 THERAPEUTIC RADIATION TREATMENT PREPARATION 1/1/2018 S 4.1087 $203.22 05613 LEVEL 3 THERAPEUTIC RADIATION TREATMENT PREPARATION 1/1/2018 S 15.0908 $746.39 05621 LEVEL 1 RADIATION THERAPY 1/1/2018 S 1.5862 $78.45 05622 LEVEL 2 RADIATION THERAPY 1/1/2018 S 2.7956 $138.27 05623 LEVEL 3 RADIATION THERAPY 1/1/2018 S 6.6421 $328.52 05624 LEVEL 4 RADIATION THERAPY 1/1/2018 S 9.0812 $449.16 05625 LEVEL 5 RADIATION THERAPY 1/1/2018 S 13.3974 $662.64 05626 LEVEL 6 RADIATION THERAPY 1/1/2018 S 21.3289 $1,054.93 05627 LEVEL 7 RADIATION THERAPY 1/1/2018 S 96.2115 $4,758.62

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05661 THERAPEUTIC NUCLEAR MEDICINE 1/1/2018 S 3.0327 $150.00 05671 LEVEL 1 PATHOLOGY 1/1/2018 S 0.5685 $28.12 05672 LEVEL 2 PATHOLOGY 1/1/2018 S 1.6427 $81.25 05673 LEVEL 3 PATHOLOGY 1/1/2018 S 2.7396 $135.50 05674 LEVEL 4 PATHOLOGY 1/1/2018 S 6.8793 $340.25 05691 LEVEL 1 DRUG ADMINISTRATION 1/1/2018 S 0.4709 $23.29 05692 LEVEL 2 DRUG ADMINISTRATION 1/1/2018 S 0.7401 $36.61 05693 LEVEL 3 DRUG ADMINISTRATION 1/1/2018 S 2.4301 $120.19 05694 LEVEL 4 DRUG ADMINISTRATION 1/1/2018 S 3.7841 $187.16 05721 LEVEL1 DIAGNOSTIC TESTS AND RELATED SERVICES 1/1/2018 S 1.7335 $85.74 05722 LEVEL 2 DIAGNOSTIC TESTS AND RELATED SERVICES 1/1/2018 S 3.1643 $156.51 05723 LEVEL 3 DIAGNOSTIC TESTS AND RELATED SERVICES 1/1/2018 S 5.6512 $279.51 05724 LEVEL 4 DIAGNOSTIC TESTS AND RELATED SERVICES 1/1/2018 S 11.4830 $567.95 05731 LEVEL 1 MINOR PROCEDURES 1/1/2018 S 0.2222 $10.99 05732 LEVEL 2 MINOR PROCEDURES 1/1/2018 S 0.4044 $20.00 05733 LEVEL 3 MINOR PROCEDURES 1/1/2018 S 0.7116 $35.20 05734 LEVEL 4 MINOR PROCEDURES 1/1/2018 S 1.3358 $66.07 05735 LEVEL 5 MINOR PROCEDURES 1/1/2018 S 4.1967 $207.57 05741 LEVEL 1 ELECTRONIC ANALYSIS OF DEVICES 1/1/2018 S 0.4799 $23.74 05742 LEVEL 2 ELECTRONIC ANALYSIS OF DEVICES 1/1/2018 S 1.4647 $72.44 05743 LEVEL 3 ELECTRONIC ANALYSIS OF DEVICES 1/1/2018 S 3.3304 $164.72 05771 CARDIAC REHABILITATION 1/1/2018 S 1.4835 $73.37 05781 RESUSCITATION AND CARDIOVERSION 1/1/2018 S 6.5194 $322.45 05791 PULMONARY TREATMENT 1/1/2018 S 2.3701 $117.23 05801 VENTILATION INITIATION AND MANAGEMENT 1/1/2018 S 5.8587 $289.77 05811 MANIPULATION THERAPY 1/1/2018 S 0.3412 $16.88 05821 LEVEL 1 HEALTH AND BEHAVIOR SERVICES 1/1/2018 S 0.3868 $19.13 05822 LEVEL 2 HEALTH AND BEHAVIOR SERVICES 1/1/2018 S 0.9149 $45.25 05823 LEVEL 3 HEALTH AND BEHAVIOR SERVICES 1/1/2018 S 1.5762 $77.96 05853 PARTIAL HOSPITALIZATION (3 OR MORE SERVICES) FOR CMHCS 1/1/2018 P 1.8224 $90.14 05863 PARTIAL HOSPITALIZATION (3 OR MORE SERVICES) FOR HOSPITAL-BASED P 1/1/2018 P 2.6480 $130.97 05871 DENTAL PROCEDURES 1/1/2018 S 9.8229 $485.84 05881 ANCILLARY OUTPATIENT SERVICES WHEN PATIENT DIES 1/1/2018 X 90.0067 $4,451.73 07000 AMIFOSTINE 7/1/2018 K 19.1540 $947.36 07011 OPRELVEKIN INJECTION 7/1/2018 K 8.3734 $414.15 07034 SOMATROPIN INJECTION 7/1/2018 K 1.4642 $72.42 07035 TENIPOSIDE 7/1/2018 K 50.3982 $2,492.69 07041 TIROFIBAN HCL 7/1/2018 K 0.1641 $8.12 07043 NOT BIOSIMIL 10MG 7/1/2018 K 1.6456 $81.39 07046 DOXORUBICIN INJ 10MG 7/1/2018 K 7.3060 $361.35 07048 ALTEPLASE RECOMBINANT 7/1/2018 K 1.7186 $85.00 07308 AMINOLEVULINIC ACID HCL TOP 4/1/2018 K 7.9356 $392.49 08001 LDR PROSTATE BRACHYTHERAPY COMPOSITE 1/1/2018 D 0.0000 $0.00 08004 ULTRASOUND COMPOSITE 1/1/2018 S 3.8136 $188.62 08005 CT AND CTA WITHOUT CONTRAST COMPOSITE 1/1/2018 S 3.4951 $172.87 08006 CT AND CTA WITH CONTRAST COMPOSITE 1/1/2018 S 6.3692 $315.02

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08007 MRI AND MRA WITHOUT CONTRAST COMPOSITE 1/1/2018 S 7.0727 $349.82 08008 MRI AND MRA WITH CONTRAST COMPOSITE 1/1/2018 S 11.0873 $548.38 08010 MENTAL HEALTH SERVICES COMPOSITE 1/1/2018 S 2.6480 $130.97 08011 COMPREHENSIVE OBSERVATION SERVICES 1/1/2018 S 29.8822 $1,477.97 09002 TENECTEPLASE INJECTION 7/1/2018 K 2.3738 $117.41 09003 PALIVIZUMAB 4/1/2018 K 29.6987 $1,468.90 09005 RETEPLASE INJECTION 4/1/2018 K 45.1493 $2,233.08 09006 INJECTION 7/1/2018 K 4.0467 $200.15 09012 ARSENIC TRIOXIDE INJECTION 7/1/2018 K 1.5115 $74.76 09014 INJECTION, CERLIPONASE ALFA 4/1/2018 G 1.8712 $92.55 09015 C-1 ESTERASE, HAEGARDA 4/1/2018 G 0.1896 $9.38 09016 INJ, TRIPTORELIN EXT REL 4/1/2018 G 55.4418 $2,742.15 09018 INJ, RIMABOTULINUMTOXINB 7/1/2018 K 0.2357 $11.66 09019 CASPOFUNGIN ACETATE 7/1/2018 K 0.2668 $13.20 09024 AMPHOTERICIN B LIPID COMPLEX 7/1/2018 K 0.3793 $18.76 09028 INJ. INOTUZUMAB OZOGAMICIN 4/1/2018 G 43.1984 $2,136.59 09029 INJECTION, GUSELKUMAB 7/1/2018 G 2.0228 $100.05 09030 INJ COPANLISIB 7/1/2018 G 1.4039 $69.44 09031 INJ, ETELCALCETIDE, 0.1 MG 7/1/2018 K 0.0622 $3.08 09032 BACLOFEN 10 MG INJECTION 7/1/2018 K 3.3993 $168.13 09033 CIDOFOVIR INJECTION 7/1/2018 K 9.1520 $452.66 09034 INJ CUVITRU, 100 MG 7/1/2018 K 0.2648 $13.10 09035 AXICABTAGENE CILOLEUCEL CAR+ 4/1/2018 G 7754.9159 $383,558.14 09036 INJECTION, RENFLEXIS 7/1/2018 G 1.3577 $67.15 09038 INJ ESTROGEN CONJUGATE 7/1/2018 K 6.0880 $301.11 09042 GLUCAGON HYDROCHLORIDE 7/1/2018 K 3.8702 $191.42 09043 INJ, AFSTYLA, 1 I.U. 7/1/2018 G 0.0273 $1.35 09044 IBUTILIDE FUMARATE INJECTION 7/1/2018 K 5.8577 $289.72 09052 FLUCICIOVINE F-18 4/1/2018 G 7.6406 $377.90 09056 GALLIUM GA-68 7/1/2018 G 1.3090 $64.74 09058 BUPRENORPHINE IMPLANT 74.2MG 7/1/2018 G 24.5354 $1,213.52 09059 VONVENDI INJ 1 IU VWF:RCO 4/1/2018 G 0.0445 $2.20 09060 DIAZOXIDE INJECTION 1/1/2018 D 0.0000 $0.00 09061 INJ MILRINONE LACTATE / 5 MG 1/1/2018 D 0.0000 $0.00 09062 TOPOTECAN INJECTION 1/1/2018 D 0.0000 $0.00 09064 ARIPIPRAZOLE INJECTION 7/1/2018 K 0.0148 $0.73 09065 ARGATROBAN ESRD DIALYSIS 1MG 7/1/2018 K 0.0258 $1.28 09066 INJ DIHYDROERGOTAMINE MESYLT 7/1/2018 K 1.8082 $89.43 09067 LUTETIUM LU 177 DOTATATE, TX 7/1/2018 G 987.5563 $48,844.53 09070 VORETIGNE NEPARVOVEC-RZYL 7/1/2018 G 58.9069 $2,913.54 09071 CAPSAICIN 8% PATCH 4/1/2018 K 0.0618 $3.06 09072 FOSPHENYTOIN INJ PE 7/1/2018 K 0.0696 $3.44 09073 BUPRENORPH XR 100 MG OR LESS 7/1/2018 G 32.8492 $1,624.72 09074 MAKENA, 10 MG 7/1/2018 K 0.5549 $27.45 09075 INJ, KOVALTRY, 1 I.U. 7/1/2018 K 0.0248 $1.23 09076 DIMECAPROL INJECTION 7/1/2018 K 0.9894 $48.94

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09077 EPOETIN BETA NON ESRD 7/1/2018 K 0.0350 $1.73 09078 TESTOSTERONE UNDECANOATE 1MG 7/1/2018 K 0.0260 $1.29 09079 GENVISC 850, INJ, 1MG 7/1/2018 K 0.1226 $6.06 09080 FLUDARABINE PHOSPHATE INJ 7/1/2018 K 1.4569 $72.06 09081 TISAGENLECLEUCEL CAR-POS T 7/1/2018 G 9824.8685 $485,938.00 09096 INJ RETACRIT ESRD ON DIALYSI 7/1/2018 K 0.0229 $1.13 09097 INJ RETACRIT NON-ESRD USE 7/1/2018 K 0.2293 $11.34 09104 ANTITHYMOCYTE GLOBULN RABBIT 7/1/2018 K 14.2336 $703.99 09108 THYROTROPIN INJECTION 7/1/2018 K 31.5531 $1,560.62 09119 INJECTION, PEGFILGRASTIM 6MG 7/1/2018 K 92.5938 $4,579.69 09120 INJECTION, FULVESTRANT 7/1/2018 K 1.9073 $94.34 09122 TRIPTORELIN PAMOATE 7/1/2018 K 5.1407 $254.26 09124 DAPTOMYCIN INJECTION 7/1/2018 K 0.0070 $0.35 09125 RISPERIDONE, LONG ACTING 7/1/2018 K 0.1844 $9.12 09126 INJECTION 7/1/2018 K 0.3903 $19.30 09130 INJ, IMM GLOB BIVIGAM, 500MG 7/1/2018 K 1.3831 $68.41 09131 INJ, ADO-TRASTUZUMAB EMT 1MG 7/1/2018 K 0.6020 $29.77 09132 KCENTRA, PER I.U. 7/1/2018 K 0.0379 $1.87 09133 RABIES IG, IM/SC 7/1/2018 K 5.8022 $286.98 09134 RABIES IG, HEAT TREATED 7/1/2018 K 5.9909 $296.31 09135 VARICELLA-ZOSTER IG, IM 7/1/2018 K 29.4081 $1,454.52 09139 RABIES VACCINE, IM 7/1/2018 K 5.6676 $280.32 09140 RABIES VACCINE, ID 7/1/2018 K 3.8549 $190.66 09171 FACTOR IX IDELVION INJ 7/1/2018 G 0.0848 $4.19 09207 BORTEZOMIB INJECTION 7/1/2018 K 0.9168 $45.34 09208 AGALSIDASE BETA INJECTION 7/1/2018 K 3.4259 $169.45 09209 LARONIDASE INJECTION 4/1/2018 K 0.6004 $29.70 09210 PALONOSETRON HCL 7/1/2018 K 0.4434 $21.93 09213 PEMETREXED INJECTION 7/1/2018 K 1.3231 $65.44 09214 BEVACIZUMAB INJECTION 7/1/2018 K 1.5466 $76.49 09215 CETUXIMAB INJECTION 7/1/2018 K 1.1921 $58.96 09217 LEUPROLIDE ACETATE SUSPNSION 7/1/2018 K 4.2792 $211.65 09224 GALSULFASE INJECTION 7/1/2018 K 7.5163 $371.76 09225 FLUOCINOLONE ACETONIDE IMPLT 7/1/2018 K 400.0298 $19,785.47 09228 TIGECYCLINE INJECTION 7/1/2018 K 0.0442 $2.19 09229 IBANDRONATE SODIUM INJECTION 7/1/2018 K 1.5320 $75.77 09230 INJECTION 7/1/2018 K 1.0126 $50.08 09231 DECITABINE INJECTION 7/1/2018 K 0.2843 $14.06 09232 IDURSULFASE INJECTION 7/1/2018 K 10.6487 $526.68 09233 RANIBIZUMAB INJECTION 7/1/2018 K 7.3258 $362.33 09234 ALGLUCOSIDASE ALFA INJECTION 4/1/2018 K 3.1310 $154.86 09235 PANITUMUMAB INJECTION 7/1/2018 K 2.2367 $110.63 09236 INJECTION 4/1/2018 K 4.5206 $223.59 09237 INJ, LANREOTIDE ACETATE 7/1/2018 K 1.1569 $57.22 09239 BUPRENORPHINE XR OVER 100 MG 7/1/2018 G 32.8492 $1,624.72 09240 INJECTION, IXABEPILONE 7/1/2018 K 1.3846 $68.48

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09242 INJECTION, FOSAPREPITANT 7/1/2018 K 0.0408 $2.02 09243 INJ., TREANDA 1 MG 7/1/2018 K 0.6031 $29.83 09245 ROMIPLOSTIM INJECTION 7/1/2018 K 1.3837 $68.44 09248 INJ, CLEVIDIPINE BUTYRATE 1/1/2018 D 0.0000 $0.00 09251 C1 ESTERASE INHIBITOR INJ 7/1/2018 K 1.0972 $54.27 09252 PLERIXAFOR INJECTION 7/1/2018 K 6.4689 $319.95 09253 TEMOZOLOMIDE INJECTION 7/1/2018 K 0.2071 $10.24 09255 PALIPERIDONE PALMITATE INJ 7/1/2018 K 0.2133 $10.55 09256 DEXAMETHASONE INTRA IMPLANT 7/1/2018 K 3.9266 $194.21 09257 INJ. EMICIZUMAB-KXWH, 0.5 MG 7/1/2018 G 0.9704 $48.00 09258 TELAVANCIN INJECTION 7/1/2018 K 0.1076 $5.32 09259 PRALATREXATE INJECTION 7/1/2018 K 5.2384 $259.09 09260 OFATUMUMAB INJECTION 7/1/2018 K 1.1462 $56.69 09261 SUB CU INJ, 1 MG 7/1/2018 K 3.8354 $189.70 09263 ECALLANTIDE INJECTION 7/1/2018 K 9.3532 $462.61 09264 INJECTION 7/1/2018 K 0.0926 $4.58 09265 ROMIDEPSIN INJECTION 7/1/2018 K 6.4538 $319.20 09269 C-1 ESTERASE, BERINERT 7/1/2018 K 0.9598 $47.47 09270 GAMMAPLEX IVIG 7/1/2018 K 1.0939 $54.10 09271 VELAGLUCERASE ALFA 7/1/2018 K 6.7717 $334.93 09272 INJ, DENOSUMAB 7/1/2018 K 0.3605 $17.83 09273 SIPULEUCEL-T AUTO CD54+ 7/1/2018 K 814.6140 $40,290.81 09274 CROTALIDAE POLY IMMUNE FAB 7/1/2018 K 63.3907 $3,135.30 09276 CABAZITAXEL INJECTION 7/1/2018 K 3.2085 $158.69 09278 INCOBOTULINUMTOXIN A 4/1/2018 K 0.0996 $4.93 09281 INJECTION, PEGLOTICASE 7/1/2018 K 45.5445 $2,252.63 09284 INJECTION 7/1/2018 K 2.9152 $144.19 09286 BELATACEPT INJECTION 7/1/2018 K 0.0751 $3.71 09287 BRENTUXIMAB VEDOTIN INJ 7/1/2018 K 2.9581 $146.31 09289 ERWINAZE INJECTION 7/1/2018 K 8.1363 $402.42 09293 INJECTION, GLUCARPIDASE 7/1/2018 K 5.8590 $289.79 09294 INJ, TALIGLUCERASE ALFA 10 U 7/1/2018 K 0.7922 $39.18 09295 INJECTION, CARFILZOMIB, 1 MG 7/1/2018 K 0.6903 $34.14 09296 INJ, ZIV-AFLIBERCEPT, 1MG 7/1/2018 K 0.1586 $7.84 09297 INJ, OMACETAXINE MEP, 0.01MG 7/1/2018 K 0.0583 $2.88 09298 INJ, OCRIPLASMIN, 0.125 MG 7/1/2018 K 19.9805 $988.24 09300 INJECTION 7/1/2018 K 0.7126 $35.25 09301 AMINOLEVULINIC ACID, 10% GEL 4/1/2018 G 0.0272 $1.35 09302 INJ, DAUNORUBICIN-CYTARABINE 4/1/2018 G 3.6620 $181.12 09441 INJ FERRIC CARBOXYMALTOS 1MG 7/1/2018 K 0.0210 $1.04 09445 INJECTION, RUCONEST 7/1/2018 K 0.5436 $26.89 09448 NETUPITANT PALONOSETRON ORAL 7/1/2018 K 6.6809 $330.44 09449 INJECTION, BLINATUMOMAB 7/1/2018 K 2.1560 $106.64 09450 FLUOCINOL ACET INTRAVIT IMP 7/1/2018 K 9.6147 $475.54 09451 INJECTION, PERAMIVIR 7/1/2018 K 0.0317 $1.57 09452 INJ CEFTOLOZANE TAZOBACTAM 7/1/2018 K 0.1072 $5.30

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09453 INJECTION, NIVOLUMAB 4/1/2018 K 0.5326 $26.34 09454 INJ, PASIREOTIDE LONG ACTING 7/1/2018 K 5.5064 $272.35 09455 INJECTION, SILTUXIMAB 7/1/2018 K 1.8681 $92.40 09456 INJECTION, ISAVUCONAZONIUM 7/1/2018 K 0.0166 $0.82 09457 INJ SULF HEXA LIPID MICROSPH 1/1/2018 D 0.0000 $0.00 09458 FLORBETABEN F18 DIAGNOSTIC 4/1/2018 G 58.2138 $2,879.25 09459 FLUTEMETAMOL F18 DIAGNOSTIC 4/1/2018 G 68.6092 $3,393.41 09460 INJECTION, CANGRELOR 7/1/2018 G 0.3038 $15.03 09461 CHOLINE C-11, DIAGNOSTIC, PER STUDY DOSE UP TO 20 MILLICURIES 4/1/2018 G 111.7988 $5,529.57 09462 INJECTION, DELAFLOXACIN 4/1/2018 G 0.0092 $0.46 09463 INJECTION, APREPITANT 4/1/2018 G 0.0472 $2.33 09464 INJECTION, ROLAPITANT 4/1/2018 G 0.0184 $0.91 09465 INJECTION, DUROLANE 4/1/2018 G 20.2709 $1,002.60 09466 INJECTION, BENRALIZUMAB 7/1/2018 G 3.2902 $162.73 09467 INJ RITUXIMAB HYALURONIDASE 7/1/2018 G 0.9097 $44.99 09468 INJ, FACTOR IX, REBINYN 4/1/2018 G 0.0874 $4.32 09469 INJ., TRIAMCINOLONE EXT REL 4/1/2018 G 0.3703 $18.32 09470 ARIPIPRAZOLE LAUROXIL 1MG 7/1/2018 G 0.0482 $2.38 09471 HYMOVIS INJECTION 1 MG 7/1/2018 G 0.3777 $18.68 09472 INJ TALIMOGENE LAHERPAREPVEC 7/1/2018 G 0.9748 $48.21 09473 INJECTION, , 1MG 7/1/2018 G 0.5814 $28.76 09474 INJ IRINOTECAN LIPOSOME 1 MG 7/1/2018 G 0.8950 $44.27 09475 INJECTION, NECITUMUMAB, 1 MG 7/1/2018 G 0.1080 $5.34 09476 INJECTION, DARATUMUMAB 10 MG 7/1/2018 G 0.9993 $49.43 09477 INJECTION, ELOTUZUMAB, 1MG 7/1/2018 G 0.1259 $6.23 09478 INJ SEBELIPASE ALFA 1 MG 7/1/2018 G 10.5273 $520.68 09479 INSTILL, CIPROFLOXACIN OTIC 4/1/2018 G 0.5879 $29.08 09480 INJECTION TRABECTEDIN 0.1MG 7/1/2018 G 5.8139 $287.56 09481 INJECTION, 7/1/2018 G 0.1787 $8.84 09482 SOTALOL HYDROCHLORIDE IV 7/1/2018 G 0.1958 $9.68 09483 INJ, ATEZOLIZUMAB,10 MG 7/1/2018 G 1.5082 $74.60 09484 INJ, ETEPLIRSEN, 10 MG 7/1/2018 G 3.2989 $163.16 09485 INJ, OLARATUMAB, 10 MG 7/1/2018 G 1.0010 $49.51 09486 INJ, GRANISETRON, XR, 0.1 MG 7/1/2018 G 0.0762 $3.77 09487 USTEKINUMAB, IV INJECT,1 MG 7/1/2018 G 0.2461 $12.17 09488 CONIVAPTAN HCL 7/1/2018 G 0.6037 $29.86 09489 INJ, NUSINERSEN, 0.1MG 7/1/2018 G 21.6272 $1,069.68 09490 INJ, BEZLOTOXUMAB, 10 MG 7/1/2018 G 0.7877 $38.96 09491 INJECTION, AVELUMAB, 10 MG 7/1/2018 G 1.5807 $78.18 09492 INJECTION, DURVALUMAB 7/1/2018 G 1.4411 $71.28 09493 INJECTION, EDARAVONE 7/1/2018 G 0.3763 $18.61 09494 INJECTION, 7/1/2018 G 1.1214 $55.46 09495 GEMTUZUMAB OZOGAMICIN INJ 4/1/2018 G 3.7885 $187.38 09497 LOXAPINE, INHALATION POWDER 7/1/2018 K 2.9687 $146.83 09500 PLATELETS, IRRADIATED 1/1/2018 R 2.2781 $112.67 09501 PLATELET PHERES LEUKOREDUCED 1/1/2018 R 6.0659 $300.02

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09502 PLATELET PHERESIS IRRADIATED 1/1/2018 R 7.0509 $348.74 09503 FR FRZ PLASMA DONOR RETESTED 1/1/2018 R 0.6149 $30.41 09504 RBC DEGLYCEROLIZED 1/1/2018 R 5.3516 $264.69 09505 RBC IRRADIATED 1/1/2018 R 2.7187 $134.47 09507 PLATELETS, PHERESIS 1/1/2018 R 5.3563 $264.92 09508 PLASMA 1 DONOR FRZ W/IN 8 HR 1/1/2018 R 0.9208 $45.54 09509 FROZEN PLASMA, POOLED, SD 1/1/2018 R 0.7703 $38.10 09510 WHOLE BLOOD FOR TRANSFUSION 1/1/2018 R 1.9955 $98.70 09511 CRYOPRECIPITATE EACH UNIT 1/1/2018 R 0.5597 $27.68 09512 RBC LEUKOCYTES REDUCED 1/1/2018 R 2.3370 $115.59 09513 PLASMA, FRZ BETWEEN 8-24HOUR 1/1/2018 R 0.9441 $46.70 09514 PLASMA PROTEIN FRACT,5%,50ML 1/1/2018 R 0.1958 $9.68 09515 PLATELETS, EACH UNIT 1/1/2018 R 1.4618 $72.30 09516 PLAELET RICH PLASMA UNIT 1/1/2018 R 1.5706 $77.68 09517 RED BLOOD CELLS UNIT 1/1/2018 R 1.8158 $89.81 09518 WASHED RED BLOOD CELLS UNIT 1/1/2018 R 4.8868 $241.70 09519 PLASMAPROTEIN FRACT,5%,250ML 1/1/2018 R 0.5964 $29.50 09520 BLOOD SPLIT UNIT 1/1/2018 R 1.3057 $64.58 09521 PLATELETS LEUKOREDUCED IRRAD 1/1/2018 R 2.1320 $105.45 09522 RBC LEUKOREDUCED IRRADIATED 1/1/2018 R 3.3089 $163.66 09523 CRYOPRECIPITATEREDUCEDPLASMA 1/1/2018 R 1.3421 $66.38 09524 BLOOD, L/R, CMV-NEG 1/1/2018 R 2.4502 $121.19 09525 PLATELETS, HLA-M, L/R, UNIT 1/1/2018 R 9.7833 $483.88 09526 PLATELETS LEUKOCYTES REDUCED 1/1/2018 R 1.4841 $73.40 09527 BLOOD, L/R, FROZ/DEGLY/WASH 1/1/2018 R 3.6052 $178.31 09528 PLT, APH/PHER, L/R, CMV-NEG 1/1/2018 R 4.3231 $213.82 09529 BLOOD, L/R, IRRADIATED 1/1/2018 R 1.9742 $97.64 09530 PLATE PHERES LEUKOREDU IRRAD 1/1/2018 R 7.9437 $392.90 09531 PLT, PHER, L/R CMV-NEG, IRR 1/1/2018 R 6.8649 $339.54 09532 RBC, FRZ/DEG/WSH, L/R, IRRAD 1/1/2018 R 3.5830 $177.22 09533 RBC, L/R, CMV-NEG, IRRAD 1/1/2018 R 3.0272 $149.73 09534 PATHOGEN REDUCED PLASMA POOL 1/1/2018 R 0.9441 $46.70 09535 PATHOGEN REDUCED PLASMA SING 1/1/2018 R 0.9208 $45.54 09536 PLATELETS, PATHOGEN REDUCED 1/1/2018 R 7.9437 $392.90

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