CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

Procedure Relative Payment Payment CT FEE Code Short Descriptor SI APC Weight Rate Type SCHED Change 0015M Adrnl cortcl tum bchm asy 25 Q4 No New 0016M Onc bladder mrna 209 gen alg Q4 No New 0203U Ai ibd mrna xprsn prfl 17 Q4 No New 0204U Onc thyr mrna xprsn alys 593 A No New 0205U Oph amd alys 3 gene variants A No New 0206U Neuro alzheimer cell aggregj Q4 No New 0207U Neuro alzheimer quan imaging N No New 0208U Onc mtc mrna xprsn alys 108 A No New 0209U Cytog const alys interrog A No New 0210U Syphilis tst antb ia quan Q4 No New 0211U Onc pan-tum dna&rna gnrj seq E1 No New 0212U Rare ds gen dna alys proband A No New 0213U Rare ds gen dna alys ea comp A No New 0214U Rare ds xom dna alys proband A No New 0215U Rare ds xom dna alys ea comp A No New 0216U Neuro inh ataxia dna 12 com A No New 0217U Neuro inh ataxia dna 51 gene A No New 0218U Neuro musc dys dmd seq alys A No New 0219U Nfct agt hiv gnrj seq alys A No New 0220U Onc brst ca ai assmt 12 feat Q4 No New 0221U Abo gnotyp next gnrj seq abo A No New 0222U Rhd&rhce gntyp next gnrj seq A No New 0225U Nfct ds dna&rna 21 sarscov2 A No New 0226U Svnt sarscov2 elisa plsm srm A No New 86408 Neutrlzg antb sarscov2 scr A FS LAB New 86409 Neutrlzg antb sarscov2 titer A FS LAB New 86413 Sars-cov-2 antb quantitative A FS LAB New 87426 Coronavirus ag ia A FS LAB New 87636 Sarscov2 & inf a&b amp prb A FS LAB New 87637 Sarscov2&inf a&b&rsv amp prb A FS LAB New 87811 Sars-cov-2 covid19 w/optic A FS LAB New 90371 Hep b ig im K 01630 $119.09 APC-PR G K 90375 Rabies ig im/sc K 09133 $273.04 APC-PR G K 90376 Rabies ig heat treated K 09134 $331.80 APC-PR G K 90675 Rabies vaccine im K 09139 $303.24 APC-PR G K 99072 Addl supl matrl&staf tm phe B No New A4226 Weekly supply maint cgs pump E1 No X A9543 Y90 ibritumomab, rx K 01643 $56,746.93 APC-PR G K A9586 Florbetapir f18 N APC X A9604 Sm 153 lexidronam K 01295 $17,259.85 APC-PR G K A9606 Radium ra223 dichloride ther K 01745 $140.96 APC-PR G K C9046 Cocaine hcl nasal solution G 09307 $1.23 APC-PR G K C9047 Injection, caplacizumab-yhdp G 09199 $690.68 APC-PR G K C9060 Fluoroestradiol f18 G 09370 $0.75 APC-PR New C9062 Daratumumab hyaluronidase G 09378 $43.34 APC-PR New C9064 Mitomycin pyelocalyceal inst G 09374 $275.22 APC-PR New as of 11/3/2020 Page 1 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

C9065 Romidepsin non-lyophilized G 09379 $329.46 APC-PR New C9066 Sacituzumab govitecan-hziy G 09376 $28.79 APC-PR New C9067 Gallium ga-68 dotatoc G 09323 $8.64 APC-PR New C9122 Mometasone furoate (sinuva) G 09346 $10.25 APC-PR G K C9257 Bevacizumab injection K 01281 $1.91 APC-PR G K C9460 Injection, cangrelor K 09460 $15.32 APC-PR G K C9462 Injection, delafloxacin G 09462 $0.28 APC-PR G K C9488 Conivaptan hcl K 09488 $32.57 APC-PR G K C9761 Cysto, litho, vacuum kidney J1 05375 52.3761 $4,231.62 APC New C9768 Endo us-guide hep porto grad N No New C9769 Cysto w/temp pros implant J1 05375 52.3761 $4,231.62 APC New E0787 Cgs dose adj insulin inf pmp E1 No X G1020 Cdsm curbside E1 No New G1021 Cdsm ehealthline E1 No New G1022 Cdsm intermountain E1 No New G1023 Cdsm persivia E1 No New J0121 Inj., omadacycline, 1 mg G 09311 $3.15 APC-PR G K J0122 Inj., eravacycline, 1 mg K 09325 $1.02 APC-PR G K J0129 Abatacept injection K 09230 $58.10 APC-PR G K J0135 Adalimumab injection K 01083 $1,430.92 APC-PR G K J0178 Aflibercept injection K 01420 $928.24 APC-PR G K J0179 Inj, brolucizumab-dbll, 1 mg G 09340 $311.99 APC-PR G K J0180 Agalsidase beta injection K 09208 $188.99 APC-PR G K J0185 Inj., aprepitant, 1 mg G 09463 $1.73 APC-PR G K J0202 Injection, alemtuzumab K 01809 $1,984.32 APC-PR G K J0221 Lumizyme injection K 01413 $174.49 APC-PR G K J0222 Inj., patisiran, 0.1 mg G 09180 $97.84 APC-PR G K J0223 Inj givosiran 0.5 mg G 09343 $106.88 APC-PR G K J0256 Alpha 1 proteinase inhibitor K 00901 $4.36 APC-PR G K J0257 Glassia injection K 01415 $4.83 APC-PR G K J0287 Amphotericin b lipid complex K 09024 $9.36 APC-PR G K J0289 Amphotericin b liposome inj K 00736 $26.56 APC-PR G K J0291 Inj., plazomicin, 5 mg G 09183 $3.11 APC-PR G K J0475 Baclofen 10 mg injection K 09032 $171.59 APC-PR G K J0480 Basiliximab K 01683 $4,005.19 APC-PR G K J0485 Belatacept injection K 09286 $3.78 APC-PR G K J0490 Belimumab injection K 01353 $46.18 APC-PR G K J0517 Inj., benralizumab, 1 mg G 09466 $170.11 APC-PR G K J0558 Peng benzathine/procaine inj K 09088 $12.00 APC-PR G K J0561 Penicillin g benzathine inj K 01829 $15.16 APC-PR G K J0565 Inj, bezlotoxumab, 10 mg K 09490 $39.65 APC-PR G K J0567 Inj., cerliponase alfa 1 mg G 09014 $95.36 APC-PR G K J0570 Buprenorphine implant 74.2mg K 09058 $1,207.16 APC-PR G K J0584 Injection, burosumab-twza 1m K 09187 $361.90 APC-PR G K J0585 Injection,onabotulinumtoxina K 00902 $6.08 APC-PR G K J0586 Abobotulinumtoxina K 01289 $8.15 APC-PR G K J0587 Inj, rimabotulinumtoxinb K 09018 $11.93 APC-PR G K J0593 Inj., lanadelumab-flyo, 1 mg K 09326 $78.65 APC-PR G K J0594 Busulfan injection K 01178 $3.41 APC-PR G K J0596 Injection, ruconest K 09445 $29.11 APC-PR G K J0597 C-1 esterase, berinert K 09269 $54.13 APC-PR G K J0598 C-1 esterase, cinryze K 09251 $56.20 APC-PR G K

as of 11/3/2020 Page 2 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

J0599 Inj., haegarda 10 units G 09015 $9.92 APC-PR G K J0606 Inj, etelcalcetide, 0.1 mg K 09031 $2.15 APC-PR G K J0630 Calcitonin salmon injection K 01433 $2,839.22 APC-PR G K J0638 Canakinumab injection K 01311 $113.24 APC-PR G K J0695 Inj ceftolozane tazobactam K 09452 $6.49 APC-PR G K J0712 Ceftaroline fosamil inj K 01824 $3.32 APC-PR G K J0714 Ceftazidime and avibactam K 01825 $92.00 APC-PR G K J0716 Centruroides immune f(ab) K 01431 $5,063.56 APC-PR G K J0717 Certolizumab pegol inj 1mg K 01474 $8.16 APC-PR G K J0740 Cidofovir injection K 09033 $666.25 APC-PR G K J0742 Inj imip 4 cilas 4 releb 2mg G 09362 $2.26 APC-PR G K J0775 Collagenase, clost hist inj K 01340 $52.39 APC-PR G K J0791 Inj crizanlizumab-tmca 5mg G 09359 $122.41 APC-PR G K J0795 Corticorelin ovine triflutal K 01684 $9.38 APC-PR G K J0800 Corticotropin injection K 09316 $4,013.24 APC-PR G K J0840 Crotalidae poly immune fab K 09274 $3,043.75 APC-PR G K J0841 Inj crotalidae im f(ab')2 eq K 09188 $1,264.21 APC-PR G K J0850 Cytomegalovirus imm iv /vial K 00903 $1,496.95 APC-PR G K J0875 Injection, dalbavancin K 01823 $15.39 APC-PR G K J0878 Daptomycin injection K 09124 $0.16 APC-PR G K J0881 Darbepoetin alfa, non-esrd K 01685 $3.72 APC-PR G K J0882 Darbepoetin alfa, esrd use K 01482 $3.72 APC-PR G K J0883 Argatroban nonesrd use 1mg K 01859 $1.31 APC-PR G K J0884 Argatroban esrd dialysis 1mg K 09065 $1.31 APC-PR G K J0885 Epoetin alfa, non-esrd K 01686 $9.11 APC-PR G K J0894 Decitabine injection K 09231 $4.26 APC-PR G K J0896 Inj luspatercept-aamt 0.25mg G 09347 $36.32 APC-PR G K J0897 Denosumab injection K 09272 $20.12 APC-PR G K J1095 Injection, dexamethasone 9% G 09172 $1.11 APC-PR G K J1096 Dexametha opth insert 0.1 mg G 09308 $139.55 APC-PR G K J1097 Phenylep ketorolac opth soln N APC X J1162 Digoxin immune fab (ovine) K 01687 $3,972.14 APC-PR G K J1190 Dexrazoxane hcl injection K 00726 $199.93 APC-PR G K J1212 Dimethyl sulfoxide 50% 50 ml K 01832 $635.67 APC-PR G K J1290 Ecallantide injection K 09263 $494.69 APC-PR G K J1301 Injection, edaravone, 1 mg K 09493 $19.89 APC-PR X J1322 Elosulfase alfa, injection K 01480 $246.20 APC-PR G K J1327 Eptifibatide injection K 01607 $4.51 APC-PR G K J1410 Inj estrogen conjugate 25 mg K 09038 $325.62 APC-PR G K J1428 Inj, eteplirsen, 10 mg K 09484 $167.45 APC-PR G K J1429 Inj golodirsen 10 mg G 09356 $166.33 APC-PR G K J1437 Inj. fe derisomaltose 10 mg K 09388 $25.38 APC-PR New J1439 Inj ferric carboxymaltos 1mg K 09441 $1.11 APC-PR G K J1442 Inj filgrastim excl biosimil K 01469 $0.93 APC-PR G K J1447 Inj tbo filgrastim 1 microg K 01748 $0.47 APC-PR G K J1451 Fomepizole, 15 mg K 01689 $5.33 APC-PR G K J1453 Fosaprepitant injection K 09242 $0.79 APC-PR G K J1454 Inj fosnetupitant, palonoset G 09099 $695.77 APC-PR G K J1458 Galsulfase injection K 09224 $405.76 APC-PR G K J1459 Inj ivig privigen 500 mg K 01214 $41.50 APC-PR G K J1460 Gamma globulin 1 cc inj K 01850 $42.93 APC-PR G K J1555 Inj cuvitru, 100 mg K 09034 $14.02 APC-PR G K J1557 Gammaplex injection K 09270 $53.66 APC-PR G K J1558 Inj. xembify, 100 mg K 09372 $14.22 APC-PR G K

as of 11/3/2020 Page 3 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

J1559 Hizentra injection K 01312 $10.86 APC-PR G K J1560 Gamma globulin > 10 cc inj K 01851 $429.26 APC-PR G K J1561 Gamunex-c/gammaked K 00948 $42.19 APC-PR G K J1566 Immune globulin, powder K 02731 $68.30 APC-PR G K J1568 Octagam injection K 00943 $41.23 APC-PR G K J1569 Gammagard liquid injection K 00944 $43.20 APC-PR G K J1571 Hepagam b im injection K 00946 $63.40 APC-PR G K J1572 Flebogamma injection K 00947 $40.38 APC-PR G K J1573 Hepagam b intravenous, inj K 01138 $65.96 APC-PR G K J1575 Hyqvia 100mg immuneglobulin K 01826 $14.49 APC-PR G K J1595 Injection glatiramer acetate K 01015 $157.42 APC-PR G K J1602 Golimumab for iv use 1mg K 01475 $19.00 APC-PR G K J1610 Glucagon hydrochloride/1 mg K 09042 $211.79 APC-PR G K J1628 Inj., guselkumab, 1 mg G 09029 $93.12 APC-PR G K J1632 Inj., brexanolone, 1 mg G 09333 $76.91 No New J1640 Hemin, 1 mg K 01690 $24.44 APC-PR G K J1670 Tetanus immune globulin inj K 01670 $476.57 APC-PR G K J1726 Makena, 10 mg K 09074 $15.88 APC-PR G K J1738 Inj. meloxicam 1 mg G 09371 $3.26 APC-PR New J1740 Ibandronate sodium injection K 09229 $51.00 APC-PR G K J1742 Ibutilide fumarate injection K 09044 $316.20 APC-PR G K J1744 Icatibant injection K 01443 $276.57 APC-PR G K J1745 Infliximab not biosimil 10mg K 07043 $47.62 APC-PR G K J1746 Inj., ibalizumab-uiyk, 10 mg K 09189 $63.62 APC-PR G K J1750 Inj iron dextran K 01237 $15.01 APC-PR G K J1786 Imuglucerase injection K 01327 $43.38 APC-PR G K J1830 Interferon beta-1b / .25 mg K 00910 $393.83 APC-PR G K J1833 Injection, isavuconazonium K 09456 $0.78 APC-PR G K J1930 Lanreotide injection K 09237 $68.48 APC-PR G K J1931 Laronidase injection K 09209 $33.10 APC-PR G K J1943 Inj., aristada initio, 1 mg G 09179 $2.86 APC-PR G K J1944 Aripirazole lauroxil 1 mg K 09470 $2.85 APC-PR G K J1950 Leuprolide acetate /3.75 mg K 00800 $1,347.56 APC-PR G K J2182 Injection, mepolizumab, 1mg K 09473 $28.70 APC-PR G K J2265 Minocycline hydrochloride K 01853 $1.99 APC-PR G K J2278 Ziconotide injection K 01694 $8.17 APC-PR G K J2315 Naltrexone, depot form K 00759 $3.26 APC-PR G K J2323 Natalizumab injection K 09126 $21.63 APC-PR G K J2325 Nesiritide injection E1 No X J2326 Inj, nusinersen, 0.1mg K 09489 $1,122.51 APC-PR G K J2350 Injection, ocrelizumab, 1 mg K 09494 $57.38 APC-PR G K J2353 Octreotide injection, depot K 01207 $205.88 APC-PR G K J2357 Omalizumab injection K 09300 $37.70 APC-PR G K J2407 Injection, oritavancin K 01660 $23.80 APC-PR G K J2425 Palifermin injection K 01696 $22.81 APC-PR G K J2426 Paliperidone palmitate inj K 09255 $12.10 APC-PR G K J2502 Inj, pasireotide long acting K 09454 $332.59 APC-PR G K J2505 Injection, pegfilgrastim 6mg K 09119 $3,571.68 APC-PR G K J2507 Pegloticase injection K 09281 $2,801.08 APC-PR G K J2515 Pentobarbital sodium inj K 01854 $33.93 APC-PR G K J2547 Injection, peramivir K 09451 $1.60 APC-PR G K J2562 Plerixafor injection K 09252 $365.29 APC-PR G K J2597 Inj desmopressin acetate K 01440 $10.45 APC-PR G K J2760 Phentolaine mesylate inj K 01458 $359.14 APC-PR G K as of 11/3/2020 Page 4 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

J2770 Quinupristin/dalfopristin K 02770 $458.04 APC-PR G K J2778 Ranibizumab injection K 09233 $324.27 APC-PR G K J2783 Rasburicase K 00738 $300.94 APC-PR G K J2786 Injection, reslizumab, 1mg K 09481 $9.76 APC-PR G K J2792 Rho(d) immune globulin h, sd K 01609 $36.37 APC-PR G K J2794 Inj risperdal consta, 0.5 mg K 09125 $10.53 APC-PR G K J2796 Romiplostim injection K 09245 $78.43 APC-PR G K J2797 Inj., rolapitant, 0.5 mg E1 No X J2798 Inj., perseris, 0.5 mg G 09181 $10.18 APC-PR G K J2820 Sargramostim injection K 00731 $48.12 APC-PR G K J2860 Injection, siltuximab K 09455 $111.94 APC-PR G K J2997 Alteplase recombinant K 07048 $87.15 APC-PR G K J3031 Inj., fremanezumab-vfrm 1 mg G 09197 $2.25 APC-PR G K J3032 Inj. eptinezumab-jjmr 1 mg G 09357 $15.40 APC-PR New J3060 Inj, taliglucerase alfa 10 u K 09294 $40.86 APC-PR G K J3095 Telavancin injection K 09258 $5.14 APC-PR G K J3101 Tenecteplase injection K 09002 $129.26 APC-PR G K J3111 Inj. romosozumab-aqqg 1 mg G 09327 $9.01 APC-PR G K J3145 Testosterone undecanoate 1mg K 09078 $1.54 APC-PR G K J3240 Thyrotropin injection K 09108 $1,740.23 APC-PR G K J3241 Inj. teprotumumab-trbw 10 mg G 09355 $315.88 APC-PR New J3243 Tigecycline injection K 09228 $1.38 APC-PR G K J3245 Inj., tildrakizumab, 1 mg G 09306 $135.67 APC-PR G K J3246 Tirofiban hcl K 07041 $2.19 APC-PR G K J3262 Tocilizumab injection K 09264 $5.40 APC-PR G K J3285 Treprostinil injection K 01701 $62.81 APC-PR G K J3304 Inj triamcinolone ace xr 1mg G 09469 $18.20 APC-PR G K J3315 Triptorelin pamoate K 09122 $385.61 APC-PR G K J3316 Inj., triptorelin xr 3.75 mg G 09016 $3,044.01 APC-PR G K J3357 Ustekinumab sub cu inj, 1 mg K 09261 $184.36 APC-PR G K J3358 Ustekinumab, iv inject, 1 mg K 09487 $12.03 APC-PR G K J3380 Injection, vedolizumab K 01489 $20.30 APC-PR G K J3385 Velaglucerase alfa K 09271 $346.15 APC-PR G K J3396 Verteporfin injection K 01203 $11.23 APC-PR G K J3397 Inj., vestronidase alfa-vjbk K 09190 $223.01 APC-PR G K J3398 Inj luxturna 1 billion vec g G 09070 $2,883.20 APC-PR G K J3399 Inj onase abepar-xioi treat K 09373 ########### APC-PR G K J7170 Inj., emicizumab-kxwh 0.5 mg G 09257 $47.47 APC-PR G K J7177 Inj., fibryga, 1 mg K 09191 $1.07 APC-PR G K J7179 Vonvendi inj 1 iu vwf:rco K 09059 $1.78 APC-PR G K J7180 Factor xiii anti-hem factor K 01416 $8.77 APC-PR G K J7181 Factor xiii recomb a-subunit K 01746 $15.53 APC-PR G K J7182 Factor viii recomb novoeight K 01856 $1.33 APC-PR G K J7183 Wilate injection K 01352 $1.02 APC-PR G K J7185 Xyntha inj K 01268 $1.31 APC-PR G K J7186 Antihemophilic viii/vwf comp K 01213 $1.14 APC-PR G K J7190 Factor viii K 00925 $1.02 APC-PR G K J7192 Factor viii recombinant nos K 00927 $1.38 APC-PR G K J7193 Factor ix non-recombinant K 00931 $1.16 APC-PR G K J7194 Factor ix complex K 00928 $1.49 APC-PR G K J7195 Factor ix recombinant nos K 00932 $1.53 APC-PR G K J7197 Antithrombin iii injection K 01263 $3.50 APC-PR G K J7198 Anti-inhibitor K 00929 $2.05 APC-PR G K J7200 Factor ix recombinan rixubis K 01467 $1.46 APC-PR G K as of 11/3/2020 Page 5 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

J7203 Factor ix recomb gly rebinyn G 09468 $4.01 APC-PR G K J7204 Inj recombin esperoct per iu G 09354 $2.29 APC-PR G K J7205 Factor viii fc fusion recomb K 01656 $2.17 APC-PR G K J7209 Factor viii nuwiq recomb 1iu K 01846 $1.36 APC-PR G K J7210 Inj, afstyla, 1 i.u. K 09043 $1.34 APC-PR G K J7308 Aminolevulinic acid hcl top K 07308 $394.75 APC-PR G K J7311 Inj., retisert, 0.01 mg K 09225 $340.62 APC-PR G K J7312 Dexamethasone intra implant K 09256 $199.76 APC-PR G K J7313 Inj., iluvien, 0.01 mg K 09450 $490.87 APC-PR G K J7323 Euflexxa inj per dose K 00875 $140.31 APC-PR G K J7324 Orthovisc inj per dose K 00877 $128.41 APC-PR G K J7325 Synvisc or synvisc-one K 00874 $10.22 APC-PR G K J7326 Gel-one K 01417 $1,219.00 APC-PR G K J7327 Monovisc inj per dose K 01747 $694.58 APC-PR G K J7331 Synojoynt, inj., 1 mg G 09337 $4.39 No X J7340 Carbidopa levodopa ent 100ml K 09320 $213.10 APC-PR G K J7342 Ciprofloxacin otic susp 6 mg K 09479 $29.97 APC-PR G K J7351 Inj bimatoprost itc imp 1mcg G 09351 $200.85 APC-PR New J7501 Azathioprine parenteral K 00887 $227.93 APC-PR G K J7504 Lymphocyte immune globulin K 00890 $2,257.67 APC-PR G K J7511 Antithymocyte globuln rabbit K 09104 $817.12 APC-PR G K J7525 Tacrolimus injection K 09006 $211.97 APC-PR G K J8510 Oral busulfan K 09335 $23.81 APC-PR G K J8560 Etoposide oral 50 mg K 00802 $75.49 APC-PR G K J8655 Oral netupitant, palonosetro K 09448 $270.10 APC-PR G K J8670 Rolapitant, oral, 1mg K 01761 $2.27 APC-PR G K J9017 Arsenic trioxide injection K 09012 $22.06 APC-PR G K J9019 Erwinaze injection K 09289 $427.27 APC-PR G K J9022 Inj, atezolizumab,10 mg K 09483 $78.28 APC-PR G K J9023 Injection, avelumab, 10 mg K 09491 $84.70 APC-PR G K J9025 Azacitidine injection K 01709 $0.80 APC-PR G K J9027 Clofarabine injection K 01710 $52.64 APC-PR G K J9030 Bcg live intravesical 1mg K 09322 $2.79 APC-PR G K J9032 Injection, belinostat, 10mg K 01658 $42.79 APC-PR G K J9033 Inj., treanda 1 mg K 09243 $24.69 APC-PR G K J9034 Inj., bendeka 1 mg K 01861 $20.27 APC-PR G K J9035 Bevacizumab injection K 09214 $76.36 APC-PR G K J9036 Inj. belrapzo/bendamustine G 09313 $21.61 APC-PR G K J9039 Injection, blinatumomab K 09449 $118.59 APC-PR G K J9041 Inj., velcade 0.1 mg K 09207 $44.97 APC-PR G K J9042 Brentuximab vedotin inj K 09287 $175.28 APC-PR G K J9043 Cabazitaxel injection K 09276 $181.51 APC-PR G K J9044 Inj, bortezomib, nos, 0.1 mg K 09192 $22.04 APC-PR G K J9047 Injection, carfilzomib, 1 mg K 09295 $39.20 APC-PR G K J9050 Carmustine injection K 00812 $2,016.27 APC-PR G K J9055 Cetuximab injection K 09215 $64.29 APC-PR G K J9057 Inj., copanlisib, 1 mg G 09030 $78.99 APC-PR G K J9065 Inj cladribine per 1 mg K 00858 $19.57 APC-PR G K J9070 Cyclophosphamide 100 mg inj K 01408 $29.67 APC-PR G K J9119 Inj., cemiplimab-rwlc, 1 mg G 09304 $27.40 APC-PR G K J9120 Dactinomycin injection K 00752 $1,044.53 APC-PR G K J9145 Injection, daratumumab 10 mg K 09476 $56.29 APC-PR G K J9150 Daunorubicin injection K 00820 $43.84 APC-PR G K J9153 Inj daunorubicin, cytarabine G 09302 $197.79 APC-PR G K

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J9155 Degarelix injection K 01296 $3.84 APC-PR G K J9171 Docetaxel injection K 00823 $0.85 APC-PR G K J9173 Inj., durvalumab, 10 mg K 09492 $76.02 APC-PR G K J9179 Eribulin mesylate injection K 01426 $117.66 APC-PR G K J9202 Goserelin acetate implant K 00810 $503.59 APC-PR G K J9203 Gemtuzumab ozogamicin 0.1 mg G 09495 $205.38 APC-PR G K J9204 Inj mogamulizumab-kpkc, 1 mg G 09182 $203.88 APC-PR G K J9205 Inj irinotecan liposome 1 mg K 09474 $54.33 APC-PR G K J9207 Ixabepilone injection K 09240 $101.19 APC-PR G K J9210 Inj., emapalumab-lzsg, 1 mg G 09310 $441.59 APC-PR G K J9214 Interferon alfa-2b inj K 00836 $34.35 APC-PR G K J9217 Leuprolide acetate suspnsion K 09217 $224.45 APC-PR G K J9225 Vantas implant K 01711 $4,558.13 APC-PR G K J9226 Supprelin la implant K 01142 $40,237.00 APC-PR G K J9227 Inj. isatuximab-irfc 10 mg G 09377 $66.67 APC-PR New J9228 Ipilimumab injection K 09284 $157.38 APC-PR G K J9229 Inj inotuzumab ozogam 0.1 mg G 09028 $2,341.50 APC-PR G K J9245 Inj melpha hydroch nos 50 mg K 00840 $260.38 APC-PR G K J9246 Inj., evomela, 1 mg K 09375 $26.96 APC-PR G K J9261 Nelarabine injection K 00825 $152.15 APC-PR G K J9262 Inj, omacetaxine mep, 0.01mg K 09297 $2.98 APC-PR G K J9264 Paclitaxel protein bound K 01712 $13.30 APC-PR G K J9266 Pegaspargase injection K 00843 $19,717.76 APC-PR G K J9268 Pentostatin injection K 00844 $2,060.28 APC-PR G K J9269 Inj. tagraxofusp-erzs 10 mcg G 09309 $270.59 APC-PR G K J9271 Inj pembrolizumab K 01490 $50.85 APC-PR G K J9280 Mitomycin injection K 01232 $49.88 APC-PR G K J9293 Mitoxantrone hydrochl / 5 mg K 00864 $28.69 APC-PR G K J9299 Injection, nivolumab K 09453 $28.56 APC-PR G K J9301 Obinutuzumab inj K 01476 $63.74 APC-PR G K J9302 Ofatumumab injection K 09260 $61.94 APC-PR G K J9303 Panitumumab injection K 09235 $123.55 APC-PR G K J9304 Inj. pemetrexed, 10 mg E2 No New J9305 Inj. pemetrexed nos 10mg K 09213 $71.81 APC-PR G K J9306 Injection, pertuzumab, 1 mg K 01471 $12.95 APC-PR G K J9307 Pralatrexate injection K 09259 $311.22 APC-PR G K J9308 Injection, ramucirumab K 01488 $60.71 APC-PR G K J9309 Inj, polatuzumab vedotin 1mg G 09331 $110.72 APC-PR G K J9311 Inj rituximab, hyaluronidase G 09467 $41.14 APC-PR G K J9312 Inj., rituximab, 10 mg K 09186 $92.56 APC-PR G K J9313 Inj., lumoxiti, 0.01 mg G 09305 $22.46 APC-PR G K J9315 Romidepsin injection K 09265 $336.54 APC-PR G K J9320 Streptozocin injection K 00850 $349.54 APC-PR G K J9325 Inj talimogene laherparepvec K 09472 $53.92 APC-PR G K J9328 Temozolomide injection K 09253 $10.38 APC-PR G K J9330 Temsirolimus injection K 01168 $44.99 APC-PR G K J9340 Thiotepa injection K 00851 $475.39 APC-PR G K J9352 Injection trabectedin 0.1mg K 09480 $318.93 APC-PR G K J9354 Inj, ado-trastuzumab emt 1mg K 09131 $32.79 APC-PR G K J9355 Inj trastuzumab excl biosimi K 01613 $99.68 APC-PR G K J9356 Inj. herceptin hylecta, 10mg G 09314 $75.08 APC-PR G K J9357 Valrubicin injection K 01235 $1,403.17 APC-PR G K J9358 Inj fam-trastu deru-nxki 1mg G 09353 $24.14 APC-PR G K J9371 Inj, vincristine sul lip 1mg K 01466 $3,320.17 APC-PR G K as of 11/3/2020 Page 7 of 8 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective October 1, 2020

J9395 Injection, fulvestrant K 09120 $52.74 APC-PR G K J9400 Inj, ziv-aflibercept, 1mg K 09296 $8.07 APC-PR G K K1006 Suct pum ext urine mgmt sys Y No New K1007 Bil hkaf pc s/d micro sensor Y No New K1009 Speech volume modulation sys Y No New K1010 Intraurethral drainag device Y No New K1011 Acti intraurethral drainage Y No New K1012 Charger base station intraur Y No New Q0138 Ferumoxytol, non-esrd K 01297 $0.98 APC-PR G K Q0139 Ferumoxytol, esrd use K 01485 $0.98 APC-PR G K Q2009 Fosphenytoin inj pe K 09321 $1.61 APC-PR G K Q2042 Tisagenlecleucel car-pos t G 09194 $429,813.31 APC-PR G K Q2043 Sipuleucel-t auto cd54+ K 09273 $49,671.77 APC-PR G K Q2050 Doxorubicin inj 10mg K 07046 $315.73 APC-PR G K Q3027 Inj beta interferon im 1 mcg K 01472 $54.32 APC-PR G K Q4195 Puraply 1 sq cm N APC X Q4196 Puraply am 1 sq cm N APC X Q4249 Amniply, per sq cm N APC New Q4250 AmnioAMP-MP per sq cm N APC New Q4254 Novafix dl per sq cm N APC New Q4255 Reguard, topical use per sq N APC New Q5101 Injection, zarxio K 01822 $0.47 APC-PR G K Q5103 Injection, inflectra K 01847 $43.72 APC-PR G K Q5104 Injection, renflexis G 09036 $44.55 APC-PR G K Q5105 Inj retacrit esrd on dialysi G 09096 $0.86 APC-PR G K Q5106 Inj retacrit non-esrd use G 09097 $8.61 APC-PR G K Q5107 Inj mvasi 10 mg G 09329 $60.94 APC-PR G K Q5108 Injection, fulphila G 09173 $269.04 APC-PR G K Q5111 Injection, udenyca 0.5 mg G 09195 $286.67 APC-PR G K Q5112 Inj ontruzant 10 mg G 09382 $92.30 APC-PR G K Q5113 Inj herzuma 10 mg G 09349 $91.52 APC-PR G K Q5114 Inj ogivri 10 mg G 09341 $76.41 No X Q5115 Inj truxima 10 mg G 09336 $68.80 No X Q5116 Inj., trazimera, 10 mg G 09350 $83.10 APC-PR G K Q5117 Inj., kanjinti, 10 mg G 09330 $78.72 APC-PR G K Q5118 Inj., zirabev, 10 mg G 09348 $62.24 APC-PR G K Q5119 Inj ruxience, 10 mg G 09367 $70.90 APC-PR G K Q5120 Inj pegfilgrastim-bmez 0.5mg G 09345 $305.55 APC-PR G K Q5121 Inj. avsola, 10 mg G 09381 $51.50 APC-PR X Q9001 VA chaplain assessment E1 No New Q9002 VA chaplain counsel individu E1 No New Q9003 VA chaplain counsel group E1 No New Q9950 Inj sulf hexa lipid microsph N APC X Q9968 Visualization adjunct K 01446 $7.55 APC-PR G K Q9982 Flutemetamol f18 diagnostic N APC X Q9983 Florbetaben f18 diagnostic N APC X Q9991 Buprenorph xr 100 mg or less G 09073 $1,743.48 APC-PR G K Q9992 Buprenorphine xr over 100 mg G 09239 $1,743.48 APC-PR G K V2524 Cntct lens hydrophil photoch A No New

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