CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

Procedure Relative Payment Payment CT FEE Code Short Descriptor SI APC Weight Rate Type SCHED Change 0001A Adm sarscov2 30mcg/0.3ml 1st S 01492 $15.50 APC-PR New 0002A Adm sarscov2 30mcg/0.3ml 2nd S 01493 $25.50 APC-PR New 0003A Fee covid-19 vac 1 booster E1 No New 0004A Fee covid-19 vac 1 res E1 No New 0010U Nfct ds strn typ whl gen seq Q4 No X 0011A Adm sarscov2 100mcg/0.5ml1st S 01492 $15.50 APC-PR New 0012A Adm sarscov2 100mcg/0.5ml2nd S 01493 $25.50 APC-PR New 0013A Fee covid-19 vac 2 booster E1 No New 0014A Fee covid-19 vac 2 res E1 No New 0016M Onc bladder mrna 209 gen alg A No X 0017M Onc dlbcl mrna 20 genes alg A No New 00192 Anesth facial bone surgery N APC X 0021A Adm sarscov2 5x1010vp/.5ml 1 E1 No New 0022A Adm sarscov2 5x1010vp/.5ml 2 E1 No New 0023A Fee covid-19 vac 3 booster E1 No New 0024A Fee covid-19 vac 3 res E1 No New 0031A Fee covid-19 vac 4 dose 1 E1 No New 0032A Fee covid-19 vac 4 dose 2 E1 No New 0033A Fee covid-19 vac 4 booster E1 No New 0034A Fee covid-19 vac 4 res E1 No New 0041A Fee covid-19 vac 5 dose 1 E1 No New 0042A Fee covid-19 vac 5 dose 2 E1 No New 0043A Fee covid-19 vac 5 booster E1 No New 0044A Fee covid-19 vac 5 res E1 No New 00474 Anesth surgery of rib N APC X 0051A Fee covid-19 vac 6 dose 1 E1 No New 0052A Fee covid-19 vac 6 dose 2 E1 No New 0053A Fee covid-19 vac 6 booster E1 No New 0054A Fee covid-19 vac 6 res E1 No New 00604 Anesth sitting procedure N APC X 0061A Fee covid-19 vac 7 dose 1 E1 No New 0062A Fee covid-19 vac 7 dose 2 E1 No New 0063A Fee covid-19 vac 7 booster E1 No New 0064A Fee covid-19 vac 7 res E1 No New 0071A Fee covid-19 vac 8 dose 1 E1 No New 0072A Fee covid-19 vac 8 dose 2 E1 No New 0073A Fee covid-19 vac 8 booster E1 No New 0074A Fee covid-19 vac 8 res E1 No New 0081A Fee covid-19 vac 9 dose 1 E1 No New 0082A Fee covid-19 vac 9 dose 2 E1 No New 0083A Fee covid-19 vac 9 booster E1 No New 0084A Fee covid-19 vac 9 res E1 No New 0086U Nfct ds bact&fng org id 6+ Q4 No X 00904 Anesth perineal surgery N APC X 0091A Fee covid-19 vac 10 dose 1 E1 No New 0092A Fee covid-19 vac 10 dose 2 E1 No New 0093A Fee covid-19 vac 10 booster E1 No New 0094A Fee covid-19 vac 10 res E1 No New 0095T Rmvl artific disc addl crvcl N no X 0098T Rev artific disc addl N No X 0101A Fee covid-19 vac 11 dose 1 E1 No New 0102A Fee covid-19 vac 11 dose 2 E1 No New

as of 2/4/2021 Page 1 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

0103A Fee covid-19 vac 11 booster E1 No New 0104A Fee covid-19 vac 11 res E1 No New 0109U Id aspergillus dna 4 species Q4 No X 01140 Anesth amputation at pelvis N APC X 01150 Anesth pelvic tumor surgery N APC X 0115U Respir iadna 18 viral&2 bact Q4 No X 01212 Anesth hip disarticulation N APC X 01232 Anesth amputation of femur N APC X 01234 Anesth radical femur surg N APC X 01274 Anesth femoral embolectomy N APC X 01404 Anesth amputation at knee N APC X 0140U Nfct ds fungi dna 15 trgt Q4 No X 0141U Nfct ds bact&fng gram pos Q4 No X 0142U Nfct ds bact&fng gram neg Q4 No X 01486 Anesth ankle replacement N APC X 0151U Nfct bct/vir resp nfctj 33 Q4 No X 0152U Nfct ds dna untrgt ngnrj seq Q4 No X 01634 Anesth shoulder joint amput N No X 01636 Anesth forequarter amput N APC X 01638 Anesth shoulder replacement N APC X 0163T Lumb artif diskectomy addl N No X 0164T Remove lumb artif disc addl N No X 0165T Revise lumb artif disc addl N No X 01756 Anesth radical humerus surg N APC X 0202T Post vert arthrplst 1 lumbar J1 05115 148.7344 $12,314.76 No X 0219T Plmt post facet implt cerv J1 05115 148.7344 $12,314.76 No X 0220T Plmt post facet implt thor J1 05115 148.7344 $12,314.76 No X 0227U Rx asy prsmv 30+rx/metablt Q4 No New 0228U Onc prst8 ma molec prfl alg Q4 No New 0229U Bcat1 promoter mthyltn alys A No New 0230U Ar full sequence analysis A No New 0231U Cacna1a full gene analysis A No New 0232U Cstb full gene analysis A No New 0233U Fxn gene analysis A No New 0234U Mecp2 full gene analysis A No New 0235U Pten full gene analysis A No New 0236U Smn1&smn2 full gene analysis A No New 0237U Car ion chnlpthy gen seq pnl A No New 0238U Onc lnch syn gen dna seq aly A No New 0239U Trgt gen seq alys pnl 311+ A No New 0240U Nfct ds vir resp rna 3 trgt A No New 0241U Nfct ds vir resp rna 4 trgt A No New 0398T Mrgfus strtctc les abltj J1 05463 135.7079 $11,236.21 No X 0524T Ev cath dir chem abltj w/img J1 05183 34.5624 $2,861.66 No X 0583T Tmpst auto tube dlvr sys J1 05163 16.3386 $1,352.79 No X 0587T Perq impltj/rplcmt isdns ptn J1 05462 74.4071 $6,160.68 No X 0588T Revision/removal isdns ptn J1 05461 39.5582 $3,275.30 No X 0609T Mrs disc pain acquisj data Q3 05523 2.7794 $230.13 No X 0610T Mrs disc pain transmis data N No X 0611T Mrs disc pain alg alys data S 05523 2.7794 $230.13 No X 0612T Mrs discogenic pain i&r M No X 0620T Evasc ven artlz tibl/prnl vn J1 05194 194.0167 $16,064.00 No New 0621T Trabeculostomy interno laser E1 No New 0622T Trabeculostomy int lsr w/scp E1 No New

as of 2/4/2021 Page 2 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

0623T Auto quantification c plaque E1 No New 0624T Auto quan c plaq data prep E1 No New 0625T Auto quan c plaq cptr alys E1 No New 0626T Auto quan c plaq i&r E1 No New 0627T Perq njx algc fluor lmbr 1st J1 05115 148.7344 $12,314.76 No New 0628T Perq njx algc fluor lmbr ea N No New 0629T Perq njx algc ct lmbr 1st J1 05115 148.7344 $12,314.76 No New 0630T Perq njx algc ct lmbr ea N No New 0631T Tc vis lit hyperspectral img Q1 05731 0.298 $24.67 No New 0632T Perq tcat us abltj nrv p-art E1 No New 0633T Ct breast w/3d uni c- Q3 05522 1.3161 $108.97 No New 0634T Ct breast w/3d uni c+ Q3 05571 2.1565 $178.55 No New 0635T Ct breast w/3d uni c-/c+ Q3 05571 2.1565 $178.55 No New 0636T Ct breast w/3d bi c- Q3 05523 2.7794 $230.13 No New 0637T Ct breast w/3d bi c+ Q3 05572 4.446 $368.12 No New 0638T Ct breast w/3d bi c-/c+ Q3 05572 4.446 $368.12 No New 0639T Wrls skn snr anisotropy meas E1 No New 20661 Application of head brace Q1 05113 34.1848 APC X 20664 Application of halo Q1 05113 34.1848 $2,830.40 APC X 20802 Replantation arm complete J1 05116 191.651 $15,868.13 APC X 20805 Replant forearm complete J1 05116 191.651 $15,868.13 APC X 20808 Replantation hand complete J1 05116 191.651 $15,868.13 APC X 20816 Replantation digit complete J1 05114 75.6664 APC X 20824 Replantation thumb complete J1 05114 75.6664 $6,264.95 APC X 20827 Replantation thumb complete J1 05114 75.6664 $6,264.95 APC X 20838 Replantation foot complete J1 05116 191.651 $15,868.13 APC X 20955 Fibula bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20956 Iliac bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20957 Mt bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20962 Other bone graft microvasc J1 05114 75.6664 $6,264.95 APC X 20969 Bone/skin graft microvasc J1 05114 75.6664 $6,264.95 APC X 20970 Bone/skin graft iliac crest J1 05114 75.6664 $6,264.95 APC X 21045 Extensive jaw surgery J1 05165 61.428 $5,086.05 APC X 21141 Lefort i-1 piece w/o graft J1 05165 61.428 APC X 21142 Lefort i-2 piece w/o graft J1 05165 61.428 APC X 21143 Lefort i-3/> piece w/o graft J1 05165 61.428 APC X 21145 Lefort i-1 piece w/ graft J1 05165 61.428 $5,086.05 APC X 21146 Lefort i-2 piece w/ graft J1 05165 61.428 APC X 21147 Lefort i-3/> piece w/ graft J1 05165 61.428 $5,086.05 APC X 21151 Lefort ii w/bone grafts J1 05165 61.428 $5,086.05 APC X 21154 Lefort iii w/o lefort i J1 05165 61.428 $5,086.05 APC X 21155 Lefort iii w/ lefort i J1 05165 61.428 $5,086.05 APC X 21159 Lefort iii w/fhdw/o lefort i J1 05165 61.428 $5,086.05 APC X 21160 Lefort iii w/fhd w/ lefort i J1 05165 61.428 $5,086.05 APC X 21179 Reconstruct entire forehead J1 05165 61.428 $5,086.05 APC X 21180 Reconstruct entire forehead J1 05165 61.428 $5,086.05 APC X 21182 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21183 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21184 Reconstruct cranial bone J1 05165 61.428 $5,086.05 APC X 21188 Reconstruction of midface J1 05165 61.428 $5,086.05 APC X 21194 Reconst lwr jaw w/graft J1 05165 61.428 $5,086.05 APC X 21196 Reconst lwr jaw w/fixation J1 05165 61.428 APC X 21247 Reconstruct lower jaw bone J1 05165 61.428 $5,086.05 APC X 21255 Reconstruct lower jaw bone J1 05165 61.428 $5,086.05 APC X

as of 2/4/2021 Page 3 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

21268 Revise eye sockets J1 05165 61.428 $5,086.05 APC X 21343 Open tx dprsd front sinus fx J1 05165 61.428 $5,086.05 APC X 21344 Open tx compl front sinus fx J1 05165 61.428 APC X 21347 Opn tx nasomax fx multple J1 05165 61.428 $5,086.05 APC X 21348 Opn tx nasomax fx w/graft J1 05165 61.428 $5,086.05 APC X 21366 Opn tx complx malar w/grft J1 05165 61.428 $5,086.05 APC X 21422 Treat mouth roof fracture J1 05165 61.428 APC X 21423 Treat mouth roof fracture J1 05165 61.428 $5,086.05 APC X 21431 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21432 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21433 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21435 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21436 Treat craniofacial fracture J1 05165 61.428 $5,086.05 APC X 21510 Drainage of bone lesion J1 05114 75.6664 $6,264.95 APC X 21602 Exc ch wal tum w/o lymphadec J1 05114 75.6664 $6,264.95 APC X 21603 Exc ch wal tum w/lymphadec J1 05114 75.6664 $6,264.95 APC X 21615 Removal of rib J1 05114 75.6664 $6,264.95 APC X 21616 Removal of rib and nerves J1 05114 75.6664 $6,264.95 APC X 21620 Partial removal of sternum J1 05114 75.6664 $6,264.95 APC X 21627 Sternal debridement J1 05114 75.6664 $6,264.95 APC X 21630 Extensive sternum surgery J1 05114 75.6664 $6,264.95 APC X 21632 Extensive sternum surgery J1 05114 75.6664 $6,264.95 APC X 21705 Revision of neck muscle/rib J1 05114 75.6664 $6,264.95 APC X 21740 Reconstruction of sternum J1 05114 75.6664 $6,264.95 APC X 21750 Repair of sternum separation J1 05114 75.6664 $6,264.95 APC X 21825 Treat sternum fracture J1 05114 75.6664 $6,264.95 APC X 22010 I&d p-spine c/t/cerv-thor J1 05114 75.6664 $6,264.95 APC X 22015 I&d abscess p-spine l/s/ls J1 05114 75.6664 $6,264.95 APC X 22110 Remove part of neck vertebra J1 05114 75.6664 $6,264.95 APC X 22112 Remove part thorax vertebra J1 05114 75.6664 $6,264.95 APC X 22114 Remove part lumbar vertebra J1 05114 75.6664 $6,264.95 APC X 22116 Remove extra spine segment N APC X 22206 Incis spine 3 column thorac J1 05114 75.6664 $6,264.95 APC X 22207 Incis spine 3 column lumbar J1 05114 75.6664 $6,264.95 APC X 22208 Incis spine 3 column adl seg N APC X 22210 Incis 1 vertebral seg cerv J1 05114 75.6664 $6,264.95 APC X 22212 Incis 1 vertebral seg thorac J1 05114 75.6664 $6,264.95 APC X 22214 Incis 1 vertebral seg lumbar J1 05114 75.6664 $6,264.95 APC X 22216 Incis addl spine segment N APC X 22220 Incis w/discectomy cervical J1 05114 75.6664 $6,264.95 APC X 22222 Incis w/discectomy thoracic J1 05114 75.6664 $6,264.95 APC X 22224 Incis w/discectomy lumbar J1 05114 75.6664 $6,264.95 APC X 22226 Revise extra spine segment N APC X 22318 Treat odontoid fx w/o graft J1 05115 148.7344 $12,314.76 APC X 22319 Treat odontoid fx w/graft J1 05115 148.7344 $12,314.76 APC X 22325 Treat spine fracture J1 05115 148.7344 $12,314.76 APC X 22326 Treat neck spine fracture J1 05115 148.7344 $12,314.76 APC X 22327 Treat thorax spine fracture J1 05115 148.7344 $12,314.76 APC X 22328 Treat each add spine fx N APC X 22532 Lat thorax spine fusion J1 05116 191.651 $15,868.13 APC X 22533 Lat lumbar spine fusion J1 05116 191.651 $15,868.13 APC X 22534 Lat thor/lumb addl seg N APC X 22548 Neck spine fusion J1 05116 191.651 $15,868.13 APC X 22556 Thorax spine fusion J1 05116 191.651 $15,868.13 APC X

as of 2/4/2021 Page 4 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

22558 Lumbar spine fusion J1 05116 191.651 APC X 22586 Prescrl fuse w/ instr l5-s1 J1 05116 191.651 $15,868.13 APC X 22590 Spine & skull spinal fusion J1 05116 191.651 $15,868.13 APC X 22595 Neck spinal fusion J1 05116 191.651 $15,868.13 APC X 22600 Neck spine fusion J1 05116 191.651 APC X 22610 Thorax spine fusion J1 05116 191.651 $15,868.13 APC X 22630 Lumbar spine fusion J1 05116 191.651 APC X 22632 Spine fusion extra segment N APC X 22800 Post fusion vert seg J1 05116 191.651 $15,868.13 APC X 22808 Ant fusion 2-3 vert seg J1 05116 191.651 $15,868.13 APC X 22810 Ant fusion 4-7 vert seg J1 05116 191.651 $15,868.13 APC X 22812 Ant fusion 8/> vert seg J1 05116 191.651 $15,868.13 APC X 22818 Kyphectomy 1-2 segments J1 05116 191.651 $15,868.13 APC X 22819 Kyphectomy 3 or more J1 05116 191.651 $15,868.13 APC X 22830 Exploration of spinal fusion J1 05115 148.7344 $12,314.76 APC X 22841 Insert spine fixation device N APC X 22843 Insert spine fixation device N APC X 22844 Insert spine fixation device N APC X 22846 Insert spine fixation device N APC X 22847 Insert spine fixation device N APC X 22848 Insert pelv fixation device N APC X 22849 Reinsert spinal fixation J1 05116 191.651 APC X 22850 Remove spine fixation device J1 05115 148.7344 APC X 22852 Remove spine fixation device J1 05115 148.7344 APC X 22855 Remove spine fixation device J1 05115 148.7344 $12,314.76 APC X 22857 Lumbar artif diskectomy J1 05116 191.651 $15,868.13 APC X 22861 Revise cerv artific disc J1 05116 191.651 $15,868.13 APC X 22862 Revise lumbar artif disc J1 05116 191.651 $15,868.13 APC X 22864 Remove cerv artif disc J1 05115 148.7344 $12,314.76 APC X 22865 Remove lumb artif disc J1 05115 148.7344 $12,314.76 APC X 23200 Resect clavicle tumor J1 05114 75.6664 $6,264.95 APC X 23210 Resect scapula tumor J1 05114 75.6664 $6,264.95 APC X 23220 Resect prox humerus tumor J1 05114 75.6664 APC X 23335 Shoulder prosthesis removal J1 05073 28.6243 $2,370.01 APC X 23472 Reconstruct shoulder joint J1 05115 148.7344 APC X 23474 Revis reconst shoulder joint J1 05115 148.7344 $12,314.76 APC X 23900 Amputation of arm & girdle J1 05115 148.7344 $12,314.76 APC X 23920 Amputation at shoulder joint J1 05115 148.7344 $12,314.76 APC X 24900 Amputation of upper arm J1 05115 148.7344 $12,314.76 APC X 24920 Amputation of upper arm J1 05115 148.7344 $12,314.76 APC X 24930 Amputation follow-up surgery J1 05114 75.6664 $6,264.95 APC X 24931 Amputate upper arm & implant J1 05115 148.7344 $12,314.76 APC X 24940 Revision of upper arm J1 05115 148.7344 $12,314.76 APC X 25900 Amputation of forearm J1 05115 148.7344 $12,314.76 APC X 25905 Amputation of forearm J1 05115 148.7344 APC X 25915 Amputation of forearm J1 05114 75.6664 $6,264.95 APC X 25920 Amputate hand at wrist J1 05114 75.6664 $6,264.95 APC X 25924 Amputation follow-up surgery J1 05114 75.6664 $6,264.95 APC X 25927 Amputation of hand J1 05113 34.1848 APC X 26551 Great toe-hand transfer J1 05114 75.6664 $6,264.95 APC X 26553 Single transfer toe-hand J1 05114 75.6664 $6,264.95 APC X 26554 Double transfer toe-hand J1 05114 75.6664 $6,264.95 APC X

as of 2/4/2021 Page 5 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

26556 Toe joint transfer J1 05114 75.6664 $6,264.95 APC X 26992 Drainage of bone lesion J1 05114 75.6664 APC X 27005 Incision of hip tendon J1 05114 75.6664 $6,264.95 APC X 27025 Incision of hip/thigh fascia J1 05114 75.6664 APC X 27030 Drainage of hip joint J1 05114 75.6664 $6,264.95 APC X 27036 Excision of hip joint/muscle J1 05114 75.6664 APC X 27054 Removal of hip joint lining J1 05113 34.1848 $2,830.40 APC X 27070 Part remove hip bone super J1 05114 75.6664 APC X 27071 Part removal hip bone deep J1 05114 75.6664 APC X 27075 Resect hip tumor J1 05114 75.6664 $6,264.95 APC X 27076 Resect hip tum incl acetabul J1 05114 75.6664 $6,264.95 APC X 27077 Resect hip tum w/innom bone J1 05115 148.7344 $12,314.76 APC X 27078 Rsect hip tum incl femur J1 05115 148.7344 $12,314.76 APC X 27090 Removal of hip prosthesis J1 05073 28.6243 $2,370.01 APC X 27091 Removal of hip prosthesis J1 05073 28.6243 $2,370.01 APC X 27120 Reconstruction of hip socket J1 05115 148.7344 $12,314.76 APC X 27122 Reconstruction of hip socket J1 05115 148.7344 $12,314.76 APC X 27125 Partial hip replacement J1 05115 148.7344 $12,314.76 APC X 27132 Total hip arthroplasty J1 05115 148.7344 $12,314.76 APC X 27134 Revise hip joint replacement J1 05115 148.7344 APC X 27137 Revise hip joint replacement J1 05115 148.7344 $12,314.76 APC X 27138 Revise hip joint replacement J1 05115 148.7344 $12,314.76 APC X 27140 Transplant femur ridge J1 05115 148.7344 $12,314.76 APC X 27146 Incision of hip bone J1 05114 75.6664 $6,264.95 APC X 27147 Revision of hip bone J1 05114 75.6664 $6,264.95 APC X 27151 Incision of hip bones J1 05114 75.6664 $6,264.95 APC X 27156 Revision of hip bones J1 05114 75.6664 $6,264.95 APC X 27158 Revision of pelvis J1 05114 75.6664 $6,264.95 APC X 27161 Incision of neck of femur J1 05114 75.6664 $6,264.95 APC X 27165 Incision/fixation of femur J1 05114 75.6664 APC X 27170 Repair/graft femur head/neck J1 05114 75.6664 APC X 27175 Treat slipped epiphysis J1 05114 75.6664 $6,264.95 APC X 27176 Treat slipped epiphysis J1 05115 148.7344 APC X 27177 Treat slipped epiphysis J1 05114 75.6664 $6,264.95 APC X 27178 Treat slipped epiphysis J1 05114 75.6664 APC X 27181 Treat slipped epiphysis J1 05114 75.6664 APC X 27185 Revision of femur epiphysis J1 05114 75.6664 $6,264.95 APC X 27187 Reinforce hip bones J1 05114 75.6664 APC X 27222 Treat hip socket fracture T 05111 2.4903 APC X 27226 Treat hip wall fracture J1 05114 75.6664 $6,264.95 APC X 27227 Treat hip fracture(s) J1 05114 75.6664 $6,264.95 APC X 27228 Treat hip fracture(s) J1 05114 75.6664 $6,264.95 APC X 27232 Treat thigh fracture J1 05112 16.8164 $1,392.35 APC X 27236 Treat thigh fracture J1 05114 75.6664 APC X 27240 Treat thigh fracture J1 05112 16.8164 $1,392.35 APC X 27244 Treat thigh fracture J1 05114 75.6664 $6,264.95 APC X 27245 Treat thigh fracture J1 05114 75.6664 APC X 27248 Treat thigh fracture J1 05114 75.6664 $6,264.95 APC X 27253 Treat hip dislocation J1 05113 34.1848 $2,830.40 APC X 27254 Treat hip dislocation J1 05113 34.1848 $2,830.40 APC X 27258 Treat hip dislocation J1 05113 34.1848 APC X 27259 Treat hip dislocation J1 05113 34.1848 $2,830.40 APC X 27268 Cltx thigh fx w/mnpj J1 05113 34.1848 $2,830.40 APC X 27269 Optx thigh fx J1 05112 16.8164 $1,392.35 APC X

as of 2/4/2021 Page 6 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

27280 Fusion of sacroiliac joint J1 05116 191.651 $15,868.13 APC X 27282 Fusion of pubic bones J1 05115 148.7344 $12,314.76 APC X 27284 Fusion of hip joint J1 05116 191.651 $15,868.13 APC X 27286 Fusion of hip joint J1 05116 191.651 $15,868.13 APC X 27290 Amputation of leg at hip J1 05116 191.651 $15,868.13 APC X 27295 Amputation of leg at hip J1 05116 191.651 $15,868.13 APC X 27303 Drainage of bone lesion J1 05114 75.6664 $6,264.95 APC X 27365 Resect femur/knee tumor J1 05114 75.6664 APC X 27445 Revision of knee joint J1 05115 148.7344 $12,314.76 APC X 27448 Incision of thigh J1 05114 75.6664 $6,264.95 APC X 27450 Incision of thigh J1 05114 75.6664 APC X 27454 Realignment of thigh bone J1 05114 75.6664 APC X 27455 Realignment of knee J1 05114 75.6664 APC X 27457 Realignment of knee J1 05114 75.6664 APC X 27465 Shortening of thigh bone J1 05114 75.6664 $6,264.95 APC X 27466 Lengthening of thigh bone J1 05114 75.6664 $6,264.95 APC X 27468 Shorten/lengthen thighs J1 05114 75.6664 $6,264.95 APC X 27470 Repair of thigh J1 05114 75.6664 APC X 27472 Repair/graft of thigh J1 05114 75.6664 $6,264.95 APC X 27486 Revise/replace knee joint J1 05115 148.7344 $12,314.76 APC X 27487 Revise/replace knee joint J1 05115 148.7344 $12,314.76 APC X 27488 Removal of knee prosthesis J1 05114 75.6664 $6,264.95 APC X 27495 Reinforce thigh J1 05114 75.6664 APC X 27506 Treatment of thigh fracture J1 05114 75.6664 $6,264.95 APC X 27507 Treatment of thigh fracture J1 05114 75.6664 $6,264.95 APC X 27511 Treatment of thigh fracture J1 05114 75.6664 $6,264.95 APC X 27513 Treatment of thigh fracture J1 05114 75.6664 $6,264.95 APC X 27514 Treatment of thigh fracture J1 05114 75.6664 APC X 27519 Treat thigh fx growth plate J1 05114 75.6664 $6,264.95 APC X 27535 Treat knee fracture J1 05114 75.6664 APC X 27536 Treat knee fracture J1 05114 75.6664 APC X 27540 Treat knee fracture J1 05114 75.6664 APC X 27556 Treat knee dislocation J1 05114 75.6664 $6,264.95 APC X 27557 Treat knee dislocation J1 05114 75.6664 APC X 27558 Treat knee dislocation J1 05114 75.6664 $6,264.95 APC X 27580 Fusion of knee J1 05115 148.7344 $12,314.76 APC X 27590 Amputate leg at thigh J1 05116 191.651 $15,868.13 APC X 27591 Amputate leg at thigh J1 05116 191.651 $15,868.13 APC X 27592 Amputate leg at thigh J1 05116 191.651 $15,868.13 APC X 27596 Amputation follow-up surgery J1 05114 75.6664 APC X 27598 Amputate lower leg at knee J1 05115 148.7344 $12,314.76 APC X 27645 Resect tibia tumor J1 05114 75.6664 $6,264.95 APC X 27646 Resect fibula tumor J1 05114 75.6664 $6,264.95 APC X 27702 Reconstruct ankle joint J1 05115 148.7344 $12,314.76 APC X 27703 Reconstruction ankle joint J1 05115 148.7344 $12,314.76 APC X 27712 Realignment of lower leg J1 05115 148.7344 $12,314.76 APC X 27715 Revision of lower leg J1 05115 148.7344 $12,314.76 APC X 27724 Repair/graft of tibia J1 05114 75.6664 APC X 27725 Repair of lower leg J1 05114 75.6664 $6,264.95 APC X 27727 Repair of lower leg J1 05114 75.6664 $6,264.95 APC X 27880 Amputation of lower leg J1 05116 191.651 $15,868.13 APC X 27881 Amputation of lower leg J1 05114 75.6664 $6,264.95 APC X 27882 Amputation of lower leg J1 05114 75.6664 $6,264.95 APC X 27886 Amputation follow-up surgery J1 05114 75.6664 APC X

as of 2/4/2021 Page 7 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

27888 Amputation of foot at ankle J1 05115 148.7344 $12,314.76 APC X 28800 Amputation of midfoot J1 05113 34.1848 $2,830.40 APC X 30468 Rpr nsl vlv collapse w/implt J1 05165 61.428 $5,086.05 APC New 32408 Core ndl bx lng/med perq J1 05072 16.9934 $1,407.00 APC New 33275 Tcat rmvl perm ldls pm w/img J1 05183 34.5624 $2,861.66 APC X 33741 Tas congenital car anomal C No New 33745 Tis cgen car anomal 1st shnt C No New 33746 Tis cgen car anomal ea addl C No New 33995 Insj perq vad r hrt venous C No New 33997 Rmvl perq right heart vad C No New 35180 Repair blood vessel lesion J1 05182 16.983 $1,406.14 APC X 35372 Rechanneling of artery J1 05184 57.6153 APC X 35800 Explore neck vessels J1 05184 57.6153 APC X 36568 Insj picc <5 yr w/o imaging J1 05182 16.983 $1,406.14 APC X 36860 External cannula declotting J1 05182 16.983 $1,406.14 APC X 37182 Insert hepatic shunt (tips) J1 05193 121.296 APC X 37617 Ligation of abdomen artery J1 05183 34.5624 APC X 38562 Removal pelvic lymph nodes J1 05362 107.5843 $8,907.66 APC X 43840 Repair of stomach lesion J1 05331 60.7331 $5,028.52 APC X 44300 Open bowel to skin J1 05302 19.6265 $1,625.02 APC X 44314 Revision of ileostomy T 05055 42.5396 $3,522.15 APC X 44345 Revision of colostomy J1 05341 38.4484 $3,183.41 APC X 44346 Revision of colostomy J1 05341 38.4484 $3,183.41 APC X 44602 Suture small intestine J1 05303 37.209 APC X 49010 Exploration behind abdomen J1 05341 38.4484 APC X 49255 Removal of omentum J1 05341 38.4484 APC X 51840 Attach bladder/urethra J1 05415 53.2572 APC X 55880 Abltj mal prst8 tiss hifu J1 05375 53.3099 $4,413.90 APC New 56630 Extensive vulva surgery J1 05415 53.2572 $4,409.54 APC X 57465 Cam cervix uteri drg colp N APC New 61624 Transcath occlusion cns J1 05194 194.0167 APC X 69705 Nps surg dilat eust tube uni J1 05165 61.428 $5,086.05 APC New 69706 Nps surg dilat eust tube bi J1 05165 61.428 $5,086.05 APC New 71271 Ct thorax lung cancer scr c- S 05521 0.9771 $80.90 APC New 76145 Med physic dos eval rad exps S 05611 1.5323 $126.87 APC New 76390 Mr spectroscopy S 05521 0.9771 $80.90 APC X 80143 Drug assay acetaminophen Q4 NO New 80151 Drug assay amiodarone Q4 NO New 80161 Asy carbamazepin 10,11-epxid Q4 NO New 80167 Drug assay felbamate Q4 NO New 80179 Drug assay salicylate Q4 NO New 80181 Drug assay flecainide Q4 NO New 80189 Drug assay itraconzaole Q4 NO New 80193 Drug assay leflunomide Q4 NO New 80204 Drug assay methotrexate Q4 NO New 80210 Drug assay rufinamide Q4 NO New 81168 Ccnd1/igh translocation alys A FS LAB New 81191 Ntrk1 translocation analysis A FS LAB New 81192 Ntrk2 translocation analysis A FS LAB New 81193 Ntrk3 translocation analysis A FS LAB New 81194 Ntrk translocation analysis A FS LAB New 81278 Igh@/bcl2 translocation alys A FS LAB New 81279 Jak2 gene trgt sequence alys A FS LAB New 81338 Mpl gene common variants A FS LAB New

as of 2/4/2021 Page 8 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

81339 Mpl gene seq alys exon 10 A FS LAB New 81347 Sf3b1 gene common variants A FS LAB New 81348 Srsf2 gene common variants A FS LAB New 81351 Tp53 gene full gene sequence A FS LAB New 81352 Tp53 gene trgt sequence alys A FS LAB New 81353 Tp53 gene known famil vrnt A FS LAB New 81357 U2af1 gene common variants A FS LAB New 81360 Zrsr2 gene common variants A FS LAB New 81419 Epilepsy gen seq alys panel A FS LAB New 81490 Autoimmune rheumatoid arthr A FS LAB X 81500 Onco (ovar) two proteins A No X 81503 Onco (ovar) five proteins A No X 81506 Endo assay seven anal Q4 No X 81513 Nfct ds bv rna vag flu alg Q4 APC-FS New 81514 Nfct ds bv&vaginitis dna alg A FS LAB New 81529 Onc cutan mlnma mrna 31 gene A FS LAB New 81535 Oncology gynecologic A FS LAB X 81536 Oncology gynecologic A FS LAB X 81539 Oncology prostate prob score A No X 81546 Onc thyr mrna 10,196 gen alg A FS LAB New 81554 Pulm ds ipf mrna 190 gen alg A FS LAB New 82077 Assay spec xcp ur&breath ia Q4 APC-FS New 82681 Assay dir meas fr estradiol Q4 No New 87110 Chlamydia culture Q4 APC-FS X 87270 Chlamydia trachomatis ag if Q4 APC-FS X 87320 Chylmd trach ag ia Q4 APC-FS X 87341 Hepatitis b surface ag ia Q4 APC-FS X 87428 Sarscov & inf vir a&b ag ia A FS LAB New 87810 Chylmd trach assay w/optic Q4 APC-FS X 87850 N. gonorrhoeae assay w/optic Q4 APC-FS X 90296 Diphtheria antitoxin N APC X 90371 Hep b ig im K 01630 $126.86 APC-PR G K 90375 Rabies ig im/sc K 09133 $271.37 APC-PR G K 90376 Rabies ig heat treated K 09134 $237.37 APC-PR G K 90377 Rabies ig ht&sol human im/sc E2 No New 90378 Rsv mab im 50mg K 09003 $1,185.67 APC-PR G K 90385 Rh ig minidose im K 09063 $151.41 APC-PR X 90396 Varicella-zoster ig im K 09135 $1,912.39 APC-PR G K 90675 Rabies vaccine im K 09139 $318.06 APC-PR G K 90676 Rabies vaccine id K 09140 $189.63 APC-PR G K 91300 Sarscov2 vac 30mcg/0.3ml im L FS OFOUT New 91301 Sarscov2 vac 100mcg/0.5ml im L FS OFOUT New 91302 Sarscov2 vac 5x1010vp/.5mlim E1 No New 91303 Coronavirus vaccine 4 E1 No New 91304 Coronavirus vaccine 5 E1 No New 91305 Coronavirus vaccine 6 E1 No New 91306 Coronavirus vaccine 7 E1 No New 91307 Coronavirus vaccine 8 E1 No New 91308 Coronavirus vaccine 9 E1 No New 91309 Coronavirus vaccine 10 E1 No New 91310 Coronavirus vaccine 11 E1 No New 92229 Img rta detc/mntr ds poc aly S 05733 0.6722 $55.66 APC New 92517 Vemp test i&r cervical S 05721 1.6854 $139.55 APC New 92518 Vemp test i&r ocular S 05721 1.6854 $139.55 APC New

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92519 Vemp tst i&r cervical&ocular S 05722 3.1939 $264.45 APC New 92650 Aep scr auditory potential E1 No New 92651 Aep hearing status deter i&r S 05721 1.6854 $139.55 APC New 92652 Aep thrshld est mlt freq i&r S 05722 3.1939 $264.45 APC New 92653 Aep neurodiagnostic i&r S 05722 3.1939 $264.45 APC New 93241 Ext ecg>48hr<7d rec scan a/r M No New 93242 Ext ecg>48hr<7d recording Q1 05732 0.4087 $33.84 APC New 93243 Ext ecg>48hr<7d scan a/r Q1 05733 0.6722 $55.66 APC New 93244 Ext ecg>48hr<7d rev&interpj M no New 93245 Ext ecg>7d<15d rec scan a/r M No New 93246 Ext ecg>7d<15d recording Q1 05733 0.6722 $55.66 APC New 93247 Ext ecg>7d<15d scan a/r Q1 05734 1.3521 $111.95 APC New 93248 Ext ecg>7d<15d rev&interpj M No New 94619 Exercise tst brncspsm wo ecg Q1 05733 0.6722 $55.66 APC New 99415 Prolng clin staff svc 1st hr B No X 99416 Prolng clin staff svc ea add B No X 99417 Prolng off/op e/m ea 15 min E1 No New 99439 Chrnc care mgmt svc ea addl N No New A9517 I131 iodide cap, rx K 01064 $20.12 APC-PR G K A9530 I131 iodide sol, rx K 01150 $13.34 APC-PR G K A9543 Y90 ibritumomab, rx K 01643 $58,910.18 APC-PR G K A9563 P32 na phosphate K 01675 $458.34 APC-PR G K A9591 Fluoroestradiol f 18 G 09370 $0.77 APC-PR New A9600 Sr89 strontium K 00701 $3,975.00 APC-PR G K A9604 Sm 153 lexidronam K 01295 $17,089.61 APC-PR G K A9606 Radium ra223 dichloride ther K 01745 $143.39 APC-PR G K C1052 Hemostatic agent, gi, topic H 02031 No New C1062 Intravertebral fx aug impl H 02032 No New C1825 Gen, neuro, carot sinus baro H 02030 No New C9046 Cocaine hcl nasal solution G 09307 $1.26 APC-PR G K C9047 Injection, caplacizumab-yhdp G 09199 $691.29 APC-PR G K C9065 Romidepsin non-lyophilized G 09379 $311.84 APC-PR G K C9068 Copper cu-64, dotatate, dx G 09383 $901.25 APC-PR New C9069 Belantamab mafodontin-blmf G 09384 $42.63 APC-PR New C9070 Injection, tafasitamab-cxix G 09385 $12.36 APC-PR New C9071 Injection, viltolarsen G 09386 $58.09 APC-PR New C9072 Inj, imm glob asceniv G 09392 $481.77 APC-PR New C9073 Brexucabtagene autoleucel ca G 09391 $384,190.00 APC-PR New C9132 Kcentra, per i.u. K 09132 $2.10 APC-PR G K C9248 Inj, clevidipine butyrate K 09087 $2.87 APC X C9257 Bevacizumab injection K 01281 $1.88 APC-PR G K C9293 Injection, glucarpidase E2 No X C9460 Injection, cangrelor K 09460 $15.46 APC-PR G K C9462 Injection, delafloxacin G 09462 $0.29 APC-PR G K C9488 Conivaptan hcl K 09488 $36.17 APC-PR G K C9770 Vitrec/mech pars, subret inj T 01561 $3,250.50 APC-PR New C9771 Nsl/sins cryo post nasal tis J1 05164 33.0494 $2,736.39 APC New C9772 Revasc lithotrip tibi/perone J1 05193 121.296 $10,042.94 APC New C9773 Revasc lithotr-stent tib/per J1 05194 194.0167 $16,064.00 APC New C9774 Revasc lithotr-ather tib/per J1 05194 194.0167 $16,064.00 APC New C9775 Revasc lith-sten-ath tib/per J1 05194 194.0167 $16,064.00 APC New D0604 Antigen test pub hlth pathog E1 No New D0605 Antibody test pub hlth path E1 No New D0701 Pano radio image E1 No New

as of 2/4/2021 Page 10 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

D0702 2d cephal radio image E1 No New D0703 2d oral/facial photo image E1 No New D0704 3d photo image capture only E1 No New D0705 Extra oral post radio image E1 No New D0706 Intraoral occlus radio image E1 No New D0707 Intraoral periap radio image E1 No New D0708 Intraoral bite radio image E1 No New D0709 Intraoral cmplt radio images E1 No New D1321 Couns for high risk sub use E1 No New D1355 Caries med app per tooth E1 No New D2928 Prefab porc/cer crown perm E1 No New D3471 Surg rep root res anterior E1 No New D3472 Surg rep root res premolar E1 No New D3473 Surg rep root res molar E1 No New D3501 Surg exp root surf anterior E1 No New D3502 Surg exp root surf premolar E1 No New D3503 Surg exp root surf molar E1 No New D5995 Peri medicament w/seal, max E1 No New D5996 Peri medicament w/seal, mand E1 No New D6191 Semi precision abutment E1 No New D6192 Semi precision attachment E1 No New D7961 Buccal/labial frenectomy E1 No New D7962 Lingual frenectomy E1 No New D7993 Surg place craniofacial impl E1 No New D7994 Surg place zygomatic impl E1 No New G0088 Adm iv drug 1st home visit A No New G0089 Adm subq drug 1st home visit A No New G0090 Adm iv chemo 1st home visit A No New G0235 Pet not otherwise specified S 05591 4.5547 $377.12 APC X G0412 Open tx iliac spine uni/bil J1 05114 75.6664 $6,264.95 APC X G0414 Pelvic ring fx treat int fix J1 05115 148.7344 $12,314.76 APC X G0415 Open tx post pelvic fxcture J1 05115 148.7344 $12,314.76 APC X G2067 Med assist tx meth wk A No X G2068 Med assist tx bupre oral A No X G2069 Med assist tx inject A No X G2070 Med assist tx implant A No X G2071 Med tx remove implant A No X G2072 Med tx insert/remove imp A No X G2073 Med tx naltrexone A No X G2074 Med assist tx no drug A No X G2075 Med tx meds nos A No X G2076 Intake act w/med exam A No X G2077 Periodic assessment A No X G2078 Take-home meth A No X G2079 Take-hom buprenorphine A No X G2080 Add 30 mins counsel A No X G2173 Uri w comorb 12m oth dx M No New G2174 Uri new rx antibiotic 30d M No New G2175 Pt comorb dx 12m of epi M No New G2176 Outpt ed obs w inpt admit M No New G2177 Bronch w rx antibx 30d M No New G2178 Pt not elig low neuro ex M No New G2179 Med doc rsn no low ex M No New G2180 Inelig footwr eval M No New

as of 2/4/2021 Page 11 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

G2181 Bmi not doc medrsn ptref M No New G2182 Pt 1st biolog antirheum M No New G2183 Doc pt unable comm M No New G2184 No caregiver M No New G2185 Caregiver dem trained M No New G2186 Pt ref app rsrcs M No New G2187 Clin ind img hd trauma M No New G2188 Pt 50 yrs w/clin ind hd M No New G2189 Img hd abnml neuro exam M No New G2190 Ind img hd rad neck M No New G2191 Ind img hd pos hd ache M No New G2192 >55 yrs temp hd ache M No New G2193 <6yr new onset hd ache M No New G2194 New hdache ped pt dis M No New G2195 Occip hdache child M No New G2196 Screen unhlthy etoh use M No New G2197 Screen hlthy etoh use M No New G2198 Med rsn no unhlthy etoh M No New G2199 Not scrn etoh no rsn M No New G2200 Unhlthy etoh rcvd couns M No New G2201 Med rsn no brief couns M No New G2202 No rsn no brief couns M No New G2203 Med rsn no etoh couns M No New G2204 Pt 50-85 w/ scope M No New G2205 Preg drng adjv trtmt M No New G2206 Adjv trtmt chemo her2 M No New G2207 Rsn no trtmt chem her2 M No New G2208 No trtmt chemo and her2 M No New G2209 Refused to participate M No New G2210 No neck fs prom no rsn M No New G2211 Complex e/m visit add on N No New G2212 Prolong outpt/office vis N No New G2213 Initiat med assist tx in er N No New G2214 Init/sub psych care m 1st 30 S 05822 0.9043 $74.87 No New G2215 Home supply nasal naloxone A No New G2216 Home supply inject naloxon A No New G2250 Remot img sub by pt, non e/m A No New G2251 Brief chkin, 5-10, non-e/m A No New G2252 Brief chkin by md/qhp, 11-20 A No New J0121 Inj., omadacycline, 1 mg G 09311 $3.27 APC-PR G K J0122 Inj., eravacycline, 1 mg N APC X J0129 Abatacept injection K 09230 $56.87 APC-PR G K J0178 Aflibercept injection K 01420 $921.76 APC-PR G K J0179 Inj, brolucizumab-dbll, 1 mg G 09340 $314.95 APC-PR G K J0180 Agalsidase beta injection K 09208 $189.29 APC-PR G K J0185 Inj., aprepitant, 1 mg G 09463 $1.59 APC-PR G K J0202 Injection, alemtuzumab K 01809 $2,017.45 APC-PR G K J0210 Methyldopate hcl injection E2 No X J0220 Alglucosidase alfa injection K 09234 $117.07 APC-PR G K J0221 Lumizyme injection K 01413 $174.63 APC-PR G K J0222 Inj., patisiran, 0.1 mg G 09180 $97.68 APC-PR G K J0256 Alpha 1 proteinase inhibitor K 00901 $4.52 APC-PR G K J0257 Glassia injection K 01415 $4.89 APC-PR G K J0287 Amphotericin b lipid complex K 09024 $9.37 APC-PR G K

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J0289 Amphotericin b liposome inj K 00736 $27.24 APC-PR G K J0291 Inj., plazomicin, 5 mg G 09183 $3.07 APC-PR G K J0300 Amobarbital 125 mg inj K 01341 $125.22 APC-PR G K J0390 Chloroquine injection K 09352 $165.22 APC-PR X J0475 Baclofen 10 mg injection K 09032 $172.78 APC-PR G K J0480 Basiliximab K 01683 $4,019.07 APC-PR G K J0485 Belatacept injection K 09286 $3.79 APC-PR G K J0490 Belimumab injection K 01353 $46.84 APC-PR G K J0517 Inj., benralizumab, 1 mg G 09466 $171.30 APC-PR G K J0558 Peng benzathine/procaine inj K 09088 $12.01 APC-PR G K J0561 Penicillin g benzathine inj K 01829 $15.10 APC-PR G K J0565 Inj, bezlotoxumab, 10 mg K 09490 $39.67 APC-PR G K J0567 Inj., cerliponase alfa 1 mg N APC X J0570 Buprenorphine implant 74.2mg K 09058 $1,204.99 APC-PR G K J0584 Injection, burosumab-twza 1m K 09187 $361.95 APC-PR G K J0585 Injection,onabotulinumtoxina K 00902 $6.06 APC-PR G K J0586 Abobotulinumtoxina K 01289 $8.27 APC-PR G K J0587 Inj, rimabotulinumtoxinb K 09018 $11.97 APC-PR G K J0588 Incobotulinumtoxin a K 09278 $5.06 APC-PR G K J0593 Inj., lanadelumab-flyo, 1 mg N APC X J0594 Busulfan injection K 01178 $2.13 APC-PR G K J0596 Injection, ruconest K 09445 $28.98 APC-PR G K J0597 C-1 esterase, berinert K 09269 $54.33 APC-PR G K J0598 C-1 esterase, cinryze K 09251 $56.41 APC-PR G K J0599 Inj., haegarda 10 units K 09015 $9.92 APC-PR X J0606 Inj, etelcalcetide, 0.1 mg N APC X J0630 Calcitonin salmon injection K 01433 $2,830.55 APC-PR G K J0638 Canakinumab injection K 01311 $113.26 APC-PR G K J0641 Inj levoleucovorin nos 0.5mg K 01236 $0.12 APC-PR G K J0642 Injection, khapzory, 0.5 mg G 09334 $1.87 No G K J0693 Inj., cefiderocol, 5 mg G 09380 $0.97 APC-PR New J0695 Inj ceftolozane tazobactam K 09452 $6.43 APC-PR G K J0712 Ceftaroline fosamil inj K 01824 $3.35 APC-PR G K J0714 Ceftazidime and avibactam K 01825 $92.28 APC-PR G K J0717 Certolizumab pegol inj 1mg K 01474 $8.18 APC-PR G K J0740 Cidofovir injection K 09033 $590.29 APC-PR G K J0745 Inj codeine phosphate /30 mg K 09393 $135.64 APC-PR X J0775 Collagenase, clost hist inj K 01340 $52.62 APC-PR G K J0791 Inj crizanlizumab-tmca 5mg G 09359 $122.43 APC-PR G K J0795 Corticorelin ovine triflutal K 01684 $9.57 APC-PR G K J0800 Corticotropin injection N APC X J0840 Crotalidae poly immune fab K 09274 $2,908.21 APC-PR G K J0841 Inj crotalidae im f(ab')2 eq K 09188 $1,263.49 APC-PR G K J0850 Cytomegalovirus imm iv /vial K 00903 $1,467.02 APC-PR G K J0878 Daptomycin injection N APC X J0881 Darbepoetin alfa, non-esrd K 01685 $3.56 APC-PR G K J0882 Darbepoetin alfa, esrd use K 01482 $3.56 APC-PR G K J0883 Argatroban nonesrd use 1mg K 01859 $1.45 APC-PR G K J0884 Argatroban esrd dialysis 1mg K 09065 $1.45 APC-PR G K J0885 Epoetin alfa, non-esrd K 01686 $8.82 APC-PR G K J0888 Epoetin beta non esrd K 09077 $1.50 APC-PR X J0894 Decitabine injection K 09231 $3.43 APC-PR G K J0896 Inj luspatercept-aamt 0.25mg G 09347 $36.31 APC-PR G K J0897 Denosumab injection K 09272 $20.11 APC-PR G K

as of 2/4/2021 Page 13 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

J1096 Dexametha opth insert 0.1 mg G 09308 $139.47 APC-PR G K J1162 Digoxin immune fab (ovine) K 01687 $3,969.27 APC-PR G K J1190 Dexrazoxane hcl injection K 00726 $195.98 APC-PR G K J1201 Inj. cetirizine hcl 0.5mg G 09361 $15.39 APC-PR G K J1212 Dimethyl sulfoxide 50% 50 ml K 01832 $635.87 APC-PR G K J1267 Doripenem injection N APC X J1290 Ecallantide injection K 09263 $492.12 APC-PR G K J1300 Eculizumab injection K 09236 $230.32 APC-PR G K J1301 Injection, edaravone, 1 mg K 09493 $19.90 APC-PR G K J1303 Inj., ravulizumab-cwvz 10 mg G 09312 $226.18 APC-PR G K J1322 Elosulfase alfa, injection K 01480 $245.34 APC-PR G K J1327 Eptifibatide injection N APC X J1364 Erythro lactobionate /500 mg K 01669 $76.85 APC-PR X J1410 Inj estrogen conjugate 25 mg K 09038 $325.51 APC-PR G K J1428 Inj, eteplirsen, 10 mg N APC X J1429 Inj golodirsen 10 mg G 09356 $166.53 APC-PR G K J1437 Inj. fe derisomaltose 10 mg G 09388 $25.38 APC-PR X J1439 Inj ferric carboxymaltos 1mg K 09441 $1.13 APC-PR G K J1442 Inj filgrastim excl biosimil K 01469 $0.94 APC-PR G K J1444 Fe pyro cit pow 0.1 mg iron E2 No X J1447 Inj tbo filgrastim 1 microg K 01748 $0.46 APC-PR G K J1451 Fomepizole, 15 mg K 01689 $7.39 APC-PR G K J1453 Fosaprepitant injection K 09242 $0.42 APC-PR G K J1454 Inj fosnetupitant, palonoset G 09099 $695.56 APC-PR G K J1458 Galsulfase injection K 09224 $404.07 APC-PR G K J1459 Inj ivig privigen 500 mg K 01214 $42.43 APC-PR G K J1460 Gamma globulin 1 cc inj K 01850 $43.30 APC-PR G K J1555 Inj cuvitru, 100 mg K 09034 $13.94 APC-PR G K J1556 Inj, imm glob bivigam, 500mg K 09130 $70.49 APC-PR X J1557 Gammaplex injection K 09270 $49.81 APC-PR G K J1558 Inj. xembify, 100 mg K 09372 $14.69 APC-PR G K J1559 Hizentra injection K 01312 $11.09 APC-PR G K J1560 Gamma globulin > 10 cc inj K 01851 $432.96 APC-PR G K J1561 Gamunex-c/gammaked K 00948 $43.67 APC-PR G K J1566 Immune globulin, powder K 02731 $66.97 APC-PR G K J1568 Octagam injection K 00943 $41.63 APC-PR G K J1569 Gammagard liquid injection K 00944 $43.63 APC-PR G K J1571 Hepagam b im injection K 00946 $65.61 APC-PR G K J1572 Flebogamma injection K 00947 $36.86 APC-PR G K J1573 Hepagam b intravenous, inj K 01138 $66.75 APC-PR G K J1575 Hyqvia 100mg immuneglobulin K 01826 $14.34 APC-PR G K J1595 Injection glatiramer acetate K 01015 $153.12 APC-PR G K J1602 Golimumab for iv use 1mg K 01475 $18.12 APC-PR G K J1610 Glucagon hydrochloride/1 mg K 09042 $194.42 APC-PR G K J1628 Inj., guselkumab, 1 mg K 09029 $88.40 APC-PR G K J1632 Inj., brexanolone, 1 mg G 09333 $76.14 No G K J1640 Hemin, 1 mg K 01690 $24.43 APC-PR G K J1670 Tetanus immune globulin inj K 01670 $469.95 APC-PR G K J1726 Makena, 10 mg K 09074 $16.05 APC-PR G K J1729 Inj hydroxyprogst capoat nos K 09318 $21.54 APC-PR G K J1740 Ibandronate sodium injection K 09229 $41.54 APC-PR G K J1742 Ibutilide fumarate injection K 09044 $273.16 APC-PR G K J1743 Idursulfase injection N APC X J1744 Icatibant injection K 01443 $273.60 APC-PR G K

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J1745 Infliximab not biosimil 10mg K 07043 $44.90 APC-PR G K J1746 Inj., ibalizumab-uiyk, 10 mg K 09189 $64.05 APC-PR G K J1750 Inj iron dextran K 01237 $15.05 APC-PR G K J1823 Inj. inebilizumab-cdon, 1 mg K 09394 $449.77 APC-PR New J1826 Interferon beta-1a inj K 01852 $2,293.85 APC-PR G K J1830 Interferon beta-1b / .25 mg K 00910 $393.47 APC-PR G K J1850 Kanamycin sulfate 75 mg inj E2 No X J1930 Lanreotide injection K 09237 $68.46 APC-PR G K J1931 Laronidase injection K 09209 $33.12 APC-PR G K J1943 Inj., aristada initio, 1 mg G 09179 $2.91 APC-PR G K J1944 Aripirazole lauroxil 1 mg K 09470 $2.90 APC-PR G K J1950 Leuprolide acetate /3.75 mg K 00800 $1,582.13 APC-PR G K J2062 Loxapine for inhalation 1 mg E2 No X J2182 Injection, mepolizumab, 1mg K 09473 $28.86 APC-PR G K J2186 Inj., meropenem, vaborbactam K 09178 $1.77 APC-PR G K J2248 Micafungin sodium injection K 09227 $1.09 APC-PR X J2265 Minocycline hydrochloride K 01853 $2.00 APC-PR G K J2278 Ziconotide injection K 01694 $8.48 APC-PR G K J2315 Naltrexone, depot form K 00759 $3.43 APC-PR G K J2323 Natalizumab injection K 09126 $22.39 APC-PR G K J2326 Inj, nusinersen, 0.1mg K 09489 $1,122.06 APC-PR G K J2350 Injection, ocrelizumab, 1 mg K 09494 $57.33 APC-PR G K J2353 Octreotide injection, depot K 01207 $205.66 APC-PR G K J2355 Oprelvekin injection N APC X J2357 Omalizumab injection K 09300 $37.42 APC-PR G K J2358 Olanzapine long-acting inj K 01331 $2.92 APC-PR X J2407 Injection, oritavancin K 01660 $23.82 APC-PR G K J2425 Palifermin injection K 01696 $22.82 APC-PR G K J2426 Paliperidone palmitate inj K 09255 $12.12 APC-PR G K J2502 Inj, pasireotide long acting K 09454 $315.84 APC-PR G K J2505 Injection, pegfilgrastim 6mg K 09119 $3,079.49 APC-PR G K J2507 Pegloticase injection K 09281 $2,771.29 APC-PR G K J2515 Pentobarbital sodium inj K 01854 $29.87 APC-PR G K J2560 Phenobarbital sodium inj K 09069 $45.66 APC-PR X J2562 Plerixafor injection K 09252 $365.02 APC-PR G K J2597 Inj desmopressin acetate K 01440 $10.57 APC-PR G K J2724 Protein c concentrate K 01139 $15.08 APC-PR G K J2760 Phentolaine mesylate inj K 01458 $356.88 APC-PR G K J2770 Quinupristin/dalfopristin K 02770 $458.83 APC-PR G K J2778 Ranibizumab injection K 09233 $322.85 APC-PR G K J2783 Rasburicase K 00738 $306.14 APC-PR G K J2786 Injection, reslizumab, 1mg K 09481 $9.75 APC-PR G K J2792 Rho(d) immune globulin h, sd K 01609 $29.40 APC-PR G K J2796 Romiplostim injection K 09245 $79.11 APC-PR G K J2798 Inj., perseris, 0.5 mg G 09181 $10.16 APC-PR G K J2820 Sargramostim injection K 00731 $48.83 APC-PR G K J2840 Inj sebelipase alfa 1 mg K 09478 $540.41 APC-PR G K J2860 Injection, siltuximab K 09455 $111.50 APC-PR G K J2910 Aurothioglucose injeciton E2 No X J2941 Somatropin injection K 09319 $36.54 APC-PR G K J2993 Reteplase injection K 09005 $2,395.94 APC-PR X J2997 Alteplase recombinant K 07048 $87.43 APC-PR G K J3031 Inj., fremanezumab-vfrm 1 mg G 09197 $2.28 APC-PR G K J3032 Inj. eptinezumab-jjmr 1 mg G 09357 $15.60 APC-PR G K

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J3060 Inj, taliglucerase alfa 10 u K 09294 $40.96 APC-PR G K J3095 Telavancin injection K 09258 $5.94 APC-PR G K J3101 Tenecteplase injection K 09002 $129.27 APC-PR G K J3111 Inj. romosozumab-aqqg 1 mg G 09327 $9.00 APC-PR G K J3145 Testosterone undecanoate 1mg K 09078 $1.53 APC-PR G K J3240 Thyrotropin injection K 09108 $1,776.21 APC-PR G K J3243 Tigecycline injection K 09228 $1.19 APC-PR G K J3245 Inj., tildrakizumab, 1 mg G 09306 $132.71 APC-PR G K J3246 Tirofiban hcl K 07041 $2.41 APC-PR G K J3262 Tocilizumab injection K 09264 $5.47 APC-PR G K J3285 Treprostinil injection K 01701 $64.03 APC-PR G K J3304 Inj triamcinolone ace xr 1mg G 09469 $18.01 APC-PR G K J3315 Triptorelin pamoate K 09122 $503.81 APC-PR G K J3316 Inj., triptorelin xr 3.75 mg K 09016 $3,044.01 APC-PR X J3357 Ustekinumab sub cu inj, 1 mg K 09261 $180.12 APC-PR G K J3358 Ustekinumab, iv inject, 1 mg K 09487 $11.95 APC-PR G K J3380 Injection, vedolizumab K 01489 $20.35 APC-PR G K J3385 Velaglucerase alfa K 09271 $346.63 APC-PR G K J3396 Verteporfin injection K 01203 $11.25 APC-PR G K J3397 Inj., vestronidase alfa-vjbk N APC X J3398 Inj luxturna 1 billion vec g G 09070 $2,915.24 APC-PR G K J3399 Inj onase abepar-xioi treat K 09373 $2,206,690.98 APC-PR G K J7170 Inj., emicizumab-kxwh 0.5 mg G 09257 $47.75 APC-PR G K J7175 Inj, factor x, (human), 1iu K 01857 $7.89 APC-PR G K J7177 Inj., fibryga, 1 mg N APC X J7178 Inj human fibrinogen con nos K 01478 $1.26 APC-PR G K J7179 Vonvendi inj 1 iu vwf:rco K 09059 $1.89 APC-PR G K J7180 Factor xiii anti-hem factor K 01416 $8.78 APC-PR G K J7181 Factor xiii recomb a-subunit K 01746 $15.45 APC-PR G K J7182 Factor viii recomb novoeight K 01856 $1.36 APC-PR G K J7183 Wilate injection K 01352 $1.04 APC-PR G K J7185 Xyntha inj K 01268 $1.23 APC-PR G K J7186 Antihemophilic viii/vwf comp K 01213 $1.12 APC-PR G K J7187 Humate-p, inj K 01704 $1.22 APC-PR G K J7189 Factor viia recomb novoseven K 01705 $2.26 APC-PR G K J7190 Factor viii K 00925 $1.07 APC-PR G K J7192 Factor viii recombinant nos K 00927 $1.35 APC-PR G K J7193 Factor ix non-recombinant K 00931 $1.19 APC-PR G K J7194 Factor ix complex K 00928 $1.48 APC-PR G K J7196 Antithrombin recombinant N APC X J7197 Antithrombin iii injection K 01263 $3.48 APC-PR G K J7198 Anti-inhibitor K 00929 $2.09 APC-PR G K J7201 Factor ix alprolix recomb K 01486 $3.26 APC-PR G K J7202 Factor ix idelvion inj K 09171 $4.46 APC-PR G K J7203 Factor ix recomb gly rebinyn G 09468 $3.96 APC-PR G K J7204 Inj recombin esperoct per iu G 09354 $2.25 APC-PR G K J7207 Factor viii pegylated recomb K 01844 $1.85 APC-PR G K J7208 Inj. jivi 1 iu G 09299 $2.03 APC-PR G K J7209 Factor viii nuwiq recomb 1iu K 01846 $1.26 APC-PR G K J7210 Inj, afstyla, 1 i.u. K 09043 $1.35 APC-PR G K J7211 Inj, kovaltry, 1 i.u. K 09075 $1.22 APC-PR X J7212 Factor viia recomb sevenfact K 09395 $2.59 APC-PR New J7308 Aminolevulinic acid hcl top K 07308 $388.42 APC-PR G K J7311 Inj., retisert, 0.01 mg K 09225 $341.22 APC-PR G K

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J7312 Dexamethasone intra implant K 09256 $199.85 APC-PR G K J7313 Inj., iluvien, 0.01 mg K 09450 $490.93 APC-PR G K J7314 Inj., yutiq, 0.01 mg K 09328 $496.42 APC-PR G K J7323 Euflexxa inj per dose K 00875 $135.14 APC-PR G K J7324 Orthovisc inj per dose K 00877 $128.55 APC-PR G K J7325 Synvisc or synvisc-one K 00874 $10.67 APC-PR G K J7327 Monovisc inj per dose K 01747 $785.19 APC-PR G K J7331 Synojoynt, inj., 1 mg G 09337 $18.02 No G K J7332 Inj., triluron, 1 mg N APC X J7340 Carbidopa levodopa ent 100ml K 09320 $213.76 APC-PR G K J7342 Ciprofloxacin otic susp 6 mg K 09479 $29.98 APC-PR G K J7345 Aminolevulinic acid, 10% gel K 09301 $1.52 APC-PR G K J7351 Inj bimatoprost itc imp1mcg G 09351 $206.38 APC-PR G K J7352 Afamelanotide implant, 1 mg K 09396 $3,218.90 APC-PR New J7501 Azathioprine parenteral K 00887 $245.17 APC-PR G K J7504 Lymphocyte immune globulin K 00890 $2,257.65 APC-PR G K J7511 Antithymocyte globuln rabbit K 09104 $790.60 APC-PR G K J7525 Tacrolimus injection K 09006 $212.22 APC-PR G K J8510 Oral busulfan N APC X J8560 Etoposide oral 50 mg K 00802 $75.77 APC-PR G K J8562 Oral fludarabine phosphate E2 No X J8655 Oral netupitant, palonosetro K 09448 $270.65 APC-PR G K J8670 Rolapitant, oral, 1mg K 01761 $2.34 APC-PR G K J9015 Aldesleukin injection K 00807 $3,795.26 APC-PR G K J9017 Arsenic trioxide injection K 09012 $17.82 APC-PR G K J9022 Inj, atezolizumab,10 mg K 09483 $78.18 APC-PR G K J9023 Injection, avelumab, 10 mg K 09491 $85.33 APC-PR G K J9025 Azacitidine injection K 01709 $0.91 APC-PR G K J9027 Clofarabine injection K 01710 $30.18 APC-PR G K J9030 Bcg live intravesical 1mg N APC X J9032 Injection, belinostat, 10mg K 01658 $42.70 APC-PR G K J9033 Inj., treanda 1 mg K 09243 $24.58 APC-PR G K J9034 Inj., bendeka 1 mg K 01861 $20.17 APC-PR G K J9035 Bevacizumab injection K 09214 $75.16 APC-PR G K J9036 Inj. belrapzo/bendamustine G 09313 $22.27 APC-PR G K J9039 Injection, blinatumomab K 09449 $118.12 APC-PR G K J9041 Inj., velcade 0.1 mg K 09207 $44.67 APC-PR G K J9042 Brentuximab vedotin inj K 09287 $182.08 APC-PR G K J9043 Cabazitaxel injection K 09276 $184.85 APC-PR G K J9044 Inj, bortezomib, nos, 0.1 mg K 09192 $21.10 APC-PR G K J9047 Injection, carfilzomib, 1 mg K 09295 $39.35 APC-PR G K J9050 Carmustine injection K 00812 $1,743.25 APC-PR G K J9055 Cetuximab injection K 09215 $65.48 APC-PR G K J9057 Inj., copanlisib, 1 mg G 09030 $79.09 APC-PR G K J9065 Inj cladribine per 1 mg K 00858 $21.02 APC-PR G K J9070 Cyclophosphamide 100 mg inj K 01408 $31.16 APC-PR G K J9098 Cytarabine liposome inj N APC X J9120 Dactinomycin injection K 00752 $934.16 APC-PR G K J9144 Daratumumab, hyaluronidase G 09378 $43.85 APC-PR New J9145 Injection, daratumumab 10 mg K 09476 $56.04 APC-PR G K J9150 Daunorubicin injection K 00820 $42.52 APC-PR G K J9151 Daunorubicin citrate inj E2 No X J9153 Inj daunorubicin, cytarabine K 09302 $201.69 APC-PR G K J9155 Degarelix injection K 01296 $3.89 APC-PR G K

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J9171 Docetaxel injection N APC X J9173 Inj., durvalumab, 10 mg K 09492 $77.05 APC-PR G K J9179 Eribulin mesylate injection K 01426 $117.76 APC-PR G K J9198 Inj. infugem, 100 mg G 09387 $39.14 APC-PR X J9202 Goserelin acetate implant K 00810 $501.27 APC-PR G K J9203 Gemtuzumab ozogamicin 0.1 mg K 09495 $205.36 APC-PR G K J9204 Inj mogamulizumab-kpkc, 1 mg G 09182 $206.42 APC-PR G K J9205 Inj irinotecan liposome 1 mg K 09474 $54.31 APC-PR G K J9207 Ixabepilone injection K 09240 $102.12 APC-PR G K J9210 Inj., emapalumab-lzsg, 1 mg G 09310 $393.16 APC-PR G K J9213 Interferon alfa-2a inj N APC X J9214 Interferon alfa-2b inj K 00836 $33.99 APC-PR G K J9217 Leuprolide acetate suspnsion K 09217 $228.93 APC-PR G K J9223 Inj. lurbinectedin, 0.1 mg G 09389 $170.80 APC-PR New J9225 Vantas implant K 01711 $4,586.21 APC-PR G K J9226 Supprelin la implant K 01142 $40,116.00 APC-PR G K J9227 Inj. isatuximab-irfc 10 mg G 09377 $66.37 APC-PR G K J9228 Ipilimumab injection K 09284 $157.23 APC-PR G K J9229 Inj inotuzumab ozogam 0.1 mg K 09028 $2,341.30 APC-PR G K J9245 Inj melpha hydroch nos 50 mg K 00840 $228.79 APC-PR G K J9246 Inj., evomela, 1 mg K 09375 $23.60 APC-PR G K J9261 Nelarabine injection K 00825 $151.89 APC-PR G K J9262 Inj, omacetaxine mep, 0.01mg K 09297 $3.31 APC-PR G K J9264 Paclitaxel protein bound K 01712 $13.43 APC-PR G K J9266 Pegaspargase injection K 00843 $19,717.46 APC-PR G K J9268 Pentostatin injection K 00844 $2,001.90 APC-PR G K J9269 Inj. tagraxofusp-erzs 10 mcg G 09309 $283.33 APC-PR G K J9270 Plicamycin (mithramycin) inj K 09093 $115.40 APC-PR X J9271 Inj pembrolizumab K 01490 $50.65 APC-PR G K J9280 Mitomycin injection K 01232 $54.24 APC-PR G K J9281 Mitomycin instillation G 09374 $282.17 APC-PR New J9293 Mitoxantrone hydrochl / 5 mg K 00864 $24.14 APC-PR G K J9295 Injection, necitumumab, 1 mg K 09475 $5.74 APC-PR G K J9299 Injection, nivolumab K 09453 $28.54 APC-PR G K J9301 Obinutuzumab inj K 01476 $63.54 APC-PR G K J9302 Ofatumumab injection K 09260 $62.15 APC-PR G K J9303 Panitumumab injection K 09235 $124.17 APC-PR G K J9305 Inj. pemetrexed nos 10mg K 09213 $73.19 APC-PR G K J9306 Injection, pertuzumab, 1 mg K 01471 $12.99 APC-PR G K J9307 Pralatrexate injection K 09259 $310.93 APC-PR G K J9308 Injection, ramucirumab K 01488 $61.66 APC-PR G K J9309 Inj, polatuzumab vedotin 1mg G 09331 $112.12 APC-PR G K J9311 Inj rituximab, hyaluronidase G 09467 $40.23 APC-PR G K J9312 Inj., rituximab, 10 mg K 09186 $91.26 APC-PR G K J9313 Inj., lumoxiti, 0.01 mg G 09305 $22.48 APC-PR G K J9315 Romidepsin injection K 09265 $336.66 APC-PR G K J9316 Pertuzu, trastuzu, 10 mg G 09390 $72.71 APC-PR New J9317 Sacituzumab govitecan-hziy G 09376 $29.51 APC-PR New J9320 Streptozocin injection K 00850 $348.73 APC-PR G K J9325 Inj talimogene laherparepvec K 09472 $54.02 APC-PR G K J9330 Temsirolimus injection K 01168 $42.86 APC-PR G K J9340 Thiotepa injection K 00851 $454.82 APC-PR G K J9352 Injection trabectedin 0.1mg K 09480 $318.92 APC-PR G K J9354 Inj, ado-trastuzumab emt 1mg K 09131 $32.85 APC-PR G K

as of 2/4/2021 Page 18 of 19 CMAP Addendum B - OPPS Payment Type by Procedure Code Effective January 1, 2021

J9355 Inj trastuzumab excl biosimi K 01613 $97.92 APC-PR G K J9356 Inj. herceptin hylecta, 10mg G 09314 $74.59 APC-PR G K J9357 Valrubicin injection K 01235 $1,513.40 APC-PR G K J9358 Inj fam-trastu deru-nxki 1mg G 09353 $24.13 APC-PR G K J9371 Inj, vincristine sul lip 1mg K 01466 $3,320.40 APC-PR G K J9395 Injection, fulvestrant K 09120 $54.77 APC-PR G K J9400 Inj, ziv-aflibercept, 1mg K 09296 $8.50 APC-PR G K M0239 Bamlanivimab-xxxx infusion S 05694 3.7532 $310.75 APC New M0243 Casirivi and imdevi infusion S 05694 3.7532 $310.75 APC New M1145 MFN drug add-on, per dose E1 No New M1146 Ongoing care not ind M No New M1147 Care not poss med rsn M No New M1148 Pt self dschg M No New M1149 No neck fs prom incap M No New P9099 Blood component/product noc R 09537 0.0965 $7.99 APC X Q0138 Ferumoxytol, non-esrd K 01297 $0.93 APC-PR G K Q0139 Ferumoxytol, esrd use K 01485 $0.93 APC-PR G K Q0239 Bamlanivimab-xxxx L FS LAB New Q0243 Casirivimab and imdevimab L FS LAB New Q2009 Fosphenytoin inj pe N APC X Q2026 Radiesse injection K 09094 $257.37 APC-PR G K Q2028 Inj, sculptra, 0.5mg K 09095 $2.49 APC-PR G K Q2042 Tisagenlecleucel car-pos t G 09194 $425,159.01 APC-PR G K Q2043 Sipuleucel-t auto cd54+ K 09273 $49,649.41 APC-PR G K Q2049 Imported lipodox inj K 01421 $311.04 APC-PR G K Q2050 Doxorubicin inj 10mg K 07046 $298.80 APC-PR G K Q3027 Inj beta interferon im 1 mcg K 01472 $54.42 APC-PR G K Q5101 Injection, zarxio K 01822 $0.41 APC-PR G K Q5103 Injection, inflectra K 01847 $43.06 APC-PR G K Q5104 Injection, renflexis G 09036 $42.09 APC-PR G K Q5106 Inj retacrit non-esrd use G 09097 $8.55 APC-PR G K Q5107 Inj mvasi 10 mg G 09329 $56.73 APC-PR G K Q5108 Injection, fulphila G 09173 $248.16 APC-PR G K Q5110 Nivestym G 09193 $0.52 APC-PR G K Q5111 Injection, udenyca 0.5 mg G 09195 $267.79 APC-PR G K Q5112 Inj ontruzant 10 mg G 09382 $88.17 APC-PR G K Q5113 Inj herzuma 10 mg G 09349 $86.43 APC-PR G K Q5114 Inj ogivri 10 mg G 09341 $73.06 No G K Q5115 Inj truxima 10 mg G 09336 $68.50 No G K Q5116 Inj., trazimera, 10 mg G 09350 $74.02 APC-PR G K Q5117 Inj., kanjinti, 10 mg G 09330 $72.50 APC-PR G K Q5118 Inj., zirabev, 10 mg G 09348 $59.47 APC-PR G K Q5119 Inj ruxience, 10 mg G 09367 $67.32 APC-PR G K Q5120 Inj pegfilgrastim-bmez 0.5mg G 09345 $297.96 APC-PR G K Q5122 Inj, nyvepria E2 No New Q9968 Visualization adjunct K 01446 $6.20 APC-PR G K Q9991 Buprenorph xr 100 mg or less G 09073 $1,737.26 APC-PR G K Q9992 Buprenorphine xr over 100 mg G 09239 $1,737.26 APC-PR G K U0005 Infec agen detec ampli probe A FS LAB New

as of 2/4/2021 Page 19 of 19