Fee* Effective CPT Code Short Description 02/15/2017

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1 90281 HUMAN IG, IM $ HUMAN IG, IV $ HUMAN IG, SC $ CMV IG, IV $1, HEP B IG, IM $ RABIES IG, IM/SC $ RABIES IG, HEAT TREATED $ RSV IG, IM, 50MG $1, RH IG, FULL-DOSE, IM $ RH IG, MINIDOSE, IM $ RH IG, IV $ TETANUS IG, IM $ ANTHRAX VACCINE, SC $ BCG VACCINE, PERCUT $ BCG VACCINE, INTRAVESICAL $ MENB RP W/OMV VACCINE IM $ MENB RLP VACCINE IM $ CHOLERA VACCINE LIVE ORAL $ FLU VACC IIV4 NO PRESERV ID $ HEP A VACCINE, ADULT IM $ HEP A VACC, PED/ADOL, 2 DOSE $ HEP A/HEP B VACC, ADULT IM $ MENINGOCCL HIB VAC 4 DOSE IM $ HIB VACCINE, PRP-OMP, IM $ HIB VACCINE, PRP-T, IM $ H PAPILLOMA VACC 3 DOSE IM $ H PAPILLOMA VACC 3 DOSE IM $ HPV VACCINE NON VALENT IM $ FLU VACCINE ADJUVANT IM $ FLU VACCINE NO PRESERV, INTRADERMAL $ FLU VACCINE NO PRESERV 3 & >, TRIVALENT $ FLU VACCINE AGE 3 & OVER, IM, TRIVALENT $ FLU VACCINE, NO PRESERV, ENHANCED IMMUNO $ PNEUMOCOCCAL CONJ VACC, 13 VALENT $ FLU VACCINE 4 VALENT NASAL $ FLU VACCINE, RIV3 PRSV FREE $ CCIIV4 VAC NO PRSV 0.5 ML IM $ RABIES VACCINE, IM $ ROTOVIRUS VACC 3 DOSE, ORAL $ ROTOVIRUS VACC 2 DOSE, ORAL $ FLU VAC NO PRSV 4 VAL 6-35 M $ FLU VAC NO PRSV 4 VAL 3 YRS+ $ FLU VACCINE 4 VAL 6-35 MO IM $ FLU VACC 4 VAL 3YRS PLUS IM $16.83 Page 1

2 90690 TYPHOID VACCINE, ORAL $ TYPHOID VACCINE, IM $ DTAP-IPV VACCINE, IM $ DTAP-HIB-IP VACCINE, IM $ DTAP VACCINE, < 7 YRS, IM $ DT VACCINE < 7, IM $ MMR VACCINE, SC $ MMRV VACCINE, SC $ POLIOVIRUS, IPV, SC/IM $ TD VACCINE NO PRSRV >/= 7 IM $ TDAP VACCINE >7 IM $ CHICKEN POX VACCINE, SC $ YELLOW FEVER VACCINE, SC $ DTAP-HEP B-IPV VACCINE, IM $ PNEUMOCOCCAL VACCINE $ MENINGOCOCCAL VACCINE, SC $ MENINGOCOCCAL VACCINE, IM $ ZOSTER VACC, SC $ INACTIVATED JE VACC IM $ HEPB VACC, ILL PAT 3 DOSE IM $ HEP B VACC, ADOL, 2 DOSE, IM $ HEPB VACC PED/ADOL 3 DOSE IM $ HEP B VACCINE, ADULT, 3 DOSE IM $ HEPB VACC, ILL PAT 4 DOSE IM $ HEP B/HIB VACCINE, IM $43.61 A9575 INJ GADOTERATE MEGLUMI 0.1ML $0.38 A9576 INJ PROHANCE MULTIPACK $1.53 A9577 INJ MULTIHANCE $2.30 A9578 INJ MULTIHANCE MULTIPACK $2.30 A9579 GAD-BASE MR CONTRAST NOS,1ML $1.91 A9581 GADOXETATE DISODIUM INJ $14.54 A9583 GADOFOSVESET TRISODIUM INJ $19.13 A9585 GADOBUTROL INJECTION $0.38 J0129 ABATACEPT INJECTION $48.20 J0130 ABCIXIMAB INJECTION $1, J0132 ACETYLCYSTEINE INJECTION $1.53 J0133 ACYCLOVIR INJECTION $0.38 J0135 ADALIMUMAB INJECTION $ J0153 ADENOSINE INJ 1MG $0.77 J0171 ADRENALIN EPINEPHRINE INJECT $0.38 J0178 AFLIBERCEPT INJECTION $1, J0180 AGALSIDASE BETA INJECTION $ J0202 INJECTION, ALEMTUZUMAB $1, J0207 AMIFOSTINE $ Page 2

3 J0221 LUMIZYME INJECTION $ J0256 ALPHA 1 PROTEINASE INHIBITOR $4.97 J0257 GLASSIA INJECTION $4.59 J0278 AMIKACIN SULFATE INJECTION $1.91 J0280 AMINOPHYLLIN 250 MG INJ $9.56 J0285 AMPHOTERICIN B $31.75 J0287 AMPHOTERICIN B LIPID COMPLEX $15.30 J0289 AMPHOTERICIN B LIPOSOME INJ $20.66 J0290 AMPICILLIN 500 MG INJ $1.15 J0295 AMPICILLIN SODIUM PER 1.5 GM $3.06 J0348 ANIDULAFUNGIN INJECTION $0.38 J0360 HYDRALAZINE HCL INJECTION $4.97 J0401 INJ ARIPIPRAZOLE EXT REL 1MG $4.97 J0456 AZITHROMYCIN $3.44 J0461 ATROPINE SULFATE INJECTION $0.38 J0470 DIMECAPROL INJECTION $47.43 J0475 BACLOFEN 10 MG INJECTION $ J0476 BACLOFEN INTRATHECAL TRIAL $80.33 J0480 BASILIXIMAB $3, J0485 BELATACEPT INJECTION $4.21 J0490 BELIMUMAB INJECTION $43.99 J0500 DICYCLOMINE INJECTION $72.68 J0515 INJ BENZTROPINE MESYLATE $27.16 J0558 PENG BENZATHINE/PROCAINE INJ $8.80 J0561 PENICILLIN G BENZATHINE INJ $11.09 J0570 BUPRENORPHINE IMPLANT 74.2MG $1, J0583 BIVALIRUDIN $1.53 J0585 INJECTION,ONABOTULINUMTOXINA $6.12 J0586 ABOBOTULINUMTOXINA $8.03 J0587 INJ, RIMABOTULINUMTOXINB $12.24 J0588 INCOBOTULINUMTOXIN A $4.97 J0592 BUPRENORPHINE HYDROCHLORIDE $3.44 J0594 BUSULFAN INJECTION $39.02 J0595 BUTORPHANOL TARTRATE 1 MG $2.68 J0597 C-1 ESTERASE, BERINERT $48.96 J0598 C-1 ESTERASE, CINRYZE $58.14 J0600 EDETATE CALCIUM DISODIUM INJ $5, J0610 CALCIUM GLUCONATE INJECTION $3.83 J0630 CALCITONIN SALMON INJECTION $2, J0636 INJ CALCITRIOL PER 0.1 MCG $0.38 J0637 CASPOFUNGIN ACETATE $12.24 J0638 CANAKINUMAB INJECTION $97.16 J0640 LEUCOVORIN CALCIUM INJECTION $3.06 J0641 LEVOLEUCOVORIN INJECTION $0.77 Page 3

4 J0670 INJ MEPIVACAINE HCL/10 ML $2.68 J0690 CEFAZOLIN SODIUM INJECTION $1.15 J0692 CEFEPIME HCL FOR INJECTION $2.68 J0694 CEFOXITIN SODIUM INJECTION $4.59 J0696 CEFTRIAXONE SODIUM INJECTION $0.77 J0697 STERILE CEFUROXIME INJECTION $2.68 J0698 CEFOTAXIME SODIUM INJECTION $1.53 J0702 BETAMETHASONE ACET&SOD PHOSP $6.50 J0712 CEFTAROLINE FOSAMIL INJ $2.68 J0713 INJ CEFTAZIDIME PER 500 MG $2.30 J0717 CERTOLIZUMAB PEGOL INJ 1MG $7.65 J0720 CHLORAMPHENICOL SODIUM INJEC $42.08 J0725 CHORIONIC GONADOTROPIN/1000U $25.25 J0735 CLONIDINE HYDROCHLORIDE $14.15 J0740 CIDOFOVIR INJECTION $ J0743 CILASTATIN SODIUM INJECTION $7.27 J0744 CIPROFLOXACIN IV $1.53 J0770 COLISTIMETHATE SODIUM INJ $11.48 J0775 COLLAGENASE, CLOST HIST INJ $43.22 J0780 PROCHLORPERAZINE INJECTION $12.62 J0795 CORTICORELIN OVINE TRIFLUTAL $8.42 J0800 CORTICOTROPIN INJECTION $3, J0834 COSYNTROPIN CORTROSYN INJ $40.16 J0840 CROTALIDAE POLY IMMUNE FAB $2, J0850 CYTOMEGALOVIRUS IMM IV /VIAL $1, J0875 INJECTION, DALBAVANCIN $15.68 J0878 DAPTOMYCIN INJECTION $0.77 J0881 DARBEPOETIN ALFA, NON-ESRD $4.21 J0882 DARBEPOETIN ALFA, ESRD USE $4.21 J0885 EPOETIN ALFA, NON-ESRD $13.01 J0887 EPOETIN BETA ESRD USE $1.53 J0888 EPOETIN BETA NON ESRD $1.53 J0894 DECITABINE INJECTION $20.66 J0895 DEFEROXAMINE MESYLATE INJ $9.18 J0897 DENOSUMAB INJECTION $17.21 J1000 DEPO-ESTRADIOL CYPIONATE INJ $18.74 J1020 METHYLPREDNISOLONE 20 MG INJ $5.36 J1030 METHYLPREDNISOLONE 40 MG INJ $5.74 J1040 METHYLPREDNISOLONE 80 MG INJ $10.71 J1050 MEDROXYPROGESTERONE ACETATE $0.38 J1071 INJ TESTOSTERONE CYPIONATE $0.38 J1100 DEXAMETHASONE SODIUM PHOS $0.38 J1110 INJ DIHYDROERGOTAMINE MESYLT $ J1120 ACETAZOLAMID SODIUM INJECTIO $20.66 Page 4

5 J1160 DIGOXIN INJECTION $8.80 J1162 DIGOXIN IMMUNE FAB (OVINE) $3, J1165 PHENYTOIN SODIUM INJECTION $0.77 J1170 HYDROMORPHONE INJECTION $2.30 J1190 DEXRAZOXANE HCL INJECTION $ J1200 DIPHENHYDRAMINE HCL INJECTIO $0.77 J1205 CHLOROTHIAZIDE SODIUM INJ $88.74 J1212 DIMETHYL SULFOXIDE 50% 50 ML $ J1230 METHADONE INJECTION $19.89 J1240 DIMENHYDRINATE INJECTION $8.03 J1245 DIPYRIDAMOLE INJECTION $0.77 J1250 INJ DOBUTAMINE HCL/250 MG $5.74 J1265 DOPAMINE INJECTION $0.38 J1267 DORIPENEM INJECTION $0.77 J1270 INJECTION, DOXERCALCIFEROL $0.77 J1290 ECALLANTIDE INJECTION $ J1300 ECULIZUMAB INJECTION $ J1325 EPOPROSTENOL INJECTION $16.45 J1335 ERTAPENEM INJECTION $51.26 J1364 ERYTHRO LACTOBIONATE /500 MG $62.73 J1380 ESTRADIOL VALERATE 10 MG INJ $17.98 J1410 INJ ESTROGEN CONJUGATE 25 MG $ J1430 ETHANOLAMINE OLEATE 100 MG $ J1439 INJ FERRIC CARBOXYMALTOS 1MG $1.15 J1442 INJ FILGRASTIM EXCL BIOSIMIL $1.15 J1447 INJ TBO FILGRASTIM 1 MICROG $0.77 J1450 FLUCONAZOLE $4.59 J1453 FOSAPREPITANT INJECTION $1.91 J1458 GALSULFASE INJECTION $ J1459 INJ IVIG PRIVIGEN 500 MG $40.55 J1460 GAMMA GLOBULIN 1 CC INJ $37.49 J1556 INJ, IMM GLOB BIVIGAM, 500MG $39.02 J1557 GAMMAPLEX INJECTION $40.93 J1559 HIZENTRA INJECTION $10.33 J1560 GAMMA GLOBULIN > 10 CC INJ $ J1561 GAMUNEX-C/GAMMAKED $38.25 J1566 IMMUNE GLOBULIN, POWDER $33.66 J1568 OCTAGAM INJECTION $37.10 J1569 GAMMAGARD LIQUID INJECTION $42.08 J1570 GANCICLOVIR SODIUM INJECTION $64.64 J1571 HEPAGAM B IM INJECTION $61.58 J1572 FLEBOGAMMA INJECTION $34.43 J1575 HYQVIA 100MG IMMUNEGLOBULIN $13.77 J1580 GARAMYCIN GENTAMICIN INJ $1.53 Page 5

6 J1602 GOLIMUMAB FOR IV USE 1MG $25.63 J1610 GLUCAGON HYDROCHLORIDE/1 MG $ J1626 GRANISETRON HCL INJECTION $0.38 J1630 HALOPERIDOL INJECTION $0.77 J1631 HALOPERIDOL DECANOATE INJ $18.74 J1640 HEMIN, 1 MG $24.10 J1642 INJ HEPARIN SODIUM PER 10 U $0.38 J1644 INJ HEPARIN SODIUM PER 1000U $0.38 J1645 DALTEPARIN SODIUM $16.83 J1650 INJ ENOXAPARIN SODIUM $0.77 J1652 FONDAPARINUX SODIUM $2.30 J1670 TETANUS IMMUNE GLOBULIN INJ $ J1720 HYDROCORTISONE SODIUM SUCC I $9.56 J1725 INJECTION HPC 1 MG (MAKENA) $3.06 J1740 IBANDRONATE SODIUM INJECTION $ J1742 IBUTILIDE FUMARATE INJECTION $ J1743 IDURSULFASE INJECTION $ J1745 INFLIXIMAB NOT BIOSIMIL 10MG $86.06 J1750 INJ IRON DEXTRAN $13.01 J1756 IRON SUCROSE INJECTION $0.38 J1786 IMUGLUCERASE INJECTION $43.99 J1800 PROPRANOLOL INJECTION $1.91 J1815 INSULIN INJECTION $0.77 J1817 INSULIN FOR INSULIN PUMP USE $10.33 J1885 KETOROLAC TROMETHAMINE INJ $0.77 J1930 LANREOTIDE INJECTION $54.70 J1931 LARONIDASE INJECTION $32.13 J1940 FUROSEMIDE INJECTION $1.53 J1950 LEUPROLIDE ACETATE /3.75 MG $1, J1953 LEVETIRACETAM INJECTION $0.38 J1955 INJ LEVOCARNITINE PER 1 GM $21.80 J1956 LEVOFLOXACIN INJECTION $1.53 J1980 HYOSCYAMINE SULFATE INJ $29.07 J2001 LIDOCAINE INJECTION $0.38 J2010 LINCOMYCIN INJECTION $12.62 J2020 LINEZOLID INJECTION $16.83 J2060 LORAZEPAM INJECTION $0.77 J2150 MANNITOL INJECTION $2.30 J2175 MEPERIDINE HYDROCHL /100 MG $4.97 J2185 MEROPENEM $1.53 J2210 METHYLERGONOVIN MALEATE INJ $8.03 J2248 MICAFUNGIN SODIUM INJECTION $1.15 J2250 INJ MIDAZOLAM HYDROCHLORIDE $0.38 J2270 MORPHINE SULFATE INJECTION $1.91 Page 6

7 J2274 IN MORPHINE PRESERVATIV FREE $10.33 J2278 ZICONOTIDE INJECTION $7.65 J2280 INJ, MOXIFLOXACIN 100 MG $8.80 J2300 INJ NALBUPHINE HYDROCHLORIDE $2.68 J2310 INJ NALOXONE HYDROCHLORIDE $30.60 J2315 NALTREXONE, DEPOT FORM $3.44 J2323 NATALIZUMAB INJECTION $19.51 J2353 OCTREOTIDE INJECTION, DEPOT $ J2354 OCTREOTIDE INJ, NON-DEPOT $1.15 J2355 OPRELVEKIN INJECTION $ J2357 OMALIZUMAB INJECTION $34.04 J2358 OLANZAPINE LONG-ACTING INJ $3.06 J2360 ORPHENADRINE INJECTION $3.83 J2400 CHLOROPROCAINE HCL INJECTION $28.69 J2405 ONDANSETRON HCL INJECTION $0.38 J2407 INJECTION, ORITAVANCIN $26.01 J2410 OXYMORPHONE HCL INJECTION $3.06 J2425 PALIFERMIN INJECTION $18.36 J2426 PALIPERIDONE PALMITATE INJ $9.95 J2430 PAMIDRONATE DISODIUM /30 MG $10.71 J2469 PALONOSETRON HCL $23.72 J2501 PARICALCITOL $1.15 J2503 PEGAPTANIB SODIUM INJECTION $1, J2504 PEGADEMASE BOVINE, 25 IU $ J2505 INJECTION, PEGFILGRASTIM 6MG $4, J2507 PEGLOTICASE INJECTION $1, J2510 PENICILLIN G PROCAINE INJ $29.45 J2515 PENTOBARBITAL SODIUM INJ $52.02 J2540 PENICILLIN G POTASSIUM INJ $1.15 J2543 PIPERACILLIN/TAZOBACTAM $2.68 J2545 PENTAMIDINE NON-COMP UNIT $ J2550 PROMETHAZINE HCL INJECTION $2.30 J2560 PHENOBARBITAL SODIUM INJ $30.98 J2562 PLERIXAFOR INJECTION $ J2597 INJ DESMOPRESSIN ACETATE $14.15 J2675 INJ PROGESTERONE PER 50 MG $1.53 J2680 FLUPHENAZINE DECANOATE 25 MG $22.57 J2690 PROCAINAMIDE HCL INJECTION $58.91 J2700 OXACILLIN SODIUM INJECITON $1.91 J2704 INJ, PROPOFOL, 10 MG $0.38 J2720 INJ PROTAMINE SULFATE/10 MG $1.15 J2724 PROTEIN C CONCENTRATE $16.07 J2765 METOCLOPRAMIDE HCL INJECTION $0.77 J2770 QUINUPRISTIN/DALFOPRISTIN $ Page 7

8 J2778 RANIBIZUMAB INJECTION $ J2780 RANITIDINE HYDROCHLORIDE INJ $1.15 J2783 RASBURICASE $ J2785 REGADENOSON INJECTION $58.14 J2788 RHO D IMMUNE GLOBULIN 50 MCG $26.39 J2790 RHO D IMMUNE GLOBULIN INJ $84.15 J2791 RHOPHYLAC INJECTION $4.97 J2792 RHO(D) IMMUNE GLOBULIN H, SD $23.33 J2794 RISPERIDONE, LONG ACTING $8.42 J2795 ROPIVACAINE HCL INJECTION $0.38 J2796 ROMIPLOSTIM INJECTION $67.32 J2800 METHOCARBAMOL INJECTION $40.93 J2805 SINCALIDE INJECTION $ J2810 INJ THEOPHYLLINE PER 40 MG $0.38 J2820 SARGRAMOSTIM INJECTION $39.02 J2850 INJ SECRETIN SYNTHETIC HUMAN $36.34 J2916 NA FERRIC GLUCONATE COMPLEX $2.30 J2920 METHYLPREDNISOLONE INJECTION $4.21 J2930 METHYLPREDNISOLONE INJECTION $5.74 J2997 ALTEPLASE RECOMBINANT $85.30 J3000 STREPTOMYCIN INJECTION $13.39 J3010 FENTANYL CITRATE INJECITON $0.38 J3060 INJ, TALIGLUCERACE ALFA 10 U $42.46 J3070 PENTAZOCINE INJECTION $ J3090 INJ TEDIZOLID PHOSPHATE $1.15 J3095 TELAVANCIN INJECTION $5.36 J3101 TENECTEPLASE INJECTION $ J3105 TERBUTALINE SULFATE INJ $3.44 J3121 INJ TESTOSTERO ENANTHATE 1MG $0.38 J3230 CHLORPROMAZINE HCL INJECTION $25.63 J3240 THYROTROPIN INJECTION $1, J3243 TIGECYCLINE INJECTION $3.44 J3250 TRIMETHOBENZAMIDE HCL INJ $28.31 J3260 TOBRAMYCIN SULFATE INJECTION $2.30 J3262 TOCILIZUMAB INJECTION $4.59 J3285 TREPROSTINIL INJECTION $64.26 J3300 TRIAMCINOLONE A INJ PRS-FREE $3.83 J3301 TRIAMCINOLONE ACET INJ NOS $1.91 J3303 TRIAMCINOLONE HEXACETONL INJ $3.83 J3315 TRIPTORELIN PAMOATE $ J3357 USTEKINUMAB SUB CU INJ, 1 MG $ J3360 DIAZEPAM INJECTION $9.95 J3370 VANCOMYCIN HCL INJECTION $3.06 J3380 INJECTION, VEDOLIZUMAB $18.36 Page 8

9 J3385 VELAGLUCERASE ALFA $ J3396 VERTEPORFIN INJECTION $11.09 J3410 HYDROXYZINE HCL INJECTION $2.30 J3411 THIAMINE HCL 100 MG $3.44 J3415 PYRIDOXINE HCL 100 MG $12.62 J3420 VITAMIN B12 INJECTION $4.21 J3430 VITAMIN K PHYTONADIONE INJ $3.83 J3465 INJECTION, VORICONAZOLE $3.83 J3471 OVINE, UP TO 999 USP UNITS $0.38 J3473 HYALURONIDASE RECOMBINANT $0.38 J3475 INJ MAGNESIUM SULFATE $0.38 J3480 INJ POTASSIUM CHLORIDE $0.38 J3485 ZIDOVUDINE $1.53 J3486 ZIPRASIDONE MESYLATE $21.04 J3489 ZOLEDRONIC ACID 1MG $13.01 J7030 NORMAL SALINE SOLUTION INFUS $1.91 J7040 NORMAL SALINE SOLUTION INFUS $1.15 J7042 5% DEXTROSE/NORMAL SALINE $0.77 J7050 NORMAL SALINE SOLUTION INFUS $0.38 J7060 5% DEXTROSE/WATER $1.91 J7070 D5W INFUSION $3.83 J7120 RINGERS LACTATE INFUSION $2.30 J7180 FACTOR XIII ANTI-HEM FACTOR $8.42 J7182 FACTOR VIII RECOMB NOVOEIGHT $1.53 J7183 WILATE INJECTION $1.15 J7185 XYNTHA INJ $1.15 J7186 ANTIHEMOPHILIC VIII/VWF COMP $1.15 J7187 HUMATE-P, INJ $1.15 J7189 FACTOR VIIA $1.91 J7190 FACTOR VIII $1.15 J7192 FACTOR VIII RECOMBINANT NOS $1.15 J7193 FACTOR IX NON-RECOMBINANT $1.15 J7194 FACTOR IX COMPLEX $1.53 J7195 FACTOR IX RECOMBINANT NOS $1.53 J7197 ANTITHROMBIN III INJECTION $3.44 J7198 ANTI-INHIBITOR $1.91 J7200 FACTOR IX RECOMBINAN RIXUBIS $1.15 J7201 FACTOR IX ALPROLIX RECOMB $3.06 J7205 FACTOR VIII FC FUSION RECOMB $1.91 J7297 LEVONORGESTREL IU CONTRACEPTIVE, 52MG, 3 YEAR $ J7298 LEVONORGESTREL IU CONTRACEPTIVE, 52MG, 5 YEAR $ J7300 INTRAUT COPPER CONTRACEPTIVE $ J7301 LEVONORGESTREL IU CONTRACEPTIVE, (SKYLA) $ J7307 ETONOGESTREL IMPLANT SYSTEM $ Page 9

10 J7308 AMINOLEVULINIC ACID HCL TOP $ J7311 FLUOCINOLONE ACETONIDE IMPLT $21, J7312 DEXAMETHASONE INTRA IMPLANT $ J7313 FLUOCINOL ACET INTRAVIT IMP $ J7316 INJ, OCRIPLASMIN, MG $1, J7320 GENVISC 850, INJ, 1MG $8.42 J7321 HYALGAN/SUPARTZ INJ PER DOSE $90.27 J7323 EUFLEXXA INJ PER DOSE $ J7324 ORTHOVISC INJ PER DOSE $ J7325 SYNVISC OR SYNVISC-ONE $13.77 J7326 GEL-ONE $ J7327 MONOVISC INJ PER DOSE $ J7336 CAPSAICIN 8% PATCH $3.06 J7500 AZATHIOPRINE ORAL 50MG $0.38 J7502 CYCLOSPORINE ORAL 100 MG $3.06 J7503 TACROL ENVARSUS EX REL ORAL $1.15 J7504 LYMPHOCYTE IMMUNE GLOBULIN $1, J7507 TACROLIMUS IMME REL ORAL 1MG $0.77 J7508 TACROL ASTAGRAF EX REL ORAL $0.38 J7509 METHYLPREDNISOLONE ORAL $0.38 J7510 PREDNISOLONE ORAL PER 5 MG $0.38 J7511 ANTITHYMOCYTE GLOBULN RABBIT $ J7512 PREDNISONE IR OR DR ORAL 1MG $0.38 J7515 CYCLOSPORINE ORAL 25 MG $0.77 J7516 CYCLOSPORIN PARENTERAL 250MG $42.46 J7517 MYCOPHENOLATE MOFETIL ORAL $1.15 J7518 MYCOPHENOLIC ACID $3.06 J7520 SIROLIMUS, ORAL $8.42 J7525 TACROLIMUS INJECTION $ J7527 ORAL EVEROLIMUS $8.42 J7605 ARFORMOTEROL NON-COMP UNIT $9.95 J7606 FORMOTEROL FUMARATE, INH $11.09 J7608 ACETYLCYSTEINE NON-COMP UNIT $4.59 J7611 ALBUTEROL NON-COMP CON $0.38 J7612 LEVALBUTEROL NON-COMP CON $0.38 J7613 ALBUTEROL NON-COMP UNIT $0.38 J7614 LEVALBUTEROL NON-COMP UNIT $0.38 J7620 ALBUTEROL IPRATROP NON-COMP $0.38 J7626 BUDESONIDE NON-COMP UNIT $2.68 J7631 CROMOLYN SODIUM NONCOMP UNIT $0.77 J7639 DORNASE ALFA NON-COMP UNIT $44.75 J7644 IPRATROPIUM BROMIDE NON-COMP $0.38 J7674 METHACHOLINE CHLORIDE, NEB $0.38 J7682 TOBRAMYCIN NON-COMP UNIT $46.28 Page 10

11 J7686 TREPROSTINIL, NON-COMP UNIT $ J8501 ORAL APREPITANT $13.01 J8510 ORAL BUSULFAN $24.86 J8520 CAPECITABINE, ORAL, 150 MG $4.21 J8521 CAPECITABINE, ORAL, 500 MG $12.62 J8530 CYCLOPHOSPHAMIDE ORAL 25 MG $3.44 J8540 ORAL DEXAMETHASONE $0.38 J8560 ETOPOSIDE ORAL 50 MG $77.27 J8600 MELPHALAN ORAL 2 MG $12.24 J8610 METHOTREXATE ORAL 2.5 MG $0.77 J8655 NETUPITANT PALONOSETRON ORAL $ J8700 TEMOZOLOMIDE $1.91 J8705 TOPOTECAN ORAL $ J9000 DOXORUBICIN HCL INJECTION $2.68 J9017 ARSENIC TRIOXIDE INJECTION $68.09 J9019 ERWINAZE INJECTION $ J9025 AZACITIDINE INJECTION $2.68 J9027 CLOFARABINE INJECTION $ J9031 BCG LIVE INTRAVESICAL VAC $ J9032 INJECTION, BELINOSTAT, 10MG $36.34 J9033 INJ., TREANDA 1 MG $29.45 J9034 INJ., BENDEKA 1 MG $24.86 J9035 BEVACIZUMAB INJECTION $77.27 J9040 BLEOMYCIN SULFATE INJECTION $52.79 J9041 BORTEZOMIB INJECTION $48.58 J9042 BRENTUXIMAB VEDOTIN INJ $ J9043 CABAZITAXEL INJECTION $ J9045 CARBOPLATIN INJECTION $3.83 J9047 INJECTION, CARFILZOMIB, 1 MG $33.28 J9050 CARMUSTINE INJECTION $4, J9055 CETUXIMAB INJECTION $59.29 J9060 CISPLATIN 10 MG INJECTION $2.30 J9065 INJ CLADRIBINE PER 1 MG $24.48 J9070 CYCLOPHOSPHAMIDE 100 MG INJ $44.37 J9098 CYTARABINE LIPOSOME INJ $ J9100 CYTARABINE HCL 100 MG INJ $0.77 J9120 DACTINOMYCIN INJECTION $1, J9130 DACARBAZINE 100 MG INJ $4.59 J9145 INJECTION, DARATUMUMAB 10 MG $49.34 J9150 DAUNORUBICIN INJECTION $32.90 J9155 DEGARELIX INJECTION $3.83 J9171 DOCETAXEL INJECTION $2.68 J9176 INJECTION, ELOTUZUMAB, 1MG $6.50 J9178 INJ, EPIRUBICIN HCL, 2 MG $1.53 Page 11

12 J9179 ERIBULIN MESYLATE INJECTION $ J9181 ETOPOSIDE INJECTION $0.77 J9185 FLUDARABINE PHOSPHATE INJ $62.73 J9190 FLUOROURACIL INJECTION $1.91 J9200 FLOXURIDINE INJECTION $78.41 J9201 GEMCITABINE HCL INJECTION $5.74 J9202 GOSERELIN ACETATE IMPLANT $ J9205 INJ IRINOTECAN LIPOSOME 1 MG $41.31 J9206 IRINOTECAN INJECTION $3.83 J9207 IXABEPILONE INJECTION $80.33 J9208 IFOSFAMIDE INJECTION $29.84 J9209 MESNA INJECTION $1.91 J9211 IDARUBICIN HCL INJECTION $35.96 J9214 INTERFERON ALFA-2B INJ $27.92 J9217 LEUPROLIDE ACETATE SUSPNSION $ J9218 LEUPROLIDE ACETATE INJECITON $23.72 J9225 VANTAS IMPLANT $3, J9226 SUPPRELIN LA IMPLANT $29, J9228 IPILIMUMAB INJECTION $ J9230 MECHLORETHAMINE HCL INJ $ J9245 INJ MELPHALAN HYDROCHL 50 MG $2, J9250 METHOTREXATE SODIUM INJ $0.38 J9260 METHOTREXATE SODIUM INJ $2.30 J9261 NELARABINE INJECTION $ J9263 OXALIPLATIN $0.38 J9264 PACLITAXEL PROTEIN BOUND $10.71 J9266 PEGASPARGASE INJECTION $14, J9267 PACLITAXEL INJECTION $0.38 J9268 PENTOSTATIN INJECTION $1, J9271 INJ PEMBROLIZUMAB $48.96 J9280 MITOMYCIN INJECTION $ J9293 MITOXANTRONE HYDROCHL / 5 MG $41.31 J9295 INJECTION, NECITUMUMAB, 1 MG $5.36 J9299 INJECTION, NIVOLUMAB $27.16 J9301 OBINUTUZUMAB INJ $60.05 J9302 OFATUMUMAB INJECTION $55.85 J9303 PANITUMUMAB INJECTION $ J9305 PEMETREXED INJECTION $66.94 J9306 INJECTION, PERTUZUMAB, 1 MG $11.48 J9307 PRALATREXATE INJECTION $ J9308 INJECTION, RAMUCIRUMAB $59.29 J9310 RITUXIMAB INJECTION $ J9315 ROMIDEPSIN INJECTION $ J9320 STREPTOZOCIN INJECTION $ Page 12

13 J9325 INJ TALIMOGENE LAHERPAREPVEC $48.58 J9328 TEMOZOLOMIDE INJECTION $8.42 J9330 TEMSIROLIMUS INJECTION $71.15 J9351 TOPOTECAN INJECTION $1.15 J9352 INJECTION TRABECTEDIN 0.1MG $ J9354 INJ, ADO-TRASTUZUMAB EMT 1MG $30.98 J9355 TRASTUZUMAB INJECTION $99.07 J9357 VALRUBICIN INJECTION $1, J9360 VINBLASTINE SULFATE INJ $3.83 J9370 VINCRISTINE SULFATE 1 MG INJ $4.59 J9371 INJ, VINCRISTINE SUL LIP 1MG $2, J9390 VINORELBINE TARTRATE INJ $9.18 J9395 INJECTION, FULVESTRANT $ J9400 INJ, ZIV-AFLIBERCEPT, 1MG $8.42 P9041 ALBUMIN (HUMAN),5%, 50ML $11.86 P9045 ALBUMIN (HUMAN), 5%, 250 ML $57.38 P9046 ALBUMIN (HUMAN), 25%, 20 ML $23.72 P9047 ALBUMIN (HUMAN), 25%, 50ML $56.23 Q0138 FERUMOXYTOL, NON-ESRD $0.77 Q0139 FERUMOXYTOL, ESRD USE $0.77 Q0162 ONDANSETRON ORAL $0.38 Q0163 DIPHENHYDRAMINE HCL 50MG $0.38 Page 13

Table III: 2019 Medicare Drug Fee Schedule* CY st Quarter Average Sales Price (ASP) Data Plus 6 Percent

Table III: 2019 Medicare Drug Fee Schedule* CY 2019 1st Quarter Average Sales Price (ASP) Data Plus 6 Percent *The Medicare payments allowance limits are effective Jan. 1 thru March. 31, 2019. CY 2019