Payment Allowance Limits for Medicare Part B Drugs
`
`Effective October 1, 2019 through December 31, 2019
`
`Note 1: Payment allowance limits subject to the ASP methodology are based on 2Q19 ASP data.
`Note 2: The absence or presence of a HCPCS code and the payment allowance limits in this table does not indicate Medicare coverage of the drug. Similarly, the inclusion of
`a payment allowance limit within a specific column does not indicate Medicare coverage of the drug in that specific category. These determinations shall be made by the local
`Medicare contractor processing the claim.
`
`HCPCS Code
`90371
`90375
`90376
`90585
`90586
`90632
`
`90653
`
`90662
`90670
`
`90672
`
`90674
`90675
`
`90682
`
`90685
`
`90686
`
`90687
`
`90688
`90691
`90714
`90715
`90732
`90739
`
`Short Description
`Hep b ig im
`Rabies ig im/sc
`Rabies ig heat treated
`Bcg vaccine percut
`Bcg vaccine intravesical
`Hepa vaccine adult im
`
`Iiv adjuvant vaccine im
`
`Iiv no prsv increased ag im
`Pcv13 vaccine im
`
`Laiv4 vaccine intranasal
`
`Cciiv4 vac no prsv 0.5 ml im
`Rabies vaccine im
`
`Riv4 vacc recombinant dna im
`
`Iiv4 vacc no prsv 0.25 ml im
`
`Iiv4 vacc no prsv 0.5 ml im
`
`Iiv4 vaccine splt 0.25 ml im
`
`Iiv4 vaccine splt 0.5 ml im
`Typhoid vaccine im
`Td vacc no presv 7 yrs+ im
`Tdap vaccine 7 yrs/> im
`Ppsv23 vacc 2 yrs+ subq/im
`Hepb vacc 2 dose adult im
`
`Vaccine
`AWP%
`
`Vaccine Limit
`
`Blood
`AWP%
`
`Blood limit
`
`Clotting
`Factor
`
`Notes
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`
`Added October 2019 - see the Seasonal
`Influenza Vaccines Pricing webpage for
`current payment limits and effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`
`HCPCS Code Dosage
`1 ML
`150 IU
`150 IU
`50 MG
`1 EACH
`1 ML
`
`Payment Limit
`110.667
`280.644
`271.374
`141.057
`141.057
`58.908
`
`0.5 ml
`
`0.5 ML
`0.5 ML
`
`0.2 ML
`
`0.5 ML
`1 ML
`
`0.5 ML
`
`0.25 mL
`
`0.5 ml
`
`0.25 ML
`
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`0.5 ML
`1 dose
`
`59.530
`
`56.006
`215.333
`
`26.876
`
`28.130
`297.589
`
`56.006
`
`20.343
`
`19.032
`
`9.403
`
`17.835
`90.584
`24.263
`32.855
`114.211
`131.100
`
`95
`
`95
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`
`95
`95
`
`59.530
`
`56.006
`215.333
`
`26.876
`
`28.130
`
`56.006
`
`20.343
`
`19.032
`
`9.403
`
`17.835
`
`114.211
`131.100
`
`Exhibit 2239
`Page 01 of 14
`
`

`

`95
`95
`95
`95
`
`95
`
`134.121
`26.898
`67.061
`134.121
`
`26.657
`
`see the Seasonal Influenza Vaccines Pricing
`webpage for current payment limits and
`effective dates
`
`microCurie 100% AWP = $164.380
`microCurie 100% WAC = $136.980
`
`Updated July 2020
`
`AMP-based payment limit
`
`90740
`90744
`90746
`90747
`
`90756
`A9575
`A9576
`A9577
`A9578
`A9579
`A9581
`A9585
`A9589
`
`A9606
`J0129
`J0130
`J0132
`J0133
`J0153
`J0171
`J0178
`J0180
`J0185
`J0202
`J0207
`J0221
`J0256
`J0257
`J0278
`J0280
`J0285
`J0287
`J0289
`J0290
`J0295
`J0348
`J0360
`J0401
`J0456
`J0461
`J0470
`J0475
`J0476
`J0480
`J0485
`
`Hepb vacc 3 dose immunsup im
`Hepb vacc 3 dose ped/adol im
`Hepb vaccine 3 dose adult im
`Hepb vacc 4 dose immunsup im
`
`Cciiv4 vacc abx free im
`Inj gadoterate meglumi 0.1ml
`Inj prohance multipack
`Inj multihance
`Inj multihance multipack
`Gad-base mr contrast nos,1ml
`Gadoxetate disodium inj
`Gadobutrol injection
`Insti hexaminolevulinate hcl
`
`Radium ra223 dichloride ther
`Abatacept injection
`Abciximab injection
`Acetylcysteine injection
`Acyclovir injection
`Adenosine inj 1mg
`Adrenalin epinephrine inject
`Aflibercept injection
`Agalsidase beta injection
`Inj., aprepitant, 1 mg
`Injection, alemtuzumab
`Amifostine
`Lumizyme injection
`Alpha 1 proteinase inhibitor
`Glassia injection
`Amikacin sulfate injection
`Aminophyllin 250 mg inj
`Amphotericin b
`Amphotericin b lipid complex
`Amphotericin b liposome inj
`Ampicillin 500 mg inj
`Ampicillin sulbactam 1.5 gm
`Anidulafungin injection
`Hydralazine hcl injection
`Inj aripiprazole ext rel 1mg
`Azithromycin
`Atropine sulfate injection
`Dimecaprol injection
`Baclofen 10 mg injection
`Baclofen intrathecal trial
`Basiliximab
`Belatacept injection
`
`40 MCG
`1 DOSE
`20 MCG
`40 MCG
`
`0.5 ML
`0.1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`0.1 ML
`100 MG
`
`1 microCurie
`10 MG
`10 MG
`100 MG
`5 MG
`1 MG
`0.1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`500 MG
`10 MG
`10 MG
`10 MG
`100 MG
`250 MG
`50 MG
`10 MG
`10 MG
`500 MG
`1.5 GM
`1 MG
`20 MG
`1 MG
`500 MG
`0.01 MG
`100 MG
`10 MG
`50 MCG
`20 MG
`1 MG
`
`134.121
`26.898
`67.061
`134.121
`
`26.657
`0.185
`1.418
`1.936
`1.943
`1.590
`14.776
`0.349
`1139.500
`
`N/A
`54.318
`1429.071
`1.038
`0.044
`0.702
`0.832
`952.473
`183.430
`2.213
`1917.042
`1003.594
`171.046
`4.550
`4.823
`1.114
`10.881
`40.280
`6.184
`26.087
`0.999
`2.063
`0.550
`4.213
`5.704
`3.049
`0.065
`55.289
`169.513
`50.046
`3799.932
`3.776
`
`Exhibit 2239
`Page 02 of 14
`
`

`

`J0490
`J0500
`J0515
`J0517
`J0558
`J0561
`J0565
`J0570
`J0583
`J0584
`J0585
`J0586
`J0587
`J0588
`J0592
`J0594
`J0595
`J0596
`J0597
`J0598
`J0600
`J0610
`J0630
`J0636
`J0637
`J0638
`J0640
`J0641
`J0642
`J0670
`J0690
`J0692
`J0694
`J0695
`J0696
`J0697
`J0698
`J0702
`J0712
`J0713
`J0714
`J0717
`J0720
`J0725
`J0735
`J0740
`J0743
`J0744
`
`Belimumab injection
`Dicyclomine injection
`Inj benztropine mesylate
`Inj., benralizumab, 1 mg
`Peng benzathine/procaine inj
`Penicillin g benzathine inj
`Inj, bezlotoxumab, 10 mg
`Buprenorphine implant 74.2mg
`Bivalirudin
`Injection, burosumab-twza 1m
`Injection,onabotulinumtoxina
`Abobotulinumtoxina
`Inj, rimabotulinumtoxinb
`Incobotulinumtoxin a
`Buprenorphine hydrochloride
`Busulfan injection
`Butorphanol tartrate 1 mg
`Injection, ruconest
`C-1 esterase, berinert
`C-1 esterase, cinryze
`Edetate calcium disodium inj
`Calcium gluconate injection
`Calcitonin salmon injection
`Inj calcitriol per 0.1 mcg
`Caspofungin acetate
`Canakinumab injection
`Leucovorin calcium injection
`Inj levoleucovorin nos 0.5mg
`Injection, khapzory, 0.5 mg
`Inj mepivacaine hcl/10 ml
`Cefazolin sodium injection
`Cefepime hcl for injection
`Cefoxitin sodium injection
`Inj ceftolozane tazobactam
`Ceftriaxone sodium injection
`Sterile cefuroxime injection
`Cefotaxime sodium injection
`Betamethasone acet&sod phosp
`Ceftaroline fosamil inj
`Inj ceftazidime per 500 mg
`Ceftazidime and avibactam
`Certolizumab pegol inj 1mg
`Chloramphenicol sodium injec
`Chorionic gonadotropin/1000u
`Clonidine hydrochloride
`Cidofovir injection
`Cilastatin sodium injection
`Ciprofloxacin iv
`
`10 MG
`20 MG
`1 MG
`1 MG
`100,000 UNITS
`100,000 UNITS
`10 MG
`74.2 MG
`1 MG
`1 MG
`1 UNIT
`5 Unit
`100 UNITS
`1 UNIT
`0.1 MG
`1 MG
`1 MG
`10 UNITS
`10 UNITS
`10 UNITS
`1000 MG
`10 ML
`400 UNITS
`0.1 MCG
`5 MG
`1 MG
`50 MG
`0.5 MG
`0.5 MG
`10 ML
`500 MG
`500 MG
`1 GM
`75mg (50mg cft/25mg taz)
`250 MG
`750 MG
`1 GM
`3 MG & 3 MG
`10 MG
`500 MG
`.625 GM
`1 MG
`1 GM
`1000 UNITS
`1 MG
`375 MG
`250 MG
`200 MG
`
`44.824
`57.583
`17.739
`168.502
`10.887
`13.820
`39.829
`1303.529
`0.619
`353.210
`6.123
`8.432
`11.987
`5.054
`4.557
`4.579
`2.707
`28.219
`51.305
`57.031
`5594.422
`2.698
`2661.047
`0.606
`6.853
`111.013
`3.018
`0.396
`2.040
`2.447
`0.769
`1.907
`5.225
`5.602
`0.537
`2.030
`2.332
`6.956
`3.190
`1.998
`92.052
`8.023
`38.541
`22.619
`13.705
`623.268
`6.138
`1.235
`
`AMP-based payment limit
`
`Added October 2019
`AMP-based payment limit
`
`Exhibit 2239
`Page 03 of 14
`
`

`

`J0770
`J0775
`J0780
`J0795
`J0800
`J0834
`J0840
`J0841
`J0850
`J0875
`J0878
`J0881
`J0882
`J0885
`J0887
`J0888
`J0894
`J0895
`J0897
`J1000
`J1020
`J1030
`J1040
`J1050
`J1071
`J1100
`J1110
`J1120
`J1160
`J1162
`J1165
`J1170
`J1190
`J1200
`J1205
`J1212
`J1230
`J1240
`J1245
`J1250
`J1265
`J1270
`J1290
`J1300
`J1301
`J1303
`J1322
`J1325
`
`Colistimethate sodium inj
`Collagenase, clost hist inj
`Prochlorperazine injection
`Corticorelin ovine triflutal
`Corticotropin injection
`Inj., cosyntropin, 0.25 mg
`Crotalidae poly immune fab
`Inj crotalidae im f(ab')2 eq
`Cytomegalovirus imm iv /vial
`Injection, dalbavancin
`Daptomycin injection
`Darbepoetin alfa, non-esrd
`Darbepoetin alfa, esrd use
`Epoetin alfa, non-esrd
`Epoetin beta esrd use
`Epoetin beta non esrd
`Decitabine injection
`Deferoxamine mesylate inj
`Denosumab injection
`Depo-estradiol cypionate inj
`Methylprednisolone 20 mg inj
`Methylprednisolone 40 mg inj
`Methylprednisolone 80 mg inj
`Medroxyprogesterone acetate
`Inj testosterone cypionate
`Dexamethasone sodium phos
`Inj dihydroergotamine mesylt
`Acetazolamid sodium injectio
`Digoxin injection
`Digoxin immune fab (ovine)
`Phenytoin sodium injection
`Hydromorphone injection
`Dexrazoxane hcl injection
`Diphenhydramine hcl injectio
`Chlorothiazide sodium inj
`Dimethyl sulfoxide 50% 50 ml
`Methadone injection
`Dimenhydrinate injection
`Dipyridamole injection
`Inj dobutamine hcl/250 mg
`Dopamine injection
`Injection, doxercalciferol
`Ecallantide injection
`Eculizumab injection
`Injection, edaravone, 1 mg
`Inj., ravulizumab-cwvz 10 mg
`Elosulfase alfa, injection
`Epoprostenol injection
`
`150 MG
`0.01 MG
`10 MG
`1 MCG
`40 UNITS
`0.25 MG
`UP TO 1 GM
`120 MG
`PER VIAL
`5 MG
`1 MG
`1 MCG
`1 MCG
`1000 UNITS
`1 MCG
`1 MCG
`1 MG
`500 MG
`1 MG
`5 MG
`20 MG
`40 MG
`80 MG
`1 MG
`1 MG
`1 MG
`1 MG
`500 MG
`0.5 MG
`PER VIAL
`50 MG
`4 MG
`250 MG
`50 MG
`500 MG
`50 ML
`10 MG
`50 MG
`10 MG
`250 MG
`40 MG
`1 MCG
`1 MG
`10 MG
`1 MG
`10 MG
`1 MG
`0.5 MG
`
`19.201
`48.760
`9.692
`9.040
`3946.500
`39.822
`3285.188
`1264.421
`1129.154
`14.945
`0.330
`3.852
`3.852
`11.031
`1.802
`1.802
`7.485
`8.522
`19.276
`21.893
`3.697
`6.245
`11.934
`0.562
`0.024
`0.142
`57.656
`17.189
`5.423
`3780.193
`0.847
`2.684
`194.341
`0.908
`49.652
`586.511
`16.542
`6.734
`0.075
`6.994
`0.756
`0.318
`493.743
`230.479
`19.485
`226.275
`241.453
`16.188
`
`Added October 2019
`
`AMP-based payment limit
`
`Added October 2019
`
`Exhibit 2239
`Page 04 of 14
`
`

`

`J1335
`J1364
`J1380
`J1410
`J1430
`J1439
`J1442
`J1447
`J1450
`J1453
`J1454
`J1458
`J1459
`J1460
`J1555
`J1556
`J1557
`J1559
`J1560
`J1561
`J1566
`J1568
`J1569
`J1570
`J1571
`J1572
`J1575
`J1580
`J1602
`J1610
`J1626
`J1627
`J1630
`J1631
`J1640
`J1642
`J1644
`J1645
`J1650
`J1652
`J1670
`J1720
`J1740
`J1742
`J1743
`J1745
`J1746
`J1750
`
`Ertapenem injection
`Erythro lactobionate /500 mg
`Estradiol valerate 10 mg inj
`Inj estrogen conjugate 25 mg
`Ethanolamine oleate 100 mg
`Inj ferric carboxymaltos 1mg
`Inj filgrastim excl biosimil
`Inj tbo filgrastim 1 microg
`Fluconazole
`Fosaprepitant injection
`Inj fosnetupitant, palonoset
`Galsulfase injection
`Inj ivig privigen 500 mg
`Gamma globulin 1 cc inj
`Inj cuvitru, 100 mg
`Inj, imm glob bivigam, 500mg
`Gammaplex injection
`Hizentra injection
`Gamma globulin > 10 cc inj
`Gamunex-c/gammaked
`Immune globulin, powder
`Octagam injection
`Gammagard liquid injection
`Ganciclovir sodium injection
`Hepagam b im injection
`Flebogamma injection
`Hyqvia 100mg immuneglobulin
`Garamycin gentamicin inj
`Golimumab for iv use 1mg
`Glucagon hydrochloride/1 mg
`Granisetron hcl injection
`Inj, granisetron, xr, 0.1 mg
`Haloperidol injection
`Haloperidol decanoate inj
`Hemin, 1 mg
`Inj heparin sodium per 10 u
`Inj heparin sodium per 1000u
`Dalteparin sodium
`Inj enoxaparin sodium
`Fondaparinux sodium
`Tetanus immune globulin inj
`Hydrocortisone sodium succ i
`Ibandronate sodium injection
`Ibutilide fumarate injection
`Idursulfase injection
`Infliximab not biosimil 10mg
`Inj., ibalizumab-uiyk, 10 mg
`Inj iron dextran
`
`500 MG
`500 MG
`10 MG
`25 MG
`100 MG
`1 MG
`1 MCG
`1 MCG
`200 MG
`1 MG
`0.25 MG
`1 MG
`500 MG
`1 CC
`100 MG
`500 MG
`500 MG
`100 MG
`10 CC
`500 MG
`500 MG
`500 MG
`500 MG
`500 MG
`0.5 ML
`500 MG
`100 MG
`80 MG
`1 MG
`1 MG
`100 MCG
`0.1 MG
`5 MG
`50 MG
`1 MG
`10 UNITS
`1000 UNITS
`2500 IU
`10 MG
`0.5 MG
`250 UNITS
`100 MG
`1 MG
`1 MG
`1 MG
`10 MG
`10 MG
`50 MG
`
`43.470
`75.764
`10.745
`308.930
`444.099
`1.097
`0.964
`0.566
`4.714
`1.969
`416.867
`397.922
`40.122
`39.909
`13.787
`70.517
`45.824
`10.437
`399.090
`38.947
`61.203
`35.683
`37.468
`48.414
`60.057
`35.475
`14.556
`1.910
`21.580
`199.272
`0.397
`2.744
`0.970
`16.483
`23.719
`0.019
`0.205
`12.577
`0.825
`1.725
`432.663
`12.901
`43.480
`278.770
`542.887
`63.285
`60.155
`14.407
`
`Updated April 2020
`
`Updated April 2020
`
`Updated April 2020
`
`Added October 2019
`
`Exhibit 2239
`Page 05 of 14
`
`

`

`Added October 2019
`
`J1756
`J1786
`J1800
`J1815
`J1817
`J1885
`J1930
`J1931
`J1940
`J1943
`J1944
`J1950
`J1953
`J1955
`J1956
`J1980
`J2001
`J2010
`J2020
`J2060
`J2150
`J2175
`J2182
`J2185
`J2210
`J2248
`J2250
`J2260
`J2270
`J2274
`J2278
`J2280
`J2300
`J2310
`J2315
`J2323
`J2350
`J2353
`J2354
`J2357
`J2358
`J2360
`J2400
`J2405
`J2407
`J2425
`J2426
`J2430
`
`Iron sucrose injection
`Imuglucerase injection
`Propranolol injection
`Insulin injection
`Insulin for insulin pump use
`Ketorolac tromethamine inj
`Lanreotide injection
`Laronidase injection
`Furosemide injection
`Inj., aristada initio, 1 mg
`Aripiprazole lauroxil 1mg
`Leuprolide acetate /3.75 mg
`Levetiracetam injection
`Inj levocarnitine per 1 gm
`Levofloxacin injection
`Hyoscyamine sulfate inj
`Lidocaine injection
`Lincomycin injection
`Linezolid injection
`Lorazepam injection
`Mannitol injection
`Meperidine hydrochl /100 mg
`Injection, mepolizumab, 1mg
`Meropenem
`Methylergonovin maleate inj
`Micafungin sodium injection
`Inj midazolam hydrochloride
`Inj milrinone lactate / 5 mg
`Morphine sulfate injection
`Inj morphine pf epid ithc
`Ziconotide injection
`Inj, moxifloxacin 100 mg
`Inj nalbuphine hydrochloride
`Inj naloxone hydrochloride
`Naltrexone, depot form
`Natalizumab injection
`Injection, ocrelizumab, 1 mg
`Octreotide injection, depot
`Octreotide inj, non-depot
`Omalizumab injection
`Olanzapine long-acting inj
`Orphenadrine injection
`Chloroprocaine hcl injection
`Ondansetron hcl injection
`Injection, oritavancin
`Palifermin injection
`Paliperidone palmitate inj
`Pamidronate disodium /30 mg
`
`1 MG
`10 UNITS
`1 MG
`5 UNITS
`50 UNITS
`15 MG
`1 MG
`0.1 MG
`20 MG
`1 MG
`1 MG
`3.75 MG
`10 MG
`1 GM
`250 MG
`0.25 MG
`10 MG
`300 MG
`200 MG
`2 MG
`50 ML
`100 MG
`1 MG
`100 MG
`0.2 MG
`1 MG
`1 MG
`5 MG
`10 MG
`10 MG
`1 MCG
`100 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`25 MCG
`5 MG
`1 MG
`60 MG
`30 ML
`1 MG
`10 MG
`50 MCG
`1 MG
`30 MG
`
`0.234
`42.937
`8.480
`0.881
`10.777
`0.500
`62.324
`32.136
`0.692
`2.856
`2.778
`1269.227
`0.112
`19.402
`0.217
`29.471
`0.031
`11.184
`6.300
`0.656
`2.618
`6.072
`29.720
`0.900
`17.391
`1.043
`0.120
`1.782
`4.396
`14.992
`7.914
`8.787
`3.170
`15.281
`3.247
`20.242
`57.417
`206.565
`0.780
`36.778
`2.917
`6.442
`23.318
`0.109
`23.780
`21.275
`11.630
`12.062
`
`Exhibit 2239
`Page 06 of 14
`
`

`

`J2469
`J2501
`J2503
`J2504
`J2505
`J2507
`J2510
`J2515
`J2540
`J2543
`J2545
`J2550
`J2560
`J2562
`J2597
`J2675
`J2680
`J2690
`J2700
`J2704
`J2720
`J2724
`J2760
`J2765
`J2770
`J2778
`J2780
`J2783
`J2785
`J2786
`J2788
`J2790
`J2791
`J2792
`J2794
`J2795
`J2796
`J2798
`J2800
`J2805
`J2810
`J2820
`J2860
`J2916
`J2920
`J2930
`J2997
`J3000
`
`Palonosetron hcl
`Paricalcitol
`Pegaptanib sodium injection
`Pegademase bovine, 25 iu
`Injection, pegfilgrastim 6mg
`Pegloticase injection
`Penicillin g procaine inj
`Pentobarbital sodium inj
`Penicillin g potassium inj
`Piperacillin/tazobactam
`Pentamidine non-comp unit
`Promethazine hcl injection
`Phenobarbital sodium inj
`Plerixafor injection
`Inj desmopressin acetate
`Inj progesterone per 50 mg
`Fluphenazine decanoate 25 mg
`Procainamide hcl injection
`Oxacillin sodium injeciton
`Inj, propofol, 10 mg
`Inj protamine sulfate/10 mg
`Protein c concentrate
`Phentolaine mesylate inj
`Metoclopramide hcl injection
`Quinupristin/dalfopristin
`Ranibizumab injection
`Ranitidine hydrochloride inj
`Rasburicase
`Regadenoson injection
`Injection, reslizumab, 1mg
`Rho d immune globulin 50 mcg
`Rho d immune globulin inj
`Rhophylac injection
`Rho(d) immune globulin h, sd
`Risperidone, long acting
`Ropivacaine hcl injection
`Romiplostim injection
`Inj., perseris, 0.5 mg
`Methocarbamol injection
`Sincalide injection
`Inj theophylline per 40 mg
`Sargramostim injection
`Injection, siltuximab
`Na ferric gluconate complex
`Methylprednisolone injection
`Methylprednisolone injection
`Alteplase recombinant
`Streptomycin injection
`
`25 MCG
`1 MCG
`0.3 MG
`25 IU
`6 MG
`1 MG
`600000 UNITS
`50 MG
`600000 UNITS
`1.125 GM
`300 MG
`50 MG
`120 MG
`1 MG
`1 MCG
`50 MG
`25 MG
`1 GM
`250 MG
`10 MG
`10 MG
`10 UNITS
`5 MG
`10 MG
`500 MG
`0.1 mg
`25 MG
`0.5 MG
`0.1 MG
`1 MG
`50 MCG (250 IU)
`300 MCG (1500 IU)
`100 IU
`100 IU
`0.5 MG
`1 MG
`10 MCG
`0.5 mg
`10 ML
`5 MCG
`40 MG
`50 MCG
`10 MG
`12.5 MG
`40 MG
`125 MG
`1 MG
`1 GM
`
`7.933
`0.792
`722.049
`367.961
`4429.626
`2512.548
`29.968
`37.015
`1.017
`1.827
`105.269
`2.022
`42.038
`347.712
`12.143
`2.213
`10.946
`77.493
`1.370
`0.106
`1.086
`15.097
`377.567
`1.542
`417.490
`352.174
`4.095
`289.815
`59.222
`9.616
`24.917
`79.562
`4.762
`29.784
`10.044
`0.069
`74.275
`9.866
`9.060
`109.971
`0.416
`43.442
`103.062
`1.622
`4.487
`6.119
`87.638
`31.525
`
`AMP-based payment limit
`
`Updated April 2020
`
`AMP-based payment limit
`
`Added October 2019
`
`Exhibit 2239
`Page 07 of 14
`
`

`

`J3010
`J3060
`J3070
`J3090
`J3095
`J3101
`J3105
`J3111
`J3121
`J3145
`J3230
`J3240
`J3243
`J3245
`J3250
`J3260
`J3262
`J3285
`J3300
`J3301
`J3304
`J3315
`J3357
`J3358
`J3360
`J3370
`J3380
`J3385
`J3396
`J3410
`J3411
`J3415
`J3420
`J3430
`J3465
`J3471
`J3473
`J3475
`J3480
`J3485
`J3486
`J3489
`J7030
`J7040
`J7042
`J7050
`J7060
`J7070
`
`Fentanyl citrate injection
`Inj, taliglucerase alfa 10 u
`Pentazocine injection
`Inj tedizolid phosphate
`Telavancin injection
`Tenecteplase injection
`Terbutaline sulfate inj
`Inj. romosozumab-aqqg 1 mg
`Inj testostero enanthate 1mg
`Testosterone undecanoate 1mg
`Chlorpromazine hcl injection
`Thyrotropin injection
`Tigecycline injection
`Inj., tildrakizumab, 1 mg
`Trimethobenzamide hcl inj
`Tobramycin sulfate injection
`Tocilizumab injection
`Treprostinil injection
`Triamcinolone a inj prs-free
`Triamcinolone acet inj nos
`Inj triamcinolone ace xr 1mg
`Triptorelin pamoate
`Ustekinumab sub cu inj, 1 mg
`Ustekinumab, iv inject, 1 mg
`Diazepam injection
`Vancomycin hcl injection
`Injection, vedolizumab
`Velaglucerase alfa
`Verteporfin injection
`Hydroxyzine hcl injection
`Thiamine hcl 100 mg
`Pyridoxine hcl 100 mg
`Vitamin b12 injection
`Vitamin k phytonadione inj
`Injection, voriconazole
`Ovine, up to 999 usp units
`Hyaluronidase recombinant
`Inj magnesium sulfate
`Inj potassium chloride
`Zidovudine
`Ziprasidone mesylate
`Zoledronic acid 1mg
`Normal saline solution infus
`Normal saline solution infus
`5% dextrose/normal saline
`Normal saline solution infus
`5% dextrose/water
`D5w infusion
`
`0.1 MG
`10 UNITS
`30 MG
`1 MG
`10 MG
`1 MG
`1 MG
`1 MG
`1 MG
`1 MG
`50 MG
`0.9 MG
`1 MG
`1 MG
`200 MG
`80 MG
`1 MG
`1 MG
`1 MG
`10 MG
`1 MG
`3.75 MG
`1 MG
`1 MG
`5 MG
`500 MG
`1 MG
`100 UNITS
`0.1 MG
`25 MG
`100 MG
`100 MG
`1000 MCG
`1 MG
`10 MG
`1 UNIT
`1 USP UNIT
`500 MG
`2 MEQ
`10 MG
`10 MG
`1 MG
`1000 ML
`500 ML
`500 ML
`250 ML
`500 ML
`1000 CC
`
`0.891
`40.084
`108.385
`1.489
`5.737
`121.825
`1.633
`8.951
`0.053
`1.466
`31.613
`1695.118
`1.566
`136.489
`36.790
`3.602
`4.958
`63.853
`3.850
`1.574
`18.880
`258.739
`191.387
`12.037
`11.088
`3.464
`19.864
`345.522
`11.078
`6.590
`1.914
`9.450
`1.885
`4.282
`2.051
`0.428
`0.359
`0.850
`0.136
`1.514
`17.714
`12.472
`2.415
`1.207
`0.910
`0.604
`1.845
`3.625
`
`Added October 2019
`
`AMP-based payment limit
`
`AMP-based payment limit
`
`Exhibit 2239
`Page 08 of 14
`
`

`

`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`1
`1
`1
`1
`1
`1
`1
`1
`1
`1
`
`J7120
`J7170
`J7175
`J7178
`J7179
`J7180
`J7181
`J7182
`J7183
`J7185
`J7186
`J7187
`J7188
`J7189
`J7190
`J7192
`J7193
`J7194
`J7195
`J7197
`J7198
`J7200
`J7201
`J7202
`J7205
`J7207
`J7208
`J7209
`J7210
`J7211
`J7308
`J7311
`J7312
`J7313
`J7316
`J7321
`J7323
`J7324
`J7325
`J7327
`J7336
`J7340
`J7345
`J7500
`J7502
`J7503
`J7504
`J7507
`
`Ringers lactate infusion
`Inj., emicizumab-kxwh 0.5 mg
`Inj, factor x, (human), 1iu
`Inj human fibrinogen con nos
`Vonvendi inj 1 iu vwf:rco
`Factor xiii anti-hem factor
`Factor xiii recomb a-subunit
`Factor viii recomb novoeight
`Wilate injection
`Xyntha inj
`Antihemophilic viii/vwf comp
`Humate-p, inj
`Factor viii recomb obizur
`Factor viia
`Factor viii
`Factor viii recombinant nos
`Factor ix non-recombinant
`Factor ix complex
`Factor ix recombinant nos
`Antithrombin iii injection
`Anti-inhibitor
`Factor ix recombinan rixubis
`Factor ix alprolix recomb
`Factor ix idelvion inj
`Factor viii fc fusion recomb
`Factor viii pegylated recomb
`Inj. Jivi 1 iu
`Factor viii nuwiq recomb 1iu
`Inj, afstyla, 1 i.u.
`Inj, kovaltry, 1 i.u.
`Aminolevulinic acid hcl top
`Fluocinolone acetonide implt
`Dexamethasone intra implant
`Fluocinol acet intravit imp
`Inj, ocriplasmin, 0.125 mg
`Hyalgan supartz visco-3 dose
`Euflexxa inj per dose
`Orthovisc inj per dose
`Synvisc or synvisc-one
`Monovisc inj per dose
`Capsaicin 8% patch
`Carbidopa levodopa ent 100ml
`Aminolevulinic acid, 10% gel
`Azathioprine oral 50mg
`Cyclosporine oral 100 mg
`Tacrol envarsus ex rel oral
`Lymphocyte immune globulin
`Tacrolimus imme rel oral 1mg
`
`1000 CC
`0.5 MG
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 I.U. VWF:RCO
`1 IU
`PER FACTOR VIII IU
`1 IU
`1 IU
`1 MCG
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`1 IU
`354 MG
`0.01 MG
`0.1 MG
`0.01 MG
`0.125 MG
`per dose
`per dose
`PER DOSE
`1 MG
`PER DOSE
`1 SQ CM
`100 ML
`10 MG
`50 MG
`100 MG
`0.25 MG
`250 MG
`1 MG
`
`2.321
`47.348
`7.513
`1.197
`1.828
`8.469
`15.519
`1.307
`0.971
`1.266
`1.059
`1.159
`3.178
`2.150
`1.069
`1.254
`1.149
`1.469
`1.502
`3.319
`1.897
`1.323
`3.110
`4.293
`2.080
`1.741
`2.018
`1.240
`1.355
`1.255
`390.979
`341.615
`200.026
`490.865
`1046.927
`81.571
`145.079
`143.397
`11.412
`769.506
`3.152
`219.448
`1.448
`0.661
`2.336
`1.326
`2066.023
`0.394
`
`Exhibit 2239
`Page 09 of 14
`
`

`

`AMP-based payment limit
`
`J7508
`J7509
`J7510
`J7511
`J7512
`J7515
`J7516
`J7517
`J7518
`J7520
`J7525
`J7527
`J7605
`J7606
`J7608
`J7611
`J7612
`J7613
`J7614
`J7620
`J7626
`J7631
`J7639
`J7644
`J7674
`J7682
`J7686
`J8501
`J8510
`J8520
`J8521
`J8530
`J8540
`J8560
`J8600
`J8610
`J8655
`J8670
`J8700
`J8705
`J9000
`J9017
`J9019
`J9022
`J9023
`J9025
`J9027
`J9030
`
`Tacrol astagraf ex rel oral
`Methylprednisolone oral
`Prednisolone oral per 5 mg
`Antithymocyte globuln rabbit
`Prednisone ir or dr oral 1mg
`Cyclosporine oral 25 mg
`Cyclosporin parenteral 250mg
`Mycophenolate mofetil oral
`Mycophenolic acid
`Sirolimus, oral
`Tacrolimus injection
`Oral everolimus
`Arformoterol non-comp unit
`Formoterol fumarate, inh
`Acetylcysteine non-comp unit
`Albuterol non-comp con
`Levalbuterol non-comp con
`Albuterol non-comp unit
`Levalbuterol non-comp unit
`Albuterol ipratrop non-comp
`Budesonide non-comp unit
`Cromolyn sodium noncomp unit
`Dornase alfa non-comp unit
`Ipratropium bromide non-comp
`Methacholine chloride, neb
`Tobramycin non-comp unit
`Treprostinil, non-comp unit
`Oral aprepitant
`Oral busulfan
`Capecitabine, oral, 150 mg
`Capecitabine, oral, 500 mg
`Cyclophosphamide oral 25 mg
`Oral dexamethasone
`Etoposide oral 50 mg
`Melphalan oral 2 mg
`Methotrexate oral 2.5 mg
`Oral netupitant, palonosetro
`Rolapitant, oral, 1mg
`Temozolomide
`Topotecan oral
`Doxorubicin hcl injection
`Arsenic trioxide injection
`Erwinaze injection
`Inj, atezolizumab,10 mg
`Injection, avelumab, 10 mg
`Azacitidine injection
`Clofarabine injection
`Bcg live intravesical 1mg
`
`0.1 MG
`4 MG
`5 MG
`25 MG
`1 MG
`25 MG
`250 MG
`250 MG
`180 MG
`1 MG
`5 MG
`0.25 MG
`15 mcg
`20 MCG
`1 GM
`1 MG
`0.5 MG
`1 MG
`0.5 MG
`2.5 MG/0.5 MG
`0.5 MG
`10 MG
`1 MG
`1 MG
`1 MG
`300 MG
` 1.74 MG
`5 MG
`2 MG
`150 MG
`500 MG
`25 MG
`0.25 MG
`50 MG
`2 MG
`2.5 MG
`0.5 MG
`1 MG
`5 MG
`0.25 mg
`10 MG
`1 MG
`1,000 IU
`10 MG
`10 MG
`1 MG
`1 MG
`1 MG
`
`0.478
`0.364
`0.086
`768.555
`0.013
`0.697
`49.253
`0.542
`3.338
`5.954
`211.839
`8.970
`10.375
`12.171
`5.813
`0.192
`0.272
`0.043
`0.064
`0.131
`2.157
`4.747
`47.787
`0.199
`0.666
`36.786
`612.957
`4.311
`24.181
`1.362
`3.482
`3.309
`0.051
`75.355
`12.000
`0.237
`245.742
`2.118
`0.731
`103.658
`3.732
`44.314
`414.825
`77.008
`82.969
`1.161
`61.690
`2.821
`
`Exhibit 2239
`Page 10 of 14
`
`

`

`J9032
`J9033
`J9034
`J9035
`J9036
`J9039
`J9040
`J9041
`J9042
`J9043
`J9044
`J9045
`J9047
`J9050
`J9055
`J9060
`J9065
`J9070
`J9100
`J9119
`J9120
`J9130
`J9145
`J9150
`J9153
`J9155
`J9171
`J9173
`J9176
`J9178
`J9179
`J9181
`J9185
`J9190
`J9200
`J9201
`J9202
`J9203
`J9204
`J9205
`J9206
`J9207
`J9208
`J9209
`J9211
`J9214
`J9217
`J9218
`
`Injection, belinostat, 10mg
`Inj., treanda 1 mg
`Inj., bendeka 1 mg
`Bevacizumab injection
`Inj. belrapzo/bendamustine
`Injection, blinatumomab
`Bleomycin sulfate injection
`Inj., velcade 0.1 mg
`Brentuximab vedotin inj
`Cabazitaxel injection
`Inj, bortezomib, nos, 0.1 mg
`Carboplatin injection
`Injection, carfilzomib, 1 mg
`Carmustine injection
`Cetuximab injection
`Cisplatin 10 mg injection
`Inj cladribine per 1 mg
`Cyclophosphamide 100 mg inj
`Cytarabine hcl 100 mg inj
`Inj., cemiplimab-rwlc, 1 mg
`Dactinomycin injection
`Dacarbazine 100 mg inj
`Injection, daratumumab 10 mg
`Daunorubicin injection
`Inj daunorubicin, cytarabine
`Degarelix injection
`Docetaxel injection
`Inj., durvalumab, 10 mg
`Injection, elotuzumab, 1mg
`Inj, epirubicin hcl, 2 mg
`Eribulin mesylate injection
`Etoposide injection
`Fludarabine phosphate inj
`Fluorouracil injection
`Floxuridine injection
`Gemcitabine hcl injection
`Goserelin acetate implant
`Gemtuzumab ozogamicin 0.1 mg
`Inj mogamulizumab-kpkc, 1 mg
`Inj irinotecan liposome 1 mg
`Irinotecan injection
`Ixabepilone injection
`Ifosfamide injection
`Mesna injection
`Idarubicin hcl injection
`Interferon alfa-2b inj
`Leuprolide acetate suspnsion
`Leuprolide acetate injeciton
`
`10 MG
`1 MG
`1 MG
`10 MG
`1 MG
`1 MCG
`15 UNITS
`0.1 MG
`1 MG
`1 MG
`0.1 MG
`50 MG
`1 MG
`100 MG
`10 MG
`10 MG
`1 MG
`100 MG
`100 MG
`1 MG
`0.5 MG
`100 MG
`10 MG
`10 MG
`1 MG/2.27 MG
`1 MG
`1 MG
`10 MG
`1 MG
`2 MG
`0.1 MG
`10 MG
`50 MG
`500 MG
`500 MG
`200 MG
`3.6 MG
`0.1 MG
`1 MG
`1 MG
`20 MG
`1 MG
`1 GM
`200 MG
`5 MG
`1 MIL UNITS
`7.5 MG
`1 MG
`
`40.070
`27.844
`22.849
`81.182
`24.355
`113.397
`26.662
`44.687
`162.437
`173.666
`25.039
`2.886
`37.599
`3039.006
`62.048
`1.876
`18.999
`34.139
`0.555
`27.447
`1098.200
`4.138
`53.948
`46.740
`192.306
`3.965
`0.865
`74.636
`6.496
`0.950
`114.274
`0.558
`56.576
`1.550
`82.677
`5.004
`497.719
`199.230
`200.870
`49.913
`2.474
`91.065
`26.438
`1.606
`32.723
`34.239
`224.698
`16.601
`
`AMP-based payment limit
`Added October 2019
`
`Added October 2019
`Added October 2019
`
`Exhibit 2239
`Page 11 of 14
`
`

`

`J9225
`J9226
`J9228
`J9229
`J9245
`J9250
`J9260
`J9261
`J9262
`J9263
`J9264
`J9266
`J9267
`J9268
`J9271
`J9280
`J9285
`J9293
`J9295
`J9299
`J9301
`J9302
`J9303
`J9305
`J9306
`J9307
`J9308
`J9311
`J9312
`J9315
`J9320
`J9325
`J9328
`J9330
`J9340
`J9351
`J9352
`J9354
`J9355
`J9356
`J9357
`J9360
`J9370
`J9371
`J9390
`J9395
`J9400
`P9041
`
`Vantas implant
`Supprelin la implant
`Ipilimumab injection
`Inj inotuzumab ozogam 0.1 mg
`Inj melphalan hydrochl 50 mg
`Methotrexate sodium inj
`Methotrexate sodium inj
`Nelarabine injection
`Inj, omacetaxine mep, 0.01mg
`Oxaliplatin
`Paclitaxel protein bound
`Pegaspargase injection
`Paclitaxel injection
`Pentostatin injection
`Inj pembrolizumab
`Mitomycin injection
`Inj, olaratumab, 10 mg
`Mitoxantrone hydrochl / 5 mg
`Injection, necitumumab, 1 mg
`Injection, nivolumab
`Obinutuzumab inj
`Ofatumumab injection
`Panitumumab injection
`Pemetrexed injection
`Injection, pertuzumab, 1 mg
`Pralatrexate injection
`Injection, ramucirumab
`Inj rituximab, hyaluronidase
`Inj., rituximab, 10 mg
`Romidepsin injection
`Streptozocin injection
`Inj talimogene laherparepvec
`Temozolomide injection
`Temsirolimus injection
`Thiotepa injection
`Topotecan injection
`Injection trabectedin 0.1mg
`Inj, ado-trastuzumab emt 1mg
`Inj trastuzumab excl biosimi
`Inj. herceptin hylecta, 10mg
`Valrubicin injection
`Vinblastine sulfate inj
`Vincristine sulfate 1 mg inj
`Inj, vincristine sul lip 1mg
`Vinorelbine tartrate inj
`Injection, fulvestrant
`Inj, ziv-aflibercept, 1mg
`Albumin (human),5%, 50ml
`
`50 MG
`50 MG
`1 MG
`0.1 MG
`50 MG
`5 MG
`50 MG
`50 MG
`0.01 MG
`0.5 MG
`1 MG
`1 EA
`1 MG
`10 MG
`1 MG
`5 MG
`10 MG
`5 MG
`1 MG
`1 MG
`10 MG
`10 MG
`10 MG
`10 MG
`1 MG
`1 MG
`5 MG
`10 mg
`10 MG
`1 MG
`1 GM
`1 million PFU
`1 MG
`1 MG
`15 MG
`0.1 MG
`0.1 MG
`1 MG
`10 MG
`10 MG
`200 MG
`1 MG
`1 MG
`1 MG
`10 MG
`25 MG
`1 MG
`50 ML
`
`4085.605
`36647.599
`153.128
`2270.312
`610.875
`0.249
`2.487
`152.479
`3.110
`0.150
`12.513
`17566.886
`0.130
`1968.606
`49.389
`87.749
`52.134
`27.385
`5.744
`27.805
`62.864
`60.093
`119.071
`69.472
`12.290
`291.264
`58.419
`43.528
`94.667
`297.586
`349.701
`51.466
`10.392
`53.135
`404.280
`0.869
`312.913
`31.364
`106.622
`80.258
`1438.588
`3.801
`4.813
`3080.040
`11.656
`94.874
`8.374
`10.490
`
`Added October 2019
`
`95
`
`10.490
`
`Exhibit 2239
`Page 12 of 14
`
`

`

`P9045
`P9046
`P9047
`Q0138
`Q0139
`Q0162
`Q0164
`Q0166
`Q0167
`Q2043
`Q2050
`Q3027
`Q4074
`Q4081
`Q4101
`Q4102
`Q4106
`Q4107
`Q4110
`Q4111
`Q4113
`Q4115
`Q4121
`Q4132
`Q4133
`Q4137
`Q4145
`Q4151
`Q4154
`Q4159
`Q4160
`Q4170
`Q4186
`Q4195
`Q4196
`Q5101
`Q5103
`Q5104
`Q5105
`Q5106
`Q5107
`Q5108
`Q5110
`Q5111
`Q5117
`Q9950
`Q9956
`Q9957
`
`Albumin (human), 5%, 250 ml
`Albumin (human), 25%, 20 ml
`Albumin (human), 25%, 50ml
`Ferumoxytol, non-esrd
`Ferumoxytol, esrd use
`Ondansetron oral
`Prochlorperazine maleate 5mg
`Granisetron hcl 1 mg oral
`Dronabinol 2.5mg oral
`Sipuleucel-t auto cd54+
`Doxorubicin inj 10mg
`Inj beta interferon im 1 mcg
`Iloprost non-comp unit dose
`Epoetin alfa, 100 units esrd
`Apligraf
`Oasis wound matrix
`Dermagraft
`Graftjacket
`Primatrix
`Gammagraft
`Graftjacket xpress
`Alloskin
`Theraskin
`Grafix core, grafixpl core
`Grafix stravix prime pl sqcm
`Amnioexcel biodexcel 1sq cm
`Epifix, inj, 1mg
`Amnioband, guardian 1 sq cm
`Biovance 1 square cm
`Affinity1 square cm
`Nushield 1 square cm
`Cygnus, per sq cm
`Epifix 1 sq cm
`Puraply 1 sq cm
`Puraply am 1 sq cm
`Injection, zarxio
`Injection, inflectra
`Injection, renflexis
`Inj retacrit esrd on dialysi
`Inj retacrit non-esrd use
`Inj mvasi 10 mg
`Injection, fulphila
`Nivestym
`Injection, udenyca 0.5 mg
`Inj., kanjinti, 10 mg
`Inj sulf hexa lipid microsph
`Inj octafluoropropane mic,ml
`Inj perflutren lip micros,ml
`
`
`
`250 ML
`20 ML
`50 ML
`1 MG
`1 MG
`1 MG
`5 MG
`1 MG
`2.5 MG
`fusion (minimum 50 million
`10 MG
`1 MCG
`UP TO 20 MCG
`100 UNITS
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 CC
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 MG
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 SQ CM
`1 MCG
`10 MG
`10 MG
`100 UNITS
`1000 UNITS
`10 MG
`0.5 MG
`1 MCG
`0.5 MG
`10 MG
`1 ML
`1 ML
`1 ML
`
`52.450
`20.980
`52.450
`0.997
`0.997
`0.020
`0.220
`0.960
`0.616
`46374.199
`355.070
`53.583
`141.832
`1.103
`30.708
`10.529
`33.002
`92.593
`47.650
`6.969
`919.550
`13.504
`41.066
`117.918
`140.558
`77.624
`21.079
`158.281
`113.981
`644.480
`110.162
`132.775
`160.419
`89.703
`104.832
`0.573
`49.247
`53.395
`0.963
`9.629
`69.772
`327.413
`0.635
`347.056
`90.671
`19.535
`32.270
`48.405
`
`95
`95
`95
`
`52.450
`20.980
`52.450
`
`AMP-based payment limit
`
`Added October 2019
`
`Added October 2019
`
`Exhibit 2239
`Page 13 of 14
`
`

`

`Q9958
`Q9960
`Q9961
`Q9963
`Q9965
`Q9966
`Q9967
`Q9991
`Q9992
`
`Hocm <=149 mg/ml iodine, 1ml
`Hocm 200-249mg/ml iodine,1ml
`Hocm 250-299mg/ml iodine,1ml
`Hocm 350-399mg/ml iodine,1ml
`Locm 100-199mg/ml iodine,1ml
`Locm 200-299mg/ml iodine,1ml
`Locm 300-399mg/ml iodine,1ml
`Buprenorph xr 100 mg or less
`Buprenorphine xr over 100 mg
`
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`1 ML
`ess than or equal to 100 M
`Greater than 100 MG
`
`0.074
`0.225
`0.258
`0.198
`1.008
`0.314
`0.115
`1673.362
`1673.362
`
`Exhibit 2239
`Page 14 of 14
`
`