APC Category APC Category Description 

1 Skin

2 Cardiovascular tests/procedures

3 GI tests/procedures

4 Genitourinary/Renal procedures

5 Musculoskeletal procedures

6 Access device procedures (Vascular /Other)

7 Access device procedures (Endoscopy /Laproscopy)

8 Nerve/Neuro tests/procedures

9 Drug administration

10 Pathology

11 Prostate tests/procedures

12 Female Reproductive tests/procedures

13 Male Reproductive tests/procedures

14 Biopsies

15 Psych tests/treatments

16 ENT

17 Eye

18 Blood/Lymph/Marrow procedures

19 E&M

20 Imaging

21 Breast procedures

22 Screening tests

23 Radiation therapies

24 Nuclear Medicine

25 Special OPPS Payment Status

26 Special OPPS Payment Status

27 Other Minor Services

28 Pulmonary tests/procedures 

29 Drugs, Vaccines 

30 Brachytherapy Sources 

31 Devices 

32 Blood and Blood Products 
Addendum A.-Final OPPS APCs for CY 2012

APC Group Title

0001 Level I Photochemotherapy

0002 Fine Needle Biopsy/Aspiration

0003 Bone Marrow Biopsy/Aspiration

0004 Level I Needle Biopsy/ Aspiration Except Bone Marrow

0005 Level II Needle Biopsy/Aspiration Except Bone Marrow

0006 Level I Incision & Drainage

0007 Level II Incision & Drainage

0008 Level III Incision and Drainage

0012 Level I Debridement & Destruction

0013 Level II Debridement & Destruction

0015 Level III Debridement & Destruction

0016 Level IV Debridement & Destruction

0017 Level V Debridement & Destruction

0019 Level I Excision/ Biopsy

0020 Level II Excision/ Biopsy

0021 Level III Excision/ Biopsy

0022 Level IV Excision/ Biopsy

0028 Level I Breast Surgery

0029 Level II Breast Surgery

0030 Level III Breast Surgery

0031 Smoking Cessation Services

0034 Mental Health Services Composite

0035 Vascular Puncture and Minor Diagnostic Procedures

0037 Level IV Needle Biopsy/Aspiration Except Bone Marrow

0039 Level I Implantation of Neurostimulator Generator

0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes 

0041 Level I Arthroscopy

0042 Level II Arthroscopy

0045 Bone/Joint Manipulation Under Anesthesia

0047 Arthroplasty without Prosthesis

0048 Level I Arthroplasty or Implantation with Prosthesis

0049 Level I Musculoskeletal Procedures Except Hand and Foot

0050 Level II Musculoskeletal Procedures Except Hand and Foot

0051 Level III Musculoskeletal Procedures Except Hand and Foot

0052 Level IV Musculoskeletal Procedures Except Hand and Foot

0053 Level I Hand Musculoskeletal Procedures

0054 Level II Hand Musculoskeletal Procedures

0055 Level I Foot Musculoskeletal Procedures

0056 Level II Foot Musculoskeletal Procedures

0057 Bunion Procedures

0058 Level I Strapping and Cast Application

0060 Manipulation Therapy

0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes 

0062 Level I Treatment Fracture/Dislocation

0063 Level II Treatment Fracture/Dislocation

0064 Level III Treatment Fracture/Dislocation
0065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG

0066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG

0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEG

0069 Thoracoscopy

0070 Thoracentesis/Lavage Procedures

0071 Level I Endoscopy Upper Airway

0072 Level II Endoscopy Upper Airway

0073 Level III Endoscopy Upper Airway

0074 Level IV Endoscopy Upper Airway

0075 Level V Endoscopy Upper Airway

0076 Level I Endoscopy Lower Airway

0077 Level I Pulmonary Treatment

0078 Level III Pulmonary Treatment

0079 Ventilation Initiation and Management

0080 Diagnostic Cardiac Catheterization

0082 Coronary or Non-Coronary Atherectomy

0083 Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity

0084 Level I Electrophysiologic Procedures

0085 Level II Electrophysiologic Procedures

0086 Level III Electrophysiologic Procedures

0088 Thrombectomy

0089 Insertion/Replacement of Permanent Pacemaker and Electrodes

0090 Level I Insertion/Replacement of Permanent Pacemaker 

0091 Level II Vascular Ligation

0092 Level I Vascular Ligation

0093 Vascular Reconstruction/Fistula Repair without Device

0094 Level I Resuscitation and Cardioversion

0095 Cardiac Rehabilitation

0096 Level II Noninvasive Physiologic Studies

0097 Level I Noninvasive Physiologic Studies

0099 Electrocardiograms/Cardiography

0100 Cardiac Stress Tests

0101 Tilt Table Evaluation

0102 Level II Pulmonary Treatment

0103 Miscellaneous Vascular Procedures

0104 Transcatheter Placement of Intracoronary Stents

0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices

0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes

0107 Insertion of Cardioverter-Defibrillator Pulse Generator

0108 Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes

0110 Transfusion

0111 Blood Product Exchange

0112 Apheresis and Stem Cell Procedures

0113 Excision Lymphatic System

0114 Thyroid/Lymphadenectomy Procedures

0115 Cannula/Access Device Procedures

0121 Level I Tube or Catheter Changes or Repositioning

0126 Level I Urinary and Anal Procedures

0127 Level IV Stereotactic Radiosurgery, MRgFUS, and MEG

0128 Echocardiogram with Contrast

0129 Level I Closed Treatment Fracture

0130 Level I Laparoscopy
0131 Level II Laparoscopy

0132 Level III Laparoscopy

0133 Level I Skin Repair

0134 Level II Skin Repair

0135 Level III Skin Repair

0136 Level IV Skin Repair

0137 Level V Skin Repair

0138 Level II Closed Treatment Fracture 

0139 Level III Closed Treatment Fracture 

0140 Esophageal Dilation without Endoscopy

0141 Level I Upper GI Procedures

0142 Level I Small Intestine Endoscopy

0143 Lower GI Endoscopy

0146 Level I Sigmoidoscopy and Anoscopy

0147 Level II Sigmoidoscopy and Anoscopy

0148 Level I Anal/Rectal Procedures

0149 Level III Anal/Rectal Procedures

0150 Level IV Anal/Rectal Procedures

0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

0152 Level I Percutaneous Abdominal and Biliary Procedures

0153 Peritoneal and Abdominal Procedures

0154 Hernia/Hydrocele Procedures

0155 Level II Anal/Rectal Procedures

0156 Level III Urinary and Anal Procedures

0157 Colorectal Cancer Screening: Barium Enema

0158 Colorectal Cancer Screening: Colonoscopy

0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy

0160 Level I Cystourethroscopy and other Genitourinary Procedures

0161 Level II Cystourethroscopy and other Genitourinary Procedures

0162 Level III Cystourethroscopy and other Genitourinary Procedures

0163 Level IV Cystourethroscopy and other Genitourinary Procedures

0164 Level II Urinary and Anal Procedures

0165 Level IV Urinary and Anal Procedures

0166 Level I Urethral Procedures

0168 Level II Urethral Procedures

0169 Lithotripsy

0170 Dialysis

0172 Level I Partial Hospitalization (3 services) for CMHCs

0173 Level II Partial Hospitalization (4 or more services) for CMHCs

0174 Level IV Laparoscopy

0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs

0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs

0181 Level II Male Genital Procedures

0183 Level I Male Genital Procedures

0184 Prostate Biopsy

0188 Level II Female Reproductive Proc

0189 Level III Female Reproductive Proc

0190 Level I Hysteroscopy

0191 Level I Female Reproductive Proc

0192 Level IV Female Reproductive Proc

0193 Level V Female Reproductive Proc

0195 Level VI Female Reproductive Procedures
0202 Level VII Female Reproductive Procedures

0203 Level IV Nerve Injections

0204 Level I Nerve Injections

0206 Level II Nerve Injections

0207 Level III Nerve Injections

0208 Laminotomies and Laminectomies

0209 Level II Extended EEG, Sleep, and Cardiovascular Studies

0213 Level I Extended EEG, Sleep, and Cardiovascular Studies

0215 Level I Nerve and Muscle Tests

0216 Level III Nerve and Muscle Tests

0218 Level II Nerve and Muscle Tests

0220 Level I Nerve Procedures

0221 Level II Nerve Procedures

0224 Implantation of Catheter/Reservoir/Shunt

0227 Implantation of Drug Infusion Device

0229 Level II Endovascular Revascularization of the Lower Extremity

0230 Level I Eye Tests & Treatments

0231 Level III Eye Tests & Treatments

0232 Level I Anterior Segment Eye Procedures

0233 Level III Anterior Segment Eye Procedures

0234 Level IV Anterior Segment Eye Procedures

0235 Level I Posterior Segment Eye Procedures

0237 Level II Posterior Segment Eye Procedures

0238 Level I Repair and Plastic Eye Procedures

0239 Level II Repair and Plastic Eye Procedures

0240 Level III Repair and Plastic Eye Procedures

0241 Level IV Repair and Plastic Eye Procedures

0242 Level V Repair and Plastic Eye Procedures

0243 Strabismus/Muscle Procedures

0244 Corneal and Amniotic Membrane Transplant

0246 Cataract Procedures with IOL Insert

0247 Laser Eye Procedures

0249 Cataract Procedures without IOL Insert

0250 Level I ENT Procedures

0251 Level II ENT Procedures

0252 Level III ENT Procedures

0253 Level IV ENT Procedures

0254 Level V ENT Procedures

0255 Level II Anterior Segment Eye Procedures

0256 Level VI ENT Procedures

0259 Level VII ENT Procedures

0260 Level I Plain Film Except Teeth

0261 Level II Plain Film Except Teeth Including Bone Density Measurement

0262 Plain Film of Teeth

0263 Level I Miscellaneous Radiology Procedures

0265 Level I Diagnostic and Screening Ultrasound

0266 Level II Diagnostic and Screening Ultrasound

0267 Level III Diagnostic and Screening Ultrasound

0269 Level II Echocardiogram Without Contrast 

0270 Level III Echocardiogram Without Contrast 

0272 Fluoroscopy

0274 Myelography
0275 Arthrography

0276 Level I Digestive Radiology

0277 Level II Digestive Radiology

0278 Diagnostic Urography

0279 Level II Angiography and Venography

0280 Level III Angiography and Venography

0282 Miscellaneous Computed Axial Tomography

0283 Computed Tomography with Contrast

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast

0288 Bone Density:Axial Skeleton

0293 Level VI Anterior Segment Eye Procedures

0299 Hyperthermia and Radiation Treatment Procedures

0300 Level I Radiation Therapy

0301 Level II Radiation Therapy

0303 Treatment Device Construction

0304 Level I Therapeutic Radiation Treatment Preparation

0305 Level II Therapeutic Radiation Treatment Preparation

0308 Positron Emission Tomography (PET) imaging

0310 Level III Therapeutic Radiation Treatment Preparation

0312 Radioelement Applications

0313 Brachytherapy

0315 Level II Implantation of Neurostimulator Generator 

0317 Level II Miscellaneous Radiology Procedures

0318 Implantation of Neurostimulator Pulse Generator and Electrode 

0319 Level III Endovascular Revascularization of the Lower Extremity

0320 Electroconvulsive Therapy

0322 Brief Individual Psychotherapy

0323 Extended Individual Psychotherapy

0324 Family Psychotherapy

0325 Group Psychotherapy

0330 Dental Procedures

0331 Combined Abdomen and Pelvis CT without Contrast 

0332 Computed Tomography without Contrast

0333 Computed Tomography without Contrast followed by Contrast

0334 Combined Abdomen and Pelvis CT with Contrast 

0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast

0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast

0340 Minor Ancillary Procedures

0341 Skin Tests

0342 Level I Pathology

0343 Level III Pathology

0344 Level IV Pathology

0345 Level I Transfusion Laboratory Procedures

0346 Level II Transfusion Laboratory Procedures

0347 Level III Transfusion Laboratory Procedures

0350 Administration of flu and PPV vaccine

0360 Level I Alimentary Tests

0361 Level II Alimentary Tests

0363 Level I Otorhinolaryngologic Function Tests

0364 Level I Audiometry

0365 Level II Audiometry

0366 Level III Audiometry
0367 Level I Pulmonary Test

0368 Level II Pulmonary Tests

0369 Level III Pulmonary Tests

0370 Multiple Allergy Tests

0373 Level I Neuropsychological Testing

0375 Ancillary Outpatient Services When Patient Expires

0377 Level II Cardiac Imaging

0378 Level II Pulmonary Imaging

0381 Single Allergy Tests

0382 Level II Neuropsychological Testing

0383 Cardiac Computed Tomographic Imaging

0384 GI Procedures with Stents

0385 Level I Prosthetic Urological Procedures

0386 Level II Prosthetic Urological Procedures

0387 Level II Hysteroscopy

0388 Discography

0389 Level I Non-imaging Nuclear Medicine

0390 Level I Endocrine Imaging

0391 Level II Endocrine Imaging

0392 Level II Non-imaging Nuclear Medicine

0393 Hematologic Processing & Studies

0394 Hepatobiliary Imaging

0395 GI Tract Imaging

0396 Bone Imaging

0397 Vascular Imaging

0398 Level I Cardiac Imaging

0400 Hematopoietic Imaging

0401 Level I Pulmonary Imaging

0402 Level II Nervous System Imaging

0403 Level I Nervous System Imaging

0404 Renal and Genitourinary Studies

0406 Level I Tumor/Infection Imaging

0407 Level I Radionuclide Therapy

0408 Level III Tumor/Infection Imaging

0409 Red Blood Cell Tests

0412 IMRT Treatment Delivery

0413 Level II Radionuclide Therapy

0414 Level II Tumor/Infection Imaging

0415 Level II Endoscopy Lower Airway

0419 Level II Upper GI Procedures 

0422 Level III Upper GI Procedures

0423 Level II Percutaneous Abdominal and Biliary Procedures

0424 Level II Small Intestine Endoscopy

0425 Level II Arthroplasty or Implantation with Prosthesis

0426 Level II Strapping and Cast Application

0427 Level II Tube or Catheter Changes or Repositioning

0428 Level III Sigmoidoscopy and Anoscopy

0429 Level V Cystourethroscopy and other Genitourinary Procedures

0432 Health and Behavior Services

0433 Level II Pathology

0434 Cardiac Defect Repair

0436 Level I Drug Administration
0437 Level II Drug Administration

0438 Level III Drug Administration

0439 Level IV Drug Administration

0440 Level V Drug Administration

0442 Dosimetric Drug Administration

0604 Level 1 Hospital Clinic Visits

0605 Level 2 Hospital Clinic Visits

0606 Level 3 Hospital Clinic Visits

0607 Level 4 Hospital Clinic Visits

0608 Level 5 Hospital Clinic Visits

0609 Level 1 Type A Emergency Visits

0613 Level 2 Type A Emergency Visits

0614 Level 3 Type A Emergency Visits

0615 Level 4 Type A Emergency Visits

0616 Level 5 Type A Emergency Visits

0617 Critical Care

0618 Trauma Response with Critical Care

0621 Level I Vascular Access Procedures

0622 Level II Vascular Access Procedures

0623 Level III Vascular Access Procedures

0624 Phlebotomy and Minor Vascular Access Device Procedures

0626 Level 1 Type B Emergency Visits

0627 Level 2 Type B Emergency Visits

0628 Level 3 Type B Emergency Visits

0629 Level 4 Type B Emergency Visits

0630 Level 5 Type B Emergency Visits

0648 Level IV Breast Surgery

0651 Complex Interstitial Radiation Source Application

0652 Insertion of Intraperitoneal and Pleural Catheters

0653 Vascular Reconstruction/Fistula Repair with Device

0654 Level II Insertion/Replacement of Permanent Pacemaker 

0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode

0656 Transcatheter Placement of Intracoronary Drug-Eluting Stents

0659 Hyperbaric Oxygen

0660 Level II Otorhinolaryngologic Function Tests

0661 Level V Pathology

0662 CT Angiography

0664 Level I Proton Beam Radiation Therapy

0665 Bone Density:AppendicularSkeleton

0667 Level II Proton Beam Radiation Therapy

0668 Level I Angiography and Venography

0672 Level III Posterior Segment Eye Procedures

0673 Level V Anterior Segment Eye Procedures

0674 Prostate Cryoablation

0676 Thrombolysis and Other Device Revisions 

0678 External Counterpulsation

0679 Level II Resuscitation and Cardioversion

0680 Insertion of Patient Activated Event Recorders

0683 Level II Photochemotherapy

0685 Level III Needle Biopsy/Aspiration Except Bone Marrow

0687 Revision/Removal of Neurostimulator Electrodes

0688 Revision/Removal of Neurostimulator Pulse Generator Receiver
0690 Level I Electronic Analysis of Devices

0691 Level III Electronic Analysis of Devices

0692 Level II Electronic Analysis of Devices

0694 Mohs Surgery

0697 Level I Echocardiogram Without Contrast 

0698 Level II Eye Tests & Treatments

0699 Level IV Eye Tests & Treatments

0701 Sr89 strontium

0726 Dexrazoxane HCl injection

0728 Filgrastim 300 mcg injection

0731 Sargramostim injection

0735 Ampho b cholesteryl sulfate

0736 Amphotericin b liposome inj

0738 Rasburicase

0747 Chlorothiazide sodium inj

0751 Mechlorethamine hcl inj

0752 Dactinomycin injection

0759 Naltrexone, depot form

0800 Leuprolide acetate

0802 Etoposide oral

0807 Aldesleukin injection

0809 Bcg live intravesical vac

0810 Goserelin acetate implant

0812 Carmustine injection

0814 Asparaginase injection

0820 Daunorubicin injection

0821 Daunorubicin citrate inj

0823 Docetaxel injection

0825 Nelarabine injection

0827 Floxuridine injection

0828 Gemcitabine hcl injection

0830 Irinotecan injection

0831 Ifosfamide injection

0832 Idarubicin hcl injection

0835 Cosyntropin injection NOS

0836 Interferon alfa-2b inj

0838 Interferon gamma 1-b inj

0840 Inj melphalan hydrochl

0842 Fludarabine phosphate inj

0843 Pegaspargase injection

0844 Pentostatin injection

0849 Rituximab injection

0850 Streptozocin injection

0851 Thiotepa injection

0856 Porfimer sodium injection

0858 Inj cladribine

0861 Leuprolide acetate injeciton

0864 Mitoxantrone hydrochl

0865 Interferon alfa-n3 inj

0868 Oral aprepitant

0873 Hyalgan/supartz inj per dose

0874 Synvisc or synvisc-one
0875 Euflexxa inj per dose

0877 Orthovisc inj per dose

0884 Rho d immune globulin inj

0887 Azathioprine parenteral

0890 Lymphocyte immune globulin

0900 Alglucerase injection

0901 Alpha 1 proteinase inhibitor

0902 Injection,onabotulinumtoxinA

0903 Cytomegalovirus imm IV /vial

0910 Interferon beta-1b / .25 MG

0913 Ganciclovir long act implant

0917 Adenosine injection

0925 Factor viii

0927 Factor viii recombinant

0928 Factor ix complex

0929 Anti-inhibitor

0931 Factor IX non-recombinant

0932 Factor IX recombinant

0933 Gamma globulin > 10 CC inj

0934 Capecitabine, oral

0943 Octagam injection

0944 Gammagard liquid injection

0945 Rhophylac injection

0946 Hepagam b im injection

0947 Flebogamma injection

0948 Gamunex/gamunex c

0949 Frozen plasma, pooled, sd

0950 Whole blood for transfusion

0951 Reclast injection

0952 Cryoprecipitate each unit

0954 RBC leukocytes reduced

0955 Plasma, frz between 8-24hour

0956 Plasma protein fract,5%,50ml

0957 Platelets, each unit

0958 Plaelet rich plasma unit

0959 Red blood cells unit

0960 Washed red blood cells unit

0961 Albumin (human),5%, 50ml

0963 Albumin (human), 5%, 250 ml

0964 Albumin (human), 25%, 20 ml

0965 Albumin (human), 25%, 50ml

0966 Plasmaprotein fract,5%,250ml

0967 Blood split unit

0968 Platelets leukoreduced irrad

0969 RBC leukoreduced irradiated

1009 Cryoprecipitatereducedplasma

1010 Blood, l/r, cmv-neg

1011 Platelets, hla-m, l/r, unit

1013 Platelets leukocytes reduced

1015 Injection glatiramer acetate

1016 Blood, l/r, froz/degly/wash

1017 Plt, aph/pher, l/r, cmv-neg
1018 Blood, l/r, irradiated

1019 Plate pheres leukoredu irrad

1020 Plt, pher, l/r cmv-neg, irr

1021 RBC, frz/deg/wsh, l/r, irrad

1022 RBC, l/r, cmv-neg, irrad

1023 Pralidoxime chloride inj

1052 Injection, voriconazole

1064 I131 iodide cap, rx

1083 Adalimumab injection

1084 Denileukin diftitox inj

1086 Temozolomide

1138 Hepagam b intravenous, inj

1139 Protein c concentrate

1142 Supprelin LA implant

1150 I131 iodide sol, rx

1166 Cytarabine liposome inj

1167 Inj, epirubicin hcl

1168 Inj, temsirolimus

1178 Busulfan injection

1203 Verteporfin injection

1207 Octreotide injection, depot

1213 Antihemophilic viii/vwf comp

1214 Inj IVIG privigen 500 mg

1221 Dimethyl sulfoxide 50%

1222 Pentastarch 10% solution

1226 Inj streptokinase /250000 IU

1232 Mitomycin 5 MG inj

1235 Valrubicin injection

1236 Levoleucovorin injection

1237 Inj iron dextran

1238 Topotecan oral

1239 Rotavirus vacc 2 dose oral

1240 Apligraf skin sub

1241 Oasis wound matrix skin sub

1242 Oasis burn matrix skin sub

1243 Integra BMWD skin sub

1244 Integra DRT skin sub

1245 Dermagraft skin sub

1246 Graftjacket skin sub

1247 Integra matrix skin sub

1248 Primatrix skin sub

1249 Cymetra allograft

1250 Graftjacket express allograf

1251 Integra flowable wound matri

1252 Gammagraft skin sub

1253 Triamcinolone A inj PRS-free

1263 Antithrombin iii injection

1268 Xyntha inj

1270 Alloderm skin sub

1272 Acetylcysteine injection

1274 Edetate calcium disodium inj

1275 Vivaglobin, inj
1279 Factor VIII (porcine)

1280 Corticotropin injection

1281 Bevacizumab injection

1287 Alloskin skin sub

1289 AbobotulinumtoxinA

1290 Human fibrinogen conc inj

1291 Rilonacept injection

1295 Sm 153 lexidronam

1296 Degarelix injection

1297 Ferumoxytol, non-esrd

1304 Perphenazine injeciton

1306 Urea injection

1307 Oral busulfan

1308 Mecasermin injection

1311 Canakinumab injection

1312 Hizentra injection

1327 Imiglucerase injection

1331 Olanzapine long-acting inj

1332 Antithrombin recombinant

1338 Methyl aminolevulinate, top

1339 Oral fludarabine phosphate

1340 Collagenase, clost hist inj

1341 Amobarbital 125 MG inj

1342 Matristem micromatrix

1343 Ganciclovir sodium injection

1344 Gonadorelin hydroch/ 100 mcg

1345 Theraskin

1347 Oxacillin sodium injeciton

1349 Anidulafungin injection

1350 Topotecan injection

1351 Matristem wound matrix

1352 Wilate injection

1353 Belimumab injection

1354 Hydroxyprogesterone caproate

1355 Itraconazole injection

1357 Inj protirelin per 250 mcg

1358 Phentolaine mesylate inj

1359 Foscarnet sodium injection

1360 Apomorphine hydrochloride

1361 Enfuvirtide injection

1362 Inj heparin sodium per 10 u

1373 Inj heparin sodium per 1000u

1374 Sumatriptan succinate / 6 MG

1408 Cyclophosphamide 100 MG inj

1412 Vinorelbine tartrate inj

1413 Lumizyme injection

1415 Glassia injection

1416 Factor XIII anti-hem factor

1417 Gel-one

1418 Oral everolimus

1419 Dermacell

1426 Eribulin mesylate injection
1491 New Technology - Level IA ($0-$10)

1492 New Technology - Level IB ($10-$20)

1493 New Technology - Level IC ($20-$30)

1494 New Technology - Level ID ($30-$40)

1495 New Technology - Level IE ($40-$50)

1496 New Technology - Level IA ($0-$10)

1497 New Technology - Level IB($10-$20)

1498 New Technology - Level IC ($20-$30)

1499 New Technology - Level ID($30-$40)

1500 New Technology - Level IE ($40-$50)

1502 New Technology - Level II ($50 - $100)

1503 New Technology - Level III ($100 - $200)

1504 New Technology - Level IV ($200 - $300)

1505 New Technology - Level V ($300 - $400)

1506 New Technology - Level VI ($400 - $500)

1507 New Technology - Level VII ($500 - $600)

1508 New Technology - Level VIII ($600 - $700)

1509 New Technology - Level IX ($700 - $800)

1510 New Technology - Level X ($800 - $900)

1511 New Technology - Level XI ($900 - $1000)

1512 New Technology - Level XII ($1000 - $1100)

1513 New Technology - Level XIII ($1100 - $1200)

1514 New Technology - Level XIV ($1200- $1300)

1515 New Technology - Level XV ($1300 - $1400)

1516 New Technology - Level XVI ($1400 - $1500)

1517 New Technology - Level XVII ($1500-$1600)

1518 New Technology - Level XVIII ($1600-$1700)

1519 New Technology - Level IXX ($1700-$1800)

1520 New Technology - Level XX ($1800-$1900)

1521 New Technology - Level XXI ($1900-$2000)

1522 New Technology - Level XXII ($2000-$2500)

1523 New Technology - Level XXIII ($2500-$3000)

1524 New Technology - Level XXIV ($3000-$3500)

1525 New Technology - Level XXV ($3500-$4000)

1526 New Technology - Level XXVI ($4000-$4500)

1527 New Technology - Level XXVII ($4500-$5000)

1528 New Technology - Level XXVIII ($5000-$5500)

1529 New Technology - Level XXIX ($5500-$6000)

1530 New Technology - Level XXX ($6000-$6500)

1531 New Technology - Level XXXI ($6500-$7000)

1532 New Technology - Level XXXII ($7000-$7500)

1533 New Technology - Level XXXIII ($7500-$8000)

1534 New Technology - Level XXXIV ($8000-$8500)

1535 New Technology - Level XXXV ($8500-$9000)

1536 New Technology - Level XXXVI ($9000-$9500)

1537 New Technology - Level XXXVII ($9500-$10000)

1539 New Technology - Level II ($50 - $100)

1540 New Technology - Level III ($100 - $200)

1541 New Technology - Level IV ($200 - $300)

1542 New Technology - Level V ($300 - $400)

1543 New Technology - Level VI ($400 - $500)

1544 New Technology - Level VII ($500 - $600)
1545 New Technology - Level VIII ($600 - $700)

1546 New Technology - Level IX ($700 - $800)

1547 New Technology - Level X ($800 - $900)

1548 New Technology - Level XI ($900 - $1000)

1549 New Technology - Level XII ($1000 - $1100)

1550 New Technology - Level XIII ($1100 - $1200)

1551 New Technology - Level XIV ($1200- $1300)

1552 New Technology - Level XV ($1300 - $1400)

1553 New Technology - Level XVI ($1400 - $1500)

1554 New Technology - Level XVII ($1500-$1600)

1555 New Technology - Level XVIII ($1600-$1700)

1556 New Technology - Level XIX ($1700-$1800)

1557 New Technology - Level XX ($1800-$1900)

1558 New Technology - Level XXI ($1900-$2000)

1559 New Technology - Level XXII ($2000-$2500)

1560 New Technology - Level XXIII ($2500-$3000)

1561 New Technology - Level XXIV ($3000-$3500)

1562 New Technology - Level XXV ($3500-$4000)

1563 New Technology - Level XXVI ($4000-$4500)

1564 New Technology - Level XXVII ($4500-$5000)

1565 New Technology - Level XXVIII ($5000-$5500)

1566 New Technology - Level XXIX ($5500-$6000)

1567 New Technology - Level XXX ($6000-$6500)

1568 New Technology - Level XXXI ($6500-$7000)

1569 New Technology - Level XXXII ($7000-$7500)

1570 New Technology - Level XXXIII ($7500-$8000)

1571 New Technology - Level XXXIV ($8000-$8500)

1572 New Technology - Level XXXV ($8500-$9000)

1573 New Technology - Level XXXVI ($9000-$9500)

1574 New Technology - Level XXXVII ($9500-$10000)

1605 Abciximab injection

1607 Eptifibatide injection

1608 Etanercept injection

1609 Rho(D) immune globulin h, sd

1612 Daclizumab, parenteral

1613 Trastuzumab injection

1630 Hep b ig, im

1631 Baclofen intrathecal trial

1633 Alefacept

1643 Y90 ibritumomab, rx

1645 I131 tositumomab, rx

1670 Tetanus immune globulin inj

1675 P32 Na phosphate

1676 P32 chromic phosphate

1683 Basiliximab

1684 Corticorelin ovine triflutal

1685 Darbepoetin alfa, non-esrd

1686 Epoetin alfa, non-esrd

1687 Digoxin immune fab (ovine)

1688 Ethanolamine oleate

1689 Fomepizole

1690 Hemin
1693 Lepirudin

1694 Ziconotide injection

1695 Nesiritide injection

1696 Palifermin injection

1697 Pegaptanib sodium injection

1700 Inj secretin synthetic human

1701 Treprostinil injection

1704 Humate-P, inj

1705 Factor viia

1709 Azacitidine injection

1710 Clofarabine injection

1711 Vantas implant

1712 Paclitaxel protein bound

1716 Brachytx, non-str, Gold-198

1717 Brachytx, non-str, HDR Ir-192

1719 Brachytx, NS, Non-HDRIr-192

1738 Oxaliplatin

1739 Pegademase bovine, 25 iu

1741 Urofollitropin, 75 iu

1749 Endo, colon, retro imaging

1830 Power bone marrow bx needle

1840 Telescopic intraocular lens

1886 Catheter, ablation

2210 Methyldopate hcl injection

2616 Brachytx, non-str,Yttrium-90

2632 Iodine I-125 sodium iodide

2634 Brachytx, non-str, HA, I-125

2635 Brachytx, non-str, HA, P-103

2636 Brachy linear, non-str,P-103

2638 Brachytx, stranded, I-125

2639 Brachytx, non-stranded,I-125

2640 Brachytx, stranded, P-103

2641 Brachytx, non-stranded,P-103

2642 Brachytx, stranded, C-131

2643 Brachytx, non-stranded,C-131

2698 Brachytx, stranded, NOS

2699 Brachytx, non-stranded, NOS

2731 Immune globulin, powder

2770 Quinupristin/dalfopristin

3041 Bivalirudin

3043 Gamma globulin 1 CC inj

3050 Sermorelin acetate injection

7000 Amifostine

7011 Oprelvekin injection

7034 Somatropin injection

7035 Teniposide

7036 Urokinase 250,000 IU inj

7038 Monoclonal antibodies

7041 Tirofiban HCl

7042 Capecitabine, oral

7043 Infliximab injection

7046 Doxorubicin hcl liposome inj
7048 Alteplase recombinant

7049 Filgrastim 480 mcg injection

7051 Leuprolide acetate implant

7308 Aminolevulinic acid hcl top

8000 Cardiac Electrophysiologic Evaluation and Ablation Composite

8001 LDR Prostate Brachytherapy Composite

8002 Level I Extended Assessment & Management Composite

8003 Level II Extended Assessment & Management Composite

8004 Ultrasound Composite

8005 CT and CTA without Contrast Composite

8006 CT and CTA with Contrast Composite

8007 MRI and MRA without Contrast Composite

8008 MRI and MRA with Contrast Composite

9001 Linezolid injection

9002 Tenecteplase injection

9003 Palivizumab

9004 Gemtuzumab ozogamicin inj

9005 Reteplase injection

9006 Tacrolimus injection

9012 Arsenic trioxide injection

9018 Inj, rimabotulinumtoxinB

9019 Caspofungin acetate

9022 IM inj interferon beta 1-a

9023 Rho d immune globulin

9024 Amphotericin b lipid complex

9032 Baclofen 10 MG injection

9033 Cidofovir injection

9038 Inj estrogen conjugate

9042 Glucagon hydrochloride

9044 Ibutilide fumarate injection

9046 Iron sucrose injection

9104 Antithymocyte globuln rabbit

9108 Thyrotropin injection

9110 Alemtuzumab injection

9115 Zoledronic acid

9119 Injection, pegfilgrastim 6mg

9120 Injection, Fulvestrant

9121 Injection, argatroban

9122 Triptorelin pamoate

9124 Daptomycin injection

9125 Risperidone, long acting

9126 Natalizumab injection

9133 Rabies ig, im/sc

9134 Rabies ig, heat treated

9135 Varicella-zoster ig, im

9137 Bcg vaccine, percut

9139 Rabies vaccine, im

9140 Rabies vaccine, id

9143 Meningococcal vaccine, sc

9144 Encephalitis vaccine, sc

9145 Meningococcal vaccine, im

9207 Bortezomib injection
9208 Agalsidase beta injection

9209 Laronidase injection

9210 Palonosetron hcl

9213 Pemetrexed injection

9214 Bevacizumab injection

9215 Cetuximab injection

9217 Leuprolide acetate suspnsion

9224 Galsulfase injection

9225 Fluocinolone acetonide implt

9227 Micafungin sodium injection

9228 Tigecycline injection

9229 Ibandronate sodium injection

9230 Abatacept injection

9231 Decitabine injection

9232 Idursulfase injection

9233 Ranibizumab injection

9234 Alglucosidase alfa injection

9235 Panitumumab injection

9236 Eculizumab injection

9237 Inj, lanreotide acetate

9240 Injection, ixabepilone

9242 Injection, fosaprepitant

9243 Bendamustine injection

9244 Regadenoson injection

9245 Romiplostim injection

9248 Inj, clevidipine butyrate

9249 Certolizumab pegol inj

9250 Artiss fibrin sealant

9251 C1 esterase inhibitor inj

9252 Plerixafor injection

9253 Temozolomide injection

9254 Injection, lacosamide

9255 Paliperidone palmitate inj

9256 Dexamethasone intra implant

9258 Telavancin injection

9259 Pralatrexate injection

9260 Ofatumumab injection

9261 Ustekinumab injection

9263 Ecallantide injection

9264 Tocilizumab injection

9265 Romidepsin injection

9268 Capsaicin 8% patch

9269 C-1 esterase, berinert

9270 Gammaplex IVIG

9271 Velaglucerase alfa

9272 Inj, denosumab

9273 Sipuleucel-T auto CD54+

9274 Crotalidae Poly Immune Fab

9275 Hexaminolevulinate HCl

9276 Cabazitaxel injection

9278 Incobotulinumtoxin A

9279 Injection, ibuprofen
9281 Injection, pegloticase

9282 Inj, ceftaroline fosamil

9283 Injection, acetaminophen

9284 Ipilimumab injection

9285 Patch, lidocaine/tetracaine

9286 Injection, belatacept

9287 Inj, brentuximab vedotin

9300 Omalizumab injection

9358 SurgiMend, fetal

9360 SurgiMend, neonatal

9363 Integra Meshed Bil Wound Mat

9365 Oasis tri-layer wound matrix

9366 EpiFix wound cover

9367 Endoform Dermal Template

9406 Iodine I-123 ioflupane

9500 Platelets, irradiated

9501 Platelet pheres leukoreduced

9502 Platelet pheresis irradiated

9503 Fr frz plasma donor retested

9504 RBC deglycerolized

9505 RBC irradiated

9506 Granulocytes, pheresis unit

9507 Platelets, pheresis

9508 Plasma 1 donor frz w/in 8 hr
SI Relative Weight 

Payment 

Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

S 0.5043 $35.31 . $7.07

T 1.6118 $112.85 . $22.57

T 3.5548 $248.89 . $49.78

T 4.5721 $320.12 . $64.03

T 8.1596 $571.30 . $114.26

T 1.4209 $99.49 . $19.90

T 12.8082 $896.78 . $179.36

T 20.5510 $1,438.90 . $287.78

T 0.3878 $27.15 . $5.43

T 0.8768 $61.39 . $12.28

T 1.4966 $104.79 . $20.96

T 2.7597 $193.22 . $38.65

T 21.6700 $1,517.25 . $303.45

T 4.3953 $307.74 . $61.55

T 8.2918 $580.56 . $116.12

T 16.9957 $1,189.97 . $238.00

T 23.2636 $1,628.82 $350.74 $325.77

T 25.5066 $1,785.87 . $357.18

T 33.3398 $2,334.32 $580.94 $466.87

T 45.0217 $3,152.24 $747.07 $630.45

X 0.2988 $20.92 . $4.19

S 2.7298 $191.13 . $38.23

X 0.2673 $18.72 . $3.75

T 15.3535 $1,074.99 $227.40 $215.00

S 216.9330 $15,188.78 . $3,037.76

S 63.3729 $4,437.12 . $887.43

T 29.7721 $2,084.52 . $416.91

T 57.0707 $3,995.86 $804.74 $799.18

T 15.4596 $1,082.42 $268.44 $216.49

T 41.2873 $2,890.77 . $578.16

T 60.9147 $4,265.00 . $853.00

T 22.0797 $1,545.93 . $309.19

T 32.4461 $2,271.75 . $454.35

T 47.5032 $3,325.98 . $665.20

T 88.8483 $6,220.80 . $1,244.16

T 17.1902 $1,203.59 $253.49 $240.72

T 28.8625 $2,020.84 . $404.17

T 22.0963 $1,547.09 $353.25 $309.42

T 58.4586 $4,093.04 . $818.61

T 32.7262 $2,291.36 $475.91 $458.28

S 1.1255 $78.80 . $15.76

S 0.3428 $24.00 . $4.80

S 88.6050 $6,203.77 . $1,240.76

T 26.1202 $1,828.83 $372.85 $365.77

T 49.8979 $3,493.65 . $698.73

T 68.1203 $4,769.51 . $953.91
S 12.8903 $902.53

. $180.51

S 35.9961 $2,520.30

. $504.06

S 48.1833 $3,373.60

. $674.72

T 34.5272 $2,417.46 $591.64 $483.50 T 5.5061 $385.52 . $77.11 T 1.0729 $75.12 . $15.03 T 1.8643 $130.53 . $26.11 T 4.4119 $308.90 $67.83 $61.78 T 21.2774 $1,489.76 . $297.96 T 30.3487 $2,124.89 $444.55 $424.98 T 10.4689 $732.99 $189.82 $146.60 S 0.4237 $29.67 $7.74 $5.94 S 1.4089 $98.65 . $19.73 S 3.1979 $223.90 . $44.78 T 38.8523 $2,720.28 $836.90 $544.06 T 105.0651 $7,356.24 . $1,471.25 T 65.8519 $4,610.69 . $922.14 S 9.9330 $695.47 . $139.10 T 53.2719 $3,729.89 . $745.98 T 121.8174 $8,529.17 . $1,705.84 T 41.0387 $2,873.37 $655.18 $574.68 T 112.1218 $7,850.32 $1,643.98 $1,570.07 T 94.2220 $6,597.05 $1,593.50 $1,319.41 T 44.2272 $3,096.61 . $619.33 T 26.8120 $1,877.27 . $375.46 T 31.1505 $2,181.03 . $436.21 S 2.2326 $156.32 $43.83 $31.27 S 0.9930 $69.53 . $13.91 S 1.5248 $106.76 $36.86 $21.36 S 0.9350 $65.46 . $13.10 S 0.3817 $26.73 . $5.35 X 2.5439 $178.11 $41.37 $35.63 S 4.2669 $298.75 $100.24 $59.75 S 0.5346 $37.43 . $7.49 T 16.3852 $1,147.23 . $229.45 T 81.1503 $5,681.82 . $1,136.37 T 21.7420 $1,522.29 . $304.46 T 47.1769 $3,303.14 . $660.63 T 341.5859 $23,916.48 . $4,783.30 T 426.1201 $29,835.22 . $5,967.05 S 3.4217 $239.57 . $47.92 S 11.6629 $816.59 $189.89 $163.32 S 35.6252 $2,494.33 . $498.87 T 25.2738 $1,769.57 . $353.92 T 51.2792 $3,590.36 . $718.08 T 37.4593 $2,622.75 . $524.55 T 6.2123 $434.96 . $87.00 T 1.1095 $77.68 $16.21 $15.54 S 106.5454 $7,459.88 . $1,491.98 S 7.9593 $557.28 $166.16 $111.46 T 1.5020 $105.16 . $21.04 T 38.9223 $2,725.18 $659.53 $545.04
T 47.9394 $3,356.53 $1,001.89 $671.31 T 71.5658 $5,010.75 $1,236.99 $1,002.15 T 1.1922 $83.47 $23.34 $16.70 T 3.2354 $226.53 . $45.31 T 4.9271 $344.98 . $69.00 T 16.7703 $1,174.19 . $234.84 T 21.4409 $1,501.21 . $300.25 T 5.0454 $353.26 . $70.66 T 18.9489 $1,326.73 . $265.35 T 6.5866 $461.17 . $92.24 T 8.4511 $591.71 $138.69 $118.35 T 10.4394 $730.93 $152.78 $146.19 T 9.3693 $656.00 $186.06 $131.20 T 6.2205 $435.53 . $87.11 T 11.0417 $773.10 . $154.62 T 5.5158 $386.19 . $77.24 T 24.4382 $1,711.07 . $342.22 T 32.9805 $2,309.16 . $461.84 T 24.6966 $1,729.16 . $345.84 T 29.1415 $2,040.37 . $408.08 T 27.2798 $1,910.02 . $382.01 T 32.9294 $2,305.58 $464.85 $461.12 T 15.4175 $1,079.47 . $215.90 T 3.1886 $223.25 . $44.65 S 2.7510 $192.61 . $38.53 T 8.3164 $582.28 $0.00 $0.00 S 5.3772 $376.49 $0.00 $0.00 T 6.7736 $474.26 . $94.86 T 17.4715 $1,223.28 . $244.66 T 26.2973 $1,841.23 . $368.25 T 37.0730 $2,595.70 . $519.14 T 1.9499 $136.52 . $27.31 T 20.4158 $1,429.43 . $285.89 T 21.0031 $1,470.55 . $294.11 T 32.3061 $2,261.94 . $452.39 T 52.0882 $3,647.01 $997.74 $729.41 S 6.2419 $437.03 . $87.41 P 1.3944 $97.63 . $19.53 P 1.6255 $113.81 . $22.77 T 111.6495 $7,817.25 $2,055.58 $1,563.45 P 2.2954 $160.71 . $32.15 P 2.7298 $191.13 . $38.23 T 34.6069 $2,423.04 $607.60 $484.61 T 23.5454 $1,648.55 . $329.71 T 13.7727 $964.31 . $192.87 T 1.5841 $110.91 . $22.19 T 3.4818 $243.78 . $48.76 T 23.0098 $1,611.05 $424.28 $322.21 T 0.1337 $9.36 $1.95 $1.88 T 6.6979 $468.96 . $93.80 T 20.6493 $1,445.78 . $289.16 T 35.9087 $2,514.18 . $502.84
T 45.9895 $3,220.00 $981.50 $644.00 T 12.7996 $896.18 . $179.24 T 2.6055 $182.43 . $36.49 T 3.8754 $271.34 . $54.27 T 7.4537 $521.88 . $104.38 T 50.7343 $3,552.21 . $710.45 S 11.3569 $795.16 $268.73 $159.04 S 2.4298 $170.12 $53.58 $34.03 S 0.6335 $44.36 . $8.88 S 2.6488 $185.46 . $37.10 S 1.2025 $84.19 . $16.84 T 18.8921 $1,322.75 . $264.55 T 36.1290 $2,529.61 . $505.93 T 41.5547 $2,909.49 . $581.90 T 192.7379 $13,494.74 . $2,698.95 T 115.5014 $8,086.95 . $1,617.39 S 0.6424 $44.98 . $9.00 S 2.0294 $142.09 . $28.42 T 2.8247 $197.77 $42.27 $39.56 T 16.6214 $1,163.76 . $232.76 T 23.2851 $1,630.33 $347.90 $326.07 T 4.8135 $337.02 . $67.41 T 21.5368 $1,507.92 . $301.59 T 3.1036 $217.30 . $43.46 T 7.6566 $536.08 . $107.22 T 19.7786 $1,384.82 $296.20 $276.97 T 27.3416 $1,914.35 $383.45 $382.87 T 40.4039 $2,828.92 $597.36 $565.79 T 24.8671 $1,741.09 $411.91 $348.22 T 37.8979 $2,653.46 $794.94 $530.70 T 23.8810 $1,672.05 $490.37 $334.41 T 5.4120 $378.93 $102.28 $75.79 T 30.9855 $2,169.48 $516.99 $433.90 T 1.0709 $74.98 $24.12 $15.00 T 3.1150 $218.10 . $43.62 T 7.4614 $522.42 $104.55 $104.49 T 16.8699 $1,181.16 $279.20 $236.24 T 24.8895 $1,742.66 . $348.54 T 7.2190 $505.45 $101.81 $101.09 T 45.0377 $3,153.36 . $630.68 T 412.7299 $28,897.70 $7,948.75 $5,779.54 X 0.6409 $44.87 . $8.98 X 1.0790 $75.55 . $15.11 X 0.4640 $32.49 . $6.50 X 3.3643 $235.55 . $47.11 S 0.8990 $62.94 $22.26 $12.59 S 1.3781 $96.49 $37.23 $19.30 S 2.1681 $151.80 $59.37 $30.36 S 5.6156 $393.18 . $78.64 S 8.2952 $580.80 $133.61 $116.16 X 1.2171 $85.22 $30.47 $17.05 S 7.0678 $494.86 . $98.98
S 4.0104 $280.79 $68.90 $56.16 S 1.2186 $85.32 $33.87 $17.07 S 2.0340 $142.41 $53.90 $28.49 S 2.6196 $183.41 $58.44 $36.69 S 29.7209 $2,080.94 . $416.19 S 49.6878 $3,478.94 . $695.79 S 1.5251 $106.78 $35.57 $21.36 S 4.2929 $300.57 $96.62 $60.12 S 6.2343 $436.50 $146.69 $87.30 S 1.0218 $71.54 $0.00 $0.00 T 117.1298 $8,200.96 . $1,640.20 S 5.6386 $394.79 . $78.96 S 1.4252 $99.79 . $19.96 S 2.4149 $169.08 . $33.82 X 2.8573 $200.06 $66.95 $40.02 X 1.5329 $107.33 $34.63 $21.47 X 3.7681 $263.83 $88.76 $52.77 S 14.8260 $1,038.06 . $207.62 X 13.6332 $954.54 $325.27 $190.91 S 5.4044 $378.39 . $75.68 S 9.9687 $697.97 $263.92 $139.60 S 285.5893 $19,995.82 . $3,999.17 X 5.7208 $400.55 . $80.11 S 346.4693 $24,258.39 $9,121.76 $4,851.68 T 203.0553 $14,217.12 $5,559.48 $2,843.43 S 5.9715 $418.10 . $83.62 S 1.1395 $79.78 . $15.96 S 1.5910 $111.40 . $22.28 S 1.8190 $127.36 . $25.48 S 0.8088 $56.63 $11.70 $11.33 S 8.2687 $578.94 . $115.79 S 5.7930 $405.60 $156.82 $81.12 S 2.7436 $192.10 $74.27 $38.42 S 4.7767 $334.45 $116.13 $66.89 S 8.2987 $581.04 $187.25 $116.21 S 4.8381 $338.74 $133.48 $67.75 S 7.6347 $534.55 $197.64 $106.91 X 0.6499 $45.50 . $9.10 X 0.0806 $5.64 $2.09 $1.13 X 0.1601 $11.21 . $2.25 X 0.5259 $36.82 $10.84 $7.37 X 0.8180 $57.27 $15.56 $11.46 X 0.2135 $14.95 . $2.99 X 0.3538 $24.77 . $4.96 X 0.6730 $47.12 . $9.43 S 0.3545 $24.82 $0.00 $0.00 X 1.7152 $120.09 $33.87 $24.02 X 4.0827 $285.85 $83.23 $57.17 X 0.9638 $67.48 $17.10 $13.50 X 0.4911 $34.38 $7.06 $6.88 X 1.2175 $85.24 $18.05 $17.05 X 1.6864 $118.07 $23.65 $23.62
X 0.7420 $51.95 $13.76 $10.39 X 0.8906 $62.36 $20.93 $12.48 X 2.6868 $188.12 $38.23 $37.63 X 1.1369 $79.60 . $15.92 X 1.3842 $96.92 . $19.39 S 86.2468 $6,038.66 . $1,207.74 S 9.6018 $672.28 . $134.46 S 4.5192 $316.42 $126.56 $63.29 X 0.4426 $30.99 . $6.20 X 2.5717 $180.06 . $36.02 S 3.7417 $261.98 . $52.40 T 29.2172 $2,045.67 . $409.14 S 104.8530 $7,341.39 . $1,468.28 S 169.3017 $11,853.83 . $2,370.77 T 38.3457 $2,684.81 $655.55 $536.97 S 22.7689 $1,594.19 . $318.84 S 1.5569 $109.01 $26.88 $21.81 S 1.8944 $132.64 $47.64 $26.53 S 3.1610 $221.32 $65.46 $44.27 S 2.2892 $160.28 $39.07 $32.06 S 6.9196 $484.48 . $96.90 S 4.1909 $293.43 $90.78 $58.69 S 3.4841 $243.94 $87.01 $48.79 S 3.5304 $247.18 $94.20 $49.44 S 2.0980 $146.89 $33.94 $29.38 S 4.2548 $297.90 $93.33 $59.58 S 3.6580 $256.12 $90.92 $51.23 S 2.8915 $202.45 $71.16 $40.49 S 8.6793 $607.69 . $121.54 S 3.4408 $240.91 $72.42 $48.19 S 4.5536 $318.82 $81.52 $63.77 S 4.0053 $280.44 $85.08 $56.09 S 3.2941 $230.64 $78.13 $46.13 S 13.6750 $957.47 . $191.50 X 0.1101 $7.71 $2.17 $1.55 S 6.5452 $458.27 . $91.66 S 4.0373 $282.68 . $56.54 S 7.0664 $494.76 . $98.96 T 28.9051 $2,023.82 $459.92 $404.77 T 12.6671 $886.90 $207.88 $177.38 T 25.9792 $1,818.96 . $363.80 T 58.4890 $4,095.17 . $819.04 T 15.7819 $1,104.99 $240.64 $221.00 T 132.5319 $9,279.35 . $1,855.87 S 2.5699 $179.93 . $35.99 T 16.2412 $1,137.14 . $227.43 T 23.9777 $1,678.82 . $335.77 T 45.7676 $3,204.46 . $640.90 S 0.5154 $36.09 . $7.22 X 0.2434 $17.04 $5.06 $3.41 T 171.3141 $11,994.73 . $2,398.95 S 0.3545 $24.82 . $4.97
S 0.4972 $34.81

. $6.97

S 1.0388 $72.73

. $14.55

S 1.8098 $126.71

. $25.35

S 2.9679 $207.80

. $41.56

S 21.9850 $1,539.30

. $307.86

V 0.7689 $53.84

. $10.77

V 1.0311 $72.19

. $14.44

V 1.3588 $95.14

. $19.03

V 1.8647 $130.56

. $26.12

V 2.5237 $176.70

. $35.34

V 0.7181 $50.28 $12.04 $10.06 V 1.2356 $86.51 $20.79 $17.31 V 1.9447 $136.16 $33.59 $27.24 V 3.1277 $218.99 $47.70 $43.80 V 4.6152 $323.14 $71.44 $64.63 S 6.6453 $465.28 $104.95 $93.06 S 11.2658 $788.79 . $157.76 T 11.0639 $774.65 . $154.93 T 25.2672 $1,769.11 . $353.83 T 30.3507 $2,125.03 . $425.01 X 0.6068 $42.49 $12.33 $8.50 V 0.5627 $39.40 . $7.88 V 0.7972 $55.82 . $11.17 V 1.3178 $92.27 . $18.46 V 1.9503 $136.55 . $27.31 V 3.7639 $263.53 . $52.71 T 62.4125 $4,369.87 . $873.98 S 11.9274 $835.11 . $167.03 T 30.8430 $2,159.50 . $431.90 T 43.8023 $3,066.86 . $613.38 T 103.3418 $7,235.58 . $1,447.12 T 137.6558 $9,638.11 . $1,927.63 T 105.6644 $7,398.20 . $1,479.64 S 1.4941 $104.61 . $20.93 X 1.8189 $127.35 $27.10 $25.47 X 2.3496 $164.51 . $32.91 S 4.8375 $338.70 $114.37 $67.74 S 16.9101 $1,183.98 . $236.80 S 0.4865 $34.06 $0.00 $0.00 S 22.1209 $1,548.82 . $309.77 T 9.4045 $658.47 . $131.70 T 41.0159 $2,871.77 . $574.36 T 41.5778 $2,911.11 $634.95 $582.23 T 113.8112 $7,968.60 . $1,593.72 T 2.3021 $161.18 . $32.24 T 1.3360 $93.54 . $18.71 S 5.3254 $372.86 $95.30 $74.58 S 80.3579 $5,626.34 . $1,125.27 S 3.0368 $212.62 . $42.53 T 9.6713 $677.15 . $135.43 T 20.7198 $1,450.72 $385.30 $290.15 T 31.1002 $2,177.51 $768.94 $435.51
S 0.4928 $34.50

. $6.90

S 2.3930 $167.55

. $33.51

S 1.5944 $111.63

. $22.33

T 5.0714 $355.08 $88.08 $71.02 S 3.1615 $221.36 . $44.28 S 1.0589 $74.14 . $14.83 T 15.4248 $1,079.98 . $216.00 K $954.77 . $190.96 K $207.92 . $41.59 K $246.80 . $49.36 K $24.22 . $4.85 K $14.56 . $2.92 K $14.25 . $2.85 K $188.98 . $37.80 K $269.86 . $53.98 K $154.88 . $30.98 K $567.28 . $113.46 K $2.78 . $0.56 K $590.71 . $118.15 K $37.54 . $7.51 K $969.60 . $193.92 K $117.34 . $23.47 K $186.43 . $37.29 K $172.53 . $34.51 K $62.08 . $12.42 K $15.60 . $3.12 K $56.58 . $11.32 K $15.75 . $3.15 K $113.99 . $22.80 K $60.82 . $12.17 K $89.64 . $17.93 K $6.42 . $1.29 K $32.03 . $6.41 K $58.32 . $11.67 K $99.76 . $19.96 K $16.82 . $3.37 K $582.59 . $116.52 K $1,512.71 . $302.55 K $101.84 . $20.37 K $2,675.40 . $535.08 K $1,084.10 . $216.82 K $615.22 . $123.05 K $265.69 . $53.14 K $131.18 . $26.24 K $19,348.11 . $3,869.63 K $23.94 . $4.79 K $4.42 . $0.89 K $37.36 . $7.48 K $31.20 . $6.24 K $6.06 . $1.22 K $88.00 . $17.60 K $11.93 . $2.39
K $146.10

. $29.22

K $166.14

. $33.23

K $82.14

. $16.43

K $122.53

. $24.51

K $556.51

. $111.31

K $41.24

. $8.25

K $3.83

. $0.77

K $5.38

. $1.08

K $947.86

. $189.58

K $211.59

. $42.32

K $16,640.00

. $3,328.00

K $94.42

. $18.89

K $0.85

. $0.17

K $1.09

. $0.22

K $0.91

. $0.19

K $1.60

. $0.32

K $0.89

. $0.18

K $1.14

. $0.23

K $206.16

. $41.24

K $24.63

. $4.93

K $55.80

. $11.16

K $37.08

. $7.42

K $5.09

. $1.02

K $52.11

. $10.43

G $35.15

. $6.90

K $36.78

. $7.36

R 0.9547 $66.84

. $13.37

R 2.7245 $190.76

. $38.16

K $218.44

. $43.69

R 1.1823 $82.78

. $16.56

R 2.8408 $198.90

. $39.78

R 1.0400 $72.82

. $14.57

R 0.2574 $18.02

. $3.61

R 1.2822 $89.77

. $17.96

R 2.0257 $141.83

. $28.37

R 2.1303 $149.16

. $29.84

R 4.1045 $287.38

. $57.48

K $21.32

. $4.27

K $61.94

. $12.39

K $26.84

. $5.37

K $68.03

. $13.61

R 1.0362 $72.55

. $14.51

R 1.6761 $117.35

. $23.47

R 1.9996 $140.00

. $28.00

R 3.7309 $261.22

. $52.25

R 1.0622 $74.37

. $14.88

R 2.6930 $188.55

. $37.71

R 11.4695 $803.05

. $160.61

R 1.8720 $131.07

. $26.22

K $109.30

. $21.86

R 1.4989 $104.95

. $20.99

R 5.4802 $383.70

. $76.74
R 2.0966 $146.80

. $29.36

R 9.8804 $691.79

. $138.36

R 8.7936 $615.69

. $123.14

R 6.4103 $448.82

. $89.77

R 4.3700 $305.97

. $61.20

K $88.51

. $17.71

K $6.07

. $1.22

K $17.26

. $3.46

K $410.95

. $82.19

K $1,603.01

. $320.61

K $9.48

. $1.90

K $52.11

. $10.43

K $12.90

. $2.58

K $15,418.48

. $3,083.70

K $10.49

. $2.10

K $503.48

. $100.70

K $1.87

. $0.38

K $50.57

. $10.12

K $18.72

. $3.75

K $9.76

. $1.96

K $117.11

. $23.43

K $0.90

. $0.18

K $34.42

. $6.89

K $94.38

. $18.88

K $13.23

. $2.65

K $19.78

. $3.96

K $19.55

. $3.91

K $959.07

. $191.82

K $1.58

. $0.32

K $11.53

. $2.31

K $77.92

. $15.59

K $106.60

. $21.32

K $35.88

. $7.18

K $5.74

. $1.15

K $5.74

. $1.15

K $16.26

. $3.26

K $9.62

. $1.93

K $40.51

. $8.11

K $94.95

. $18.99

K $21.73

. $4.35

K $31.42

. $6.29

K $332.25

. $66.45

K $332.25

. $66.45

K $1,019.89

. $203.98

K $6.78

. $1.36

K $3.41

. $0.69

K $2.71

. $0.55

K $1.07

. $0.22

K $31.72

. $6.35

K $2.74

. $0.55

K $189.47

. $37.90

K $12.48

. $2.50
K $9.12

. $1.83

K $2,516.22

. $503.25

K $1.50

. $0.30

K $8.26

. $1.66

K $7.29

. $1.46

K $71.57

. $14.32

K $23.64

. $4.73

K $7,592.00

. $1,518.40

K $2.71

. $0.55

K $0.65

. $0.13

K $19.54

. $3.91

K $72.00

. $14.40

K $3.77

. $0.76

K $25.65

. $5.13

G $88.97

. $17.46

K $7.15

. $1.43

K $41.20

. $8.24

K $2.70

. $0.54

K $101.40

. $20.28

K $74.52

. $14.91

G $77.93

. $15.30

G $37.51

. $7.36

K $113.08

. $22.62

K $2.94

. $0.59

K $66.58

. $13.32

K $167.25

. $33.45

K $32.84

. $6.57

K $2.51

. $0.51

K $1.20

. $0.24

K $9.85

. $1.97

K $4.52

. $0.91

G $0.87

. $0.17

G $38.61

. $7.58

K $2.52

. $0.51

K $372.55

. $74.51

K $27.03

. $5.41

K $53.76

. $10.76

K $14.37

. $2.88

K $5.12

. $1.03

K $0.51

. $0.11

K $0.18

. $0.04

K $0.27

. $0.06

K $76.71

. $15.35

K $13.43

. $2.69

K $17.45

. $3.49

G $148.30

. $29.10

K $3.81

. $0.77

G $8.44

. $1.66

K $1,014.00

. $202.80

K $5.68

. $1.14

K $31.52

. $6.31

G $90.06

. $17.68
S $5.00

. $1.00

S $15.00

. $3.00

S $25.00

. $5.00

S $35.00

. $7.00

S $45.00

. $9.00

T $5.00

. $1.00

T $15.00

. $3.00

T $25.00

. $5.00

T $35.00

. $7.00

T $45.00

. $9.00

S $75.00

. $15.00

S $150.00

. $30.00

S $250.00

. $50.00

S $350.00

. $70.00

S $450.00

. $90.00

S $550.00

. $110.00

S $650.00

. $130.00

S $750.00

. $150.00

S $850.00

. $170.00

S $950.00

. $190.00

S $1,050.00

. $210.00

S $1,150.00

. $230.00

S $1,250.00

. $250.00

S $1,350.00

. $270.00

S $1,450.00

. $290.00

S $1,550.00

. $310.00

S $1,650.00

. $330.00

S $1,750.00

. $350.00

S $1,850.00

. $370.00

S $1,950.00

. $390.00

S $2,250.00

. $450.00

S $2,750.00

. $550.00

S $3,250.00

. $650.00

S $3,750.00

. $750.00

S $4,250.00

. $850.00

S $4,750.00

. $950.00

S $5,250.00

. $1,050.00

S $5,750.00

. $1,150.00

S $6,250.00

. $1,250.00

S $6,750.00

. $1,350.00

S $7,250.00

. $1,450.00

S $7,750.00

. $1,550.00

S $8,250.00

. $1,650.00

S $8,750.00

. $1,750.00

S $9,250.00

. $1,850.00

S $9,750.00

. $1,950.00

T $75.00

. $15.00

T $150.00

. $30.00

T $250.00

. $50.00

T $350.00

. $70.00

T $450.00

. $90.00

T $550.00

. $110.00
T $650.00

. $130.00

T $750.00

. $150.00

T $850.00

. $170.00

T $950.00

. $190.00

T $1,050.00

. $210.00

T $1,150.00

. $230.00

T $1,250.00

. $250.00

T $1,350.00

. $270.00

T $1,450.00

. $290.00

T $1,550.00

. $310.00

T $1,650.00

. $330.00

T $1,750.00

. $350.00

T $1,850.00

. $370.00

T $1,950.00

. $390.00

T $2,250.00

. $450.00

T $2,750.00

. $550.00

T $3,250.00

. $650.00

T $3,750.00

. $750.00

T $4,250.00

. $850.00

T $4,750.00

. $950.00

T $5,250.00

. $1,050.00

T $5,750.00

. $1,150.00

T $6,250.00

. $1,250.00

T $6,750.00

. $1,350.00

T $7,250.00

. $1,450.00

T $7,750.00

. $1,550.00

T $8,250.00

. $1,650.00

T $8,750.00

. $1,750.00

T $9,250.00

. $1,850.00

T $9,750.00

. $1,950.00

K $548.95

. $109.79

K $22.02

. $4.41

K $204.31

. $40.87

K $17.21

. $3.45

K $516.41

. $103.29

K $71.08

. $14.22

K $113.50

. $22.70

K $76.39

. $15.28

K $38.72

. $7.75

K $36,100.41

. $7,220.09

K $29,618.96

. $5,923.80

K $245.02

. $49.01

K $126.14

. $25.23

K $579.98

. $116.00

K $2,190.58

. $438.12

K $5.58

. $1.12

K $3.14

. $0.63

K $9.70

. $1.94

K $626.71

. $125.35

K $294.28

. $58.86

K $6.91

. $1.39

K $10.41

. $2.09
K $346.19

. $69.24

K $6.48

. $1.30

K $46.36

. $9.28

K $11.45

. $2.29

K $1,001.34

. $200.27

K $26.98

. $5.40

K $60.08

. $12.02

K $0.88

. $0.18

K $1.52

. $0.31

K $5.15

. $1.03

K $119.68

. $23.94

K $3,816.98

. $763.40

K $9.33

. $1.87

U 0.5004 $35.04

. $7.01

U 3.3224 $232.62

. $46.53

U 0.4544 $31.82

. $6.37

K $9.96

. $2.00

K $248.56

. $49.72

K $65.66

. $13.14

HHHHK $39.16

. $7.84

U 224.7054 $15,732.97

. $3,146.60

U 0.2404 $16.83

. $3.37

U 0.8944 $62.62

. $12.53

U 0.3855 $26.99

. $5.40

U 0.5294 $37.07

. $7.42

U 0.6498 $45.50

. $9.10

U 0.5078 $35.55

. $7.11

U 1.1433 $80.05

. $16.01

U 0.9180 $64.27

. $12.86

U 1.7379 $121.68

. $24.34

U 1.1044 $77.33

. $15.47

U 0.6498 $45.50

. $9.10

U 0.3855 $26.99

. $5.40

K $30.46

. $6.10

K $171.48

. $34.30

K $2.71

. $0.55

K $20.62

. $4.13

K $1.77

. $0.36

K $315.94

. $63.19

K $239.90

. $47.98

K $61.81

. $12.37

K $316.31

. $63.27

K $449.09

. $89.82

K $1,111.59

. $222.32

K $8.92

. $1.79

K $7.32

. $1.47

K $62.01

. $12.41

K $525.35

. $105.07
K $42.24

. $8.45

K $390.07

. $78.02

K $4,728.88

. $945.78

K $147.80

. $29.56

T 161.5528 $11,311.28

. $2,262.26

T 47.7031 $3,339.98

. $668.00

V 5.6151 $393.15

. $78.63

V 10.2925 $720.64

. $144.13

S 2.7374 $191.66

. $38.34

S 6.1687 $431.91

. $86.39

S 10.3084 $721.75

. $144.35

S 9.9975 $699.98

. $140.00

S 14.2917 $1,000.65

. $200.13

K $34.48

. $6.90

K $57.15

. $11.43

K $1,158.85

. $231.77

K $2,690.84

. $538.17

K $1,623.59

. $324.72

K $136.86

. $27.38

K $40.10

. $8.02

K $10.78

. $2.16

K $13.32

. $2.67

K $238.30

. $47.66

K $21.52

. $4.31

K $8.42

. $1.69

K $187.46

. $37.50

K $742.66

. $148.54

K $103.54

. $20.71

K $101.30

. $20.26

K $133.80

. $26.76

K $0.32

. $0.07

K $432.20

. $86.44

K $1,032.25

. $206.45

K $575.18

. $115.04

K $220.30

. $44.06

K $2,676.49

. $535.30

K $83.63

. $16.73

K $20.16

. $4.04

K $176.18

. $35.24

K $0.48

. $0.10

K $5.07

. $1.02

K $10.32

. $2.07

K $185.74

. $37.15

K $177.81

. $35.57

K $94.28

. $18.86

K $112.23

. $22.45

K $205.48

. $41.10

K $139.69

. $27.94

K $110.75

. $22.15

K $100.15

. $20.03

K $92.92

. $18.59

K $40.67

. $8.14
K $138.53

. $27.71

K $26.33

. $5.27

K $18.83

. $3.77

K $52.76

. $10.56

K $59.98

. $12.00

K $49.53

. $9.91

K $216.90

. $43.38

K $341.40

. $68.28

K $18,980.00

. $3,796.00

K $0.98

. $0.20

K $1.30

. $0.26

K $148.02

. $29.61

K $20.72

. $4.15

K $31.94

. $6.39

K $446.44

. $89.29

K $395.53

. $79.11

K $155.84

. $31.17

K $85.59

. $17.12

K $186.37

. $37.28

K $30.98

. $6.20

K $63.47

. $12.70

K $1.69

. $0.34

K $18.47

. $3.70

K $51.22

. $10.25

K $45.87

. $9.18

K $2.66

. $0.54

K $4.12

. $0.83

K $129.72

. $25.95

K $43.37

. $8.68

K $275.80

. $55.16

K $4.75

. $0.95

K $0.15

. $0.03

K $6.56

. $1.32

K $192.26

. $38.46

G $2.10

. $0.42

G $165.63

. $32.50

G $45.41

. $8.91

G $117.56

. $23.07

G $289.07

. $56.73

G $3.47

. $0.68

G $224.79

. $44.11

G $25.55

. $5.02

G $30.23

. $5.94

G $37.29

. $7.32

G $349.51

. $68.59

G $14.47

. $2.84

G $32,860.00

. $6,448.00

G $2,111.36

. $414.31

G $623.28 $0.00 $0.00 G $135.57 . $26.61 G $5.53 . $1.08 G $1.62 . $0.32
G $301.75

. $59.22

G $0.74

. $0.14

G $0.11

. $0.03

G $127.20

. $24.96

G $13.57

. $2.67

G $3.91

. $0.77

G $95.40

. $18.72

K $21.34

. $4.27

K $10.91

. $2.19

K $11.23

. $2.25

K $20.60

. $4.12

G $10.39

. $2.04

G $177.77

. $34.89

G $4.35

. $0.86

G $1,908.00 $0.00 $0.00 R 1.8342 $128.42 . $25.69 R 7.6960 $538.84 . $107.77 R 7.9257 $554.93 . $110.99 R 1.1562 $80.95 . $16.19 R 3.4084 $238.64 . $47.73 R 2.8419 $198.98 . $39.80 R 19.1478 $1,340.65 . $268.13 R 6.3148 $442.14 . $88.43 R 1.1408 $79.87 . $15.98