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**Ad dendum A** **.-Final OPPS A PCs for CY 2012** 

**AP C**  **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 0035Vascular 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 0047Arthroplasty

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/Dislocation0065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG

0066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG 0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEG 0069Thoracoscopy 0070Thoracentesis/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 0079Ventilation Initiation and Management 0080 Diagnostic Cardiac Catheterization 0082 Coronary

or Non-Coronary

Atherectomy 0083Coronary

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 0088Thrombectomy 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 0093Vascular Reconstruction/Fistula Repair without Device 0094 Level I Resuscitation and Cardioversion 0095Cardiac 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 0104Transcatheter 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 0110Transfusion 0111 Blood Product Exchange 0112Apheresis and Stem Cell Procedures 0113 Excision Lymphatic System 0114Thyroid/Lymphadenectomy Procedures 0115Cannula/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 Laparoscopy0131 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 0157Colorectal Cancer Screening: Barium Enema 0158Colorectal Cancer Screening: Colonoscopy 0159Colorectal 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 Procedures0202 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 0243Strabismus/Muscle Procedures 0244 Corneal and Amniotic Membrane Transplant 0246Cataract Procedures with IOL Insert 0247 Laser Eye Procedures 0249Cataract 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 FilmExcept Teeth 0261 Level II Plain FilmExcept Teeth Including Bone Density Measurement 0262 Plain Filmof 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 Myelography0275Arthrography

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 0283Computed 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 0303Treatment 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 Brachy

therapy 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 0325Group Psychotherapy 0330 Dental Procedures 0331 Combined Abdomen and Pelvis CT without Contrast 0332 Computed Tomography without Contrast 0333Computed 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 0350Administration 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 Audiometry0367 Level I Pulmonary Test 0368 Level II Pulmonary Tests 0369 Level III Pulmonary Tests 0370 Multiple Allergy

Tests 0373 Level I Neuropsychological Testing 0375Ancillary

Outpatient Services When Patient Expires 0377 Level II Cardiac Imaging 0378 Level II Pulmonary Imaging 0381 Single Allergy

Tests 0382 Level II Neuropsychological Testing 0383Cardiac 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 0395GI Tract Imaging 0396 Bone Imaging 0397Vascular 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 Administration0437 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 0617Critical Care 0618Trauma Response with Critical Care 0621 Level I Vascular Access Procedures 0622 Level II Vascular Access Procedures 0623 Level III Vascular Access Procedures 0624 Phlebotomyand 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 0653Vascular 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 0656Transcatheter 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 BeamRadiation Therapy 0665 Bone Density:AppendicularSkeleton 0667 Level II Proton BeamRadiation Therapy 0668 Level I Angiography and Venography 0672 Level III Posterior Segment Eye Procedures 0673 Level V Anterior Segment Eye Procedures 0674 Prostate Cryoablation 0676Thrombolysis 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 Receiver0690 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 0735Ampho b cholesteryl sulfate 0736Amphotericin b liposome inj 0738 Rasburicase 0747Chlorothiazide sodiuminj 0751 Mechlorethamine hcl inj 0752 Dactinomycin injection 0759 Naltrexone, depot form 0800 Leuprolide acetate 0802 Etoposide oral 0807Aldesleukin injection 0809 Bcg live intravesical vac 0810 Goserelin acetate implant 0812 Carmustine injection 0814Asparaginase 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 0835Cosyntropin 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 0850Streptozocin injection 0851 Thiotepa injection 0856 Porfimer sodium injection 0858 Inj cladribine 0861 Leuprolide acetate injeciton 0864 Mitoxantrone hydrochl 0865 Interferon alfa-n3 inj 0868Oral aprepitant 0873 Hyalgan/supartz inj per dose 0874Synvisc or synvisc-one0875 Euflexxa inj per dose

0877Orthovisc inj per dose 0884 Rho d immune globulin inj 0887Azathioprine parenteral 0890 Lymphocy

te immune globulin 0900Alglucerase injection 0901 Alpha 1 proteinase inhibitor 0902 Injection,onabotulinumtoxinA 0903Cy

tomegalovirus imm IV /vial 0910 Interferon beta-1b / .25 MG 0913 Ganciclovir long act implant 0917Adenosine injection 0925 Factor viii 0927 Factor viii recombinant 0928 Factor ix complex 0929Anti-inhibitor 0931 Factor IX non-recombinant 0932 Factor IX recombinant 0933 Gamma globulin > 10 CC inj 0934 Capecitabine, oral 0943Octagam 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 0950Whole blood for transfusion 0951 Reclast injection 0952 Cryoprecipitate each unit 0954 RBC leukocy

tes 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 0960Washed red blood cells unit 0961 Albumin (human),5%, 50ml 0963Albumin (human), 5%, 250 ml 0964Albumin (human), 25%, 20 ml 0965Albumin (human), 25%, 50ml 0966 Plasmaprotein fract,5%,250ml 0967 Blood split unit 0968 Platelets leukoreduced irrad 0969 RBC leukoreduced irradiated 1009Cryoprecipitatereducedplasma 1010 Blood, l/r, cmv-neg 1011 Platelets, hla-m, l/r, unit 1013 Platelets leukocy tes reduced 1015 Injection glatiramer acetate 1016 Blood, l/r, froz/degly /wash 1017 Plt, aph/pher, l/r, cmv-neg1018 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 1083Adalimumab injection 1084 Denileukin diftitox inj 1086Temozolomide 1138 Hepagam b intravenous, inj 1139 Protein c concentrate 1142 Supprelin LA implant 1150 I131 iodide sol, rx 1166Cy

tarabine liposome inj 1167 Inj, epirubicin hcl 1168 Inj, temsirolimus 1178 Busulfan injection 1203Verteporfin injection 1207Octreotide injection, depot 1213Antihemophilic 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 1235Valrubicin injection 1236 Levoleucovorin injection 1237 Inj iron dextran 1238Topotecan oral 1239 Rotavirus vacc 2 dose oral 1240Apligraf 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 1249Cymetra allograft 1250 Graftjacket express allograf 1251 Integra flowable wound matri 1252 Gammagraft skin sub 1253Triamcinolone A inj PRS-free 1263Antithrombin iii injection 1268Xyntha inj 1270Allodermskin sub 1272Acetylcysteine injection 1274 Edetate calcium disodium inj 1275Vivaglobin, inj1279 Factor VIII (porcine)

1280 Corticotropin injection 1281 Bevacizumab injection 1287Alloskin skin sub 1289AbobotulinumtoxinA 1290 Human fibrinogen conc inj 1291 Rilonacept injection 1295Sm153 lexidronam 1296 Degarelix injection 1297 Ferumoxy

tol, non-esrd 1304 Perphenazine injeciton 1306 Urea injection 1307Oral busulfan 1308 Mecasermin injection 1311 Canakinumab injection 1312 Hizentra injection 1327 Imiglucerase injection 1331 Olanzapine long-acting inj 1332Antithrombin recombinant 1338 Methyl aminolevulinate, top 1339Oral fludarabine phosphate 1340 Collagenase, clost hist inj 1341 Amobarbital 125 MG inj 1342 Matristem micromatrix 1343 Ganciclovir sodium injection 1344 Gonadorelin hydroch/ 100 mcg 1345Theraskin 1347Oxacillin sodium injeciton 1349Anidulafungin injection 1350Topotecan injection 1351 Matristem wound matrix 1352Wilate injection 1353 Belimumab injection 1354 Hydroxyprogesterone caproate 1355 Itraconazole injection 1357 Inj protirelin per 250 mcg 1358 Phentolaine mesylate inj 1359 Foscarnet sodium injection 1360Apomorphine hydrochloride 1361 Enfuvirtide injection 1362 Inj heparin sodium per 10 u 1373 Inj heparin sodium per 1000u 1374Sumatriptan succinate / 6 MG 1408Cyclophosphamide 100 MG inj 1412Vinorelbine tartrate inj 1413 Lumizyme injection 1415Glassia injection 1416 Factor XIII anti-hem factor 1417 Gel-one 1418Oral everolimus 1419 Dermacell 1426 Eribulin mesylate injection1491 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) 1605Abciximab injection 1607 Eptifibatide injection 1608 Etanercept injection 1609 Rho(D) immune globulin h, sd 1612 Daclizumab, parenteral 1613Trastuzumab injection 1630 Hep b ig, im 1631 Baclofen intrathecal trial 1633Alefacept 1643Y90 ibritumomab, rx 1645 I131 tositumomab, rx 1670Tetanus 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 Hemin1693 Lepirudin

1694Ziconotide injection 1695 Nesiritide injection 1696 Palifermin injection 1697 Pegaptanib sodiuminjection 1700 Inj secretin synthetic human 1701 Treprostinil injection 1704 Humate-P, inj 1705 Factor viia 1709Azacitidine injection 1710 Clofarabine injection 1711 Vantas implant 1712 Paclitaxel protein bound 1716 Brachy

tx, non-str, Gold-198 1717 Brachy

tx, non-str, HDR Ir-192 1719 Brachy

tx, NS, Non-HDRIr-192 1738Oxaliplatin 1739 Pegademase bovine, 25 iu 1741 Urofollitropin, 75 iu 1749 Endo, colon, retro imaging 1830 Power bone marrow bx needle 1840Telescopic intraocular lens 1886Catheter, ablation 2210 Methyldopate hcl injection 2616 Brachy

tx, non-str,Yttrium-90 2632 Iodine I-125 sodium iodide 2634 Brachy

tx, non-str, HA, I-125 2635 Brachy

tx, non-str, HA, P-103 2636 Brachy

linear, non-str,P-103 2638 Brachy

tx, stranded, I-125 2639 Brachy

tx, non-stranded,I-125 2640 Brachy

tx, stranded, P-103 2641 Brachy

tx, non-stranded,P-103 2642 Brachy

tx, stranded, C-131 2643 Brachy

tx, non-stranded,C-131 2698 Brachy

tx, stranded, NOS 2699 Brachy

tx, non-stranded, NOS 2731 Immune globulin, powder 2770Quinupristin/dalfopristin 3041 Bivalirudin 3043 Gamma globulin 1 CC inj 3050Sermorelin acetate injection 7000Amifostine 7011 Oprelvekin injection 7034Somatropin injection 7035Teniposide 7036 Urokinase 250,000 IU inj 7038 Monoclonal antibodies 7041 Tirofiban HCl 7042 Capecitabine, oral 7043 Infliximab injection 7046 Doxorubicin hcl liposome inj7048Alteplase recombinant

7049 Filgrastim 480 mcg injection 7051 Leuprolide acetate implant 7308Aminolevulinic acid hcl top 8000 Cardiac Electrophysiologic Evaluation and Ablation Composite 8001 LDR Prostate Brachy therapy Composite 8002 Level I Extended Assessment & Management Composite 8003 Level II Extended Assessment & Management Composite 8004 Ultrasound Composite 8005CT and CTA without Contrast Composite 8006CT and CTA with Contrast Composite 8007 MRI and MRA without Contrast Composite 8008 MRI and MRA with Contrast Composite 9001 Linezolid injection 9002Tenecteplase injection 9003 Palivizumab 9004 Gemtuzumab ozogamicin inj 9005 Reteplase injection 9006Tacrolimus injection 9012Arsenic trioxide injection 9018 Inj, rimabotulinumtoxinB 9019Caspofungin acetate 9022 IM inj interferon beta 1-a 9023 Rho d immune globulin 9024Amphotericin b lipid complex 9032 Baclofen 10 MG injection 9033Cidofovir injection 9038 Inj estrogen conjugate 9042 Glucagon hydrochloride 9044 Ibutilide fumarate injection 9046 Iron sucrose injection 9104Antithymocy

te globuln rabbit 9108Thyrotropin injection 9110Alemtuzumab injection 9115Zoledronic acid 9119 Injection, pegfilgrastim 6mg 9120 Injection, Fulvestrant 9121 Injection, argatroban 9122Triptorelin pamoate 9124 Daptomycin injection 9125 Risperidone, long acting 9126 Natalizumab injection 9133 Rabies ig, im/sc 9134 Rabies ig, heat treated 9135Varicella-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 injection9208Agalsidase beta injection

9209 Laronidase injection 9210 Palonosetron hcl 9213 Pemetrexed injection 9214 Bevacizumab injection 9215Cetuximab injection 9217 Leuprolide acetate suspnsion 9224 Galsulfase injection 9225 Fluocinolone acetonide implt 9227 Micafungin sodium injection 9228Tigecycline injection 9229 Ibandronate sodium injection 9230Abatacept injection 9231 Decitabine injection 9232 Idursulfase injection 9233 Ranibizumab injection 9234Alglucosidase 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 9249Certolizumab pegol inj 9250Artiss fibrin sealant 9251 C1 esterase inhibitor inj 9252 Plerixafor injection 9253Temozolomide injection 9254 Injection, lacosamide 9255 Paliperidone palmitate inj 9256 Dexamethasone intra implant 9258Telavancin injection 9259 Pralatrexate injection 9260 Ofatumumab injection 9261 Ustekinumab injection 9263 Ecallantide injection 9264Tocilizumab injection 9265 Romidepsin injection 9268Capsaicin 8% patch 9269C-1 esterase, berinert 9270 Gammaplex IVIG 9271 Velaglucerase alfa 9272 Inj, denosumab 9273Sipuleucel-T auto CD54+ 9274 Crotalidae Poly

Immune Fab 9275 Hexaminolevulinate HCl 9276Cabazitaxel injection 9278 Incobotulinumtoxin A 9279 Injection, ibuprofen9281 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 9358SurgiMend, fetal 9360SurgiMend, neonatal 9363 Integra Meshed Bil Wound Mat 9365Oasis 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 Granulocy

tes, 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 . $953.91S 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 $545.04T 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 . $502.84T 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 . $98.98S 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 $23.62X 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 . $4.97S 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 $435.51S 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 . $2.39K $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 . $76.74R 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 . $2.50K $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 . $17.68S $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 . $110.00T $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 . $2.09K $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 H H H H K $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 . $105.07K $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 . $8.14K $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 . $0.32G $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