Addendum A.-Final OPPS APCs for CY 2013

APC Group Title SI

Relative 

Weight 

0001 Level I Photochemotherapy S 0.5210

0002 Fine Needle Biopsy/Aspiration T 1.7194

0003 Bone Marrow Biopsy/Aspiration T 3.7917

0004 Level I Needle Biopsy/ Aspiration Except Bone Marrow T 4.8451

0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 8.7675

0006 Level I Incision & Drainage T 1.7592

0007 Level II Incision & Drainage T 10.1746

0008 Level III Incision and Drainage T 18.4976

0012 Level I Debridement & Destruction T 0.3982

0013 Level II Debridement & Destruction T 1.0032

0015 Level III Debridement & Destruction T 1.4998

0016 Level IV Debridement & Destruction T 2.9399

0017 Level V Debridement & Destruction T 19.8814

0019 Level I Excision/ Biopsy T 4.7170

0020 Level II Excision/ Biopsy T 8.1838

0021 Level III Excision/ Biopsy T 15.7299

0022 Level IV Excision/ Biopsy T 23.2928

0028 Level I Breast Surgery T 26.1210

0029 Level II Breast Surgery T 34.4816

0030 Level III Breast Surgery T 45.3768

0031 Level I Health and Behavior Services S 0.3135

0034 Mental Health Services Composite S 3.2008

0035 Vascular Puncture and Minor Diagnostic Procedures X 0.3286

0037 Level IV Needle Biopsy/Aspiration Except Bone Marrow T 15.6849

0039 Level I Implantation of Neurostimulator Generator S 229.8982

0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes S 61.6966

0041 Level I Arthroscopy T 29.6106

0042 Level II Arthroscopy T 54.4111

0045 Bone/Joint Manipulation Under Anesthesia T 14.5706

0047 Arthroplasty without Prosthesis T 40.2172

0048 Level I Arthroplasty or Implantation with Prosthesis T 62.4025

0049 Level I Musculoskeletal Procedures Except Hand and Foot T 21.8096

0050 Level II Musculoskeletal Procedures Except Hand and Foot T 32.3471

0051 Level III Musculoskeletal Procedures Except Hand and Foot T 48.2042

0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 82.2078

0053 Level I Hand Musculoskeletal Procedures T 16.6230

0054 Level II Hand Musculoskeletal Procedures T 28.9725

0055 Level I Foot Musculoskeletal Procedures T 22.2111

0056 Level II Foot Musculoskeletal Procedures T 60.6876

0057 Bunion Procedures T 34.4317

0058 Level I Cast Application S 1.3257

0059 Level I Strapping S 0.7563

0060 Manipulation Therapy S 0.2738

0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes S 95.2427

0062 Level I Treatment Fracture/Dislocation T 26.7671

0063 Level II Treatment Fracture/Dislocation T 52.7806

0064 Level III Treatment Fracture/Dislocation T 70.6785
0065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG S 13.7177

0066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG S 33.0205

0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEG S 46.2838

0069 Thoracoscopy T 35.9647

0070 Thoracentesis/Lavage Procedures T 5.7828

0071 Level I Endoscopy Upper Airway T 1.0839

0072 Level II Endoscopy Upper Airway T 2.0036

0073 Level III Endoscopy Upper Airway T 4.7291

0074 Level IV Endoscopy Upper Airway T 18.9594

0075 Level V Endoscopy Upper Airway T 28.4215

0076 Level I Endoscopy Lower Airway T 10.7117

0077 Level I Pulmonary Treatment S 0.4920

0078 Level III Pulmonary Treatment S 1.4155

0079 Ventilation Initiation and Management S 3.4693

0080 Diagnostic Cardiac Catheterization T 37.1534

0082 Coronary or Non-Coronary Atherectomy T 107.5706

0083 Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity T 56.4140

0084 Level I Electrophysiologic Procedures S 9.8911

0085 Level II Electrophysiologic Procedures T 55.0013

0088 Thrombectomy T 43.4735

0089 Insertion/Replacement of Permanent Pacemaker and Electrodes T 115.4087

0090 Level I Insertion/Replacement of Permanent Pacemaker T 92.7231

0091 Level II Vascular Ligation T 42.4137

0092 Level I Vascular Ligation T 27.4658

0093 Vascular Reconstruction/Fistula Repair without Device T 30.1384

0094 Level I Resuscitation and Cardioversion S 2.2552

0095 Cardiac Rehabilitation S 1.1206

0096 Level II Noninvasive Physiologic Studies S 1.5230

0097 Level I Noninvasive Physiologic Studies S 0.9328

0099 Electrocardiograms/Cardiography S 0.3740

0100 Cardiac Stress Tests X 2.4795

0101 Tilt Table Evaluation S 4.2562

0102 Level II Pulmonary Treatment S 0.5512

0103 Miscellaneous Vascular Procedures T 16.2173

0104 Transcatheter Placement of Intracoronary Stents T 85.6848

0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular DevicesT 23.6020

0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes T 52.8101

0107 Level I Implantation of Cardioverter-Defibrillators (ICDs) T 315.6793

0108 Level II Implantation of Cardioverter-Defibrillators (ICDs) T 430.2162

0110 Transfusion S 3.6520

0111 Blood Product Exchange S 13.3306

0112 Apheresis and Stem Cell Procedures S 40.5074

0113 Excision Lymphatic System T 25.5213

0114 Thyroid/Lymphadenectomy Procedures T 51.4794

0115 Cannula/Access Device Procedures T 37.5770

0121 Level I Tube or Catheter Changes or Repositioning T 6.1648

0126 Level I Urinary and Anal Procedures T 1.1497

0127 Level IV Stereotactic Radiosurgery, MRgFUS, and MEG S 110.9266

0129 Level I Closed Treatment Fracture T 1.8741

0130 Level I Laparoscopy T 38.2829

0131 Level II Laparoscopy T 48.8992

0132 Level III Laparoscopy T 71.8156
0133 Level I Skin Repair T 1.2024

0134 Level II Skin Repair T 3.5264

0135 Level III Skin Repair T 5.5162

0136 Level IV Skin Repair T 15.5878

0137 Level V Skin Repair T 21.1752

0138 Level II Closed Treatment Fracture T 5.5931

0139 Level III Closed Treatment Fracture T 11.7147

0140 Esophageal Dilation without Endoscopy T 6.7737

0141 Level I Upper GI Procedures T 8.7424

0142 Level I Small Intestine Endoscopy T 10.5266

0143 Lower GI Endoscopy T 9.6941

0146 Level I Sigmoidoscopy and Anoscopy T 5.8940

0147 Level II Sigmoidoscopy and Anoscopy T 10.0341

0148 Level I Anal/Rectal Procedures T 6.1609

0149 Level III Anal/Rectal Procedures T 25.6535

0150 Level IV Anal/Rectal Procedures T 33.1772

0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 24.2214

0152 Level I Percutaneous Abdominal and Biliary Procedures T 28.4347

0153 Peritoneal and Abdominal Procedures T 25.9781

0154 Hernia/Hydrocele Procedures T 34.0627

0155 Level II Anal/Rectal Procedures T 17.9329

0156 Level III Urinary and Anal Procedures T 3.2577

0157 Colorectal Cancer Screening: Barium Enema S 2.5831

0158 Colorectal Cancer Screening: Colonoscopy T 8.5787

0159 Colorectal Cancer Screening: Flexible Sigmoidoscopy S 5.8206

0160 Level I Cystourethroscopy and other Genitourinary Procedures T 7.1482

0161 Level II Cystourethroscopy and other Genitourinary Procedures T 15.8635

0162 Level III Cystourethroscopy and other Genitourinary Procedures T 26.7673

0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 38.3814

0164 Level II Urinary and Anal Procedures T 2.1419

0165 Level IV Urinary and Anal Procedures T 19.7656

0166 Level I Urethral Procedures T 21.5966

0168 Level II Urethral Procedures T 33.2789

0169 Lithotripsy T 39.8005

0170 Dialysis S 6.9597

0172 Level I Partial Hospitalization (3 services) for CMHCs P 1.1913

0173 Level II Partial Hospitalization (4 or more services) for CMHCs P 1.5378

0174 Level IV Laparoscopy T 127.3348

0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs P 2.5340

0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs P 3.2008

0177 Level I Echocardiogram with Contrast S 6.0848

0178 Level II Echocardiogram with Contrast S 8.1101

0181 Level II Male Genital Procedures T 38.9199

0183 Level I Male Genital Procedures T 23.7942

0184 Prostate Biopsy T 13.5630

0188 Level II Female Reproductive Proc T 1.6625

0189 Level III Female Reproductive Proc T 3.2826

0190 Level I Hysteroscopy T 23.5870

0191 Level I Female Reproductive Proc T 0.1157

0192 Level IV Female Reproductive Proc T 6.9849

0193 Level V Female Reproductive Proc T 20.3967

0195 Level VI Female Reproductive Procedures T 37.0120
0202 Level VII Female Reproductive Procedures T 47.7547

0203 Level IV Nerve Injections T 12.0130

0204 Level I Nerve Injections T 2.5607

0206 Level II Nerve Injections T 4.0910

0207 Level III Nerve Injections T 7.9333

0208 Laminotomies and Laminectomies T 52.7056

0209 Level II Extended EEG, Sleep, and Cardiovascular Studies S 11.3041

0213 Level I Extended EEG, Sleep, and Cardiovascular Studies S 2.4204

0215 Level I Nerve and Muscle Services S 0.6045

0216 Level III Nerve and Muscle Services S 2.5805

0218 Level II Nerve and Muscle Services S 1.1195

0220 Level I Nerve Procedures T 18.8566

0221 Level II Nerve Procedures T 34.7984

0224 Implantation of Catheter/Reservoir/Shunt T 45.5890

0227 Implantation of Drug Infusion Device T 197.8775

0229 Level II Endovascular Revascularization of the Lower Extremity T 121.3919

0230 Level I Eye Tests & Treatments S 0.6788

0231 Level III Eye Tests & Treatments S 2.0317

0232 Level I Anterior Segment Eye Procedures T 2.0304

0233 Level III Anterior Segment Eye Procedures T 15.8380

0234 Level IV Anterior Segment Eye Procedures T 23.5107

0235 Level I Posterior Segment Eye Procedures T 5.8389

0237 Level II Posterior Segment Eye Procedures T 20.2224

0238 Level I Repair and Plastic Eye Procedures T 3.2499

0239 Level II Repair and Plastic Eye Procedures T 8.6336

0240 Level III Repair and Plastic Eye Procedures T 19.1819

0241 Level IV Repair and Plastic Eye Procedures T 26.7000

0242 Level V Repair and Plastic Eye Procedures T 39.7223

0243 Strabismus/Muscle Procedures T 25.2082

0244 Corneal and Amniotic Membrane Transplant T 41.6106

0246 Cataract Procedures with IOL Insert T 24.2659

0247 Laser Eye Procedures T 5.7604

0249 Cataract Procedures without IOL Insert T 29.3838

0250 Level I ENT Procedures T 1.0950

0251 Level II ENT Procedures T 3.2225

0252 Level III ENT Procedures T 6.9913

0253 Level IV ENT Procedures T 16.0895

0254 Level V ENT Procedures T 25.2377

0255 Level II Anterior Segment Eye Procedures T 9.2948

0256 Level VI ENT Procedures T 45.9788

0259 Level VII ENT Procedures T 425.2643

0260 Level I Plain Film Except Teeth X 0.6443

0261 Level II Plain Film Except Teeth Including Bone Density MeasurementX 0.9933

0262 Plain Film of Teeth X 0.5031

0263 Level I Miscellaneous Radiology Procedures X 3.5823

0265 Level I Diagnostic and Screening Ultrasound S 0.9054

0266 Level II Diagnostic and Screening Ultrasound S 1.3928

0267 Level III Diagnostic and Screening Ultrasound S 2.1699

0269 Level II Echocardiogram Without Contrast S 5.4757

0270 Level III Echocardiogram Without Contrast S 7.8339

0272 Fluoroscopy X 1.6023

0274 Myelography S 7.1179
0275 Arthrography S 4.1881

0276 Level I Digestive Radiology S 1.1600

0277 Level II Digestive Radiology S 1.7222

0278 Diagnostic Urography S 2.9385

0279 Level II Angiography and Venography S 31.1279

0280 Level III Angiography and Venography S 50.9080

0282 Miscellaneous Computed Axial Tomography S 1.3864

0283 Computed Tomography with Contrast S 4.1669

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast S 6.3741

0288 Bone Density:Axial Skeleton S 1.0359

0293 Level VI Anterior Segment Eye Procedures T 123.3630

0299 Hyperthermia and Radiation Treatment Procedures S 5.5027

0300 Level I Radiation Therapy S 1.3392

0301 Level II Radiation Therapy S 2.5173

0303 Treatment Device Construction X 2.8292

0304 Level I Therapeutic Radiation Treatment Preparation X 1.5387

0305 Level II Therapeutic Radiation Treatment Preparation X 4.0804

0308 Positron Emission Tomography (PET) imaging S 14.8096

0310 Level III Therapeutic Radiation Treatment Preparation X 13.8052

0312 Radioelement Applications S 5.7609

0313 Brachytherapy S 9.6431

0315 Level II Implantation of Neurostimulator Generator S 288.8990

0317 Level II Miscellaneous Radiology Procedures X 4.5159

0318 Implantation of Neurostimulator Pulse Generator and Electrode S 359.7987

0319 Level III Endovascular Revascularization of the Lower Extremity T 204.6785

0320 Electroconvulsive Therapy S 6.1511

0322 Brief Individual Psychotherapy S 1.1619

0323 Extended Individual Psychotherapy S 1.5448

0324 Family Psychotherapy S 1.7979

0325 Group Psychotherapy S 0.8506

0330 Dental Procedures S 7.5832

0331 Combined Abdomen and Pelvis CT without Contrast S 4.2917

0332 Computed Tomography without Contrast S 2.4340

0333 Computed Tomography without Contrast followed by Contrast S 4.6182

0334 Combined Abdomen and Pelvis CT with Contrast S 6.7671

0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast S 4.7466

0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast S 7.7051

0340 Minor Ancillary Procedures X 0.6961

0341 Skin Tests X 0.0957

0342 Level I Pathology X 0.1782

0343 Level III Pathology X 0.5342

0344 Level IV Pathology X 0.8477

0345 Level I Transfusion Laboratory Procedures X 0.2519

0346 Level II Transfusion Laboratory Procedures X 0.3504

0347 Level III Transfusion Laboratory Procedures X 0.4810

0350 Administration of flu and PPV vaccine S 0.3788

0360 Level I Alimentary Tests X 1.9249

0361 Level II Alimentary Tests X 4.2433

0363 Level I Otorhinolaryngologic Function Tests X 0.9156

0364 Level I Audiometry X 0.5032

0365 Level II Audiometry X 1.2424

0366 Level III Audiometry X 1.6401
0367 Level I Pulmonary Test X 0.6318

0368 Level II Pulmonary Tests X 0.8816

0369 Level III Pulmonary Tests X 2.5221

0370 Multiple Allergy Tests X 1.3347

0373 Level I Neuropsychological Testing X 1.2128

0375 Ancillary Outpatient Services When Patient Expires S 92.7277

0377 Level II Cardiac Imaging S 9.5309

0378 Level II Pulmonary Imaging S 4.7173

0381 Single Allergy Tests X 0.3478

0382 Level II Neuropsychological Testing X 2.4863

0383 Cardiac Computed Tomographic Imaging S 3.7468

0384 GI Procedures with Stents T 29.6863

0385 Level I Prosthetic Urological Procedures S 107.0677

0386 Level II Prosthetic Urological Procedures S 175.4934

0387 Level II Hysteroscopy T 37.5259

0388 Discography S 24.2728

0389 Level I Non-imaging Nuclear Medicine S 1.5990

0390 Level I Endocrine Imaging S 2.1040

0391 Level II Endocrine Imaging S 3.2664

0392 Level II Non-imaging Nuclear Medicine S 2.7567

0393 Hematologic Processing & Studies S 6.1109

0394 Hepatobiliary Imaging S 4.4086

0395 GI Tract Imaging S 3.6004

0396 Bone Imaging S 3.6694

0397 Vascular Imaging S 4.6411

0398 Level I Cardiac Imaging S 4.3329

0400 Hematopoietic Imaging S 3.9257

0401 Level I Pulmonary Imaging S 3.0984

0402 Level II Nervous System Imaging S 6.4272

0403 Level I Nervous System Imaging S 3.7033

0404 Renal and Genitourinary Studies S 4.6683

0406 Level I Tumor/Infection Imaging S 4.2080

0407 Level I Radionuclide Therapy S 3.3193

0408 Level III Tumor/Infection Imaging S 13.4001

0409 Red Blood Cell Tests X 0.1356

0412 Level III Radiation Therapy S 6.7828

0413 Level II Radionuclide Therapy S 4.2209

0414 Level II Tumor/Infection Imaging S 7.0469

0415 Level II Endoscopy Lower Airway T 22.0465

0419 Level II Upper GI Procedures T 12.9960

0422 Level III Upper GI Procedures T 26.1852

0423 Level II Percutaneous Abdominal and Biliary Procedures T 56.7444

0424 Level II Small Intestine Endoscopy T 15.5387

0425 Level II Arthroplasty or Implantation with Prosthesis T 134.6442

0426 Level II Strapping and Cast Application S 2.6522

0427 Level II Tube or Catheter Changes or Repositioning T 16.8497

0428 Level III Sigmoidoscopy and Anoscopy T 21.4711

0429 Level V Cystourethroscopy and other Genitourinary Procedures T 45.7285

0432 Level II Health and Behavior Services S 0.6290

0433 Level II Pathology X 0.3285

0434 Cardiac Defect Repair T 167.9170

0436 Level I Drug Administration S 0.3788
0437 Level II Drug Administration S 0.5487

0438 Level III Drug Administration S 1.0473

0439 Level IV Drug Administration S 2.0507

0440 Level V Drug Administration S 3.2322

0442 Dosimetric Drug Administration S 27.5195

0604 Level 1 Hospital Clinic Visits V 0.7960

0605 Level 2 Hospital Clinic Visits V 1.0332

0606 Level 3 Hospital Clinic Visits V 1.3596

0607 Level 4 Hospital Clinic Visits V 1.8017

0608 Level 5 Hospital Clinic Visits V 2.4650

0609 Level 1 Type A Emergency Visits V 0.7266

0613 Level 2 Type A Emergency Visits V 1.2923

0614 Level 3 Type A Emergency Visits V 2.0103

0615 Level 4 Type A Emergency Visits V 3.2164

0616 Level 5 Type A Emergency Visits V 4.8338

0617 Critical Care S 7.5142

0618 Trauma Response with Critical Care S 12.8233

0621 Level I Vascular Access Procedures T 11.0230

0622 Level II Vascular Access Procedures T 24.5972

0623 Level III Vascular Access Procedures T 31.2425

0624 Phlebotomy and Minor Vascular Access Device Procedures X 0.6889

0626 Level 1 Type B Emergency Visits V 0.9504

0627 Level 2 Type B Emergency Visits V 0.7589

0628 Level 3 Type B Emergency Visits V 1.2605

0629 Level 4 Type B Emergency Visits V 1.9113

0630 Level 5 Type B Emergency Visits V 2.9070

0648 Level IV Breast Surgery T 63.9715

0651 Complex Interstitial Radiation Source Application S 12.2772

0652 Insertion of Intraperitoneal and Pleural Catheters T 31.6784

0653 Vascular Reconstruction/Fistula Repair with Device T 37.4589

0654 Level II Insertion/Replacement of Permanent Pacemaker T 108.1809

0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode T 142.8432

0656 Transcatheter Placement of Intracoronary Drug-Eluting Stents T 108.8606

0659 Hyperbaric Oxygen S 1.5109

0660 Level II Otorhinolaryngologic Function Tests X 1.8519

0661 Level V Pathology X 2.2023

0662 CT Angiography S 4.7570

0664 Level I Proton Beam Radiation Therapy S 15.9383

0665 Bone Density:AppendicularSkeleton S 0.4941

0667 Level II Proton Beam Radiation Therapy S 9.5685

0668 Level I Angiography and Venography T 10.0404

0672 Level III Posterior Segment Eye Procedures T 40.8587

0673 Level V Anterior Segment Eye Procedures T 41.7586

0674 Prostate Cryoablation T 109.7287

0676 Thrombolysis and Other Device Revisions T 2.4212

0678 External Counterpulsation T 1.3951

0679 Level II Resuscitation and Cardioversion S 5.6047

0680 Insertion of Patient Activated Event Recorders S 82.6392

0683 Level II Photochemotherapy S 2.4161

0685 Level III Needle Biopsy/Aspiration Except Bone Marrow T 10.0060

0687 Revision/Removal of Neurostimulator Electrodes T 21.1894

0688 Revision/Removal of Neurostimulator Pulse Generator Receiver T 36.4346
0690 Level I Electronic Analysis of Devices

S 0.4761

0691 Level III Electronic Analysis of Devices

S 2.6879

0692 Level II Electronic Analysis of Devices

S 1.5631

0694 Mohs Surgery

T 5.1585

0697 Level I Echocardiogram Without Contrast 

S 2.9820

0698 Level II Eye Tests & Treatments

S 1.0386

0699 Level IV Eye Tests & Treatments

T 15.8683

0701 Sr89 strontium

K

0726 Dexrazoxane HCl injection

K

0728 Filgrastim 300 mcg injection

K

0731 Sargramostim injection

K

0735 Ampho b cholesteryl sulfate

K

0736 Amphotericin b liposome inj

K

0738 Rasburicase

K

0747 Chlorothiazide sodium inj

K

0751 Mechlorethamine hcl inj

K

0752 Dactinomycin injection

K

0759 Naltrexone, depot form

K

0800 Leuprolide acetate

K

0802 Etoposide oral

K

0807 Aldesleukin injection

K

0809 Bcg live intravesical vac

K

0810 Goserelin acetate implant

K

0812 Carmustine injection

K

0814 Asparaginase, NOS

K

0820 Daunorubicin injection

K

0821 Daunorubicin citrate inj

K

0823 Docetaxel injection

K

0825 Nelarabine injection

K

0827 Floxuridine injection

K

0828 Gemcitabine hcl injection

K

0831 Ifosfamide injection

K

0832 Idarubicin hcl injection

K

0835 Cosyntropin injection NOS

K

0836 Interferon alfa-2b inj

K

0838 Interferon gamma 1-b inj

K

0840 Inj melphalan hydrochl

K

0842 Fludarabine phosphate inj

K

0843 Pegaspargase injection

K

0844 Pentostatin injection

K

0849 Rituximab injection

K

0850 Streptozocin injection

K

0851 Thiotepa injection

K

0856 Porfimer sodium injection

K

0858 Inj cladribine

K

0861 Leuprolide acetate injeciton

K

0864 Mitoxantrone hydrochl

K

0868 Oral aprepitant

K

0873 Hyalgan/supartz inj per dose

K

0874 Synvisc or synvisc-one

K

0875 Euflexxa inj per dose

K

0877 Orthovisc inj per dose

K
0884 Rho d immune globulin inj

K

0887 Azathioprine parenteral

K

0890 Lymphocyte immune globulin

K

0900 Alglucerase injection

K

0901 Alpha 1 proteinase inhibitor

K

0902 Injection,onabotulinumtoxinA

K

0903 Cytomegalovirus imm IV /vial

K

0910 Interferon beta-1b / .25 MG

K

0913 Ganciclovir long act implant

K

0917 Adenosine injection

K

0925 Factor viii

K

0927 Factor viii recombinant

K

0928 Factor ix complex

K

0929 Anti-inhibitor

K

0931 Factor IX non-recombinant

K

0932 Factor IX recombinant

K

0933 Gamma globulin > 10 CC inj

K

0934 Capecitabine, oral

K

0943 Octagam injection

K

0944 Gammagard liquid injection

K

0945 Rhophylac injection

K

0946 Hepagam b im injection

K

0947 Flebogamma injection

G

0948 Gamunex-C/Gammaked

K

0949 Frozen plasma, pooled, sd

R 1.0129

0950 Whole blood for transfusion

R 2.3815

0951 Reclast injection

K

0952 Cryoprecipitate each unit

R 1.1028

0954 RBC leukocytes reduced

R 2.7097

0955 Plasma, frz between 8-24hour

R 1.0591

0956 Plasma protein fract,5%,50ml

R 0.2848

0957 Platelets, each unit

R 1.2846

0958 Plaelet rich plasma unit

R 2.4626

0959 Red blood cells unit

R 2.1285

0960 Washed red blood cells unit

R 4.1562

0961 Albumin (human),5%, 50ml

K

0963 Albumin (human), 5%, 250 ml

K

0964 Albumin (human), 25%, 20 ml

K

0965 Albumin (human), 25%, 50ml

K

0966 Plasmaprotein fract,5%,250ml

R 0.6613

0967 Blood split unit

R 1.9121

0968 Platelets leukoreduced irrad

R 2.1939

0969 RBC leukoreduced irradiated

R 3.8309

1009 Cryoprecipitatereducedplasma

R 0.9531

1010 Blood, l/r, cmv-neg

R 2.5982

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

R 10.8739

1013 Platelets leukocytes reduced

R 1.6595

1015 Injection glatiramer acetate

K

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

R 1.7169

1017 Plt, aph/pher, l/r, cmv-neg

R 4.7192

1018 Blood, l/r, irradiated

R 2.4667

1019 Plate pheres leukoredu irrad

R 9.4536
1020 Plt, pher, l/r cmv-neg, irr

R 9.2615

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

R 5.1700

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

R 4.0183

1023 Pralidoxime chloride inj

K

1052 Injection, voriconazole

K

1064 I131 iodide cap, rx

K

1083 Adalimumab injection

K

1084 Denileukin diftitox inj

K

1086 Temozolomide

K

1138 Hepagam b intravenous, inj

K

1139 Protein c concentrate

K

1142 Supprelin LA implant

K

1150 I131 iodide sol, rx

K

1166 Cytarabine liposome inj

K

1167 Inj, epirubicin hcl

K

1168 Inj, temsirolimus

K

1178 Busulfan injection

K

1203 Verteporfin injection

K

1207 Octreotide injection, depot

K

1213 Antihemophilic viii/vwf comp

K

1214 Inj IVIG privigen 500 mg

K

1221 Dimethyl sulfoxide 50%

K

1232 Mitomycin injection

K

1235 Valrubicin injection

K

1236 Levoleucovorin injection

K

1237 Inj iron dextran

K

1238 Topotecan oral

K

1239 Rotavirus vacc 2 dose oral

K

1240 Apligraf skin sub

K

1241 Oasis wound matrix skin sub

K

1242 Oasis burn matrix skin sub

K

1243 Integra BMWD skin sub

K

1244 Integra DRT 

K

1245 Dermagraft skin sub

K

1246 Graftjacket skin sub

K

1247 Integra matrix skin sub

K

1248 Primatrix skin sub

K

1249 Cymetra allograft

K

1250 Graftjacket express allograf

K

1251 Integra flowable wound matri

K

1252 Gammagraft skin sub

K

1253 Triamcinolone A inj PRS-free

K

1263 Antithrombin iii injection

K

1268 Xyntha inj

K

1270 Alloderm skin sub

K

1272 Acetylcysteine injection

K

1274 Edetate calcium disodium inj

K

1275 Vivaglobin, inj

K

1280 Corticotropin injection

K

1281 Bevacizumab injection

K

1287 Alloskin skin sub

K

1289 AbobotulinumtoxinA

K
1291 Rilonacept injection

K

1295 Sm 153 lexidronam

K

1296 Degarelix injection

K

1297 Ferumoxytol, non-esrd

K

1307 Oral busulfan

K

1311 Canakinumab injection

G

1312 Hizentra injection

K

1327 Imiglucerase injection

K

1331 Olanzapine long-acting inj

K

1332 Antithrombin recombinant

K

1338 Methyl aminolevulinate, top

K

1339 Oral fludarabine phosphate

K

1340 Collagenase, clost hist inj

K

1341 Amobarbital 125 MG inj

K

1342 Matristem micromatrix

K

1343 Ganciclovir sodium injection

K

1344 Gonadorelin hydroch/ 100 mcg

K

1345 Theraskin

K

1347 Oxacillin sodium injeciton

K

1349 Anidulafungin injection

K

1350 Topotecan injection

K

1351 Matristem wound matrix

K

1352 Wilate injection

K

1353 Belimumab injection

G

1354 Hydroxyprogesterone caproate

K

1355 Itraconazole injection

K

1357 Inj protirelin per 250 mcg

K

1361 Enfuvirtide injection

K

1408 Cyclophosphamide 100 MG inj

K

1413 Lumizyme injection

K

1414 Human fibrinogen conc inj

K

1415 Glassia injection

K

1416 Factor XIII anti-hem factor

G

1417 Gel-one

K

1419 Dermacell

K

1420 Aflibercept injection

G

1421 Imported lipodox inj

K

1422 Anthrax vaccine sc or im

K

1423 Minocycline hydrochloride

K

1424 Nabilone oral

K

1426 Eribulin mesylate injection

G

1427 Alloskin

K

1428 Arthroflex

K

1429 Flexhd/Allopatchhd/matrixhd

K

1430 Unite biomatrix

K

1431 Centruroides immune f(ab)

G

1432 Arbutamine hcl injection

K

1433 Calcitonin salmon injection

K

1434 Testosterone enanthate inj

K

1435 Injection estrone per 1 MG

K

1437 Gatifloxacin injection

K

1438 Diazoxide injection

K
1439 Aprotonin, 10,000 kiu

K

1440 Inj desmopressin acetate

K

1441 Intraocular Fomivirsen na

K

1442 Non-HEU TC-99M add-on/dose

K

1443 Icatibant injection

K

1444 Oral everolimus

K

1445 Methylnaltrexone injection

K

1446 Visualization adjunct

K

1447 Interferon alfacon-1 inj

K

1491 New Technology - Level IA ($0-$10)

S

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

S

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

S

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

S

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

S

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

T

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

T

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

T

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

T

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

T

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

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

S

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

S

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

S

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

T

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

T

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

T

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

T

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

T

1544 New Technology - Level VII ($500 - $600)

T

1545 New Technology - Level VIII ($600 - $700)

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

1605 Abciximab injection

K

1607 Eptifibatide injection

K

1608 Etanercept injection

K

1609 Rho(D) immune globulin h, sd

K

1612 Daclizumab, parenteral

K

1613 Trastuzumab injection

K

1630 Hep b ig, im

K

1631 Baclofen intrathecal trial

K

1633 Alefacept

K

1643 Y90 ibritumomab, rx

K

1645 I131 tositumomab, rx

K

1670 Tetanus immune globulin inj

K

1675 P32 Na phosphate

K
1676 P32 chromic phosphate

K

1683 Basiliximab

K

1684 Corticorelin ovine triflutal

K

1685 Darbepoetin alfa, non-esrd

K

1686 Epoetin alfa, non-esrd

K

1687 Digoxin immune fab (ovine)

K

1688 Ethanolamine oleate

K

1689 Fomepizole

K

1690 Hemin

K

1693 Lepirudin

K

1694 Ziconotide injection

K

1695 Nesiritide injection

K

1696 Palifermin injection

K

1697 Pegaptanib sodium injection

K

1700 Inj secretin synthetic human

K

1701 Treprostinil injection

K

1704 Humate-P, inj

K

1705 Factor viia

K

1709 Azacitidine injection

K

1710 Clofarabine injection

K

1711 Vantas implant

K

1712 Paclitaxel protein bound

K

1716 Brachytx, non-str, Gold-198

U 1.5340

1717 Brachytx, non-str, HDR Ir-192

U 3.4927

1719 Brachytx, NS, Non-HDRIr-192

U 0.5205

1738 Oxaliplatin

K

1739 Pegademase bovine, 25 iu

K

1741 Urofollitropin, 75 iu

K

1830 Power bone marrow bx needle

H

1840 Telescopic intraocular lens

H

1886 Catheter, ablation

H

2210 Methyldopate hcl injection

K

2616 Brachytx, non-str,Yttrium-90

U 219.7241

2632 Iodine I-125 sodium iodide

U 0.2949

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

U 0.9229

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

U 0.4285

2636 Brachy linear, non-str,P-103

U 0.4994

2638 Brachytx, stranded, I-125

U 0.6548

2639 Brachytx, non-stranded,I-125

U 0.5005

2640 Brachytx, stranded, P-103

U 1.0578

2641 Brachytx, non-stranded,P-103

U 0.8481

2642 Brachytx, stranded, C-131

U 1.5461

2643 Brachytx, non-stranded,C-131

U 0.9259

2698 Brachytx, stranded, NOS

U 0.6548

2699 Brachytx, non-stranded, NOS

U 0.4285

2731 Immune globulin, powder

K

2770 Quinupristin/dalfopristin

K

3041 Bivalirudin

K

3043 Gamma globulin 1 CC inj

K

3050 Sermorelin acetate injection

K

7000 Amifostine

K

7011 Oprelvekin injection

K
7034 Somatropin injection K

7035 Teniposide K

7036 Urokinase 250,000 IU inj K

7038 Monoclonal antibodies K

7041 Tirofiban HCl K

7042 Capecitabine, oral K

7043 Infliximab injection K

7046 Doxil injection K

7048 Alteplase recombinant K

7049 Filgrastim 480 mcg injection K

7051 Leuprolide acetate implant K

7308 Aminolevulinic acid hcl top K

8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T 156.2930

8001 LDR Prostate Brachytherapy Composite T 45.6392

8002 Level I Extended Assessment & Management Composite V 6.1710

8003 Level II Extended Assessment & Management Composite V 11.1967

8004 Ultrasound Composite S 2.7570

8005 CT and CTA without Contrast Composite S 5.6130

8006 CT and CTA with Contrast Composite S 9.5649

8007 MRI and MRA without Contrast Composite S 9.9120

8008 MRI and MRA with Contrast Composite S 14.5688

9001 Linezolid injection K

9002 Tenecteplase injection K

9003 Palivizumab K

9004 Gemtuzumab ozogamicin inj K

9005 Reteplase injection K

9006 Tacrolimus injection K

9012 Arsenic trioxide injection K

9018 Inj, rimabotulinumtoxinB K

9019 Caspofungin acetate K

9022 IM inj interferon beta 1-a K

9023 Rho d immune globulin K

9024 Amphotericin b lipid complex K

9032 Baclofen 10 MG injection K

9033 Cidofovir injection K

9038 Inj estrogen conjugate K

9042 Glucagon hydrochloride K

9044 Ibutilide fumarate injection K

9104 Antithymocyte globuln rabbit K

9108 Thyrotropin injection K

9110 Alemtuzumab injection K

9115 Zoledronic acid K

9119 Injection, pegfilgrastim 6mg K

9120 Injection, Fulvestrant K

9121 Injection, argatroban K

9122 Triptorelin pamoate K

9124 Daptomycin injection K

9125 Risperidone, long acting K

9126 Natalizumab injection K

9133 Rabies ig, im/sc K

9134 Rabies ig, heat treated K

9135 Varicella-zoster ig, im K
9137 Bcg vaccine, percut

K

9139 Rabies vaccine, im

K

9140 Rabies vaccine, id

K

9143 Meningococcal vaccine, sc

K

9144 Encephalitis vaccine, sc

K

9145 Meningococcal vaccine, im

K

9207 Bortezomib injection

K

9208 Agalsidase beta injection

K

9209 Laronidase injection

K

9210 Palonosetron hcl

K

9213 Pemetrexed injection

K

9214 Bevacizumab injection

K

9215 Cetuximab injection

K

9217 Leuprolide acetate suspnsion

K

9224 Galsulfase injection

K

9225 Fluocinolone acetonide implt

K

9227 Micafungin sodium injection

K

9228 Tigecycline injection

K

9229 Ibandronate sodium injection

K

9230 Abatacept injection

K

9231 Decitabine injection

K

9232 Idursulfase injection

K

9233 Ranibizumab injection

K

9234 Alglucosidase alfa injection

K

9235 Panitumumab injection

K

9236 Eculizumab injection

K

9237 Inj, lanreotide acetate

K

9240 Injection, ixabepilone

K

9242 Injection, fosaprepitant

K

9243 Bendamustine injection

K

9244 Regadenoson injection

K

9245 Romiplostim injection

K

9248 Inj, clevidipine butyrate

K

9249 Certolizumab pegol inj

K

9250 Artiss fibrin sealant

K

9251 C1 esterase inhibitor inj

K

9252 Plerixafor injection

K

9253 Temozolomide injection

K

9255 Paliperidone palmitate inj

K

9256 Dexamethasone intra implant

K

9258 Telavancin injection

K

9259 Pralatrexate injection

K

9260 Ofatumumab injection

K

9261 Ustekinumab injection

K

9263 Ecallantide injection

K

9264 Tocilizumab injection

K

9265 Romidepsin injection

K

9268 Capsaicin 8% patch

K

9269 C-1 esterase, berinert

K

9270 Gammaplex IVIG

K

9271 Velaglucerase alfa

K

9272 Inj, denosumab

K
9273 Sipuleucel-T auto CD54+

K

9274 Crotalidae Poly Immune Fab

K

9276 Cabazitaxel injection

K

9278 Incobotulinumtoxin A

K

9281 Injection, pegloticase

G

9282 Inj, ceftaroline fosamil

G

9283 Injection, acetaminophen

G

9284 Ipilimumab injection

G

9285 Patch, lidocaine/tetracaine

G

9286 Belatacept injection

G

9287 Brentuximab vedotin inj

G

9289 Erwinaze injection

G

9290 Inj, bupivacaine liposome

G

9292 Injection, pertuzumab

G

9293 Injection, glucarpidase 

G

9294 Inj, taliglucerase alfa

G

9295 Injection, carfilzomib

G

9296 Injection, ziv-aflibercept

G

9300 Omalizumab injection

K

9358 SurgiMend, fetal

K

9360 SurgiMend, neonatal

K

9363 Integra Meshed Bil Wound Mat

K

9365 Oasis tri-layer wound matrix

G

9366 Epifix

G

9367 Endoform Dermal Template

K

9368 Grafix core

G

9369 Grafix prime

G

9406 Iodine I-123 ioflupane

G

9500 Platelets, irradiated

R 1.8822

9501 Platelet pheres leukoreduced

R 7.1694

9502 Platelet pheresis irradiated

R 9.4761

9503 Fr frz plasma donor retested

R 0.7967

9504 RBC deglycerolized

R 6.7273

9505 RBC irradiated

R 2.8319

9506 Granulocytes, pheresis unit

R 22.6900

9507 Platelets, pheresis

R 6.0577

9508 Plasma 1 donor frz w/in 8 hr

R 1.1037
Payment Rate 

National 

Unadjusted 

Copayment 

Minimum 

Unadjusted 

Copayment 

$37.15 . $7.43

$122.62 . $24.53

$270.40 . $54.08

$345.52 . $69.11

$625.24 . $125.05

$125.45 . $25.09

$725.58 . $145.12

$1,319.12 . $263.83

$28.40 . $5.68

$71.54 . $14.31

$106.96 . $21.40

$209.65 . $41.93

$1,417.80 . $283.56

$336.38 . $67.28

$583.61 . $116.73

$1,121.75 . $224.35

$1,661.08 $350.78 $332.22

$1,862.77 . $372.56

$2,458.99 $581.52 $491.80

$3,235.96 $747.07 $647.20

$22.36 . $4.48

$228.26 . $45.66

$23.43 . $4.69

$1,118.54 $227.35 $223.71

$16,394.73 . $3,278.95

$4,399.77 . $879.96

$2,111.62 . $422.33

$3,880.22 $782.23 $776.05

$1,039.07 $257.70 $207.82

$2,868.01 . $573.61

$4,450.11 . $890.03

$1,555.31 . $311.07

$2,306.77 . $461.36

$3,437.59 . $687.52

$5,862.48 . $1,172.50

$1,185.44 $249.64 $237.09

$2,066.12 . $413.23

$1,583.94 $353.37 $316.79

$4,327.81 . $865.57

$2,455.43 . $491.09

$94.54 . $18.91

$53.93 . $10.79

$19.53 . $3.91

$6,792.04 . $1,358.41

$1,908.84 . $381.77

$3,763.94 . $752.79

$5,040.30 . $1,008.06
$978.25

. $195.65

$2,354.79. $470.96

$3,300.64. $660.13

$2,564.75 $591.64 $512.95

$412.39. $82.48

$77.30. $15.46

$142.88. $28.58

$337.25 $67.83 $67.45

$1,352.05. $270.41

$2,026.82. $405.37

$763.88 $189.82 $152.78

$35.09 $7.74 $7.02

$100.94. $20.19

$247.41. $49.49

$2,649.52 $815.13 $529.91

$7,671.18. $1,534.24

$4,023.05. $804.61

$705.36. $141.08

$3,922.31. $784.47

$3,100.23 $655.22 $620.05

$8,230.14. $1,646.03

$6,612.36 $1,593.50 $1,322.48

$3,024.65. $604.93

$1,958.67. $391.74

$2,149.26. $429.86

$160.83 $43.80 $32.17

$79.91. $15.99

$108.61 $36.86 $21.73

$66.52. $13.31

$26.67. $5.34

$176.82 $41.07 $35.37

$303.52 $100.24 $60.71

$39.31. $7.87

$1,156.50. $231.30

$6,110.44. $1,222.09

$1,683.13. $336.63

$3,766.05. $753.21

$22,512.04. $4,502.41

$30,680.01. $6,136.01

$260.44. $52.09

$950.65. $190.13

$2,888.70. $577.74

$1,820.00. $364.00

$3,671.15. $734.23

$2,679.73. $535.95

$439.63. $87.93

$81.99. $16.40

$7,910.51. $1,582.11

$133.65. $26.73

$2,730.07 $659.53 $546.02

$3,487.15 $1,001.89 $697.43

$5,121.39 $1,236.99 $1,024.28
$85.75 $23.38 $17.15

$251.48. $50.30

$393.38. $78.68

$1,111.61. $222.33

$1,510.07. $302.02

$398.86. $79.78

$835.41. $167.09

$483.05. $96.61

$623.45 $138.69 $124.69

$750.68 $152.78 $150.14

$691.32 $186.06 $138.27

$420.32. $84.07

$715.56. $143.12

$439.35. $87.87

$1,829.43. $365.89

$2,365.97. $473.20

$1,727.30. $345.46

$2,027.76. $405.56

$1,852.58. $370.52

$2,429.11. $485.83

$1,278.85. $255.77

$232.32. $46.47

$184.21. $36.85

$611.77 $0.00 $0.00

$415.08 $0.00 $0.00

$509.76. $101.96

$1,131.27. $226.26

$1,908.86. $381.78

$2,737.09. $547.42

$152.75. $30.55

$1,409.54. $281.91

$1,540.12. $308.03

$2,373.22. $474.65

$2,838.29 $979.42 $567.66

$496.32. $99.27

$84.96. $17.00

$109.67. $21.94

$9,080.63 $2,020.00 $1,816.13

$180.71. $36.15

$228.26. $45.66

$433.93 $129.40 $86.79

$578.36 $172.48 $115.68

$2,775.49 $607.88 $555.10

$1,696.84. $339.37

$967.22. $193.45

$118.56. $23.72

$234.09. $46.82

$1,682.06 $424.28 $336.42

$8.25 $1.73 $1.65

$498.11. $99.63

$1,454.55. $290.91

$2,639.44. $527.89
$3,405.53 $981.50 $681.11

$856.68. $171.34

$182.61. $36.53

$291.74. $58.35

$565.75. $113.15

$3,758.59. $751.72

$806.13 $268.73 $161.23

$172.61 $53.58 $34.53

$43.11. $8.63

$184.02. $36.81

$79.83. $15.97

$1,344.72. $268.95

$2,481.58. $496.32

$3,251.09. $650.22

$14,111.24. $2,822.25

$8,656.82. $1,731.37

$48.41. $9.69

$144.89. $28.98

$144.79 $30.45 $28.96

$1,129.46. $225.90

$1,676.62 $347.84 $335.33

$416.39. $83.28

$1,442.12. $288.43

$231.76. $46.36

$615.69. $123.14

$1,367.92 $294.00 $273.59

$1,904.06 $382.94 $380.82

$2,832.72 $597.36 $566.55

$1,797.67 $412.25 $359.54

$2,967.38 $794.86 $593.48

$1,730.47 $490.32 $346.10

$410.79 $102.26 $82.16

$2,095.45 $499.26 $419.09

$78.09 $24.11 $15.62

$229.81. $45.97

$498.57 $99.78 $99.72

$1,147.39. $229.48

$1,799.78. $359.96

$662.84. $132.57

$3,278.89. $655.78

$30,326.87 $7,921.74 $6,065.38

$45.95. $9.19

$70.84. $14.17

$35.88. $7.18

$255.46. $51.10

$64.57 $22.26 $12.92

$99.32 $37.23 $19.87

$154.74 $59.55 $30.95

$390.49. $78.10

$558.66 $128.73 $111.74

$114.26 $30.47 $22.86

$507.60. $101.52
$298.67 $68.90 $59.74

$82.72 $32.84 $16.55

$122.82 $46.51 $24.57

$209.55 $58.44 $41.91

$2,219.82. $443.97

$3,630.40. $726.08

$98.87 $32.94 $19.78

$297.15 $95.46 $59.43

$454.56 $146.59 $90.92

$73.87 $0.00 $0.00

$8,797.39. $1,759.48

$392.41. $78.49

$95.50. $19.10

$179.52. $35.91

$201.76 $66.95 $40.36

$109.73 $34.63 $21.95

$290.99 $88.78 $58.20

$1,056.12. $211.23

$984.49 $325.27 $196.90

$410.83. $82.17

$687.68 $259.86 $137.54

$20,602.25. $4,120.45

$322.04. $64.41

$25,658.32 $9,121.76 $5,131.67

$14,596.24 $5,559.48 $2,919.25

$438.65. $87.73

$82.86. $16.58

$110.16. $22.04

$128.21. $25.65

$60.66. $12.14

$540.78. $108.16

$306.05 $118.33 $61.21

$173.58 $67.11 $34.72

$329.34 $114.38 $65.87

$482.58 $155.52 $96.52

$338.49 $133.38 $67.70

$549.47 $197.64 $109.90

$49.64. $9.93

$6.82 $2.09 $1.37

$12.71. $2.55

$38.10 $10.84 $7.62

$60.45 $15.56 $12.09

$17.96. $3.60

$24.99. $5.00

$34.30. $6.86

$27.01 $0.00 $0.00

$137.27 $33.59 $27.46

$302.60 $83.23 $60.52

$65.29 $16.12 $13.06

$35.88. $7.18

$88.60 $18.04 $17.72

$116.96 $23.43 $23.40
$45.06 $11.97 $9.02

$62.87 $20.93 $12.58

$179.86 $36.55 $35.98

$95.18. $19.04

$86.49. $17.30

$6,612.69. $1,322.54

$679.68. $135.94

$336.40 $126.64 $67.28

$24.80. $4.96

$177.31. $35.47

$267.20. $53.44

$2,117.02. $423.41

$7,635.32. $1,527.07

$12,514.96. $2,503.00

$2,676.08 $654.35 $535.22

$1,730.97. $346.20

$114.03 $26.88 $22.81

$150.04 $47.69 $30.01

$232.94 $65.46 $46.59

$196.59. $39.32

$435.79. $87.16

$314.39 $90.78 $62.88

$256.76 $87.01 $51.36

$261.68 $94.20 $52.34

$330.97. $66.20

$308.99 $93.33 $61.80

$279.95 $90.90 $55.99

$220.96 $71.16 $44.20

$458.34. $91.67

$264.09 $72.42 $52.82

$332.91 $81.55 $66.59

$300.09 $85.06 $60.02

$236.71 $78.13 $47.35

$955.60. $191.12

$9.67 $2.17 $1.94

$483.70. $96.74

$301.01. $60.21

$502.54. $100.51

$1,572.20 $357.09 $314.44

$926.78 $207.70 $185.36

$1,867.35. $373.47

$4,046.61. $809.33

$1,108.11 $240.83 $221.63

$9,601.88. $1,920.38

$189.14. $37.83

$1,201.60. $240.32

$1,531.17. $306.24

$3,261.04. $652.21

$44.86. $8.98

$23.43 $5.17 $4.69

$11,974.67. $2,394.94

$27.01. $5.41
$39.13

. $7.83

$74.69. $14.94

$146.24. $29.25

$230.50. $46.10

$1,962.50. $392.50

$56.77. $11.36

$73.68. $14.74

$96.96. $19.40

$128.48. $25.70

$175.79. $35.16

$51.82 $12.04 $10.37

$92.16 $20.80 $18.44

$143.36 $33.60 $28.68

$229.37 $47.70 $45.88

$344.71 $71.54 $68.95

$535.86. $107.18

$914.47. $182.90

$786.08. $157.22

$1,754.10. $350.82

$2,228.00. $445.60

$49.13 $12.39 $9.83

$67.78. $13.56

$54.12. $10.83

$89.89. $17.98

$136.30. $27.26

$207.31. $41.47

$4,562.00. $912.40

$875.52. $175.11

$2,259.08. $451.82

$2,671.31. $534.27

$7,714.70. $1,542.94

$10,186.58. $2,037.32

$7,763.18. $1,552.64

$107.75. $21.55

$132.06 $27.10 $26.42

$157.05. $31.41

$339.24 $114.37 $67.85

$1,136.61. $227.33

$35.24 $0.00 $0.00

$682.36. $136.48

$716.01. $143.21

$2,913.76. $582.76

$2,977.93 $635.64 $595.59

$7,825.08. $1,565.02

$172.66. $34.54

$99.49. $19.90

$399.69 $95.30 $79.94

$5,893.25. $1,178.65

$172.30. $34.46

$713.56. $142.72

$1,511.08 $389.48 $302.22

$2,598.26 $768.94 $519.66
$33.95

. $6.79

$191.68. $38.34

$111.47. $22.30

$367.87 $88.07 $73.58

$212.66. $42.54

$74.07. $14.82

$1,131.62. $226.33

$1,071.86. $214.38

$159.00. $31.80

$268.91. $53.79

$31.59. $6.32

$14.84. $2.97

$14.83. $2.97

$204.73. $40.95

$259.14. $51.83

$157.86. $31.58

$578.93. $115.79

$2.85. $0.57

$663.95. $132.79

$52.17. $10.44

$1,246.98. $249.40

$116.81. $23.37

$166.01. $33.21

$175.76. $35.16

$63.21. $12.65

$19.19. $3.84

$243.80. $48.76

$6.69. $1.34

$122.65. $24.53

$52.39. $10.48

$12.25. $2.45

$30.49. $6.10

$100.00. $20.00

$101.68. $20.34

$19.06. $3.82

$2,517.90. $503.58

$1,312.54. $262.51

$84.88. $16.98

$5,890.00. $1,178.00

$946.92. $189.39

$659.72. $131.95

$274.16. $54.84

$175.30. $35.06

$19,325.78. $3,865.16

$28.24. $5.65

$5.98. $1.20

$36.22. $7.25

$6.29. $1.26

$92.25. $18.45

$12.22. $2.45

$151.09. $30.22

$169.91. $33.99
$83.77

. $16.76

$144.62. $28.93

$646.10. $129.22

$41.99. $8.40

$3.97. $0.80

$5.47. $1.10

$1,013.87. $202.78

$243.35. $48.67

$16,960.00. $3,392.00

$109.40. $21.88

$0.90. $0.18

$1.11. $0.23

$1.03. $0.21

$1.63. $0.33

$0.94. $0.19

$1.24. $0.25

$233.37. $46.68

$27.55. $5.51

$33.21. $6.65

$37.62. $7.53

$5.19. $1.04

$52.14. $10.43

$34.43. $6.89

$38.28. $7.66

$72.23. $14.45

$169.83. $33.97

$224.75. $44.95

$78.64. $15.73

$193.24. $38.65

$75.53. $15.11

$20.31. $4.07

$91.61. $18.33

$175.62. $35.13

$151.79. $30.36

$296.39. $59.28

$22.63. $4.53

$60.67. $12.14

$30.24. $6.05

$69.20. $13.84

$47.16. $9.44

$136.36. $27.28

$156.45. $31.29

$273.19. $54.64

$67.97. $13.60

$185.29. $37.06

$775.45. $155.09

$118.34. $23.67

$129.42. $25.89

$122.44. $24.49

$336.54. $67.31

$175.91. $35.19

$674.16. $134.84
$660.47

. $132.10

$368.69. $73.74

$286.56. $57.32

$88.60. $17.72

$6.63. $1.33

$40.70. $8.14

$456.38. $91.28

$1,646.18. $329.24

$10.67. $2.14

$52.14. $10.43

$13.59. $2.72

$16,172.58. $3,234.52

$11.23. $2.25

$523.87. $104.78

$1.61. $0.33

$53.51. $10.71

$21.90. $4.38

$10.16. $2.04

$127.00. $25.40

$0.93. $0.19

$35.14. $7.03

$87.15. $17.43

$22.90. $4.58

$1,006.27. $201.26

$1.91. $0.39

$12.00. $2.40

$83.93. $16.79

$108.65. $21.73

$38.06. $7.62

$7.78. $1.56

$7.78. $1.56

$20.97. $4.20

$11.40. $2.28

$42.57. $8.52

$98.39. $19.68

$25.17. $5.04

$37.76. $7.56

$442.20. $88.44

$442.20. $88.44

$1,176.14. $235.23

$6.87. $1.38

$3.57. $0.72

$3.04. $0.61

$1.10. $0.22

$32.21. $6.45

$3.04. $0.61

$201.40. $40.28

$12.72. $2.55

$2,948.92. $589.79

$1.56. $0.32

$10.19. $2.04

$6.95. $1.39
$24.09

. $4.82

$7,919.26. $1,583.86

$2.99. $0.60

$0.64. $0.13

$5.31. $1.07

$89.41. $17.89

$7.29. $1.46

$41.74. $8.35

$2.75. $0.55

$103.35. $20.67

$75.95. $15.19

$81.77. $16.36

$37.51. $7.51

$152.43. $30.49

$2.87. $0.58

$73.04. $14.61

$6.06. $1.22

$22.29. $4.46

$2.38. $0.48

$1.25. $0.25

$3.13. $0.63

$4.40. $0.88

$0.88. $0.18

$38.32. $7.67

$2.70. $0.54

$88.27. $17.66

$29.74. $5.95

$0.53. $0.11

$23.48. $4.70

$153.61. $30.73

$0.91. $0.19

$3.92. $0.79

$6.41. $1.29

$614.91. $122.99

$86.61. $17.33

$980.50. $196.10

$498.27. $99.66

$112.86. $22.58

$0.58. $0.12

$25.78. $5.16

$92.81. $18.57

$13.37. $2.68

$134.24. $26.85

$46.69. $9.34

$31.26. $6.26

$3,635.80. $727.16

$86.37. $17.28

$62.74. $12.55

$33.36. $6.68

$1.54. $0.31

$86.33. $17.27

$88.27. $17.66
$2.65

. $0.53

$6.12. $1.23

$85.00. $17.00

$10.00. $2.00

$235.05. $47.01

$6.18. $1.24

$0.37. $0.08

$1.77. $0.36

$17.06. $3.42

$5.00. $1.00

$15.00. $3.00

$25.00. $5.00

$35.00. $7.00

$45.00. $9.00

$5.00. $1.00

$15.00. $3.00

$25.00. $5.00

$35.00. $7.00

$45.00. $9.00

$75.00. $15.00

$150.00. $30.00

$250.00. $50.00

$350.00. $70.00

$450.00. $90.00

$550.00. $110.00

$650.00. $130.00

$750.00. $150.00

$850.00. $170.00

$950.00. $190.00

$1,050.00. $210.00

$1,150.00. $230.00

$1,250.00. $250.00

$1,350.00. $270.00

$1,450.00. $290.00

$1,550.00. $310.00

$1,650.00. $330.00

$1,750.00. $350.00

$1,850.00. $370.00

$1,950.00. $390.00

$2,250.00. $450.00

$2,750.00. $550.00

$3,250.00. $650.00

$3,750.00. $750.00

$4,250.00. $850.00

$4,750.00. $950.00

$5,250.00. $1,050.00

$5,750.00. $1,150.00

$6,250.00. $1,250.00

$6,750.00. $1,350.00

$7,250.00. $1,450.00

$7,750.00. $1,550.00

$8,250.00. $1,650.00
$8,750.00

. $1,750.00

$9,250.00. $1,850.00

$9,750.00. $1,950.00

$75.00. $15.00

$150.00. $30.00

$250.00. $50.00

$350.00. $70.00

$450.00. $90.00

$550.00. $110.00

$650.00. $130.00

$750.00. $150.00

$850.00. $170.00

$950.00. $190.00

$1,050.00. $210.00

$1,150.00. $230.00

$1,250.00. $250.00

$1,350.00. $270.00

$1,450.00. $290.00

$1,550.00. $310.00

$1,650.00. $330.00

$1,750.00. $350.00

$1,850.00. $370.00

$1,950.00. $390.00

$2,250.00. $450.00

$2,750.00. $550.00

$3,250.00. $650.00

$3,750.00. $750.00

$4,250.00. $850.00

$4,750.00. $950.00

$5,250.00. $1,050.00

$5,750.00. $1,150.00

$6,250.00. $1,250.00

$6,750.00. $1,350.00

$7,250.00. $1,450.00

$7,750.00. $1,550.00

$8,250.00. $1,650.00

$8,750.00. $1,750.00

$9,250.00. $1,850.00

$9,750.00. $1,950.00

$575.03. $115.01

$24.64. $4.93

$231.10. $46.22

$18.43. $3.69

$526.34. $105.27

$76.40. $15.28

$97.15. $19.43

$76.47. $15.30

$41.64. $8.33

$38,058.06. $7,611.62

$30,188.56. $6,037.72

$276.27. $55.26

$170.10. $34.02
$114.95

. $22.99

$2,324.18. $464.84

$5.82. $1.17

$3.32. $0.67

$9.87. $1.98

$899.63. $179.93

$299.94. $59.99

$6.51. $1.31

$13.26. $2.66

$551.76. $110.36

$6.61. $1.33

$51.81. $10.37

$12.12. $2.43

$1,029.95. $205.99

$27.49. $5.50

$61.24. $12.25

$0.90. $0.18

$1.61. $0.33

$5.52. $1.11

$125.76. $25.16

$3,016.50. $603.30

$9.59. $1.92

$109.39. $21.88

$249.07. $49.82

$37.12. $7.43

$9.25. $1.85

$265.48. $53.10

$66.69. $13.34 . . . . . .

$42.40. $8.48

$15,669.18. $3,133.84

$21.03. $4.21

$65.81. $13.17

$30.56. $6.12

$35.61. $7.13

$46.70. $9.34

$35.69. $7.14

$75.43. $15.09

$60.48. $12.10

$110.26. $22.06

$66.03. $13.21

$46.70. $9.34

$30.56. $6.12

$32.21. $6.45

$175.05. $35.01

$2.98. $0.60

$23.34. $4.67

$1.80. $0.36

$310.18. $62.04

$244.00. $48.80
$66.98

. $13.40

$321.83. $64.37

$457.73. $91.55

$1,156.08. $231.22

$8.69. $1.74

$8.28. $1.66

$65.18. $13.04

$532.03. $106.41

$49.22. $9.85

$426.87. $85.38

$4,819.82. $963.97

$161.18. $32.24

$11,145.72 $4,458.28 $2,229.15

$3,254.67. $650.94

$440.07. $88.02

$798.47. $159.70

$196.61. $39.33

$400.28. $80.06

$682.10. $136.42

$706.85. $141.37

$1,038.94. $207.79

$39.32. $7.87

$66.50. $13.30

$1,240.19. $248.04

$2,742.59. $548.52

$2,301.90. $460.38

$139.36. $27.88

$44.99. $9.00

$10.89. $2.18

$12.85. $2.57

$287.09. $57.42

$25.86. $5.18

$10.99. $2.20

$179.99. $36.00

$757.02. $151.41

$125.45. $25.09

$111.23. $22.25

$139.24. $27.85

$465.73. $93.15

$1,053.79. $210.76

$587.78. $117.56

$224.10. $44.82

$2,838.89. $567.78

$87.04. $17.41

$18.30. $3.66

$160.30. $32.06

$0.54. $0.11

$5.45. $1.09

$11.59. $2.32

$207.35. $41.47

$194.67. $38.94

$79.88. $15.98
$116.14

. $23.23

$208.73. $41.75

$155.64. $31.13

$106.49. $21.30

$102.08. $20.42

$94.13. $18.83

$43.47. $8.70

$140.30. $28.06

$26.67. $5.34

$19.02. $3.81

$56.51. $11.31

$62.32. $12.47

$51.09. $10.22

$217.02. $43.41

$354.35. $70.87

$19,345.00. $3,869.00

$0.94. $0.19

$1.46. $0.30

$151.64. $30.33

$22.19. $4.44

$33.40. $6.68

$455.03. $91.01

$398.31. $79.67

$204.42. $40.89

$89.02. $17.81

$195.46. $39.10

$33.82. $6.77

$66.49. $13.30

$1.72. $0.35

$20.61. $4.13

$53.67. $10.74

$48.18. $9.64

$2.96. $0.60

$4.91. $0.99

$66.43. $13.29

$45.70. $9.14

$287.45. $57.49

$4.82. $0.97

$7.02. $1.41

$195.76. $39.16

$2.65. $0.53

$173.94. $34.79

$45.44. $9.09

$130.53. $26.11

$318.22. $63.65

$3.57. $0.72

$233.16. $46.64

$25.55. $5.11

$30.23. $6.05

$37.25. $7.45

$349.31. $69.87

$14.32. $2.87
$32,696.25

. $6,539.25

$2,216.80. $443.36

$136.07. $27.22

$4.46. $0.90

$320.77. $64.16

$0.78. $0.16

$0.11. $0.03

$125.16. $25.04

$13.28 $0.00 $0.00

$3.80. $0.76

$95.40. $19.08

$334.32. $66.87

$1.14 $0.00 $0.00

$102.86. $20.58

$233.73. $46.75

$31.54. $6.31

$29.29. $5.86

$16.96. $3.40

$23.53. $4.71

$12.03. $2.41

$11.80. $2.36

$24.15. $4.83

$10.36. $2.08

$129.38. $25.88

$4.35. $0.87

$137.47. $27.50

$109.40. $21.88

$1,974.93 $0.00 $0.00

$134.23. $26.85

$511.27. $102.26

$675.77. $135.16

$56.82. $11.37

$479.74. $95.95

$201.95. $40.39

$1,618.09. $323.62

$431.99. $86.40

$78.71. $15.75