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 0003Bone Marrow Biopsy/Aspiration T 3.7917 0004Level I Needle Biopsy/ Aspiration Except Bone Marrow T 4.8451 0005 Level II Needle Biopsy/Aspiration Except Bone Marrow T 8.7675 0006Level I Incision & Drainage T 1.7592 0007Level II Incision & Drainage T 10.1746 0008 Level III Incision and Drainage T 18.4976 0012 Level I Debridement & Destruction T 0.3982 0013Level II Debridement & Destruction T 1.0032 0015 Level III Debridement & Destruction T 1.4998 0016Level IV Debridement & Destruction T 2.9399 0017Level V Debridement & Destruction T 19.8814 0019 Level I Excision/ Biopsy T 4.7170 0020Level 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 0030Level III Breast Surgery T 45.3768 0031 Level I Health and Behavior Services S 0.3135 0034Mental Health Services Composite S 3.2008 0035Vascular Puncture and Minor Diagnostic Procedures X 0.3286 0037Level IV Needle Biopsy/Aspiration Except Bone Marrow T 15.6849 0039 Level I Implantation of Neurostimulator Generator S 229.8982 0040Level 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 0047Arthroplasty 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 0050Level 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 0053Level I Hand Musculoskeletal Procedures T 16.6230 0054Level II Hand Musculoskeletal Procedures T 28.9725 0055 Level I Foot Musculoskeletal Procedures T 22.2111 0056Level II Foot Musculoskeletal Procedures T 60.6876 0057Bunion Procedures T 34.4317 0058 Level I Cast Application S 1.3257 0059 Level I Strapping S 0.7563 0060Manipulation 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 0063Level II Treatment Fracture/Dislocation T 52.7806 0064Level III Treatment Fracture/Dislocation T 70.67850065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG S 13.7177

0066Level II Stereotactic Radiosurgery, MRgFUS, and MEG S 33.0205 0067Level III Stereotactic Radiosurgery, MRgFUS, and MEG S 46.2838 0069Thoracoscopy T 35.9647 0070Thoracentesis/Lavage Procedures T 5.7828 0071 Level I Endoscopy Upper Airway T 1.0839 0072 Level II Endoscopy Upper Airway T 2.0036 0073Level III Endoscopy Upper Airway T 4.7291 0074Level IV Endoscopy Upper Airway T 18.9594 0075 Level V Endoscopy Upper Airway T 28.4215 0076Level I Endoscopy Lower Airway T 10.7117 0077Level I Pulmonary Treatment S 0.4920 0078 Level III Pulmonary Treatment S 1.4155 0079Ventilation Initiation and Management S 3.4693 0080 Diagnostic Cardiac Catheterization T 37.1534 0082Coronary or Non-Coronary Atherectomy T 107.5706 0083Coronary Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity T 56.4140 0084Level I Electrophysiologic Procedures S 9.8911 0085 Level II Electrophysiologic Procedures T 55.0013 0088Thrombectomy T 43.4735 0089 Insertion/Replacement of Permanent Pacemaker and Electrodes T 115.4087 0090Level 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 0093Vascular Reconstruction/Fistula Repair without Device T 30.1384 0094Level I Resuscitation and Cardioversion S 2.2552 0095Cardiac Rehabilitation S 1.1206 0096Level II Noninvasive Physiologic Studies S 1.5230 0097Level I Noninvasive Physiologic Studies S 0.9328 0099 Electrocardiograms/Cardiography S 0.3740 0100Cardiac Stress Tests X 2.4795 0101 Tilt Table Evaluation S 4.2562 0102 Level II Pulmonary Treatment S 0.5512 0103Miscellaneous Vascular Procedures T 16.2173 0104Transcatheter Placement of Intracoronary Stents T 85.6848 0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices T 23.6020 0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes T 52.8101 0107Level I Implantation of Cardioverter-Defibrillators (ICDs) T 315.6793 0108 Level II Implantation of Cardioverter-Defibrillators (ICDs) T 430.2162 0110Transfusion S 3.6520 0111 Blood Product Exchange S 13.3306 0112Apheresis and Stem Cell Procedures S 40.5074 0113 Excision Lymphatic System T 25.5213 0114Thyroid/Lymphadenectomy Procedures T 51.4794 0115Cannula/Access Device Procedures T 37.5770 0121 Level I Tube or Catheter Changes or Repositioning T 6.1648 0126Level I Urinary and Anal Procedures T 1.1497 0127Level IV Stereotactic Radiosurgery, MRgFUS, and MEG S 110.9266 0129 Level I Closed Treatment Fracture T 1.8741 0130Level I Laparoscopy T 38.2829 0131 Level II Laparoscopy T 48.8992 0132 Level III Laparoscopy T 71.81560133Level I Skin Repair T 1.2024

0134Level II Skin Repair T 3.5264 0135 Level III Skin Repair T 5.5162 0136Level IV Skin Repair T 15.5878 0137Level 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 0143Lower GI Endoscopy T 9.6941 0146Level I Sigmoidoscopy and Anoscopy T 5.8940 0147Level 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 0150Level 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 0154Hernia/Hydrocele Procedures T 34.0627 0155 Level II Anal/Rectal Procedures T 17.9329 0156Level III Urinary and Anal Procedures T 3.2577 0157Colorectal Cancer Screening: Barium Enema S 2.5831 0158Colorectal Cancer Screening: Colonoscopy T 8.5787 0159Colorectal Cancer Screening: Flexible Sigmoidoscopy S 5.8206 0160Level 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 0163Level IV Cystourethroscopy and other Genitourinary Procedures T 38.3814 0164Level II Urinary and Anal Procedures T 2.1419 0165 Level IV Urinary and Anal Procedures T 19.7656 0166Level 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 0173Level II Partial Hospitalization (4 or more services) for CMHCs P 1.5378 0174Level IV Laparoscopy T 127.3348 0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPsP 2.5340 0176Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs P 3.2008 0177Level 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 0183Level 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 0190Level I Hysteroscopy T 23.5870 0191 Level I Female Reproductive Proc T 0.1157 0192 Level IV Female Reproductive Proc T 6.9849 0193Level V Female Reproductive Proc T 20.3967 0195 Level VI Female Reproductive Procedures T 37.01200202 Level VII Female Reproductive Procedures T 47.7547

0203Level IV Nerve Injections T 12.0130 0204Level I Nerve Injections T 2.5607 0206Level II Nerve Injections T 4.0910 0207Level 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 0213Level I Extended EEG, Sleep, and Cardiovascular Studies S 2.4204 0215 Level I Nerve and Muscle Services S 0.6045 0216Level III Nerve and Muscle Services S 2.5805 0218 Level II Nerve and Muscle Services S 1.1195 0220Level 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 0230Level 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 0233Level III Anterior Segment Eye Procedures T 15.8380 0234Level IV Anterior Segment Eye Procedures T 23.5107 0235 Level I Posterior Segment Eye Procedures T 5.8389 0237Level 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 0240Level 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 0243Strabismus/Muscle Procedures T 25.2082 0244Corneal and Amniotic Membrane Transplant T 41.6106 0246Cataract Procedures with IOL Insert T 24.2659 0247Laser Eye Procedures T 5.7604 0249Cataract Procedures without IOL Insert T 29.3838 0250Level I ENT Procedures T 1.0950 0251 Level II ENT Procedures T 3.2225 0252 Level III ENT Procedures T 6.9913 0253Level IV ENT Procedures T 16.0895 0254Level V ENT Procedures T 25.2377 0255 Level II Anterior Segment Eye Procedures T 9.2948 0256Level VI ENT Procedures T 45.9788 0259 Level VII ENT Procedures T 425.2643 0260Level I Plain Film Except Teeth X 0.6443 0261 Level II Plain Film Except Teeth Including Bone Density Measurement X 0.9933 0262 Plain Film of Teeth X 0.5031 0263Level I Miscellaneous Radiology Procedures X 3.5823 0265 Level I Diagnostic and Screening Ultrasound S 0.9054 0266Level II Diagnostic and Screening Ultrasound S 1.3928 0267Level III Diagnostic and Screening Ultrasound S 2.1699 0269 Level II Echocardiogram Without Contrast S 5.4757 0270Level III Echocardiogram Without Contrast S 7.8339 0272 Fluoroscopy X 1.6023 0274Myelography S 7.11790275Arthrography S 4.1881

0276Level I Digestive Radiology S 1.1600 0277Level II Digestive Radiology S 1.7222 0278 Diagnostic Urography S 2.9385 0279 Level II Angiography and Venography S 31.1279 0280Level III Angiography and Venography S 50.9080 0282 Miscellaneous Computed Axial Tomography S 1.3864 0283Computed Tomography with Contrast S 4.1669 0284Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast S 6.3741 0288Bone Density:Axial Skeleton S 1.0359 0293Level VI Anterior Segment Eye Procedures T 123.3630 0299 Hyperthermia and Radiation Treatment Procedures S 5.5027 0300Level I Radiation Therapy S 1.3392 0301 Level II Radiation Therapy S 2.5173 0303Treatment Device Construction X 2.8292 0304Level 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 0310Level III Therapeutic Radiation Treatment Preparation X 13.8052 0312 Radioelement Applications S 5.7609 0313Brachytherapy S 9.6431 0315 Level II Implantation of Neurostimulator Generator S 288.8990 0317Level 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 0325Group Psychotherapy S 0.8506 0330 Dental Procedures S 7.5832 0331 Combined Abdomen and Pelvis CT without Contrast S 4.2917 0332Computed Tomography without Contrast S 2.4340 0333Computed Tomography without Contrast followed by Contrast S 4.6182 0334Combined Abdomen and Pelvis CT with Contrast S 6.7671 0336Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast S 4.7466 0337Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast S 7.7051 0340Minor Ancillary Procedures X 0.6961 0341 Skin Tests X 0.0957 0342 Level I Pathology X 0.1782 0343Level III Pathology X 0.5342 0344Level IV Pathology X 0.8477 0345 Level I Transfusion Laboratory Procedures X 0.2519 0346Level II Transfusion Laboratory Procedures X 0.3504 0347Level III Transfusion Laboratory Procedures X 0.4810 0350Administration of flu and PPV vaccine S 0.3788 0360Level I Alimentary Tests X 1.9249 0361 Level II Alimentary Tests X 4.2433 0363Level I Otorhinolaryngologic Function Tests X 0.9156 0364Level I Audiometry X 0.5032 0365 Level II Audiometry X 1.2424 0366Level III Audiometry X 1.64010367Level I Pulmonary Test X 0.6318

0368 Level II Pulmonary Tests X 0.8816 0369 Level III Pulmonary Tests X 2.5221 0370Multiple Allergy Tests X 1.3347 0373Level I Neuropsychological Testing X 1.2128 0375Ancillary Outpatient Services When Patient Expires S 92.7277 0377Level 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 0383Cardiac Computed Tomographic Imaging S 3.7468 0384GI Procedures with Stents T 29.6863 0385 Level I Prosthetic Urological Procedures S 107.0677 0386Level II Prosthetic Urological Procedures S 175.4934 0387Level II Hysteroscopy T 37.5259 0388 Discography S 24.2728 0389 Level I Non-imaging Nuclear Medicine S 1.5990 0390Level I Endocrine Imaging S 2.1040 0391 Level II Endocrine Imaging S 3.2664 0392 Level II Non-imaging Nuclear Medicine S 2.7567 0393Hematologic Processing & Studies S 6.1109 0394Hepatobiliary Imaging S 4.4086 0395GI Tract Imaging S 3.6004 0396Bone Imaging S 3.6694 0397Vascular 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 0403Level I Nervous System Imaging S 3.7033 0404 Renal and Genitourinary Studies S 4.6683 0406Level I Tumor/Infection Imaging S 4.2080 0407Level 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 0413Level II Radionuclide Therapy S 4.2209 0414Level 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 0423Level II Percutaneous Abdominal and Biliary Procedures T 56.7444 0424Level II Small Intestine Endoscopy T 15.5387 0425 Level II Arthroplasty or Implantation with Prosthesis T 134.6442 0426Level II Strapping and Cast Application S 2.6522 0427Level 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 0433Level II Pathology X 0.3285 0434Cardiac Defect Repair T 167.9170 0436Level I Drug Administration S 0.37880437Level II Drug Administration S 0.5487

0438 Level III Drug Administration S 1.0473 0439 Level IV Drug Administration S 2.0507 0440Level V Drug Administration S 3.2322 0442 Dosimetric Drug Administration S 27.5195 0604Level 1 Hospital Clinic Visits V 0.7960 0605 Level 2 Hospital Clinic Visits V 1.0332 0606Level 3 Hospital Clinic Visits V 1.3596 0607Level 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 0613Level 2 Type A Emergency Visits V 1.2923 0614Level 3 Type A Emergency Visits V 2.0103 0615 Level 4 Type A Emergency Visits V 3.2164 0616Level 5 Type A Emergency Visits V 4.8338 0617Critical Care S 7.5142 0618Trauma 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 0623Level III Vascular Access Procedures T 31.2425 0624 Phlebotomy and Minor Vascular Access Device Procedures X 0.6889 0626Level 1 Type B Emergency Visits V 0.9504 0627Level 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 0630Level 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 0653Vascular Reconstruction/Fistula Repair with Device T 37.4589 0654Level 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 0656Transcatheter Placement of Intracoronary Drug-Eluting Stents T 108.8606 0659 Hyperbaric Oxygen S 1.5109 0660Level II Otorhinolaryngologic Function Tests X 1.8519 0661 Level V Pathology X 2.2023 0662CT Angiography S 4.7570 0664Level I Proton Beam Radiation Therapy S 15.9383 0665 Bone Density:AppendicularSkeleton S 0.4941 0667Level 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 0673Level V Anterior Segment Eye Procedures T 41.7586 0674 Prostate Cryoablation T 109.7287 0676Thrombolysis 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 0683Level 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 36.43460690Level 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 0694Mohs Surgery T 5.1585 0697Level 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 0735Ampho b cholesteryl sulfate K 0736Amphotericin b liposome inj K 0738 Rasburicase K 0747Chlorothiazide sodium inj K 0751 Mechlorethamine hcl inj K 0752 Dactinomycin injection K 0759 Naltrexone, depot form K 0800Leuprolide acetate K 0802 Etoposide oral K 0807Aldesleukin injection K 0809 Bcg live intravesical vac K 0810Goserelin acetate implant K 0812Carmustine injection K 0814Asparaginase, NOS K 0820 Daunorubicin injection K 0821 Daunorubicin citrate inj K 0823 Docetaxel injection K 0825 Nelarabine injection K 0827 Floxuridine injection K 0828Gemcitabine hcl injection K 0831 Ifosfamide injection K 0832 Idarubicin hcl injection K 0835Cosyntropin 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 0850Streptozocin injection K 0851 Thiotepa injection K 0856 Porfimer sodium injection K 0858 Inj cladribine K 0861 Leuprolide acetate injeciton K 0864Mitoxantrone hydrochl K 0868Oral aprepitant K 0873Hyalgan/supartz inj per dose K 0874Synvisc or synvisc-one K 0875 Euflexxa inj per dose K 0877Orthovisc inj per dose K0884 Rho d immune globulin inj K

0887Azathioprine parenteral K 0890Lymphocyte immune globulin K 0900Alglucerase injection K 0901 Alpha 1 proteinase inhibitor K 0902 Injection,onabotulinumtoxinA K 0903Cytomegalovirus imm IV /vial K 0910 Interferon beta-1b / .25 MG K 0913Ganciclovir long act implant K 0917Adenosine injection K 0925 Factor viii K 0927 Factor viii recombinant K 0928 Factor ix complex K 0929Anti-inhibitor K 0931 Factor IX non-recombinant K 0932 Factor IX recombinant K 0933Gamma globulin > 10 CC inj K 0934Capecitabine, oral K 0943Octagam injection K 0944Gammagard liquid injection K 0945 Rhophylac injection K 0946 Hepagam b im injection K 0947 Flebogamma injection G 0948Gamunex-C/Gammaked K 0949 Frozen plasma, pooled, sd R 1.0129 0950Whole blood for transfusion R 2.3815 0951 Reclast injection K 0952Cryoprecipitate 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 0960Washed red blood cells unit R 4.1562 0961 Albumin (human),5%, 50ml K 0963Albumin (human), 5%, 250 ml K 0964Albumin (human), 25%, 20 ml K 0965Albumin (human), 25%, 50ml K 0966 Plasmaprotein fract,5%,250ml R 0.6613 0967Blood split unit R 1.9121 0968 Platelets leukoreduced irrad R 2.1939 0969 RBC leukoreduced irradiated R 3.8309 1009Cryoprecipitatereducedplasma R 0.9531 1010Blood, 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 1016Blood, l/r, froz/degly/wash R 1.7169 1017 Plt, aph/pher, l/r, cmv-neg R 4.7192 1018Blood, l/r, irradiated R 2.4667 1019 Plate pheres leukoredu irrad R 9.45361020 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 1083Adalimumab injection K 1084Denileukin diftitox inj K 1086Temozolomide K 1138 Hepagam b intravenous, inj K 1139 Protein c concentrate K 1142Supprelin LA implant K 1150 I131 iodide sol, rx K 1166Cytarabine liposome inj K 1167 Inj, epirubicin hcl K 1168 Inj, temsirolimus K 1178Busulfan injection K 1203Verteporfin injection K 1207Octreotide injection, depot K 1213Antihemophilic viii/vwf comp K 1214 Inj IVIG privigen 500 mg K 1221 Dimethyl sulfoxide 50% K 1232 Mitomycin injection K 1235Valrubicin injection K 1236Levoleucovorin injection K 1237 Inj iron dextran K 1238Topotecan oral K 1239 Rotavirus vacc 2 dose oral K 1240Apligraf skin sub K 1241 Oasis wound matrix skin sub K 1242Oasis burn matrix skin sub K 1243 Integra BMWD skin sub K 1244 Integra DRT K 1245 Dermagraft skin sub K 1246Graftjacket skin sub K 1247 Integra matrix skin sub K 1248 Primatrix skin sub K 1249Cymetra allograft K 1250Graftjacket express allograf K 1251 Integra flowable wound matri K 1252Gammagraft skin sub K 1253Triamcinolone A inj PRS-free K 1263Antithrombin iii injection K 1268Xyntha inj K 1270Alloderm skin sub K 1272Acetylcysteine injection K 1274 Edetate calcium disodium inj K 1275Vivaglobin, inj K 1280Corticotropin injection K 1281 Bevacizumab injection K 1287Alloskin skin sub K 1289AbobotulinumtoxinA K1291 Rilonacept injection K

1295Sm 153 lexidronam K 1296 Degarelix injection K 1297 Ferumoxytol, non-esrd K 1307Oral busulfan K 1311 Canakinumab injection G 1312 Hizentra injection K 1327 Imiglucerase injection K 1331 Olanzapine long-acting inj K 1332Antithrombin recombinant K 1338Methyl aminolevulinate, top K 1339Oral fludarabine phosphate K 1340Collagenase, clost hist inj K 1341 Amobarbital 125 MG inj K 1342 Matristem micromatrix K 1343Ganciclovir sodium injection K 1344Gonadorelin hydroch/ 100 mcg K 1345Theraskin K 1347Oxacillin sodium injeciton K 1349Anidulafungin injection K 1350Topotecan injection K 1351 Matristem wound matrix K 1352Wilate injection K 1353Belimumab injection G 1354Hydroxyprogesterone caproate K 1355 Itraconazole injection K 1357 Inj protirelin per 250 mcg K 1361 Enfuvirtide injection K 1408Cyclophosphamide 100 MG inj K 1413Lumizyme injection K 1414Human fibrinogen conc inj K 1415Glassia injection K 1416 Factor XIII anti-hem factor G 1417Gel-one K 1419 Dermacell K 1420Aflibercept injection G 1421 Imported lipodox inj K 1422Anthrax vaccine sc or im K 1423Minocycline hydrochloride K 1424Nabilone oral K 1426 Eribulin mesylate injection G 1427Alloskin K 1428Arthroflex K 1429 Flexhd/Allopatchhd/matrixhd K 1430 Unite biomatrix K 1431 Centruroides immune f(ab) G 1432Arbutamine hcl injection K 1433Calcitonin salmon injection K 1434Testosterone enanthate inj K 1435 Injection estrone per 1 MG K 1437Gatifloxacin injection K 1438 Diazoxide injection K1439Aprotonin, 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 1444Oral everolimus K 1445 Methylnaltrexone injection K 1446Visualization adjunct K 1447 Interferon alfacon-1 inj K 1491 New Technology - Level IA ($0-$10) S 1492 New Technology - Level IB ($10-$20) S 1493New Technology - Level IC ($20-$30) S 1494New Technology - Level ID ($30-$40) S 1495 New Technology - Level IE ($40-$50) S 1496New Technology - Level IA ($0-$10) T 1497New Technology - Level IB($10-$20) T 1498 New Technology - Level IC ($20-$30) T 1499 New Technology - Level ID($30-$40) T 1500New Technology - Level IE ($40-$50) T 1502 New Technology - Level II ($50 - $100) S 1503New Technology - Level III ($100 - $200) S 1504New Technology - Level IV ($200 - $300) S 1505 New Technology - Level V ($300 - $400) S 1506New Technology - Level VI ($400 - $500) S 1507New Technology - Level VII ($500 - $600) S 1508 New Technology - Level VIII ($600 - $700) S 1509 New Technology - Level IX ($700 - $800) S 1510New Technology - Level X ($800 - $900) S 1511 New Technology - Level XI ($900 - $1000) S 1512 New Technology - Level XII ($1000 - $1100) S 1513New Technology - Level XIII ($1100 - $1200) S 1514New Technology - Level XIV ($1200- $1300) S 1515 New Technology - Level XV ($1300 - $1400) S 1516New Technology - Level XVI ($1400 - $1500) S 1517New Technology - Level XVII ($1500-$1600) S 1518 New Technology - Level XVIII ($1600-$1700) S 1519 New Technology - Level IXX ($1700-$1800) S 1520New Technology - Level XX ($1800-$1900) S 1521 New Technology - Level XXI ($1900-$2000) S 1522 New Technology - Level XXII ($2000-$2500) S 1523New Technology - Level XXIII ($2500-$3000) S 1524New Technology - Level XXIV ($3000-$3500) S 1525 New Technology - Level XXV ($3500-$4000) S 1526New Technology - Level XXVI ($4000-$4500) S 1527New Technology - Level XXVII ($4500-$5000) S 1528 New Technology - Level XXVIII ($5000-$5500) S 1529 New Technology - Level XXIX ($5500-$6000) S 1530New Technology - Level XXX ($6000-$6500) S 1531 New Technology - Level XXXI ($6500-$7000) S 1532 New Technology - Level XXXII ($7000-$7500) S 1533New Technology - Level XXXIII ($7500-$8000) S 1534New Technology - Level XXXIV ($8000-$8500) S1535 New Technology - Level XXXV ($8500-$9000) S

1536New Technology - Level XXXVI ($9000-$9500) S 1537New Technology - Level XXXVII ($9500-$10000) S 1539 New Technology - Level II ($50 - $100) T 1540New Technology - Level III ($100 - $200) T 1541 New Technology - Level IV ($200 - $300) T 1542 New Technology - Level V ($300 - $400) T 1543New Technology - Level VI ($400 - $500) T 1544New Technology - Level VII ($500 - $600) T 1545 New Technology - Level VIII ($600 - $700) T 1546New Technology - Level IX ($700 - $800) T 1547New Technology - Level X ($800 - $900) T 1548 New Technology - Level XI ($900 - $1000) T 1549 New Technology - Level XII ($1000 - $1100) T 1550New Technology - Level XIII ($1100 - $1200) T 1551 New Technology - Level XIV ($1200- $1300) T 1552 New Technology - Level XV ($1300 - $1400) T 1553New Technology - Level XVI ($1400 - $1500) T 1554New Technology - Level XVII ($1500-$1600) T 1555 New Technology - Level XVIII ($1600-$1700) T 1556New Technology - Level XIX ($1700-$1800) T 1557New Technology - Level XX ($1800-$1900) T 1558 New Technology - Level XXI ($1900-$2000) T 1559 New Technology - Level XXII ($2000-$2500) T 1560New Technology - Level XXIII ($2500-$3000) T 1561 New Technology - Level XXIV ($3000-$3500) T 1562 New Technology - Level XXV ($3500-$4000) T 1563New Technology - Level XXVI ($4000-$4500) T 1564New Technology - Level XXVII ($4500-$5000) T 1565 New Technology - Level XXVIII ($5000-$5500) T 1566New Technology - Level XXIX ($5500-$6000) T 1567New Technology - Level XXX ($6000-$6500) T 1568 New Technology - Level XXXI ($6500-$7000) T 1569 New Technology - Level XXXII ($7000-$7500) T 1570New Technology - Level XXXIII ($7500-$8000) T 1571 New Technology - Level XXXIV ($8000-$8500) T 1572 New Technology - Level XXXV ($8500-$9000) T 1573New Technology - Level XXXVI ($9000-$9500) T 1574New Technology - Level XXXVII ($9500-$10000) T 1605Abciximab injection K 1607 Eptifibatide injection K 1608 Etanercept injection K 1609 Rho(D) immune globulin h, sd K 1612 Daclizumab, parenteral K 1613Trastuzumab injection K 1630 Hep b ig, im K 1631 Baclofen intrathecal trial K 1633Alefacept K 1643Y90 ibritumomab, rx K 1645 I131 tositumomab, rx K 1670Tetanus immune globulin inj K 1675 P32 Na phosphate K1676 P32 chromic phosphate K

1683Basiliximab K 1684Corticorelin ovine triflutal K 1685 Darbepoetin alfa, non-esrd K 1686 Epoetin alfa, non-esrd K 1687Digoxin immune fab (ovine) K 1688 Ethanolamine oleate K 1689 Fomepizole K 1690 Hemin K 1693Lepirudin K 1694Ziconotide 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 1704Humate-P, inj K 1705 Factor viia K 1709Azacitidine injection K 1710Clofarabine injection K 1711 Vantas implant K 1712 Paclitaxel protein bound K 1716Brachytx, non-str, Gold-198 U 1.5340 1717Brachytx, non-str, HDR Ir-192 U 3.4927 1719 Brachytx, NS, Non-HDRIr-192 U 0.5205 1738Oxaliplatin K 1739 Pegademase bovine, 25 iu K 1741 Urofollitropin, 75 iu K 1830 Power bone marrow bx needle H 1840Telescopic intraocular lens H 1886Catheter, ablation H 2210Methyldopate hcl injection K 2616Brachytx, non-str,Yttrium-90 U 219.7241 2632 Iodine I-125 sodium iodide U 0.2949 2634Brachytx, non-str, HA, I-125 U 0.9229 2635 Brachytx, non-str, HA, P-103 U 0.4285 2636Brachy linear, non-str,P-103 U 0.4994 2638Brachytx, stranded, I-125 U 0.6548 2639 Brachytx, non-stranded,I-125 U 0.5005 2640Brachytx, stranded, P-103 U 1.0578 2641 Brachytx, non-stranded,P-103 U 0.8481 2642 Brachytx, stranded, C-131 U 1.5461 2643Brachytx, non-stranded,C-131 U 0.9259 2698Brachytx, stranded, NOS U 0.6548 2699 Brachytx, non-stranded, NOS U 0.4285 2731 Immune globulin, powder K 2770Quinupristin/dalfopristin K 3041 Bivalirudin K 3043Gamma globulin 1 CC inj K 3050Sermorelin acetate injection K 7000Amifostine K 7011 Oprelvekin injection K7034Somatropin injection K

7035Teniposide K 7036 Urokinase 250,000 IU inj K 7038Monoclonal antibodies K 7041 Tirofiban HCl K 7042Capecitabine, oral K 7043 Infliximab injection K 7046 Doxil injection K 7048Alteplase recombinant K 7049 Filgrastim 480 mcg injection K 7051 Leuprolide acetate implant K 7308Aminolevulinic acid hcl top K 8000Cardiac 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 8003Level II Extended Assessment & Management Composite V 11.1967 8004Ultrasound Composite S 2.7570 8005CT and CTA without Contrast Composite S 5.6130 8006CT and CTA with Contrast Composite S 9.5649 8007MRI and MRA without Contrast Composite S 9.9120 8008MRI and MRA with Contrast Composite S 14.5688 9001 Linezolid injection K 9002Tenecteplase injection K 9003 Palivizumab K 9004Gemtuzumab ozogamicin inj K 9005 Reteplase injection K 9006Tacrolimus injection K 9012Arsenic trioxide injection K 9018 Inj, rimabotulinumtoxinB K 9019Caspofungin acetate K 9022 IM inj interferon beta 1-a K 9023 Rho d immune globulin K 9024Amphotericin b lipid complex K 9032 Baclofen 10 MG injection K 9033Cidofovir injection K 9038 Inj estrogen conjugate K 9042Glucagon hydrochloride K 9044 Ibutilide fumarate injection K 9104Antithymocyte globuln rabbit K 9108Thyrotropin injection K 9110Alemtuzumab injection K 9115Zoledronic acid K 9119 Injection, pegfilgrastim 6mg K 9120 Injection, Fulvestrant K 9121 Injection, argatroban K 9122Triptorelin pamoate K 9124Daptomycin injection K 9125 Risperidone, long acting K 9126Natalizumab injection K 9133 Rabies ig, im/sc K 9134 Rabies ig, heat treated K 9135Varicella-zoster ig, im K9137Bcg vaccine, percut K

9139 Rabies vaccine, im K 9140 Rabies vaccine, id K 9143Meningococcal vaccine, sc K 9144 Encephalitis vaccine, sc K 9145 Meningococcal vaccine, im K 9207Bortezomib injection K 9208Agalsidase beta injection K 9209 Laronidase injection K 9210 Palonosetron hcl K 9213 Pemetrexed injection K 9214Bevacizumab injection K 9215Cetuximab injection K 9217Leuprolide acetate suspnsion K 9224Galsulfase injection K 9225 Fluocinolone acetonide implt K 9227Micafungin sodium injection K 9228Tigecycline injection K 9229 Ibandronate sodium injection K 9230Abatacept injection K 9231 Decitabine injection K 9232 Idursulfase injection K 9233 Ranibizumab injection K 9234Alglucosidase alfa injection K 9235 Panitumumab injection K 9236 Eculizumab injection K 9237 Inj, lanreotide acetate K 9240 Injection, ixabepilone K 9242 Injection, fosaprepitant K 9243Bendamustine injection K 9244 Regadenoson injection K 9245 Romiplostim injection K 9248 Inj, clevidipine butyrate K 9249Certolizumab pegol inj K 9250Artiss fibrin sealant K 9251 C1 esterase inhibitor inj K 9252 Plerixafor injection K 9253Temozolomide injection K 9255 Paliperidone palmitate inj K 9256 Dexamethasone intra implant K 9258Telavancin injection K 9259 Pralatrexate injection K 9260Ofatumumab injection K 9261 Ustekinumab injection K 9263 Ecallantide injection K 9264Tocilizumab injection K 9265 Romidepsin injection K 9268Capsaicin 8% patch K 9269C-1 esterase, berinert K 9270Gammaplex IVIG K 9271 Velaglucerase alfa K 9272 Inj, denosumab K9273Sipuleucel-T auto CD54+ K

9274Crotalidae Poly Immune Fab K 9276Cabazitaxel 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 9286Belatacept injection G 9287Brentuximab 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 9300Omalizumab injection K 9358SurgiMend, fetal K 9360SurgiMend, neonatal K 9363 Integra Meshed Bil Wound Mat K 9365Oasis tri-layer wound matrix G 9366 Epifix G 9367 Endoform Dermal Template K 9368Grafix core G 9369Grafix 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 9506Granulocytes, pheresis unit R 22.6900 9507 Platelets, pheresis R 6.0577 9508 Plasma 1 donor frz w/in 8 hr R 1.1037Payment 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