**Ad dendum A** **.-Proposed OPPS A PCs for CY 2013** 

**AP C**  **Group Title SI**  0001 Level I Photochemotherapy S 0002 Fine Needle Biopsy /Aspiration T 0003 Bone Marrow Biopsy /Aspiration T 0004 Level I Needle Biopsy / Aspiration Except Bone Marrow T 0005 Level II Needle Biopsy /Aspiration Except Bone Marrow T 0006 Level I Incision & Drainage T 0007 Level II Incision & Drainage T 0008 Level III Incision and Drainage T 0012 Level I Debridement & Destruction T 0013 Level II Debridement & Destruction T 0015 Level III Debridement & Destruction T 0016 Level IV Debridement & Destruction T 0017 Level V Debridement & Destruction T 0019 Level I Excision/ Biopsy T 0020 Level II Excision/ Biopsy T 0021 Level III Excision/ Biopsy T 0022 Level IV Excision/ Biopsy T 0028 Level I Breast Surgery T 0029 Level II Breast Surgery T 0030 Level III Breast Surgery T 0031 Level I Health and Behavior Services S 0034 Mental Health Services Composite S 0035Vascular Puncture and Minor Diagnostic Procedures X 0037 Level IV Needle Biopsy /Aspiration Except Bone Marrow T 0039 Level I Implantation of Neurostimulator Generator S 0040 Level I Implantation/Revision/Replacement of Neurostimulator Electrodes S 0041 Level I Arthroscopy T 0042 Level II Arthroscopy T 0045 Bone/Joint Manipulation Under Anesthesia T 0047Arthroplasty

without Prosthesis T 0048 Level I Arthroplasty or Implantation with Prosthesis T 0049 Level I Musculoskeletal Procedures Except Hand and Foot T 0050 Level II Musculoskeletal Procedures Except Hand and Foot T 0051 Level III Musculoskeletal Procedures Except Hand and Foot T 0052 Level IV Musculoskeletal Procedures Except Hand and Foot T 0053 Level I Hand Musculoskeletal Procedures T 0054 Level II Hand Musculoskeletal Procedures T 0055 Level I Foot Musculoskeletal Procedures T 0056 Level II Foot Musculoskeletal Procedures T 0057 Bunion Procedures T 0058 Level I Cast Application S 0059 Level I Strapping S 0060 Manipulation Therapy S 0061 Level II Implantation/Revision/Replacement of Neurostimulator Electrodes S 0062 Level I Treatment Fracture/Dislocation T 0063 Level II Treatment Fracture/Dislocation T0064 Level III Treatment Fracture/Dislocation T

0065 Level I Stereotactic Radiosurgery, MRgFUS, and MEG S 0066 Level II Stereotactic Radiosurgery, MRgFUS, and MEG S 0067 Level III Stereotactic Radiosurgery, MRgFUS, and MEG S 0069Thoracoscopy T 0070Thoracentesis/Lavage Procedures T 0071 Level I Endoscopy Upper Airway T 0072 Level II Endoscopy Upper Airway T 0073 Level III Endoscopy Upper Airway T 0074 Level IV Endoscopy Upper Airway T 0075 Level V Endoscopy Upper Airway T 0076 Level I Endoscopy Lower Airway T 0077 Level I Pulmonary Treatment S 0078 Level III Pulmonary Treatment S 0079Ventilation Initiation and Management S 0080 Diagnostic Cardiac Catheterization T 0082 Coronary

or Non-Coronary

Atherectomy T 0083Coronary

Angioplasty, Valvuloplasty, and Level I Endovascular Revascularization of the Lower Extremity T 0084 Level I Electrophysiologic Procedures S 0085 Level II Electrophysiologic Procedures T 0086 Level III Electrophysiologic Procedures T 0088Thrombectomy T 0089 Insertion/Replacement of Permanent Pacemaker and Electrodes T 0090 Level I Insertion/Replacement of Permanent Pacemaker T 0091 Level II Vascular Ligation T 0092 Level I Vascular Ligation T 0093Vascular Reconstruction/Fistula Repair without Device T 0094 Level I Resuscitation and Cardioversion S 0095Cardiac Rehabilitation S 0096 Level II Noninvasive Physiologic Studies S 0097 Level I Noninvasive Physiologic Studies S 0099 Electrocardiograms/Cardiography S 0100 Cardiac Stress Tests X 0101 Tilt Table Evaluation S 0102 Level II Pulmonary Treatment S 0103 Miscellaneous Vascular Procedures T 0104Transcatheter Placement of Intracoronary Stents T 0105 Repair/Revision/Removal of Pacemakers, AICDs, or Vascular Devices T 0106 Insertion/Replacement of Pacemaker Leads and/or Electrodes T 0107 Insertion of Cardioverter-Defibrillator Pulse Generator T 0108 Insertion/Replacement/Repair of AICD Leads, Generator, and Pacing Electrodes T 0110Transfusion S 0111 Blood Product Exchange S 0112Apheresis and Stem Cell Procedures S 0113 Excision Lymphatic System T 0114Thyroid/Lymphadenectomy Procedures T 0115Cannula/Access Device Procedures T 0121 Level I Tube or Catheter Changes or Repositioning T 0126 Level I Urinary

and Anal Procedures T 0127 Level IV Stereotactic Radiosurgery, MRgFUS, and MEG S 0128 Echocardiogram with Contrast S 0129 Level I Closed Treatment Fracture T0130 Level I Laparoscopy T

0131 Level II Laparoscopy T 0132 Level III Laparoscopy T 0133 Level I Skin Repair T 0134 Level II Skin Repair T 0135 Level III Skin Repair T 0136 Level IV Skin Repair T 0137 Level V Skin Repair T 0138 Level II Closed Treatment Fracture T 0139 Level III Closed Treatment Fracture T 0140 Esophageal Dilation without Endoscopy T 0141 Level I Upper GI Procedures T 0142 Level I Small Intestine Endoscopy T 0143 Lower GI Endoscopy T 0146 Level I Sigmoidoscopy and Anoscopy T 0147 Level II Sigmoidoscopy and Anoscopy T 0148 Level I Anal/Rectal Procedures T 0149 Level III Anal/Rectal Procedures T 0150 Level IV Anal/Rectal Procedures T 0151 Endoscopic Retrograde Cholangio-Pancreatography (ERCP) T 0152 Level I Percutaneous Abdominal and Biliary Procedures T 0153 Peritoneal and Abdominal Procedures T 0154 Hernia/Hydrocele Procedures T 0155 Level II Anal/Rectal Procedures T 0156 Level III Urinary and Anal Procedures T 0157Colorectal Cancer Screening: Barium Enema S 0158Colorectal Cancer Screening: Colonoscopy T 0159Colorectal Cancer Screening: Flexible Sigmoidoscopy S 0160 Level I Cystourethroscopy and other Genitourinary Procedures T 0161 Level II Cystourethroscopy and other Genitourinary Procedures T 0162 Level III Cystourethroscopy and other Genitourinary Procedures T 0163 Level IV Cystourethroscopy and other Genitourinary Procedures T 0164 Level II Urinary and Anal Procedures T 0165 Level IV Urinary and Anal Procedures T 0166 Level I Urethral Procedures T 0168 Level II Urethral Procedures T 0169 Lithotripsy T 0170 Dialysis S 0172 Level I Partial Hospitalization (3 services) for CMHCs P 0173 Level II Partial Hospitalization (4 or more services) for CMHCs P 0174 Level IV Laparoscopy T 0175 Level I Partial Hospitalization (3 services) for Hospital-based PHPs P 0176 Level II Partial Hospitalization (4 or more services) for Hospital-based PHPs P 0181 Level II Male Genital Procedures T 0183 Level I Male Genital Procedures T 0184 Prostate Biopsy T 0188 Level II Female Reproductive Proc T 0189 Level III Female Reproductive Proc T 0190 Level I Hysteroscopy T 0191 Level I Female Reproductive Proc T 0192 Level IV Female Reproductive Proc T 0193 Level V Female Reproductive Proc T0195 Level VI Female Reproductive Procedures T

0202 Level VII Female Reproductive Procedures T 0203 Level IV Nerve Injections T 0204 Level I Nerve Injections T 0206 Level II Nerve Injections T 0207 Level III Nerve Injections T 0208 Laminotomies and Laminectomies T 0209 Level II Extended EEG, Sleep, and Cardiovascular Studies S 0213 Level I Extended EEG, Sleep, and Cardiovascular Studies S 0215 Level I Nerve and Muscle Tests S 0216 Level III Nerve and Muscle Tests S 0218 Level II Nerve and Muscle Tests S 0220 Level I Nerve Procedures T 0221 Level II Nerve Procedures T 0224 Implantation of Catheter/Reservoir/Shunt T 0227 Implantation of Drug Infusion Device T 0229 Level II Endovascular Revascularization of the Lower Extremity T 0230 Level I Eye Tests & Treatments S 0231 Level III Eye Tests & Treatments S 0232 Level I Anterior Segment Eye Procedures T 0233 Level III Anterior Segment Eye Procedures T 0234 Level IV Anterior Segment Eye Procedures T 0235 Level I Posterior Segment Eye Procedures T 0237 Level II Posterior Segment Eye Procedures T 0238 Level I Repair and Plastic Eye Procedures T 0239 Level II Repair and Plastic Eye Procedures T 0240 Level III Repair and Plastic Eye Procedures T 0241 Level IV Repair and Plastic Eye Procedures T 0242 Level V Repair and Plastic Eye Procedures T 0243Strabismus/Muscle Procedures T 0244 Corneal and Amniotic Membrane Transplant T 0246 Cataract Procedures with IOL Insert T 0247 Laser Eye Procedures T 0249Cataract Procedures without IOL Insert T 0250 Level I ENT Procedures T 0251 Level II ENT Procedures T 0252 Level III ENT Procedures T 0253 Level IV ENT Procedures T 0254 Level V ENT Procedures T 0255 Level II Anterior Segment Eye Procedures T 0256 Level VI ENT Procedures T 0259 Level VII ENT Procedures T 0260 Level I Plain FilmExcept Teeth X 0261 Level II Plain FilmExcept Teeth Including Bone Density Measurement X 0262 Plain Filmof Teeth X 0263 Level I Miscellaneous Radiology Procedures X 0265 Level I Diagnostic and Screening Ultrasound S 0266 Level II Diagnostic and Screening Ultrasound S 0267 Level III Diagnostic and Screening Ultrasound S 0269 Level II Echocardiogram Without Contrast S 0270 Level III Echocardiogram Without Contrast S 0272 Fluoroscopy X0274 Myelography S

0275Arthrography S 0276 Level I Digestive Radiology S 0277 Level II Digestive Radiology S 0278 Diagnostic Urography S 0279 Level II Angiography and Venography S 0280 Level III Angiography and Venography S 0282 Miscellaneous Computed Axial Tomography S 0283Computed Tomography with Contrast S 0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with ContrastS 0288 Bone Density:Axial Skeleton S 0293 Level VI Anterior Segment Eye Procedures T 0299 Hyperthermia and Radiation Treatment Procedures S 0300 Level I Radiation Therapy S 0301 Level II Radiation Therapy S 0303Treatment Device Construction X 0304 Level I Therapeutic Radiation Treatment Preparation X 0305 Level II Therapeutic Radiation Treatment Preparation X 0308 Positron Emission Tomography (PET) imaging S 0310 Level III Therapeutic Radiation Treatment Preparation X 0312 Radioelement Applications S 0313 Brachy

therapy S 0315 Level II Implantation of Neurostimulator Generator S 0317 Level II Miscellaneous Radiology Procedures X 0318 Implantation of Neurostimulator Pulse Generator and Electrode S 0319 Level III Endovascular Revascularization of the Lower Extremity T 0320 Electroconvulsive Therapy S 0322 Brief Individual Psychotherapy S 0323 Extended Individual Psychotherapy S 0324 Family

Psychotherapy S 0325Group Psychotherapy S 0330 Dental Procedures S 0331 Combined Abdomen and Pelvis CT without Contrast S 0332 Computed Tomography without Contrast S 0333Computed Tomography without Contrast followed by Contrast S 0334 Combined Abdomen and Pelvis CT with Contrast S 0336 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast

S 0337 Magnetic Resonance Imaging and Magnetic Resonance Angiography without Contrast followed by Contrast S 0340 Minor Ancillary Procedures X 0341 Skin Tests X 0342 Level I Pathology X 0343 Level III Pathology X 0344 Level IV Pathology X 0345 Level I Transfusion Laboratory Procedures X 0346 Level II Transfusion Laboratory Procedures X 0347 Level III Transfusion Laboratory Procedures X 0350Administration of flu and PPV vaccine S 0360 Level I Alimentary Tests X 0361 Level II Alimentary Tests X 0363 Level I Otorhinolaryngologic Function Tests X 0364 Level I Audiometry X 0365 Level II Audiometry X0366 Level III Audiometry X

0367 Level I Pulmonary Test X 0368 Level II Pulmonary Tests X 0369 Level III Pulmonary Tests X 0370 Multiple Allergy Tests X 0373 Level I Neuropsychological Testing X 0375Ancillary

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

Tests X 0382 Level II Neuropsychological Testing X 0383Cardiac Computed Tomographic Imaging S 0384 GI Procedures with Stents T 0385 Level I Prosthetic Urological Procedures S 0386 Level II Prosthetic Urological Procedures S 0387 Level II Hysteroscopy T 0388 Discography S 0389 Level I Non-imaging Nuclear Medicine S 0390 Level I Endocrine Imaging S 0391 Level II Endocrine Imaging S 0392 Level II Non-imaging Nuclear Medicine S 0393 Hematologic Processing & Studies S 0394 Hepatobiliary

Imaging S 0395GI Tract Imaging S 0396 Bone Imaging S 0397Vascular Imaging S 0398 Level I Cardiac Imaging S 0400 Hematopoietic Imaging S 0401 Level I Pulmonary Imaging S 0402 Level II Nervous System Imaging S 0403 Level I Nervous System Imaging S 0404 Renal and Genitourinary Studies S 0406 Level I Tumor/Infection Imaging S 0407 Level I Radionuclide Therapy S 0408 Level III Tumor/Infection Imaging S 0409 Red Blood Cell Tests X 0412 Level III Radiation Therapy S 0413 Level II Radionuclide Therapy S 0414 Level II Tumor/Infection Imaging S 0415 Level II Endoscopy Lower Airway T 0419 Level II Upper GI Procedures T 0422 Level III Upper GI Procedures T 0423 Level II Percutaneous Abdominal and Biliary Procedures T 0424 Level II Small Intestine Endoscopy T 0425 Level II Arthroplasty or Implantation with Prosthesis T 0426 Level II Strapping and Cast Application S 0427 Level II Tube or Catheter Changes or Repositioning T 0428 Level III Sigmoidoscopy and Anoscopy T 0429 Level V Cystourethroscopy and other Genitourinary Procedures T 0432 Level II Health and Behavior Services S 0433 Level II Pathology X 0434 Cardiac Defect Repair T0436 Level I Drug Administration S

0437 Level II Drug Administration S 0438 Level III Drug Administration S 0439 Level IV Drug Administration S 0440 Level V Drug Administration S 0442 Dosimetric Drug Administration S 0604 Level 1 Hospital Clinic Visits V 0605 Level 2 Hospital Clinic Visits V 0606 Level 3 Hospital Clinic Visits V 0607 Level 4 Hospital Clinic Visits V 0608 Level 5 Hospital Clinic Visits V 0609 Level 1 Type A Emergency Visits V 0613 Level 2 Type A Emergency Visits V 0614 Level 3 Type A Emergency Visits V 0615 Level 4 Type A Emergency Visits V 0616 Level 5 Type A Emergency Visits V 0617Critical Care S 0618Trauma Response with Critical Care S 0621 Level I Vascular Access Procedures T 0622 Level II Vascular Access Procedures T 0623 Level III Vascular Access Procedures T 0624 Phlebotomyand Minor Vascular Access Device Procedures X 0626 Level 1 Type B Emergency Visits V 0627 Level 2 Type B Emergency Visits V 0628 Level 3 Type B Emergency Visits V 0629 Level 4 Type B Emergency Visits V 0630 Level 5 Type B Emergency Visits V 0648 Level IV Breast Surgery T 0651 Complex Interstitial Radiation Source Application S 0652 Insertion of Intraperitoneal and Pleural Catheters T 0653Vascular Reconstruction/Fistula Repair with Device T 0654 Level II Insertion/Replacement of Permanent Pacemaker T 0655 Insertion/Replacement/Conversion of a Permanent Dual Chamber Pacemaker or Pacing Electrode T 0656Transcatheter Placement of Intracoronary Drug-Eluting Stents T 0659 Hyperbaric Oxygen S 0660 Level II Otorhinolaryngologic Function Tests X 0661 Level V Pathology X 0662 CT Angiography S 0664 Level I Proton BeamRadiation Therapy S 0665 Bone Density:AppendicularSkeleton S 0667 Level II Proton BeamRadiation Therapy S 0668 Level I Angiography and Venography T 0672 Level III Posterior Segment Eye Procedures T 0673 Level V Anterior Segment Eye Procedures T 0674 Prostate Cryoablation T 0676Thrombolysis and Other Device Revisions T 0678 External Counterpulsation T 0679 Level II Resuscitation and Cardioversion S 0680 Insertion of Patient Activated Event Recorders S 0683 Level II Photochemotherapy S 0685 Level III Needle Biopsy /Aspiration Except Bone Marrow T 0687 Revision/Removal of Neurostimulator Electrodes T0688 Revision/Removal of Neurostimulator Pulse Generator Receiver T

0690 Level I Electronic Analysis of Devices S 0691 Level III Electronic Analysis of Devices S 0692 Level II Electronic Analysis of Devices S 0694 Mohs Surgery T 0697 Level I Echocardiogram Without Contrast S 0698 Level II Eye Tests & Treatments S 0699 Level IV Eye Tests & Treatments T 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 sodiuminj K 0751 Mechlorethamine hcl inj K 0752 Dactinomycin injection K 0759 Naltrexone, depot form K 0800 Leuprolide acetate K 0802 Etoposide oral K 0807Aldesleukin injection K 0809 Bcg live intravesical vac K 0810 Goserelin acetate implant K 0812 Carmustine injection K 0814Asparaginase injection 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 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 0864 Mitoxantrone hydrochl K 0868Oral aprepitant K 0873 Hyalgan/supartz inj per dose K 0874Synvisc or synvisc-one K 0875 Euflexxa inj per dose K0877Orthovisc inj per dose K

0884 Rho d immune globulin inj K 0887Azathioprine parenteral K 0890 Lymphocy

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

tomegalovirus imm IV /vial K 0910 Interferon beta-1b / .25 MG K 0913 Ganciclovir 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 0934 Capecitabine, oral K 0943Octagam injection K 0944 Gammagard liquid injection K 0945 Rhophylac injection K 0946 Hepagam b im injection K 0947 Flebogamma injection G 0948 Gamunex, Gamunex-C, Gammaked K 0949 Frozen plasma, pooled, sd R 0950Whole blood for transfusion R 0951 Reclast injection K 0952 Cryoprecipitate each unit R 0954 RBC leukocy

tes reduced R 0955 Plasma, frz between 8-24hour R 0956 Plasma protein fract,5%,50ml R 0957 Platelets, each unit R 0958 Plaelet rich plasma unit R 0959 Red blood cells unit R 0960Washed red blood cells unit R 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 0967 Blood split unit R 0968 Platelets leukoreduced irrad R 0969 RBC leukoreduced irradiated R 1009Cryoprecipitatereducedplasma R 1010 Blood, l/r, cmv-neg R 1011 Platelets, hla-m, l/r, unit R 1013 Platelets leukocy tes reduced R 1015 Injection glatiramer acetate K 1016 Blood, l/r, froz/degly /wash R 1017 Plt, aph/pher, l/r, cmv-neg R 1018 Blood, l/r, irradiated R 1019 Plate pheres leukoredu irrad R1020 Plt, pher, l/r cmv-neg, irr R

1021 RBC, frz/deg/wsh, l/r, irrad R 1022 RBC, l/r, cmv-neg, irrad R 1023 Pralidoxime chloride inj K 1052 Injection, voriconazole K 1064 I131 iodide cap, rx K 1083Adalimumab injection K 1084 Denileukin diftitox inj K 1086Temozolomide K 1138 Hepagam b intravenous, inj K 1139 Protein c concentrate K 1142 Supprelin LA implant K 1150 I131 iodide sol, rx K 1166 Cy

tarabine liposome inj K 1167 Inj, epirubicin hcl K 1168 Inj, temsirolimus K 1178 Busulfan 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 5 MG inj K 1235Valrubicin injection K 1236 Levoleucovorin 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 1242 Oasis burn matrix skin sub K 1243 Integra BMWD skin sub K 1245 Dermagraft skin sub K 1246 Graftjacket skin sub K 1247 Integra matrix skin sub K 1248 Primatrix skin sub K 1249Cymetra allograft K 1250 Graftjacket express allograf K 1251 Integra flowable wound matri K 1252 Gammagraft skin sub K 1253Triamcinolone A inj PRS-free K 1263Antithrombin iii injection K 1268Xyntha inj K 1270Allodermskin sub K 1272Acetylcysteine injection K 1274 Edetate calcium disodium inj K 1275Vivaglobin, inj K 1280 Corticotropin injection K 1281 Bevacizumab injection K 1287Alloskin skin sub K 1289AbobotulinumtoxinA K 1290 Human fibrinogen conc inj K1291 Rilonacept injection K

1295Sm153 lexidronam K 1296 Degarelix injection K 1297 Ferumoxy

tol, 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 1338 Methyl aminolevulinate, top K 1339Oral 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 1345Theraskin K 1347Oxacillin sodium injeciton K 1349Anidulafungin injection K 1350Topotecan injection K 1351 Matristem wound matrix K 1353 Belimumab injection G 1354 Hydroxyprogesterone caproate K 1357 Inj protirelin per 250 mcg K 1361 Enfuvirtide injection K 1408Cyclophosphamide 100 MG inj K 1413 Lumizyme injection K 1415Glassia injection K 1416 Factor XIII anti-hem factor G 1417 Gel-one K 1418Oral everolimus K 1419 Dermacell K 1422Anthrax vaccine sc or im K 1423 Minocycline hydrochloride K 1424 Nabilone oral K 1426 Eribulin mesylate injection G 1427Alloskin K 1428Arthroflex K 1429 Flexhd or allopatch hd K 1430 Unite biomatrix K 1432Arbutamine hcl injection K 1433Calcitonin salmon injection K 1434Testosterone enanthate inj K 1435 Injection estrone per 1 MG K 1437 Gatifloxacin injection K 1438 Diazoxide injection K 1440 Inj desmopressin acetate K 1446Visualization adjunct K 1491 New Technology - Level IA ($0-$10) S 1492 New Technology - Level IB ($10-$20) S 1493 New Technology - Level IC ($20-$30) S1494 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) T1548 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 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 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 1694Ziconotide injection K 1695 Nesiritide injection K1696 Palifermin injection K

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

tx, non-str, Gold-198 U 1717 Brachy

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

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

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

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

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

linear, non-str,P-103 U 2638 Brachy

tx, stranded, I-125 U 2639 Brachy

tx, non-stranded,I-125 U 2640 Brachy

tx, stranded, P-103 U 2641 Brachy

tx, non-stranded,P-103 U 2642 Brachy

tx, stranded, C-131 U 2643 Brachy

tx, non-stranded,C-131 U 2698 Brachy

tx, stranded, NOS U 2699 Brachy

tx, non-stranded, NOS U 2731 Immune globulin, powder K 2770Quinupristin/dalfopristin K 3041 Bivalirudin K 3050Sermorelin acetate injection K 7000Amifostine K 7011 Oprelvekin injection K 7034Somatropin injection K 7035Teniposide 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 Doxorubicin hcl liposome inj K 7048Alteplase recombinant K 7049 Filgrastim 480 mcg injection K 7051 Leuprolide acetate implant K 7308Aminolevulinic acid hcl top K8000 Cardiac Electrophysiologic Evaluation and Ablation Composite T

8001 LDR Prostate Brachy therapy Composite T 8002 Level I Extended Assessment & Management Composite V 8003 Level II Extended Assessment & Management Composite V 8004 Ultrasound Composite S 8005CT and CTA without Contrast Composite S 8006 CT and CTA with Contrast Composite S 8007 MRI and MRA without Contrast Composite S 8008 MRI and MRA with Contrast Composite S 9001 Linezolid injection K 9002Tenecteplase injection K 9003 Palivizumab K 9004 Gemtuzumab 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 9042 Glucagon hydrochloride K 9044 Ibutilide fumarate injection K 9104Antithymocy

te 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 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 9135Varicella-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 9208Agalsidase beta injection K 9209 Laronidase injection K 9210 Palonosetron hcl K 9213 Pemetrexed injection K 9214 Bevacizumab injection K9215Cetuximab injection K

9217 Leuprolide acetate suspnsion K 9224 Galsulfase injection K 9225 Fluocinolone acetonide implt K 9227 Micafungin 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 9243 Bendamustine 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 9260 Ofatumumab 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 9270 Gammaplex IVIG K 9271 Velaglucerase alfa K 9272 Inj, denosumab K 9273Sipuleucel-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 Injection, belatacept G 9287 Inj, brentuximab vedotin G 9288 Inj, centruroides (scorpion) G9289 Inj, erwinia chrysanthemi G

9290 Inj, bupivicaine liposome G 9291 Injection, aflibercept G 9300 Omalizumab injection K 9358SurgiMend, fetal K 9360SurgiMend, neonatal K 9363 Integra Meshed Bil Wound Mat K 9365Oasis tri-layer wound matrix G 9366 EpiFix wound cover G 9367 Endoform Dermal Template K 9406 Iodine I-123 ioflupane G 9500 Platelets, irradiated R 9501 Platelet pheres leukoreduced R 9502 Platelet pheresis irradiated R 9503 Fr frz plasma donor retested R 9504 RBC deglycerolized R 9505 RBC irradiated R 9506 Granulocy

tes, pheresis unit R 9507 Platelets, pheresis R 9508 Plasma 1 donor frz w/in 8 hr R**Relative Weight Payment Rate**  **National Unadjusted**  **Copayment Minimum** 

**Unadjusted Copayment**  0.5254 $37.59 . $7.52 1.6907 $120.95 . $24.19 3.7979 $271.69 . $54.34 4.8296 $345.50 . $69.10 8.7706 $627.42 . $125.49 1.7480 $125.05 . $25.01 10.3129 $737.75 . $147.55 18.1848 $1,300.89 . $260.18 0.3984 $28.50 . $5.70 0.9990 $71.47 . $14.30 1.4931 $106.81 . $21.37 2.9250 $209.25 . $41.85 19.9851 $1,429.67 . $285.94 4.7176 $337.48 . $67.50 8.2121 $587.47 . $117.50 15.7492 $1,126.65 . $225.33 23.2461 $1,662.96 $350.78 $332.60 26.0408 $1,862.88 . $372.58 34.1948 $2,446.19 $581.52 $489.24 45.4542 $3,251.66 $747.07 $650.34 0.3106 $22.22 . $4.45 3.1730 $226.99 . $45.40 0.3234 $23.14 . $4.63 15.6800 $1,121.70 $227.35 $224.34 233.1243 $16,677.01 . $3,335.41 62.4195 $4,465.30 . $893.06 29.6655 $2,122.18 . $424.44 53.8580 $3,852.84 $776.71 $770.57 14.5624 $1,041.75 $258.36 $208.35 40.5562 $2,901.27 . $580.26 62.0282 $4,437.31 . $887.47 21.8975 $1,566.48 . $313.30 32.1975 $2,303.31 . $460.67 48.2459 $3,451.37 . $690.28 82.4593 $5,898.89 . $1,179.78 16.5837 $1,186.35 $249.84 $237.27 28.8522 $2,064.00 . $412.80 22.1850 $1,587.05 $353.37 $317.41 60.5037 $4,328.25 . $865.65 34.3979 $2,460.72 . $492.15 1.3212 $94.51 . $18.91 0.7545 $53.97 . $10.80 0.2735 $19.57 . $3.92 96.8296 $6,926.90 . $1,385.38 26.7317 $1,912.31 . $382.47 52.5982 $3,762.72 . $752.5570.5556 $5,047.34 . $1,009.47 13.5157 $966.87 . $193.38 33.0062 $2,361.16 . $472.24 46.0493 $3,294.23 . $658.85 35.8288 $2,563.08 $591.64 $512.62 5.7616 $412.17 . $82.44 1.0784 $77.15 . $15.43 1.9995 $143.04 . $28.61 4.7396 $339.06 $67.83 $67.82 18.9778 $1,357.61 . $271.53 28.5087 $2,039.43 . $407.89 10.6786 $763.92 $189.82 $152.79 0.4909 $35.12 $7.74 $7.03 1.4148 $101.21 . $20.25 3.6238 $259.24 . $51.85 36.9974 $2,646.68 $814.26 $529.34 105.2367 $7,528.32 . $1,505.67 56.7154 $4,057.25 . $811.45 9.4704 $677.48 . $135.50 54.9610 $3,931.75 . $786.35 114.6545 $8,202.04 . $1,640.41 43.3335 $3,099.95 $655.22 $619.99 115.6854 $8,275.79 . $1,655.16 93.1522 $6,663.83 $1,593.50 $1,332.77 42.3205 $3,027.48 . $605.50 27.4197 $1,961.52 . $392.31 31.4543 $2,250.15 . $450.03 2.2476 $160.79 $43.80 $32.16 1.1192 $80.06 . $16.02 1.5192 $108.68 $36.86 $21.74 0.9381 $67.11 . $13.43 0.3734 $26.71 . $5.35 2.4849 $177.76 $41.29 $35.56 4.2461 $303.75 $100.24 $60.75 0.5533 $39.58 . $7.92 16.3036 $1,166.31 . $233.27 84.6536 $6,055.86 . $1,211.18 24.0233 $1,718.55 . $343.71 52.8526 $3,780.92 . $756.19 312.1605 $22,331.03 . $4,466.21 429.3365 $30,713.45 . $6,142.69 3.6370 $260.18 . $52.04 13.3379 $954.15 . $190.83 40.2240 $2,877.50 . $575.50 25.4594 $1,821.29 . $364.26 51.3560 $3,673.85 . $734.77 39.4529 $2,822.34 . $564.47 6.1459 $439.66 . $87.94 1.1030 $78.91 $16.21 $15.79 111.9857 $8,011.12 . $1,602.23 7.9786 $570.77 $166.16 $114.16 1.8591 $132.99 . $26.6037.9697 $2,716.24 $657.95 $543.25 48.8897 $3,497.42 $1,001.89 $699.49 71.2368 $5,096.07 $1,236.99 $1,019.22 1.2009 $85.91 $23.38 $17.19 3.5170 $251.60 . $50.32 5.5137 $394.43 . $78.89 15.6276 $1,117.95 . $223.59 21.1855 $1,515.55 . $303.11 5.5865 $399.64 . $79.93 12.5151 $895.29 . $179.06 6.7872 $485.54 . $97.11 8.7174 $623.62 $138.69 $124.73 10.3526 $740.59 $152.78 $148.12 9.6675 $691.58 $186.06 $138.32 5.8661 $419.64 . $83.93 10.0248 $717.14 . $143.43 6.2985 $450.58 . $90.12 25.5694 $1,829.16 . $365.84 33.0918 $2,367.29 . $473.46 24.1832 $1,729.99 . $346.00 27.4809 $1,965.90 . $393.18 24.6167 $1,761.00 . $352.20 33.9755 $2,430.51 . $486.11 18.0581 $1,291.82 . $258.37 3.2049 $229.27 . $45.86 2.4454 $174.94 . $34.99 8.5615 $612.46 $0.00 $0.00 5.7865 $413.95 $0.00 $0.00 7.1868 $514.12 . $102.83 15.7268 $1,125.05 . $225.01 26.7444 $1,913.21 . $382.65 38.2928 $2,739.35 . $547.87 2.1103 $150.96 . $30.20 20.0058 $1,431.15 . $286.23 21.7305 $1,554.53 . $310.91 33.2292 $2,377.12 . $475.43 39.8171 $2,848.40 $982.91 $569.68 6.9116 $494.44 . $98.89 1.1965 $85.59 . $17.12 1.5254 $109.12 . $21.83 127.1491 $9,095.87 $2,020.00 $1,819.18 2.4903 $178.15 . $35.63 3.1730 $226.99 . $45.40 37.8242 $2,705.83 $607.88 $541.17 23.7733 $1,700.67 . $340.14 13.5726 $970.94 . $194.19 1.6584 $118.64 . $23.73 3.2763 $234.38 . $46.88 23.5219 $1,682.69 $424.28 $336.54 0.1155 $8.26 $1.73 $1.66 7.0140 $501.76 . $100.36 20.3268 $1,454.12 . $290.8336.9280 $2,641.72 . $528.35 47.7993 $3,419.42 $981.50 $683.89 12.0337 $860.85 . $172.17 2.5701 $183.86 . $36.78 4.1225 $294.91 . $58.99 7.9441 $568.30 . $113.66 52.7307 $3,772.20 . $754.44 11.2956 $808.05 $268.73 $161.61 2.4206 $173.16 $53.58 $34.64 0.6035 $43.17 . $8.64 2.5454 $182.09 . $36.42 1.1274 $80.65 . $16.13 18.8390 $1,347.69 . $269.54 34.1093 $2,440.08 . $488.02 44.6585 $3,194.74 . $638.95 197.6879 $14,142.00 . $2,828.40 121.0619 $8,660.41 . $1,732.09 0.6755 $48.32 . $9.67 2.0063 $143.52 . $28.71 2.1105 $150.98 $31.75 $30.20 15.6845 $1,122.02 . $224.41 23.3409 $1,669.74 $347.84 $333.95 5.7978 $414.76 . $82.96 20.0163 $1,431.91 . $286.39 3.2670 $233.71 . $46.75 8.5434 $611.17 . $122.24 19.1469 $1,369.71 $294.39 $273.95 26.8526 $1,920.95 . $384.19 39.1619 $2,801.52 $592.01 $560.31 25.2961 $1,809.61 $412.25 $361.93 41.5672 $2,973.59 $794.86 $594.72 24.2726 $1,736.39 $490.32 $347.28 5.7277 $409.74 $102.26 $81.95 29.3351 $2,098.55 $500.00 $419.71 1.0886 $77.88 $24.11 $15.58 3.1743 $227.08 . $45.42 7.0106 $501.52 $100.37 $100.31 16.1612 $1,156.12 . $231.23 25.1050 $1,795.94 . $359.19 9.3488 $668.79 . $133.76 45.8191 $3,277.76 . $655.56 429.2950 $30,710.48 $7,921.74 $6,142.10 0.6444 $46.10 . $9.22 0.9939 $71.10 . $14.22 0.5038 $36.04 . $7.21 3.5937 $257.08 . $51.42 0.9048 $64.73 $22.26 $12.95 1.3912 $99.52 $37.23 $19.91 2.1724 $155.41 $59.55 $31.09 5.4729 $391.51 . $78.31 7.8018 $558.12 $128.60 $111.63 1.5638 $111.87 $30.47 $22.387.0831 $506.70 . $101.34 4.1819 $299.16 $68.90 $59.84 1.1580 $82.84 $32.89 $16.57 1.7199 $123.04 $46.59 $24.61 2.9140 $208.46 $58.44 $41.70 31.0202 $2,219.09 . $443.82 50.3190 $3,599.67 . $719.94 1.3855 $99.11 $33.02 $19.83 4.1591 $297.53 $95.58 $59.51 6.3386 $453.44 $146.59 $90.69 1.0345 $74.01 $0.00 $0.00 122.6861 $8,776.60 . $1,755.32 5.4996 $393.42 . $78.69 1.3445 $96.18 . $19.24 2.5103 $179.58 . $35.92 2.8223 $201.90 $66.95 $40.38 1.5332 $109.68 $34.63 $21.94 4.0619 $290.58 $88.78 $58.12 14.7924 $1,058.20 . $211.64 13.7671 $984.86 $325.27 $196.98 6.0908 $435.72 . $87.15 9.5758 $685.02 $258.85 $137.01 294.7618 $21,086.37 . $4,217.28 4.5839 $327.92 . $65.59 365.4831 $26,145.56 $9,121.76 $5,229.12 204.5012 $14,629.40 $5,559.48 $2,925.88 6.1609 $440.73 . $88.15 1.1775 $84.23 . $16.85 1.5327 $109.64 . $21.93 1.7756 $127.02 . $25.41 0.8420 $60.23 . $12.05 7.4526 $533.14 . $106.63 4.2852 $306.55 $118.52 $61.31 2.4318 $173.96 $67.26 $34.80 4.6212 $330.59 $114.81 $66.12 6.7610 $483.66 $155.87 $96.74 4.7484 $339.69 $133.46 $67.94 7.6939 $550.40 $197.64 $110.08 0.6842 $48.95 . $9.79 0.0951 $6.80 $2.09 $1.36 0.1745 $12.48 . $2.50 0.5329 $38.12 $10.84 $7.63 0.8437 $60.36 $15.56 $12.08 0.2510 $17.96 . $3.60 0.3454 $24.71 . $4.95 0.4782 $34.21 . $6.85 0.3785 $27.08 $0.00 $0.00 1.9062 $136.36 $33.59 $27.28 4.2382 $303.19 $83.23 $60.64 0.9283 $66.41 $16.39 $13.29 0.5034 $36.01 . $7.21 1.2436 $88.96 $18.04 $17.801.6472 $117.84 $23.61 $23.57 0.6282 $44.94 $11.94 $8.99 0.8794 $62.91 $20.93 $12.59 2.5614 $183.23 $37.24 $36.65 1.3608 $97.35 . $19.47 1.1894 $85.09 . $17.02 85.8109 $6,138.65 . $1,227.73 9.5396 $682.43 . $136.49 4.6922 $335.67 $126.64 $67.14 0.3666 $26.23 . $5.25 2.5082 $179.43 . $35.89 3.7434 $267.79 . $53.56 29.5262 $2,112.22 . $422.45 107.0250 $7,656.25 . $1,531.25 175.3015 $12,540.54 . $2,508.11 37.4400 $2,678.35 $654.91 $535.67 24.0522 $1,720.62 . $344.13 1.6141 $115.47 $26.88 $23.10 2.1030 $150.44 $47.69 $30.09 3.2734 $234.17 $65.46 $46.84 2.7659 $197.86 . $39.58 5.9172 $423.30 . $84.66 4.4003 $314.78 $90.78 $62.96 3.5975 $257.35 $87.01 $51.47 3.6693 $262.49 $94.20 $52.50 2.6869 $192.21 . $38.45 4.3237 $309.30 $93.33 $61.86 3.9108 $279.77 $90.90 $55.96 3.0769 $220.11 $71.16 $44.03 6.6677 $476.99 . $95.40 3.6785 $263.15 $72.42 $52.63 4.6512 $332.73 $81.55 $66.55 4.2057 $300.86 $85.06 $60.18 3.3171 $237.30 $78.13 $47.46 13.6417 $975.89 . $195.18 0.1352 $9.67 $2.17 $1.94 6.7605 $483.63 . $96.73 4.1401 $296.17 . $59.24 7.0927 $507.39 . $101.48 21.8294 $1,561.61 $354.68 $312.33 12.9655 $927.51 $207.70 $185.51 26.2520 $1,877.99 . $375.60 56.8197 $4,064.71 . $812.95 15.6413 $1,118.93 $240.83 $223.79 125.1124 $8,950.17 . $1,790.04 2.6537 $189.84 . $37.97 16.7086 $1,195.28 . $239.06 22.1946 $1,587.74 . $317.55 45.6142 $3,263.10 . $652.62 0.6335 $45.32 . $9.07 0.3272 $23.41 $5.17 $4.69 168.8994 $12,082.56 . $2,416.520.3785 $27.08 . $5.42 0.5466 $39.10 . $7.82 1.0462 $74.84 . $14.97 2.0425 $146.11 . $29.23 3.2265 $230.81 . $46.17 28.1454 $2,013.44 . $402.69 0.7925 $56.69 . $11.34 1.0287 $73.59 . $14.72 1.3504 $96.60 . $19.32 1.7870 $127.84 . $25.57 2.4304 $173.86 . $34.78 0.7230 $51.72 $12.04 $10.35 1.2884 $92.17 $20.80 $18.44 2.0025 $143.25 $33.60 $28.65 3.2022 $229.08 $47.70 $45.82 4.8085 $343.99 $71.54 $68.80 7.4708 $534.44 . $106.89 12.8243 $917.41 . $183.49 11.0410 $789.84 . $157.97 24.5089 $1,753.29 . $350.66 31.2603 $2,236.27 . $447.26 0.6874 $49.17 $12.39 $9.84 0.9493 $67.91 . $13.59 0.7568 $54.14 . $10.83 1.2614 $90.24 . $18.05 1.8896 $135.18 . $27.04 2.8514 $203.98 . $40.80 64.4193 $4,608.36 . $921.68 13.1991 $944.22 . $188.85 31.7089 $2,268.36 . $453.68 34.1843 $2,445.44 . $489.09 107.1276 $7,663.59 . $1,532.72 143.4184 $10,259.72 . $2,051.95 108.0208 $7,727.48 . $1,545.50 1.5107 $108.07 . $21.62 1.8607 $133.11 $27.10 $26.63 2.1783 $155.83 . $31.17 4.7607 $340.57 $114.37 $68.12 6.2961 $450.40 . $90.08 0.4887 $34.96 $0.00 $0.00 15.5196 $1,110.23 . $222.05 10.0722 $720.53 . $144.11 40.5599 $2,901.53 . $580.31 41.8435 $2,993.36 $635.64 $598.68 108.8394 $7,786.04 . $1,557.21 2.4087 $172.31 . $34.47 1.4108 $100.92 . $20.19 5.5944 $400.21 $95.30 $80.05 82.6419 $5,911.95 . $1,182.39 2.3899 $170.97 . $34.20 9.9714 $713.32 . $142.67 22.0360 $1,576.39 $389.48 $315.2836.6798 $2,623.96 $768.94 $524.80 0.4741 $33.92 . $6.79 2.6793 $191.67 . $38.34 1.5756 $112.71 . $22.55 5.1217 $366.39 $88.07 $73.28 2.9595 $211.71 . $42.35 1.0325 $73.86 . $14.78 15.9003 $1,137.46 . $227.50

$977.14 . $195.43 $199.93 . $39.99 $260.33 . $52.07 $24.83 . $4.97 $14.84 . $2.97 $14.58 . $2.92 $201.27 . $40.26 $277.37 . $55.48 $157.86 . $31.58 $578.75 . $115.75 $2.84 . $0.57 $607.26 . $121.46 $47.13 . $9.43 $1,097.99 . $219.60 $119.88 . $23.98 $172.90 . $34.58 $175.80 . $35.16 $63.27 . $12.66 $17.64 . $3.53 $57.67 . $11.54 $11.72 . $2.35 $119.55 . $23.91 $68.03 . $13.61 $35.17 . $7.04 $31.70 . $6.34 $104.43 . $20.89 $101.68 . $20.34 $17.96 . $3.60 $593.79 . $118.76 $1,352.09 . $270.42 $89.12 . $17.83 $5,889.99 . $1,178.00 $839.53 . $167.91 $641.95 . $128.39 $274.19 . $54.84 $143.01 . $28.61 $19,325.79 . $3,865.16 $23.15 . $4.63 $5.17 . $1.04 $29.97 . $6.00 $6.18 . $1.24 $89.49 . $17.90 $12.35 . $2.47 $147.39 . $29.48$166.38 . $33.28 $83.87 . $16.78 $119.28 . $23.86 $618.09 . $123.62 $41.99 . $8.40 $3.93 . $0.79 $5.47 . $1.10 $966.09 . $193.22 $224.19 . $44.84 $16,960.00 . $3,392.00 $105.06 . $21.02 $0.90 . $0.18 $1.11 . $0.23 $0.88 . $0.18 $1.63 . $0.33 $0.92 . $0.19 $1.19 . $0.24 $26.02 . $5.21 $34.64 . $6.93 $40.21 . $8.05 $5.19 . $1.04 $48.16 . $9.64 $34.93 . $6.99 $37.61 . $7.53 1.0142 $72.55 . $14.51 2.3764 $170.00 . $34.00

$222.63 . $44.53 1.1330 $81.05 . $16.21 2.7005 $193.19 . $38.64 1.0513 $75.21 . $15.05 0.3485 $24.93 . $4.99 1.2528 $89.62 . $17.93 2.4364 $174.29 . $34.86 2.1111 $151.02 . $30.21 4.3667 $312.38 . $62.48

$22.19 . $4.44 $60.45 . $12.09 $30.37 . $6.08 $69.50 . $13.90 0.6693 $47.88 . $9.58 1.9812 $141.73 . $28.35 2.1351 $152.74 . $30.55 3.8041 $272.13 . $54.43 0.9372 $67.04 . $13.41 2.5568 $182.91 . $36.59 10.8958 $779.45 . $155.89 1.6564 $118.49 . $23.70

$113.07 . $22.62 1.7577 $125.74 . $25.15 4.7739 $341.51 . $68.31 2.4756 $177.10 . $35.42 9.4363 $675.04 . $135.019.0891 $650.21 . $130.05 5.2432 $375.08 . $75.02 4.0243 $287.89 . $57.58

$84.79 . $16.96 $6.57 . $1.32 $17.92 . $3.59 $428.51 . $85.71 $1,646.18 . $329.24 $10.16 . $2.04 $48.16 . $9.64 $13.11 . $2.63 $15,936.02 . $3,187.21 $11.20 . $2.24 $513.16 . $102.64 $1.70 . $0.34 $52.17 . $10.44 $19.08 . $3.82 $10.06 . $2.02 $123.10 . $24.62 $0.92 . $0.19 $35.04 . $7.01 $86.57 . $17.32 $18.15 . $3.63 $991.66 . $198.34 $1.66 . $0.34 $12.10 . $2.42 $81.84 . $16.37 $108.65 . $21.73 $36.56 . $7.32 $7.41 . $1.49 $7.41 . $1.49 $18.87 . $3.78 $41.31 . $8.27 $95.00 . $19.00 $26.96 . $5.40 $31.49 . $6.30 $163.52 . $32.71 $276.33 . $55.27 $1,101.34 . $220.27 $7.05 . $1.41 $3.50 . $0.70 $2.75 . $0.55 $1.09 . $0.22 $32.30 . $6.46 $2.84 . $0.57 $189.16 . $37.84 $12.72 . $2.55 $2,692.84 . $538.57 $1.53 . $0.31 $7.93 . $1.59 $7.22 . $1.45 $26.72 . $5.35$24.09 . $4.82 $7,738.00 . $1,547.60 $2.97 . $0.60 $0.63 . $0.13 $4.12 . $0.83 $89.13 . $17.83 $7.29 . $1.46 $41.99 . $8.40 $2.75 . $0.55 $103.35 . $20.67 $74.85 . $14.97 $83.34 . $16.67 $38.23 . $7.65 $132.55 . $26.51 $2.95 . $0.59 $75.68 . $15.14 $3.72 . $0.75 $22.49 . $4.50 $2.81 . $0.57 $1.36 . $0.28 $6.71 . $1.35 $4.75 . $0.95 $38.32 . $7.67 $2.30 . $0.46 $29.82 . $5.97 $0.53 . $0.11 $14.96 . $3.00 $151.16 . $30.24 $3.88 . $0.78 $6.41 . $1.29 $1,033.50 . $206.70 $5.78 . $1.16 $34.27 . $6.86 $112.86 . $22.58 $0.58 . $0.12 $23.43 . $4.69 $91.04 . $18.21 $14.03 . $2.81 $125.99 . $25.20 $40.70 . $8.14 $36.18 . $7.24 $86.37 . $17.28 $57.09 . $11.42 $33.36 . $6.68 $1.54 . $0.31 $86.53 . $17.31 $88.31 . $17.67 $5.73 . $1.15 $3.34 . $0.67 $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 $549.23 . $109.85 $23.50 . $4.70 $219.33 . $43.87 $16.41 . $3.29 $526.34 . $105.27 $74.34 . $14.87 $113.12 . $22.63 $76.24 . $15.25 $38.26 . $7.66 $36,612.79 . $7,322.56 $30,188.56 . $6,037.72 $251.63 . $50.33 $178.35 . $35.67 $56.16 . $11.24 $2,227.72 . $445.55 $5.32 . $1.07 $3.26 . $0.66 $9.76 . $1.96 $783.48 . $156.70 $299.94 . $59.99 $7.07 . $1.42 $10.61 . $2.13 $396.86 . $79.38 $6.61 . $1.33 $49.25 . $9.85$11.77 . $2.36 $1,030.50 . $206.10 $27.50 . $5.50 $61.24 . $12.25 $0.89 . $0.18 $1.58 . $0.32 $5.39 . $1.08 $122.54 . $24.51 $3,139.61 . $627.93 $9.59 . $1.92 1.5481 $110.75 . $22.15 3.4759 $248.66 . $49.74 0.5106 $36.53 . $7.31

$9.78 . $1.96 $259.70 . $51.94 $61.77 . $12.36

..

..

..

.. $42.40 . $8.48 219.8701 $15,728.85 . $3,145.77 0.2916 $20.86 . $4.18 0.9330 $66.74 . $13.35 0.4232 $30.27 . $6.06 0.4995 $35.73 . $7.15 0.6459 $46.21 . $9.25 0.5006 $35.81 . $7.17 1.0587 $75.74 . $15.15 0.8383 $59.97 . $12.00 1.5393 $110.12 . $22.03 0.9277 $66.36 . $13.28 0.6459 $46.21 . $9.25 0.4232 $30.27 . $6.06

$31.50 . $6.30 $174.44 . $34.89 $2.78 . $0.56 $1.80 . $0.36 $323.69 . $64.74 $243.70 . $48.74 $63.20 . $12.64 $322.24 . $64.45 $457.73 . $91.55 $1,156.08 . $231.22 $8.71 . $1.75 $7.87 . $1.58 $63.53 . $12.71 $538.79 . $107.76 $46.36 . $9.28 $414.06 . $82.82 $4,819.82 . $963.97 $150.74 . $30.15156.2062 $11,174.52 . $2,234.91 45.8369 $3,279.03 . $655.81 6.0780 $434.80 . $86.96 11.0788 $792.54 . $158.51 2.7458 $196.43 . $39.29 5.6132 $401.55 . $80.31 9.5434 $682.71 . $136.55 9.8907 $707.55 . $141.51 14.5362 $1,039.88 . $207.98

$37.04 . $7.41 $55.87 . $11.18 $1,181.14 . $236.23 $2,742.59 . $548.52 $2,301.89 . $460.38 $139.61 . $27.93 $40.58 . $8.12 $10.93 . $2.19 $12.62 . $2.53 $250.52 . $50.11 $25.12 . $5.03 $10.44 . $2.09 $183.42 . $36.69 $757.18 . $151.44 $115.05 . $23.01 $110.77 . $22.16 $191.70 . $38.34 $445.03 . $89.01 $1,053.29 . $210.66 $586.73 . $117.35 $226.20 . $45.24 $2,798.77 . $559.76 $86.08 . $17.22 $19.17 . $3.84 $193.78 . $38.76 $0.51 . $0.11 $5.29 . $1.06 $11.11 . $2.23 $186.90 . $37.38 $174.92 . $34.99 $76.31 . $15.27 $113.89 . $22.78 $201.17 . $40.24 $156.92 . $31.39 $112.88 . $22.58 $102.08 . $20.42 $87.64 . $17.53 $42.45 . $8.49 $141.19 . $28.24 $26.84 . $5.37 $18.44 . $3.69 $54.96 . $11.00 $60.96 . $12.20$50.42 . $10.09 $214.97 . $43.00 $346.06 . $69.22 $19,345.00 . $3,869.00 $0.96 . $0.20 $1.33 . $0.27 $151.90 . $30.38 $21.68 . $4.34 $33.23 . $6.65 $455.03 . $91.01 $400.71 . $80.15 $205.32 . $41.07 $87.22 . $17.45 $195.47 . $39.10 $33.24 . $6.65 $65.60 . $13.12 $1.71 . $0.35 $18.82 . $3.77 $52.65 . $10.53 $47.75 . $9.55 $3.00 . $0.60 $4.35 . $0.87 $139.81 . $27.97 $45.68 . $9.14 $286.00 . $57.20 $4.81 . $0.97 $6.83 . $1.37 $195.95 . $39.19 $2.09 . $0.42 $168.82 . $33.77 $46.29 . $9.26 $128.04 . $25.61 $290.36 . $58.08 $3.53 . $0.71 $230.38 . $46.08 $26.04 . $5.21 $30.81 . $6.17 $38.01 . $7.61 $356.07 . $71.22 $14.67 . $2.94 $33,491.92 . $6,698.39 $2,151.96 . $430.40 $136.91 . $27.39 $4.56 . $0.92 $302.04 . $60.41 $0.73 . $0.15 $0.11 . $0.03 $125.18 . $25.04 $13.24 $0.00 $0.00 $3.81 . $0.77 $95.40 . $19.08 $4,156.25 . $831.25$337.29 . $67.46 $1.14 $0.00 $0.00 $1,961.00 . $392.20 $22.73 . $4.55 $11.33 . $2.27 $11.60 . $2.32 $18.68 . $3.74 $10.36 . $2.08 $102.05 . $20.41 $4.43 . $0.89 $1,905.21 $0.00 $0.00 1.8712 $133.86 . $26.78 7.1309 $510.12 . $102.03 9.2677 $662.98 . $132.60 0.8285 $59.27 . $11.86 6.8857 $492.58 . $98.52 2.8518 $204.01 . $40.81 22.6910 $1,623.25 . $324.65 6.0352 $431.74 . $86.35 1.0805 $77.30 . $15.46