Addendum A.-Proposed OPPS APCs for CY 2013

APC 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

0035 Vascular 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

0047 Arthroplasty 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 T
0064 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

0069 Thoracoscopy T

0070 Thoracentesis/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

0079 Ventilation Initiation and Management S

0080 Diagnostic Cardiac Catheterization T

0082 Coronary or Non-Coronary Atherectomy T

0083 Coronary 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

0088 Thrombectomy 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

0093 Vascular Reconstruction/Fistula Repair without Device T

0094 Level I Resuscitation and Cardioversion S

0095 Cardiac 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

0104 Transcatheter 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

0110 Transfusion S

0111 Blood Product Exchange S

0112 Apheresis and Stem Cell Procedures S

0113 Excision Lymphatic System T

0114 Thyroid/Lymphadenectomy Procedures T

0115 Cannula/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 T
0130 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

0157 Colorectal Cancer Screening: Barium Enema S

0158 Colorectal Cancer Screening: Colonoscopy T

0159 Colorectal 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 T
0195 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

0243 Strabismus/Muscle Procedures T

0244 Corneal and Amniotic Membrane Transplant T

0246 Cataract Procedures with IOL Insert T

0247 Laser Eye Procedures T

0249 Cataract 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 Film Except Teeth X

0261 Level II Plain Film Except Teeth Including Bone Density Measurement X

0262 Plain Film of 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 X
0274 Myelography S

0275 Arthrography 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

0283 Computed Tomography with Contrast S

0284 Magnetic Resonance Imaging and Magnetic Resonance Angiography with Contrast S

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

0303 Treatment 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 Brachytherapy 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

0325 Group Psychotherapy S

0330 Dental Procedures S

0331 Combined Abdomen and Pelvis CT without Contrast S

0332 Computed Tomography without Contrast S

0333 Computed 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

0350 Administration 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 X
0366 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

0375 Ancillary 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

0383 Cardiac 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

0395 GI Tract Imaging

S

0396 Bone Imaging

S

0397 Vascular 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

T
0436 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

0617 Critical Care S

0618 Trauma 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 Phlebotomy and 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

0653 Vascular 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

0656 Transcatheter 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 Beam Radiation Therapy S

0665 Bone Density:AppendicularSkeleton S

0667 Level II Proton Beam Radiation 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

0676 Thrombolysis 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 T
0688 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

0735 Ampho b cholesteryl sulfate

K

0736 Amphotericin b liposome inj

K

0738 Rasburicase

K

0747 Chlorothiazide sodium inj

K

0751 Mechlorethamine hcl inj

K

0752 Dactinomycin injection

K

0759 Naltrexone, depot form

K

0800 Leuprolide acetate

K

0802 Etoposide oral

K

0807 Aldesleukin injection

K

0809 Bcg live intravesical vac

K

0810 Goserelin acetate implant

K

0812 Carmustine injection

K

0814 Asparaginase 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

0835 Cosyntropin injection NOS

K

0836 Interferon alfa-2b inj

K

0838 Interferon gamma 1-b inj

K

0840 Inj melphalan hydrochl

K

0842 Fludarabine phosphate inj

K

0843 Pegaspargase injection

K

0844 Pentostatin injection

K

0849 Rituximab injection

K

0850 Streptozocin injection

K

0851 Thiotepa injection

K

0856 Porfimer sodium injection

K

0858 Inj cladribine

K

0861 Leuprolide acetate injeciton

K

0864 Mitoxantrone hydrochl

K

0868 Oral aprepitant

K

0873 Hyalgan/supartz inj per dose

K

0874 Synvisc or synvisc-one

K

0875 Euflexxa inj per dose

K
0877 Orthovisc inj per dose

K

0884 Rho d immune globulin inj

K

0887 Azathioprine parenteral

K

0890 Lymphocyte immune globulin

K

0900 Alglucerase injection

K

0901 Alpha 1 proteinase inhibitor

K

0902 Injection,onabotulinumtoxinA

K

0903 Cytomegalovirus imm IV /vial

K

0910 Interferon beta-1b / .25 MG

K

0913 Ganciclovir long act implant

K

0917 Adenosine injection

K

0925 Factor viii

K

0927 Factor viii recombinant

K

0928 Factor ix complex

K

0929 Anti-inhibitor

K

0931 Factor IX non-recombinant

K

0932 Factor IX recombinant

K

0934 Capecitabine, oral

K

0943 Octagam injection

K

0944 Gammagard liquid injection

K

0945 Rhophylac injection

K

0946 Hepagam b im injection

K

0947 Flebogamma injection

G

0948 Gamunex, Gamunex-C, Gammaked

K

0949 Frozen plasma, pooled, sd

R

0950 Whole blood for transfusion

R

0951 Reclast injection

K

0952 Cryoprecipitate each unit

R

0954 RBC leukocytes 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

0960 Washed red blood cells unit

R

0961 Albumin (human),5%, 50ml

K

0963 Albumin (human), 5%, 250 ml

K

0964 Albumin (human), 25%, 20 ml

K

0965 Albumin (human), 25%, 50ml

K

0966 Plasmaprotein fract,5%,250ml

R

0967 Blood split unit

R

0968 Platelets leukoreduced irrad

R

0969 RBC leukoreduced irradiated

R

1009 Cryoprecipitatereducedplasma

R

1010 Blood, l/r, cmv-neg

R

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

R

1013 Platelets leukocytes 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

R
1020 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

1083 Adalimumab injection

K

1084 Denileukin diftitox inj

K

1086 Temozolomide

K

1138 Hepagam b intravenous, inj

K

1139 Protein c concentrate

K

1142 Supprelin LA implant

K

1150 I131 iodide sol, rx

K

1166 Cytarabine liposome inj

K

1167 Inj, epirubicin hcl

K

1168 Inj, temsirolimus

K

1178 Busulfan injection

K

1203 Verteporfin injection

K

1207 Octreotide injection, depot

K

1213 Antihemophilic viii/vwf comp

K

1214 Inj IVIG privigen 500 mg

K

1221 Dimethyl sulfoxide 50%

K

1232 Mitomycin 5 MG inj

K

1235 Valrubicin injection

K

1236 Levoleucovorin injection

K

1237 Inj iron dextran

K

1238 Topotecan oral

K

1239 Rotavirus vacc 2 dose oral

K

1240 Apligraf skin sub

K

1241 Oasis wound matrix skin sub

K

1242 Oasis burn matrix skin sub

K

1243 Integra BMWD skin sub

K

1245 Dermagraft skin sub

K

1246 Graftjacket skin sub

K

1247 Integra matrix skin sub

K

1248 Primatrix skin sub

K

1249 Cymetra allograft

K

1250 Graftjacket express allograf

K

1251 Integra flowable wound matri

K

1252 Gammagraft skin sub

K

1253 Triamcinolone A inj PRS-free

K

1263 Antithrombin iii injection

K

1268 Xyntha inj

K

1270 Alloderm skin sub

K

1272 Acetylcysteine injection

K

1274 Edetate calcium disodium inj

K

1275 Vivaglobin, inj

K

1280 Corticotropin injection

K

1281 Bevacizumab injection

K

1287 Alloskin skin sub

K

1289 AbobotulinumtoxinA

K

1290 Human fibrinogen conc inj

K
1291 Rilonacept injection

K

1295 Sm 153 lexidronam

K

1296 Degarelix injection

K

1297 Ferumoxytol, non-esrd

K

1307 Oral busulfan

K

1311 Canakinumab injection

G

1312 Hizentra injection

K

1327 Imiglucerase injection

K

1331 Olanzapine long-acting inj

K

1332 Antithrombin recombinant

K

1338 Methyl aminolevulinate, top

K

1339 Oral fludarabine phosphate

K

1340 Collagenase, clost hist inj

K

1341 Amobarbital 125 MG inj

K

1342 Matristem micromatrix

K

1343 Ganciclovir sodium injection

K

1344 Gonadorelin hydroch/ 100 mcg

K

1345 Theraskin

K

1347 Oxacillin sodium injeciton

K

1349 Anidulafungin injection

K

1350 Topotecan injection

K

1351 Matristem wound matrix

K

1353 Belimumab injection

G

1354 Hydroxyprogesterone caproate

K

1357 Inj protirelin per 250 mcg

K

1361 Enfuvirtide injection

K

1408 Cyclophosphamide 100 MG inj

K

1413 Lumizyme injection

K

1415 Glassia injection

K

1416 Factor XIII anti-hem factor

G

1417 Gel-one

K

1418 Oral everolimus

K

1419 Dermacell

K

1422 Anthrax vaccine sc or im

K

1423 Minocycline hydrochloride

K

1424 Nabilone oral

K

1426 Eribulin mesylate injection

G

1427 Alloskin

K

1428 Arthroflex

K

1429 Flexhd or allopatch hd

K

1430 Unite biomatrix

K

1432 Arbutamine hcl injection

K

1433 Calcitonin salmon injection

K

1434 Testosterone enanthate inj

K

1435 Injection estrone per 1 MG

K

1437 Gatifloxacin injection

K

1438 Diazoxide injection

K

1440 Inj desmopressin acetate

K

1446 Visualization 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)

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

S

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

S

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

T

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

T

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

T

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

T

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

T

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

S

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

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

T

1605 Abciximab injection

K

1607 Eptifibatide injection

K

1608 Etanercept injection

K

1609 Rho(D) immune globulin h, sd

K

1612 Daclizumab, parenteral

K

1613 Trastuzumab injection

K

1630 Hep b ig, im

K

1631 Baclofen intrathecal trial

K

1633 Alefacept

K

1643 Y90 ibritumomab, rx

K

1645 I131 tositumomab, rx

K

1670 Tetanus immune globulin inj

K

1675 P32 Na phosphate

K

1676 P32 chromic phosphate

K

1683 Basiliximab

K

1684 Corticorelin ovine triflutal

K

1685 Darbepoetin alfa, non-esrd

K

1686 Epoetin alfa, non-esrd

K

1687 Digoxin immune fab (ovine)

K

1688 Ethanolamine oleate

K

1689 Fomepizole

K

1690 Hemin

K

1693 Lepirudin

K

1694 Ziconotide injection

K

1695 Nesiritide injection

K
1696 Palifermin injection

K

1697 Pegaptanib sodium injection

K

1700 Inj secretin synthetic human

K

1701 Treprostinil injection

K

1704 Humate-P, inj

K

1705 Factor viia

K

1709 Azacitidine injection

K

1710 Clofarabine injection

K

1711 Vantas implant

K

1712 Paclitaxel protein bound

K

1716 Brachytx, non-str, Gold-198

U

1717 Brachytx, non-str, HDR Ir-192

U

1719 Brachytx, NS, Non-HDRIr-192

U

1738 Oxaliplatin

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

1840 Telescopic intraocular lens

H

1886 Catheter, ablation

H

2210 Methyldopate hcl injection

K

2616 Brachytx, non-str,Yttrium-90

U

2632 Iodine I-125 sodium iodide

U

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

U

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

U

2636 Brachy linear, non-str,P-103

U

2638 Brachytx, stranded, I-125

U

2639 Brachytx, non-stranded,I-125

U

2640 Brachytx, stranded, P-103

U

2641 Brachytx, non-stranded,P-103

U

2642 Brachytx, stranded, C-131

U

2643 Brachytx, non-stranded,C-131

U

2698 Brachytx, stranded, NOS

U

2699 Brachytx, non-stranded, NOS

U

2731 Immune globulin, powder

K

2770 Quinupristin/dalfopristin

K

3041 Bivalirudin

K

3050 Sermorelin acetate injection

K

7000 Amifostine

K

7011 Oprelvekin injection

K

7034 Somatropin injection

K

7035 Teniposide

K

7036 Urokinase 250,000 IU inj

K

7038 Monoclonal antibodies

K

7041 Tirofiban HCl

K

7042 Capecitabine, oral

K

7043 Infliximab injection

K

7046 Doxorubicin hcl liposome inj

K

7048 Alteplase recombinant

K

7049 Filgrastim 480 mcg injection

K

7051 Leuprolide acetate implant

K

7308 Aminolevulinic acid hcl top

K
8000 Cardiac Electrophysiologic Evaluation and Ablation Composite

T

8001 LDR Prostate Brachytherapy Composite

T

8002 Level I Extended Assessment & Management Composite

V

8003 Level II Extended Assessment & Management Composite

V

8004 Ultrasound Composite

S

8005 CT 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

9002 Tenecteplase injection

K

9003 Palivizumab

K

9004 Gemtuzumab ozogamicin inj

K

9005 Reteplase injection

K

9006 Tacrolimus injection

K

9012 Arsenic trioxide injection

K

9018 Inj, rimabotulinumtoxinB

K

9019 Caspofungin acetate

K

9022 IM inj interferon beta 1-a

K

9023 Rho d immune globulin

K

9024 Amphotericin b lipid complex

K

9032 Baclofen 10 MG injection

K

9033 Cidofovir injection

K

9038 Inj estrogen conjugate

K

9042 Glucagon hydrochloride

K

9044 Ibutilide fumarate injection

K

9104 Antithymocyte globuln rabbit

K

9108 Thyrotropin injection

K

9110 Alemtuzumab injection

K

9115 Zoledronic acid

K

9119 Injection, pegfilgrastim 6mg

K

9120 Injection, Fulvestrant

K

9121 Injection, argatroban

K

9122 Triptorelin pamoate

K

9124 Daptomycin injection

K

9125 Risperidone, long acting

K

9126 Natalizumab injection

K

9133 Rabies ig, im/sc

K

9134 Rabies ig, heat treated

K

9135 Varicella-zoster ig, im

K

9137 Bcg vaccine, percut

K

9139 Rabies vaccine, im

K

9140 Rabies vaccine, id

K

9143 Meningococcal vaccine, sc

K

9144 Encephalitis vaccine, sc

K

9145 Meningococcal vaccine, im

K

9207 Bortezomib injection

K

9208 Agalsidase beta injection

K

9209 Laronidase injection

K

9210 Palonosetron hcl

K

9213 Pemetrexed injection

K

9214 Bevacizumab injection

K
9215 Cetuximab injection

K

9217 Leuprolide acetate suspnsion

K

9224 Galsulfase injection

K

9225 Fluocinolone acetonide implt

K

9227 Micafungin sodium injection

K

9228 Tigecycline injection

K

9229 Ibandronate sodium injection

K

9230 Abatacept injection

K

9231 Decitabine injection

K

9232 Idursulfase injection

K

9233 Ranibizumab injection

K

9234 Alglucosidase alfa injection

K

9235 Panitumumab injection

K

9236 Eculizumab injection

K

9237 Inj, lanreotide acetate

K

9240 Injection, ixabepilone

K

9242 Injection, fosaprepitant

K

9243 Bendamustine injection

K

9244 Regadenoson injection

K

9245 Romiplostim injection

K

9248 Inj, clevidipine butyrate

K

9249 Certolizumab pegol inj

K

9250 Artiss fibrin sealant

K

9251 C1 esterase inhibitor inj

K

9252 Plerixafor injection

K

9253 Temozolomide injection

K

9255 Paliperidone palmitate inj

K

9256 Dexamethasone intra implant

K

9258 Telavancin injection

K

9259 Pralatrexate injection

K

9260 Ofatumumab injection

K

9261 Ustekinumab injection

K

9263 Ecallantide injection

K

9264 Tocilizumab injection

K

9265 Romidepsin injection

K

9268 Capsaicin 8% patch

K

9269 C-1 esterase, berinert

K

9270 Gammaplex IVIG

K

9271 Velaglucerase alfa

K

9272 Inj, denosumab

K

9273 Sipuleucel-T auto CD54+

K

9274 Crotalidae Poly Immune Fab

K

9276 Cabazitaxel injection

K

9278 Incobotulinumtoxin A

K

9281 Injection, pegloticase

G

9282 Inj, ceftaroline fosamil

G

9283 Injection, acetaminophen

G

9284 Ipilimumab injection

G

9285 Patch, lidocaine/tetracaine

G

9286 Injection, belatacept

G

9287 Inj, brentuximab vedotin

G

9288 Inj, centruroides (scorpion)

G
9289 Inj, erwinia chrysanthemi

G

9290 Inj, bupivicaine liposome

G

9291 Injection, aflibercept

G

9300 Omalizumab injection

K

9358 SurgiMend, fetal

K

9360 SurgiMend, neonatal

K

9363 Integra Meshed Bil Wound Mat

K

9365 Oasis tri-layer wound matrix

G

9366 EpiFix 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 Granulocytes, 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 . $752.55
70.5556 $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. $26.60
37.9697 $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. $290.83
36.9280 $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 $22.38
7.0831 $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 $17.80
1.6472 $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. $2,416.52
0.3785 $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 $315.28
36.6798 $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. $135.01
9.0891 $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

. $30.15
156.2062 $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