| Code | Description | Claims | Beneficiaries | Total Paid |
| 99283 |
|
79,898 |
73,716 |
$9.66M |
| 99284 |
|
68,470 |
63,185 |
$7.94M |
| 96361 |
|
28,248 |
24,988 |
$7.09M |
| 99285 |
|
54,885 |
49,291 |
$6.65M |
| 99213 |
|
25,935 |
23,322 |
$3.52M |
| 59025 |
|
13,119 |
6,506 |
$2.57M |
| 99214 |
|
16,383 |
15,374 |
$2.20M |
| 99392 |
|
13,166 |
13,070 |
$1.76M |
| 99282 |
|
14,477 |
14,001 |
$1.62M |
| 74177 |
|
13,359 |
12,638 |
$1.60M |
| S9485 |
Crisis intervention mental h |
2,483 |
2,310 |
$1.59M |
| 99391 |
|
13,414 |
11,747 |
$1.57M |
| 70450 |
|
14,066 |
13,063 |
$1.24M |
| 99393 |
|
8,489 |
8,419 |
$1.19M |
| 96365 |
|
8,891 |
8,151 |
$758K |
| 96360 |
|
7,196 |
6,815 |
$730K |
| 74176 |
|
5,958 |
5,716 |
$680K |
| 99394 |
|
4,572 |
4,535 |
$633K |
| 97110 |
|
15,278 |
4,426 |
$591K |
| 43239 |
|
1,315 |
1,282 |
$584K |
| 80307 |
|
20,891 |
17,199 |
$574K |
| 94640 |
|
8,930 |
8,182 |
$559K |
| U0003 |
Cov-19 amp prb hgh thruput |
12,781 |
11,958 |
$502K |
| 71275 |
|
3,387 |
3,239 |
$476K |
| 99281 |
|
3,754 |
3,638 |
$430K |
| 76816 |
|
4,460 |
3,669 |
$407K |
| 92587 |
|
3,744 |
3,743 |
$399K |
| 85025 |
|
109,736 |
91,349 |
$392K |
| 93971 |
|
2,492 |
2,360 |
$371K |
| 76705 |
|
4,882 |
4,648 |
$367K |
| 76856 |
|
3,286 |
3,144 |
$320K |
| G0463 |
Hospital outpt clinic visit |
11,508 |
10,367 |
$315K |
| 77063 |
|
5,061 |
5,016 |
$302K |
| 99211 |
|
2,586 |
2,128 |
$275K |
| 93975 |
|
3,064 |
2,943 |
$264K |
| 99212 |
|
1,675 |
1,614 |
$260K |
| ATP14 |
|
26,694 |
22,153 |
$244K |
| 87635 |
|
6,399 |
6,006 |
$224K |
| 76819 |
|
5,071 |
3,308 |
$218K |
| 72148 |
|
1,249 |
1,205 |
$215K |
| 78452 |
|
790 |
744 |
$213K |
| G0480 |
Drug test def 1-7 classes |
11,029 |
9,067 |
$203K |
| 76830 |
|
2,514 |
2,397 |
$201K |
| 87804 |
|
24,089 |
12,222 |
$196K |
| 87426 |
|
9,159 |
8,758 |
$196K |
| 71046 |
|
32,315 |
30,586 |
$194K |
| G0378 |
Hospital observation per hr |
11,225 |
4,645 |
$192K |
| 93306 |
|
1,398 |
1,278 |
$192K |
| 45378 |
|
250 |
246 |
$190K |
| 64493 |
|
449 |
422 |
$180K |
| 12001 |
|
952 |
909 |
$180K |
| 11042 |
|
1,700 |
1,106 |
$173K |
| 76815 |
|
2,398 |
1,931 |
$168K |
| U0005 |
Infec agen detec ampli probe |
12,656 |
11,922 |
$165K |
| 77067 |
|
6,493 |
6,439 |
$161K |
| 84484 |
|
38,803 |
25,092 |
$160K |
| 76642 |
|
1,550 |
1,335 |
$157K |
| 87651 |
|
8,755 |
8,561 |
$156K |
| 90471 |
|
33,058 |
32,220 |
$155K |
| 87631 |
|
2,171 |
2,108 |
$148K |
| 96374 |
|
34,736 |
31,403 |
$148K |
| 70551 |
|
594 |
550 |
$141K |
| 76817 |
|
2,794 |
2,442 |
$129K |
| 96366 |
|
855 |
793 |
$129K |
| 76801 |
|
3,059 |
2,827 |
$123K |
| 97597 |
|
1,832 |
1,015 |
$120K |
| 97803 |
|
1,512 |
1,455 |
$114K |
| 84702 |
|
13,872 |
12,385 |
$113K |
| 93017 |
|
1,615 |
1,529 |
$111K |
| 70553 |
|
481 |
457 |
$109K |
| 93976 |
|
1,291 |
1,218 |
$108K |
| ATP08 |
|
15,426 |
12,366 |
$108K |
| 81025 |
|
25,357 |
23,517 |
$99K |
| 99219 |
|
2,003 |
991 |
$95K |
| 71260 |
|
1,348 |
1,298 |
$94K |
| 97161 |
|
2,739 |
2,546 |
$92K |
| 76700 |
|
623 |
603 |
$90K |
| 76775 |
|
825 |
783 |
$90K |
| 83690 |
|
25,015 |
22,658 |
$87K |
| 76536 |
|
815 |
794 |
$84K |
| 87086 |
|
19,360 |
17,911 |
$80K |
| 80053 |
|
60,473 |
53,336 |
$78K |
| 19318 |
|
12 |
12 |
$78K |
| 45380 |
|
179 |
175 |
$75K |
| 87591 |
|
3,957 |
3,744 |
$73K |
| 95810 |
|
110 |
97 |
$72K |
| 97802 |
|
928 |
917 |
$72K |
| 88305 |
|
7,473 |
6,326 |
$70K |
| 83880 |
|
5,851 |
5,229 |
$68K |
| 93005 |
|
39,143 |
34,925 |
$68K |
| 87491 |
|
3,679 |
3,472 |
$68K |
| 81001 |
|
42,744 |
39,190 |
$67K |
| 71250 |
|
1,104 |
1,063 |
$66K |
| 12011 |
|
276 |
268 |
$65K |
| 99173 |
|
3,235 |
3,235 |
$59K |
| 80048 |
|
49,758 |
42,081 |
$59K |
| 97140 |
|
3,400 |
1,117 |
$57K |
| 87880 |
|
6,385 |
6,148 |
$56K |
| ATP15 |
|
6,322 |
5,287 |
$55K |
| 20610 |
|
561 |
510 |
$54K |
| 96372 |
|
15,170 |
13,585 |
$53K |
| 99291 |
|
687 |
653 |
$52K |
| 20553 |
|
333 |
322 |
$49K |
| 90715 |
|
3,711 |
3,624 |
$47K |
| U0004 |
Cov-19 test non-cdc hgh thru |
904 |
881 |
$45K |
| 72141 |
|
253 |
249 |
$44K |
| 64494 |
|
411 |
354 |
$43K |
| 72100 |
|
3,401 |
3,279 |
$43K |
| 70498 |
|
418 |
387 |
$41K |
| 97010 |
|
950 |
403 |
$40K |
| 84600 |
|
5,198 |
4,432 |
$40K |
| 93970 |
|
103 |
94 |
$38K |
| 77080 |
|
667 |
658 |
$37K |
| 71045 |
|
14,854 |
13,783 |
$36K |
| 84703 |
|
8,634 |
8,205 |
$35K |
| 90733 |
|
700 |
685 |
$35K |
| 85379 |
|
6,640 |
6,283 |
$35K |
| 76811 |
|
444 |
442 |
$35K |
| 72125 |
|
4,088 |
3,841 |
$34K |
| 0241U |
|
3,973 |
3,785 |
$34K |
| 73721 |
|
121 |
116 |
$34K |
| 86850 |
|
6,447 |
6,002 |
$33K |
| 12002 |
|
179 |
175 |
$33K |
| 96375 |
|
25,577 |
22,586 |
$33K |
| 87040 |
|
7,327 |
4,039 |
$31K |
| 81003 |
|
26,835 |
25,043 |
$30K |
| 83735 |
|
10,118 |
7,693 |
$30K |
| 82306 |
|
1,558 |
1,526 |
$30K |
| 73562 |
|
3,595 |
3,322 |
$29K |
| 76770 |
|
206 |
204 |
$28K |
| 83605 |
|
5,828 |
4,686 |
$26K |
| 87807 |
|
2,647 |
2,573 |
$25K |
| 64495 |
|
151 |
144 |
$25K |
| 87081 |
|
5,392 |
5,197 |
$25K |
| 80050 |
|
1,858 |
1,756 |
$24K |
| 87186 |
|
5,561 |
5,159 |
$24K |
| 85610 |
|
13,046 |
11,256 |
$22K |
| 76805 |
|
223 |
220 |
$22K |
| 76870 |
|
282 |
256 |
$21K |
| 73030 |
|
3,277 |
3,053 |
$20K |
| 86900 |
|
7,744 |
7,181 |
$20K |
| 84443 |
|
3,586 |
3,348 |
$20K |
| 73130 |
|
3,200 |
2,981 |
$19K |
| 73630 |
|
3,741 |
3,559 |
$19K |
| 87077 |
|
5,205 |
4,791 |
$19K |
| 74018 |
|
1,713 |
1,622 |
$19K |
| 82947 |
|
20,892 |
12,973 |
$19K |
| 17250 |
|
77 |
66 |
$18K |
| 87070 |
|
4,011 |
3,677 |
$18K |
| 97112 |
|
712 |
276 |
$17K |
| 10060 |
|
103 |
102 |
$17K |
| 90472 |
|
15,207 |
15,036 |
$17K |
| 85027 |
|
5,608 |
4,784 |
$17K |
| 73610 |
|
4,170 |
3,996 |
$17K |
| 36415 |
|
44,954 |
34,226 |
$17K |
| 92557 |
|
579 |
571 |
$17K |
| 90621 |
|
245 |
245 |
$16K |
| 45385 |
|
25 |
25 |
$16K |
| 70486 |
|
358 |
349 |
$16K |
| 82728 |
|
2,099 |
2,029 |
$16K |
| 83036 |
|
3,715 |
3,412 |
$16K |
| 82805 |
|
578 |
490 |
$16K |
| 87147 |
|
2,870 |
2,689 |
$15K |
| 99204 |
|
112 |
112 |
$15K |
| 86901 |
|
7,752 |
7,181 |
$14K |
| 85730 |
|
5,135 |
4,632 |
$14K |
| 77065 |
Tomosynthesis, mammo |
292 |
273 |
$14K |
| G0297 |
Ldct for lung ca screen |
40 |
40 |
$13K |
| 62323 |
|
68 |
66 |
$13K |
| 90853 |
|
384 |
70 |
$12K |
| 82607 |
|
1,396 |
1,359 |
$12K |
| 90834 |
|
137 |
73 |
$12K |
| J2405 |
Ondansetron hcl injection |
27,553 |
22,373 |
$12K |
| 90791 |
|
66 |
66 |
$11K |
| 70496 |
|
495 |
453 |
$11K |
| J1885 |
Ketorolac tromethamine inj |
23,592 |
20,641 |
$11K |
| 92567 |
|
1,292 |
1,283 |
$11K |
| 84466 |
|
1,382 |
1,328 |
$10K |
| 92556 |
|
156 |
156 |
$10K |
| 73110 |
|
2,010 |
1,895 |
$10K |
| J0696 |
Ceftriaxone sodium injection |
7,139 |
5,855 |
$10K |
| 70491 |
|
81 |
77 |
$10K |
| 97035 |
|
228 |
77 |
$9K |
| 88304 |
|
1,718 |
1,602 |
$9K |
| J3010 |
Fentanyl citrate injection |
12,766 |
9,035 |
$9K |
| 82746 |
|
962 |
940 |
$9K |
| 73502 |
|
1,174 |
1,087 |
$9K |
| J7030 |
Normal saline solution infus |
16,486 |
12,700 |
$8K |
| 87641 |
|
365 |
333 |
$8K |
| J1650 |
Inj enoxaparin sodium |
1,063 |
442 |
$8K |
| Q9967 |
Locm 300-399mg/ml iodine,1ml |
12,204 |
11,458 |
$8K |
| 87661 |
|
430 |
400 |
$8K |
| 77336 |
|
63 |
25 |
$8K |
| 72131 |
|
319 |
306 |
$8K |
| 88342 |
|
1,811 |
1,655 |
$8K |
| 77066 |
Tomosynthesis, mammo |
221 |
218 |
$8K |
| J2704 |
Inj, propofol, 10 mg |
14,458 |
11,370 |
$8K |
| 80076 |
|
13,745 |
12,457 |
$7K |
| 87502 |
|
141 |
136 |
$7K |
| 85007 |
|
4,198 |
3,589 |
$7K |
| J7120 |
Ringers lactate infusion |
2,359 |
1,911 |
$7K |
| 87428 |
|
111 |
110 |
$7K |
| 36430 |
|
34 |
25 |
$7K |
| ATP02 |
|
2,270 |
1,800 |
$6K |
| 99381 |
|
90 |
88 |
$6K |
| 99395 |
|
55 |
55 |
$6K |
| 87205 |
|
3,161 |
2,857 |
$6K |
| 76813 |
|
89 |
87 |
$6K |
| 83540 |
|
1,586 |
1,522 |
$6K |
| 97530 |
|
317 |
202 |
$6K |
| 72040 |
|
301 |
287 |
$6K |
| G0121 |
Colon ca scrn not hi rsk ind |
12 |
12 |
$6K |
| J1170 |
Hydromorphone injection |
7,647 |
4,876 |
$6K |
| 97116 |
|
232 |
112 |
$6K |
| ATP03 |
|
1,644 |
1,417 |
$6K |
| 87798 |
|
152 |
134 |
$6K |
| J2270 |
Morphine sulfate injection |
9,546 |
6,696 |
$5K |
| 76857 |
|
71 |
67 |
$5K |
| 94060 |
|
60 |
60 |
$5K |
| 87486 |
|
247 |
240 |
$5K |
| 93010 |
|
1,467 |
1,394 |
$4K |
| 64483 |
|
12 |
12 |
$4K |
| J1030 |
Methylprednisolone 40 mg inj |
4,084 |
3,708 |
$4K |
| 77062 |
|
40 |
40 |
$4K |
| 87808 |
|
593 |
552 |
$4K |
| 85652 |
|
2,972 |
2,672 |
$4K |
| 84425 |
|
265 |
260 |
$4K |
| 80179 |
|
1,142 |
1,090 |
$4K |
| 73140 |
|
451 |
438 |
$3K |
| J0690 |
Cefazolin sodium injection |
3,634 |
3,083 |
$3K |
| 76000 |
|
305 |
297 |
$3K |
| 74246 |
|
21 |
21 |
$3K |
| J1100 |
Dexamethasone sodium phos |
7,948 |
7,152 |
$3K |
| 80061 |
|
4,354 |
4,107 |
$3K |
| U0002 |
Covid-19 lab test non-cdc |
1,252 |
1,161 |
$3K |
| 81513 |
|
32 |
29 |
$3K |
| J0702 |
Betamethasone acet&sod phosp |
130 |
116 |
$3K |
| 82565 |
|
3,536 |
3,327 |
$3K |
| 95816 |
|
13 |
13 |
$3K |
| ATP17 |
|
372 |
351 |
$3K |
| 72070 |
|
49 |
46 |
$2K |
| 83921 |
|
169 |
168 |
$2K |
| 86140 |
|
834 |
727 |
$2K |
| J2250 |
Inj midazolam hydrochloride |
7,202 |
6,573 |
$2K |
| 73080 |
|
562 |
544 |
$2K |
| J1200 |
Diphenhydramine hcl injectio |
9,726 |
8,141 |
$2K |
| J3490 |
Drugs unclassified injection |
70 |
62 |
$2K |
| 82570 |
|
789 |
683 |
$2K |
| 99253 |
|
13 |
13 |
$2K |
| 87075 |
|
504 |
437 |
$2K |
| 83655 |
|
181 |
179 |
$2K |
| 84112 |
|
26 |
25 |
$2K |
| 73221 |
|
13 |
13 |
$2K |
| 87640 |
|
201 |
195 |
$2K |
| 99215 |
Prolong outpt/office vis |
13 |
13 |
$2K |
| J7512 |
Prednisone ir or dr oral 1mg |
3,319 |
2,849 |
$2K |
| 87088 |
|
472 |
448 |
$2K |
| J1644 |
Inj heparin sodium per 1000u |
1,615 |
690 |
$2K |
| J2060 |
Lorazepam injection |
4,509 |
3,304 |
$1K |
| J2930 |
Methylprednisolone injection |
2,787 |
2,348 |
$1K |
| J3475 |
Inj magnesium sulfate |
583 |
450 |
$1K |
| 90474 |
|
5,592 |
5,539 |
$1K |
| 97162 |
|
27 |
26 |
$1K |
| 80143 |
|
1,426 |
1,331 |
$1K |
| 90837 |
|
13 |
12 |
$1K |
| 94729 |
|
59 |
59 |
$1K |
| 84520 |
|
3,347 |
3,157 |
$995.64 |
| 84590 |
|
125 |
123 |
$942.36 |
| J7050 |
Normal saline solution infus |
1,450 |
1,020 |
$941.44 |
| 71271 |
|
17 |
17 |
$896.31 |
| J3370 |
Vancomycin hcl injection |
508 |
240 |
$893.35 |
| 87899 |
|
123 |
107 |
$874.19 |
| 87481 |
|
47 |
44 |
$839.89 |
| 86580 |
|
91 |
89 |
$740.70 |
| 83550 |
|
154 |
147 |
$694.22 |
| 90686 |
|
90 |
80 |
$684.68 |
| 82272 |
|
333 |
295 |
$620.80 |
| 83918 |
|
68 |
66 |
$610.56 |
| 96376 |
|
3,600 |
3,216 |
$609.76 |
| 93041 |
|
390 |
216 |
$595.87 |
| G0108 |
Diab manage trn per indiv |
13 |
13 |
$573.32 |
| J2785 |
Regadenoson injection |
159 |
149 |
$564.86 |
| 84439 |
|
105 |
100 |
$497.09 |
| 83090 |
|
41 |
40 |
$486.75 |
| 99383 |
|
14 |
14 |
$471.80 |
| J0780 |
Prochlorperazine injection |
813 |
728 |
$467.41 |
| 84445 |
|
13 |
13 |
$463.90 |
| 80164 |
|
76 |
68 |
$461.34 |
| 77002 |
|
30 |
27 |
$447.15 |
| 83970 |
|
13 |
13 |
$436.92 |
| 73590 |
|
69 |
63 |
$415.98 |
| 88142 |
|
28 |
28 |
$406.56 |
| ATP09 |
|
85 |
63 |
$394.24 |
| 84146 |
|
28 |
28 |
$382.36 |
| 82550 |
|
980 |
883 |
$353.70 |
| 82533 |
|
27 |
26 |
$333.61 |
| 82150 |
|
85 |
74 |
$327.32 |
| 73521 |
|
12 |
12 |
$298.45 |
| J1956 |
Levofloxacin injection |
603 |
417 |
$280.54 |
| 86703 |
|
28 |
27 |
$262.50 |
| J0171 |
Adrenalin epinephrine inject |
91 |
81 |
$261.22 |
| J2001 |
Lidocaine injection |
4,560 |
4,051 |
$240.47 |
| J7040 |
Normal saline solution infus |
172 |
148 |
$221.69 |
| J0295 |
Ampicillin sulbactam 1.5 gm |
14 |
12 |
$219.32 |
| 72072 |
|
12 |
12 |
$217.23 |
| 87480 |
|
14 |
14 |
$212.16 |
| 82248 |
|
375 |
272 |
$197.09 |
| 82247 |
|
208 |
144 |
$184.41 |
| 86923 |
|
15 |
12 |
$183.42 |
| 83615 |
|
317 |
270 |
$180.80 |
| A9585 |
Gadobutrol injection |
1,350 |
1,194 |
$175.58 |
| J1630 |
Haloperidol injection |
554 |
450 |
$160.07 |
| 73090 |
|
26 |
25 |
$157.48 |
| 80320 |
|
868 |
780 |
$156.91 |
| 90658 |
|
6,040 |
6,037 |
$155.25 |
| 84134 |
|
15 |
15 |
$154.44 |
| 84460 |
|
298 |
271 |
$148.09 |
| P9016 |
Rbc leukocytes reduced |
16 |
12 |
$147.83 |
| 84450 |
|
226 |
202 |
$144.62 |
| 86618 |
|
14 |
13 |
$132.74 |
| 85384 |
|
16 |
13 |
$128.55 |
| 87046 |
|
15 |
13 |
$126.62 |
| 87045 |
|
15 |
13 |
$107.14 |
| 81002 |
|
42 |
25 |
$105.60 |
| 83525 |
|
13 |
13 |
$104.30 |
| ATP06 |
|
14 |
12 |
$98.28 |
| 84550 |
|
275 |
241 |
$97.93 |
| 84153 |
|
12 |
12 |
$97.32 |
| 86592 |
|
29 |
29 |
$93.21 |
| 84156 |
|
33 |
27 |
$92.15 |
| 85651 |
|
33 |
27 |
$80.30 |
| J2765 |
Metoclopramide hcl injection |
5,695 |
4,984 |
$77.24 |
| 88311 |
|
12 |
12 |
$72.75 |
| 82043 |
|
27 |
25 |
$68.64 |
| J7510 |
Prednisolone oral per 5 mg |
754 |
692 |
$62.27 |
| 80177 |
|
17 |
13 |
$54.68 |
| 86308 |
|
13 |
12 |
$53.40 |
| 82010 |
|
15 |
13 |
$50.47 |
| 90734 |
|
1,344 |
1,343 |
$42.87 |
| 84100 |
|
159 |
125 |
$42.08 |
| 90707 |
|
2,066 |
2,050 |
$31.11 |
| 90716 |
|
1,992 |
1,981 |
$22.02 |
| 73560 |
|
32 |
30 |
$19.73 |
| 90685 |
|
3,899 |
3,888 |
$13.26 |
| J7613 |
Albuterol non-comp unit |
1,642 |
1,039 |
$9.11 |
| 99406 |
|
142 |
121 |
$6.92 |
| 90634 |
|
684 |
657 |
$0.00 |
| 80329 |
|
347 |
320 |
$0.00 |
| 90680 |
|
5,703 |
5,648 |
$0.00 |
| 90657 |
|
2,601 |
2,576 |
$0.00 |
| J2370 |
Phenylephrine hcl injection |
501 |
397 |
$0.00 |
| 94760 |
|
83 |
52 |
$0.00 |
| J8540 |
Oral dexamethasone |
384 |
337 |
$0.00 |
| 90698 |
|
1,531 |
1,459 |
$0.00 |
| C1769 |
Guide wire |
150 |
139 |
$0.00 |
| J7644 |
Ipratropium bromide non-comp |
47 |
45 |
$0.00 |
| G0008 |
Admin influenza virus vac |
48 |
47 |
$0.00 |
| 90647 |
|
84 |
84 |
$0.00 |
| J2795 |
Ropivacaine hcl injection |
29 |
24 |
$0.00 |
| 90744 |
|
704 |
666 |
$0.00 |
| J3480 |
Inj potassium chloride |
20 |
12 |
$0.00 |
| Q3014 |
Telehealth facility fee |
35 |
35 |
$0.00 |
| J1010 |
Inj, methylpred acetate 1 mg |
44 |
37 |
$0.00 |
| J1040 |
Methylprednisolone 80 mg inj |
63 |
58 |
$0.00 |
| 90723 |
|
71 |
71 |
$0.00 |
| A9579 |
Gad-base mr contrast nos,1ml |
17 |
16 |
$0.00 |
| J0330 |
Succinycholine chloride inj |
15 |
13 |
$0.00 |
| Q9966 |
Locm 200-299mg/ml iodine,1ml |
67 |
62 |
$0.00 |
| A9502 |
Tc99m tetrofosmin |
627 |
590 |
$0.00 |
| 90649 |
|
2,408 |
2,390 |
$0.00 |
| G8979 |
Mobility goal status |
288 |
262 |
$0.00 |
| G8978 |
Mobility current status |
233 |
222 |
$0.00 |
| J2919 |
Inj, methylpred sod succ 5mg |
98 |
88 |
$0.00 |
| C9113 |
Inj pantoprazole sodium, via |
462 |
308 |
$0.00 |
| G1004 |
Cdsm ndsc |
422 |
331 |
$0.00 |
| 90710 |
|
229 |
220 |
$0.00 |
| A4649 |
Surgical supplies |
224 |
200 |
$0.00 |
| J2710 |
Neostigmine methylslfte inj |
105 |
80 |
$0.00 |
| C1765 |
Adhesion barrier |
41 |
38 |
$0.00 |
| C1713 |
Anchor/screw bn/bn,tis/bn |
44 |
39 |
$0.00 |
| 84145 |
|
13 |
13 |
$0.00 |