| Code | Description | Claims | Beneficiaries | Total Paid |
| 99283 |
Emergency department visit for the evaluation and management, moderate severity |
33,472 |
28,789 |
$5.46M |
| 99284 |
Emergency department visit for the evaluation and management, high severity |
25,048 |
20,565 |
$3.73M |
| 96361 |
Intravenous infusion, hydration; each additional hour |
12,004 |
8,143 |
$2.62M |
| G0463 |
Hospital outpatient clinic visit for assessment and management of a patient |
32,291 |
23,757 |
$2.25M |
| 99282 |
Emergency department visit for the evaluation and management, low to moderate severity |
10,020 |
7,164 |
$1.62M |
| 74177 |
Computed tomography, abdomen and pelvis; with contrast material |
4,287 |
3,621 |
$690K |
| 93306 |
Echocardiography, transthoracic, real-time with image documentation, with and without Doppler, complete |
2,398 |
2,091 |
$575K |
| 70450 |
Computed tomography, head or brain; without contrast material |
4,383 |
3,606 |
$569K |
| 97110 |
Therapeutic procedure, each 15 minutes; therapeutic exercises to develop strength and endurance, flexibility and range of motion |
11,765 |
3,143 |
$491K |
| 99285 |
Emergency department visit for the evaluation and management, high severity with immediate threat to life |
4,620 |
3,592 |
$457K |
| 96360 |
Intravenous infusion, hydration; initial, 31 minutes to 1 hour |
3,816 |
3,000 |
$371K |
| 96365 |
Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour |
6,275 |
4,378 |
$361K |
| 74176 |
Computed tomography, abdomen and pelvis; without contrast material |
2,364 |
2,013 |
$360K |
| 96366 |
Intravenous infusion, for therapy, prophylaxis, or diagnosis; each additional hour |
2,534 |
1,581 |
$297K |
| G0378 |
Hospital observation service, per hour |
2,415 |
1,894 |
$271K |
| 59025 |
Fetal non-stress test |
1,824 |
1,062 |
$256K |
| 20610 |
|
1,929 |
1,474 |
$234K |
| 96413 |
Chemotherapy administration, intravenous infusion; up to 1 hour, single or initial substance |
2,569 |
1,156 |
$227K |
| 43239 |
Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple |
419 |
381 |
$208K |
| 87635 |
Infectious agent detection by nucleic acid; SARS-CoV-2 (COVID-19), amplified probe |
2,473 |
2,263 |
$203K |
| 76805 |
Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation |
2,032 |
1,863 |
$175K |
| 45380 |
Colonoscopy, flexible; with biopsy, single or multiple |
306 |
284 |
$175K |
| 80307 |
Drug test(s), presumptive, any number of drug classes; immunoassay |
4,379 |
3,518 |
$162K |
| 94640 |
Pressurized or nonpressurized inhalation treatment for acute airway obstruction |
4,426 |
3,145 |
$153K |
| 70553 |
Magnetic resonance imaging, brain; without contrast material, followed by contrast material and further sequences |
425 |
387 |
$133K |
| 99281 |
Emergency department visit for the evaluation and management, self-limited or minor |
676 |
571 |
$131K |
| 71260 |
Computed tomography, thorax, diagnostic; with contrast material |
1,444 |
1,301 |
$119K |
| 0202U |
Oncology (prostate), multianalyte, gene expression profiling |
1,356 |
1,264 |
$115K |
| 71275 |
Computed tomographic angiography, chest, with contrast material |
560 |
496 |
$102K |
| C9803 |
Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source |
5,561 |
4,950 |
$100K |
| 77067 |
Screening mammography, bilateral, including computer-aided detection |
3,615 |
3,421 |
$99K |
| 76705 |
Ultrasound, abdominal, real time with image documentation; limited |
1,023 |
947 |
$92K |
| 93017 |
|
981 |
858 |
$91K |
| 77063 |
Screening digital breast tomosynthesis, bilateral |
1,885 |
1,797 |
$90K |
| 80053 |
Comprehensive metabolic panel |
24,734 |
18,416 |
$84K |
| 97530 |
Therapeutic activities, direct patient contact, each 15 minutes |
2,022 |
897 |
$81K |
| 11056 |
|
1,429 |
1,112 |
$79K |
| 78452 |
Myocardial perfusion imaging, tomographic (SPECT); multiple studies at rest and/or stress |
159 |
134 |
$71K |
| 97162 |
|
595 |
531 |
$69K |
| 76642 |
|
589 |
543 |
$64K |
| 97112 |
Therapeutic procedure, each 15 minutes; neuromuscular reeducation of movement, balance, coordination |
3,623 |
1,282 |
$60K |
| 96367 |
|
1,092 |
683 |
$55K |
| 97140 |
Manual therapy techniques, each 15 minutes (e.g., mobilization/manipulation, manual lymphatic drainage) |
4,500 |
1,604 |
$54K |
| 71046 |
Radiologic examination, chest; 2 views |
5,178 |
4,462 |
$48K |
| 93005 |
Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report |
18,423 |
14,349 |
$48K |
| 76856 |
Ultrasound, pelvic (nonobstetric), real time with image documentation; complete |
310 |
292 |
$40K |
| 72125 |
Computed tomography, cervical spine; without contrast material |
1,399 |
1,199 |
$37K |
| 93971 |
|
459 |
389 |
$37K |
| 70551 |
Magnetic resonance imaging, brain; without contrast material |
215 |
194 |
$35K |
| 87040 |
|
6,136 |
2,802 |
$32K |
| 96372 |
Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular |
10,477 |
6,698 |
$29K |
| 73560 |
|
1,952 |
1,456 |
$28K |
| 94060 |
|
516 |
463 |
$28K |
| 10060 |
|
385 |
298 |
$28K |
| 71250 |
|
453 |
415 |
$27K |
| 80048 |
Basic metabolic panel (calcium, ionized) |
10,452 |
7,827 |
$25K |
| 96374 |
Therapeutic, prophylactic, or diagnostic injection; intravenous push, single or initial substance |
11,915 |
9,194 |
$25K |
| 85025 |
Blood count; complete (CBC), automated, and automated differential WBC count |
36,665 |
25,342 |
$24K |
| 71271 |
|
223 |
214 |
$22K |
| 72148 |
Magnetic resonance imaging, lumbar spine; without contrast material |
123 |
112 |
$22K |
| 83880 |
|
2,746 |
2,138 |
$19K |
| 73630 |
|
1,602 |
1,379 |
$19K |
| 66984 |
Extracapsular cataract removal with insertion of intraocular lens prosthesis |
27 |
25 |
$19K |
| 73030 |
|
1,678 |
1,367 |
$18K |
| 99291 |
Critical care, evaluation and management of the critically ill patient, first 30-74 minutes |
102 |
89 |
$18K |
| 73610 |
|
1,394 |
1,219 |
$18K |
| 90715 |
|
1,075 |
1,001 |
$17K |
| 76815 |
Ultrasound, pregnant uterus, real time with image documentation, limited |
204 |
182 |
$15K |
| 71045 |
Radiologic examination, chest; single view |
12,977 |
10,454 |
$15K |
| 84443 |
Thyroid stimulating hormone (TSH) |
3,107 |
2,617 |
$13K |
| 90471 |
Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections), 1 vaccine |
1,426 |
1,292 |
$12K |
| 94729 |
|
433 |
399 |
$12K |
| 94618 |
|
177 |
129 |
$12K |
| 87591 |
Infectious agent detection by nucleic acid; Neisseria gonorrhoeae, amplified probe |
1,493 |
1,326 |
$11K |
| 73110 |
|
682 |
558 |
$11K |
| 76830 |
Ultrasound, transvaginal |
106 |
98 |
$10K |
| 97163 |
|
74 |
69 |
$10K |
| 80076 |
|
3,601 |
2,585 |
$10K |
| 84484 |
|
12,303 |
7,364 |
$10K |
| 36415 |
Collection of venous blood by venipuncture |
15,249 |
11,430 |
$10K |
| 80047 |
|
3,370 |
2,826 |
$10K |
| 94726 |
|
345 |
321 |
$10K |
| Q5106 |
Injection, epoetin alfa-epbx, biosimilar, (retacrit) (for non-esrd use), 1000 units |
188 |
76 |
$9K |
| J3490 |
Unclassified drugs |
15,758 |
7,184 |
$9K |
| 45385 |
Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) |
13 |
13 |
$9K |
| 96375 |
Therapeutic injection; each additional sequential IV push |
10,344 |
7,221 |
$8K |
| U0003 |
Infectious agent detection by nucleic acid (dna or rna); severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), amplified probe technique, making use of high throughput technologies as described by cms-2020-01-r |
560 |
496 |
$7K |
| 93325 |
|
57 |
50 |
$7K |
| J1885 |
Injection, ketorolac tromethamine, per 15 mg |
8,428 |
6,581 |
$7K |
| 97161 |
|
430 |
353 |
$7K |
| U0002 |
2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc |
4,321 |
3,824 |
$6K |
| 74018 |
|
432 |
396 |
$6K |
| 73502 |
|
586 |
518 |
$6K |
| 73130 |
|
645 |
570 |
$6K |
| 76536 |
|
56 |
54 |
$6K |
| 83735 |
|
11,315 |
7,636 |
$6K |
| 87077 |
|
3,662 |
2,683 |
$6K |
| J2405 |
Injection, ondansetron hydrochloride, per 1 mg |
7,841 |
5,901 |
$5K |
| 86885 |
|
2,613 |
2,185 |
$5K |
| 86756 |
|
411 |
381 |
$5K |
| 88305 |
Level IV - Surgical pathology, gross and microscopic examination |
3,990 |
2,340 |
$5K |
| 80061 |
Lipid panel |
2,308 |
2,055 |
$4K |
| 87086 |
Culture, bacterial; quantitative colony count, urine |
10,508 |
8,823 |
$4K |
| 83605 |
|
4,403 |
2,754 |
$4K |
| 85379 |
|
873 |
759 |
$4K |
| 93350 |
|
13 |
13 |
$4K |
| 76775 |
|
43 |
40 |
$4K |
| 81025 |
|
7,357 |
6,363 |
$4K |
| 87491 |
Infectious agent detection by nucleic acid; Chlamydia trachomatis, amplified probe |
1,482 |
1,316 |
$4K |
| 82306 |
Vitamin D; 25 hydroxy, includes fraction(s), if performed |
568 |
517 |
$4K |
| 83036 |
Hemoglobin; glycosylated (A1C) |
2,764 |
2,364 |
$4K |
| 77065 |
Tomosynthesis, mammo |
79 |
76 |
$4K |
| 70498 |
|
13 |
12 |
$4K |
| A9150 |
Non-prescription drugs |
42,392 |
16,980 |
$3K |
| 81002 |
|
8,175 |
4,841 |
$3K |
| J2469 |
Injection, palonosetron hcl, 25 mcg |
170 |
88 |
$3K |
| 96415 |
|
21 |
12 |
$3K |
| 12001 |
|
16 |
15 |
$3K |
| 81003 |
|
2,452 |
2,071 |
$3K |
| 82728 |
|
1,841 |
1,402 |
$3K |
| 73721 |
Magnetic resonance imaging, any joint of lower extremity; without contrast material |
15 |
13 |
$3K |
| 77336 |
|
43 |
12 |
$3K |
| 86900 |
|
2,869 |
2,391 |
$3K |
| 85027 |
|
1,314 |
1,132 |
$3K |
| J3010 |
Injection, fentanyl citrate, 0.1 mg |
4,149 |
3,203 |
$3K |
| 70486 |
|
45 |
41 |
$2K |
| J2704 |
Injection, propofol, 10 mg |
7,512 |
3,527 |
$2K |
| J1650 |
Injection, enoxaparin sodium, 10 mg |
2,443 |
1,041 |
$2K |
| G0127 |
Trimming of dystrophic nails, any number |
549 |
421 |
$2K |
| 81001 |
|
16,824 |
13,714 |
$2K |
| 82947 |
|
8,155 |
4,446 |
$2K |
| 77066 |
Tomosynthesis, mammo |
44 |
41 |
$2K |
| 93880 |
|
33 |
27 |
$2K |
| 87804 |
Infectious agent antigen detection by immunoassay; Influenza, each type |
10,488 |
4,740 |
$2K |
| 87081 |
|
2,646 |
2,436 |
$2K |
| 86901 |
|
2,869 |
2,391 |
$2K |
| 83550 |
|
1,694 |
1,297 |
$2K |
| J1100 |
Injection, dexamethasone sodium phosphate, 1 mg |
5,371 |
2,976 |
$2K |
| G0279 |
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) |
68 |
65 |
$2K |
| 86140 |
|
1,069 |
829 |
$2K |
| 11721 |
|
534 |
367 |
$1K |
| 87430 |
|
2,716 |
2,516 |
$1K |
| 83540 |
|
1,719 |
1,314 |
$1K |
| 84702 |
|
648 |
493 |
$1K |
| 85610 |
|
3,513 |
2,753 |
$1K |
| 72100 |
|
95 |
81 |
$1K |
| 80069 |
|
702 |
572 |
$1K |
| 87186 |
|
3,822 |
2,760 |
$1K |
| 74220 |
|
28 |
26 |
$1K |
| 84439 |
|
642 |
518 |
$960.42 |
| 82565 |
|
1,809 |
1,545 |
$918.73 |
| Q0163 |
Diphenhydramine hydrochloride, 50 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at time of chemotherapy treatment not to exceed a 48 hour dosage regimen |
1,277 |
880 |
$881.88 |
| 73562 |
|
261 |
236 |
$879.09 |
| 73140 |
|
120 |
105 |
$855.61 |
| 83970 |
|
192 |
157 |
$837.88 |
| 11057 |
|
20 |
13 |
$824.46 |
| Q9967 |
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
8,811 |
6,331 |
$816.68 |
| 0100U |
|
69 |
48 |
$728.05 |
| 73080 |
|
59 |
52 |
$715.77 |
| J1200 |
Injection, diphenhydramine hcl, up to 50 mg |
1,599 |
1,228 |
$704.37 |
| Q3014 |
Telehealth originating site facility fee |
111 |
101 |
$703.38 |
| 80143 |
|
142 |
108 |
$681.75 |
| J2250 |
Injection, midazolam hydrochloride, per 1 mg |
2,946 |
2,448 |
$665.28 |
| 87389 |
Infectious agent antigen detection by immunoassay technique, HIV-1 antigen with HIV-1 and HIV-2 antibodies |
217 |
201 |
$651.21 |
| 80164 |
|
136 |
96 |
$616.03 |
| 82570 |
|
781 |
630 |
$607.63 |
| 87340 |
|
229 |
212 |
$581.07 |
| 82607 |
|
270 |
224 |
$577.94 |
| 87653 |
|
12 |
12 |
$549.06 |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
47 |
45 |
$521.41 |
| 85652 |
|
819 |
659 |
$498.40 |
| J2930 |
Injection, methylprednisolone sodium succinate, up to 125 mg |
666 |
444 |
$498.24 |
| 83690 |
|
6,538 |
5,206 |
$486.18 |
| 73590 |
|
65 |
52 |
$481.14 |
| 85730 |
|
1,156 |
915 |
$448.48 |
| 87070 |
|
516 |
407 |
$419.90 |
| 80179 |
|
134 |
107 |
$407.94 |
| J2765 |
Injection, metoclopramide hcl, up to 10 mg |
753 |
628 |
$385.67 |
| 85014 |
|
3,626 |
2,998 |
$372.55 |
| 86592 |
|
190 |
164 |
$362.14 |
| 90686 |
|
50 |
45 |
$335.43 |
| 96417 |
|
19 |
13 |
$333.27 |
| J7620 |
Albuterol, up to 2.5 mg and ipratropium bromide, up to 0.5 mg, fda-approved final product, non-compounded, administered through dme |
1,083 |
817 |
$331.91 |
| A9585 |
Injection, gadobutrol, 0.1 ml |
1,818 |
1,145 |
$312.58 |
| 87205 |
|
820 |
597 |
$278.41 |
| 73565 |
|
33 |
26 |
$262.70 |
| 76817 |
Ultrasound, pregnant uterus, real time with image documentation, transvaginal |
43 |
38 |
$255.78 |
| J2270 |
Injection, morphine sulfate, up to 10 mg |
2,668 |
1,810 |
$254.04 |
| J1815 |
Injection, insulin, per 5 units |
698 |
281 |
$223.95 |
| J2550 |
Injection, promethazine hcl, up to 50 mg |
208 |
152 |
$215.95 |
| 84156 |
|
541 |
461 |
$209.08 |
| J1040 |
Injection, methylprednisolone acetate, 80 mg |
1,823 |
1,491 |
$159.52 |
| 82077 |
|
1,710 |
1,351 |
$158.84 |
| J0690 |
Injection, cefazolin sodium, 500 mg |
607 |
468 |
$131.35 |
| J0696 |
Injection, ceftriaxone sodium, per 250 mg |
2,749 |
1,912 |
$127.89 |
| 51798 |
|
27 |
25 |
$125.68 |
| 84550 |
|
241 |
207 |
$117.21 |
| 84703 |
|
1,308 |
1,173 |
$110.56 |
| J3475 |
Injection, magnesium sulfate, per 500 mg |
2,218 |
1,221 |
$109.41 |
| 87210 |
|
236 |
211 |
$108.96 |
| Q0162 |
Ondansetron 1 mg, oral, fda approved prescription anti-emetic, for use as a complete therapeutic substitute for an iv anti-emetic at the time of chemotherapy treatment, not to exceed a 48 hour dosage regimen |
2,310 |
2,108 |
$95.04 |
| 82270 |
|
361 |
285 |
$82.84 |
| 84153 |
|
13 |
12 |
$76.30 |
| 74022 |
|
42 |
28 |
$74.56 |
| 83615 |
|
164 |
126 |
$73.66 |
| 86803 |
|
27 |
25 |
$67.79 |
| J2060 |
Injection, lorazepam, 2 mg |
966 |
699 |
$66.87 |
| 84100 |
|
76 |
66 |
$57.40 |
| A4351 |
Intermittent urinary catheter; straight tip, with or without coating (teflon, silicone, or silicone elastomer, etc.), each |
1,160 |
835 |
$56.41 |
| J1030 |
Injection, methylprednisolone acetate, 40 mg |
23 |
15 |
$55.77 |
| 96376 |
|
2,535 |
1,671 |
$54.03 |
| P9612 |
Catheterization for collection of specimen, single patient, all places of service |
1,500 |
1,163 |
$51.82 |
| 82248 |
|
117 |
96 |
$51.62 |
| 00811 |
|
31 |
26 |
$51.19 |
| J1756 |
Injection, iron sucrose, 1 mg |
145 |
64 |
$47.39 |
| 36592 |
|
107 |
74 |
$44.29 |
| J1642 |
Injection, heparin sodium, (heparin lock flush), per 10 units |
1,476 |
744 |
$43.54 |
| 99152 |
|
38 |
27 |
$25.74 |
| 88342 |
|
59 |
51 |
$17.14 |
| 82550 |
|
74 |
66 |
$15.89 |
| J7613 |
Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, unit dose, 1 mg |
921 |
733 |
$15.79 |
| J1010 |
Injection, methylprednisolone acetate, 1 mg |
256 |
224 |
$14.32 |
| 82803 |
|
250 |
199 |
$14.23 |
| J3480 |
Injection, potassium chloride, per 2 meq |
268 |
170 |
$13.20 |
| J7512 |
Prednisone, immediate release or delayed release, oral, 1 mg |
712 |
602 |
$12.15 |
| 99153 |
Mod sedat endo service >5yrs |
49 |
38 |
$12.14 |
| J0780 |
Injection, prochlorperazine, up to 10 mg |
120 |
98 |
$8.76 |
| J3370 |
Injection, vancomycin hcl, 500 mg |
190 |
124 |
$4.49 |
| J2370 |
Injection, phenylephrine hcl, up to 1 ml |
58 |
54 |
$3.67 |
| J1170 |
Injection, hydromorphone, up to 4 mg |
61 |
47 |
$3.03 |
| J0330 |
Injection, succinylcholine chloride, up to 20 mg |
29 |
26 |
$2.74 |
| J1940 |
Injection, furosemide, up to 20 mg |
49 |
29 |
$1.09 |
| 82533 |
|
15 |
12 |
$0.31 |
| A6402 |
Gauze, non-impregnated, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
191 |
156 |
$0.11 |
| G1004 |
Clinical decision support mechanism national decision support company, as defined by the medicare appropriate use criteria program |
2,867 |
2,226 |
$0.02 |
| J1596 |
Injection, glycopyrrolate, 0.1 mg |
162 |
142 |
$0.00 |
| 00731 |
|
159 |
147 |
$0.00 |
| J2919 |
Injection, methylprednisolone sodium succinate, 5 mg |
54 |
38 |
$0.00 |
| J8499 |
Prescription drug, oral, non chemotherapeutic, nos |
64 |
36 |
$0.00 |
| 00812 |
|
164 |
157 |
$0.00 |
| J0665 |
Injection, bupivicaine, not otherwise specified, 0.5 mg |
62 |
42 |
$0.00 |
| 51701 |
|
16 |
12 |
$0.00 |
| 84295 |
|
14 |
13 |
$0.00 |
| 94664 |
|
48 |
41 |
$0.00 |
| G8978 |
Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at reporting intervals |
35 |
24 |
$0.00 |
| G8979 |
Mobility: walking & moving around functional limitation, projected goal status, at therapy episode outset, at reporting intervals, and at discharge or to end reporting |
37 |
24 |
$0.00 |
| A6403 |
Gauze, non-impregnated, sterile, pad size more than 16 sq. in. less than or equal to 48 sq. in., without adhesive border, each dressing |
38 |
32 |
$0.00 |
| J0688 |
Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg |
27 |
25 |
$0.00 |
| A9270 |
Non-covered item or service |
9,140 |
1,972 |
$0.00 |
| A9500 |
Technetium tc-99m sestamibi, diagnostic, per study dose |
172 |
148 |
$0.00 |
| G0008 |
Administration of influenza virus vaccine |
66 |
51 |
$0.00 |
| J2003 |
Injection, lidocaine hydrochloride, 1 mg |
118 |
101 |
$0.00 |
| 96368 |
|
85 |
68 |
$0.00 |
| 84132 |
|
16 |
14 |
$0.00 |
| J2543 |
Injection, piperacillin sodium/tazobactam sodium, 1 gram/0.125 grams (1.125 grams) |
100 |
43 |
$0.00 |
| J8540 |
Dexamethasone, oral, 0.25 mg |
72 |
61 |
$0.00 |
| V2632 |
Posterior chamber intraocular lens |
42 |
37 |
$0.00 |
| 71101 |
|
14 |
12 |
$0.00 |
| J2371 |
Injection, phenylephrine hydrochloride, 20 micrograms |
29 |
26 |
$0.00 |
| 00142 |
|
43 |
38 |
$0.00 |
| 70496 |
|
13 |
12 |
$0.00 |
| A9579 |
Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml |
16 |
13 |
$0.00 |
| J2785 |
Injection, regadenoson, 0.1 mg |
16 |
13 |
$0.00 |
| A6222 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size 16 sq. in. or less, without adhesive border, each dressing |
32 |
29 |
$0.00 |
| 86762 |
|
14 |
13 |
$0.00 |