| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| 0450 |
|
50,310 |
43,914 |
$3.73M |
| 0519 |
|
52,058 |
43,260 |
$2.48M |
| G0378 |
Hospital observation service, per hour |
32,280 |
25,067 |
$1.65M |
| 74177 |
|
4,284 |
4,115 |
$1.16M |
| 80053 |
|
56,931 |
51,329 |
$951K |
| 99199 |
|
16,158 |
14,005 |
$947K |
| 96374 |
|
9,126 |
7,855 |
$750K |
| 0250 |
|
36,693 |
20,464 |
$746K |
| 77067 |
|
5,354 |
5,342 |
$630K |
| 97110 |
|
14,264 |
6,368 |
$605K |
| 85025 |
|
53,486 |
47,357 |
$601K |
| 0760 |
|
11,098 |
10,215 |
$564K |
| 70450 |
|
3,234 |
3,040 |
$546K |
| 93306 |
|
2,513 |
2,492 |
$528K |
| 84443 |
|
19,346 |
18,854 |
$472K |
| 96375 |
|
8,402 |
6,669 |
$449K |
| 93005 |
|
14,301 |
12,880 |
$448K |
| G0480 |
Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 1-7 drug class(es), including metabolite(s) if performed |
5,912 |
5,221 |
$438K |
| 87635 |
|
6,541 |
6,261 |
$403K |
| 96365 |
|
3,949 |
3,021 |
$366K |
| 87631 |
|
3,894 |
3,812 |
$364K |
| C9803 |
Hospital outpatient clinic visit specimen collection for severe acute respiratory syndrome coronavirus 2 (sars-cov-2) (coronavirus disease [covid-19]), any specimen source |
9,197 |
8,866 |
$354K |
| 87591 |
|
6,416 |
6,316 |
$347K |
| 80061 |
|
19,949 |
19,791 |
$342K |
| 96372 |
|
9,298 |
7,836 |
$334K |
| 87491 |
|
5,885 |
5,793 |
$319K |
| 72125 |
|
1,328 |
1,278 |
$315K |
| 71046 |
|
9,753 |
9,308 |
$300K |
| 73721 |
|
739 |
734 |
$294K |
| 99283 |
|
3,641 |
3,413 |
$286K |
| 76830 |
|
3,055 |
2,985 |
$273K |
| 71260 |
|
1,138 |
1,127 |
$262K |
| 80307 |
|
5,771 |
4,591 |
$255K |
| 72148 |
|
572 |
570 |
$243K |
| 82306 |
|
6,465 |
6,404 |
$237K |
| 76700 |
|
2,370 |
2,346 |
$236K |
| 76856 |
|
2,813 |
2,782 |
$236K |
| Z7500 |
|
6,396 |
5,514 |
$210K |
| 74176 |
|
1,182 |
1,144 |
$207K |
| Q9967 |
Low osmolar contrast material, 300-399 mg/ml iodine concentration, per ml |
6,685 |
6,343 |
$196K |
| 43239 |
|
1,402 |
1,276 |
$189K |
| 83036 |
|
13,458 |
13,339 |
$182K |
| U0001 |
Cdc 2019 novel coronavirus (2019-ncov) real-time rt-pcr diagnostic panel |
3,281 |
3,195 |
$173K |
| 93971 |
|
1,269 |
1,248 |
$172K |
| 84439 |
|
13,177 |
12,929 |
$172K |
| 0761 |
|
3,290 |
1,823 |
$165K |
| 45380 |
|
795 |
717 |
$156K |
| 97139 |
|
3,624 |
1,251 |
$154K |
| 73630 |
|
3,766 |
3,615 |
$142K |
| 76705 |
|
1,853 |
1,811 |
$141K |
| 97161 |
|
2,480 |
2,474 |
$133K |
| G0463 |
Hospital outpatient clinic visit for assessment and management of a patient |
11,358 |
9,928 |
$133K |
| 76770 |
|
1,339 |
1,323 |
$130K |
| 97140 |
|
2,994 |
1,455 |
$128K |
| 0710 |
|
3,002 |
2,811 |
$128K |
| 99282 |
|
2,317 |
2,221 |
$120K |
| J3490 |
Unclassified drugs |
7,736 |
4,574 |
$118K |
| 80306 |
|
3,820 |
3,546 |
$116K |
| 85027 |
|
11,816 |
11,054 |
$114K |
| 59025 |
|
3,357 |
1,713 |
$113K |
| 0750 |
|
507 |
507 |
$112K |
| Z7502 |
|
3,010 |
2,909 |
$111K |
| 87389 |
|
3,960 |
3,922 |
$108K |
| 81025 |
|
7,494 |
6,895 |
$105K |
| 70553 |
|
119 |
119 |
$105K |
| 73130 |
|
2,457 |
2,312 |
$103K |
| 73610 |
|
2,596 |
2,476 |
$103K |
| 80048 |
|
7,008 |
6,378 |
$102K |
| 76641 |
|
1,196 |
1,097 |
$101K |
| 77063 |
|
3,383 |
3,380 |
$101K |
| J7030 |
Infusion, normal saline solution , 1000 cc |
4,721 |
3,830 |
$100K |
| 73564 |
|
2,123 |
2,037 |
$98K |
| 73030 |
|
2,780 |
2,682 |
$97K |
| 83880 |
|
2,623 |
2,433 |
$96K |
| 90715 |
|
1,980 |
1,966 |
$95K |
| 87086 |
|
8,829 |
8,046 |
$95K |
| G0422 |
Intensive cardiac rehabilitation; with or without continuous ecg monitoring with exercise, per session |
1,253 |
187 |
$94K |
| 76536 |
|
1,289 |
1,281 |
$93K |
| 99284 |
|
806 |
761 |
$92K |
| 84484 |
|
6,432 |
5,058 |
$92K |
| 71045 |
|
4,723 |
4,517 |
$90K |
| 97597 |
|
1,689 |
906 |
$89K |
| 73110 |
|
2,099 |
1,988 |
$87K |
| 71275 |
|
412 |
396 |
$86K |
| 86803 |
|
3,876 |
3,831 |
$86K |
| 81001 |
|
15,045 |
13,577 |
$82K |
| 84466 |
|
4,679 |
4,602 |
$82K |
| 82728 |
|
4,442 |
4,366 |
$81K |
| 83690 |
|
7,168 |
6,435 |
$80K |
| 83735 |
|
7,666 |
6,348 |
$76K |
| 0370 |
|
937 |
932 |
$76K |
| 78815 |
|
52 |
52 |
$76K |
| 96413 |
|
1,907 |
1,141 |
$75K |
| G0108 |
Diabetes outpatient self-management training services, individual, per 30 minutes |
877 |
837 |
$74K |
| 94640 |
|
2,714 |
2,267 |
$73K |
| 87480 |
|
2,064 |
2,035 |
$72K |
| 87502 |
|
635 |
580 |
$71K |
| 73502 |
|
1,450 |
1,415 |
$69K |
| 82607 |
|
3,162 |
3,112 |
$66K |
| 73221 |
|
173 |
172 |
$65K |
| 82746 |
|
3,039 |
2,992 |
$64K |
| 96366 |
|
845 |
630 |
$62K |
| 72100 |
|
1,487 |
1,467 |
$62K |
| 87660 |
|
2,588 |
2,548 |
$61K |
| 0360 |
|
255 |
255 |
$61K |
| 72110 |
|
884 |
878 |
$57K |
| 84153 |
|
2,036 |
2,015 |
$57K |
| 87340 |
|
3,285 |
3,246 |
$56K |
| 93017 |
|
848 |
840 |
$55K |
| 76642 |
|
758 |
744 |
$53K |
| 87040 |
|
3,239 |
1,698 |
$52K |
| 83605 |
|
3,169 |
2,500 |
$52K |
| 73562 |
|
1,539 |
1,505 |
$51K |
| 0272 |
|
5,066 |
2,939 |
$50K |
| A6210 |
Foam dressing, wound cover, sterile, pad size more than 16 sq. in. but less than or equal to 48 sq. in., without adhesive border, each dressing |
1,034 |
393 |
$49K |
| A9500 |
Technetium tc-99m sestamibi, diagnostic, per study dose |
403 |
392 |
$45K |
| 99285 |
|
251 |
245 |
$45K |
| J1885 |
Injection, ketorolac tromethamine, per 15 mg |
7,862 |
7,190 |
$45K |
| 0270 |
|
2,737 |
2,295 |
$45K |
| 84403 |
|
1,457 |
1,409 |
$45K |
| 83540 |
|
4,806 |
4,708 |
$45K |
| 87510 |
|
1,263 |
1,244 |
$45K |
| 87811 |
|
993 |
968 |
$44K |
| 87651 |
|
686 |
669 |
$44K |
| 90686 |
|
1,560 |
1,551 |
$42K |
| 87186 |
|
3,164 |
3,005 |
$40K |
| 85652 |
|
6,238 |
5,988 |
$39K |
| 77065 |
Tomosynthesis, mammo |
375 |
370 |
$39K |
| 86140 |
|
5,082 |
4,849 |
$38K |
| J2704 |
Injection, propofol, 10 mg |
2,898 |
2,241 |
$37K |
| 81003 |
|
9,098 |
7,984 |
$36K |
| 72141 |
|
68 |
68 |
$36K |
| 86850 |
|
2,538 |
2,445 |
$36K |
| 87880 |
|
1,861 |
1,832 |
$35K |
| 87077 |
|
3,700 |
3,503 |
$34K |
| 92557 |
|
596 |
587 |
$34K |
| 71250 |
|
186 |
185 |
$33K |
| 70551 |
|
79 |
79 |
$32K |
| 87081 |
|
3,088 |
3,000 |
$32K |
| 85610 |
|
5,630 |
4,447 |
$31K |
| J2405 |
Injection, ondansetron hydrochloride, per 1 mg |
5,792 |
4,852 |
$31K |
| 86038 |
|
1,766 |
1,742 |
$31K |
| 76815 |
|
390 |
377 |
$31K |
| 82043 |
|
3,563 |
3,445 |
$30K |
| 81513 |
|
176 |
174 |
$29K |
| 99281 |
|
655 |
587 |
$28K |
| 84481 |
|
1,213 |
1,196 |
$27K |
| 86762 |
|
1,285 |
1,267 |
$26K |
| 86592 |
|
3,968 |
3,930 |
$25K |
| 78452 |
|
83 |
83 |
$25K |
| 0949 |
|
519 |
501 |
$25K |
| A9579 |
Injection, gadolinium-based magnetic resonance contrast agent, not otherwise specified (nos), per ml |
591 |
578 |
$24K |
| 87804 |
|
1,971 |
997 |
$24K |
| 85379 |
|
1,519 |
1,467 |
$24K |
| 0942 |
|
334 |
303 |
$22K |
| 86787 |
|
1,121 |
1,097 |
$22K |
| 70486 |
|
96 |
96 |
$22K |
| 77066 |
Tomosynthesis, mammo |
165 |
165 |
$21K |
| 83970 |
|
332 |
323 |
$21K |
| 82550 |
|
2,256 |
1,971 |
$21K |
| 87810 |
|
1,262 |
1,246 |
$21K |
| J2270 |
Injection, morphine sulfate, up to 10 mg |
2,557 |
2,095 |
$20K |
| 85007 |
|
3,900 |
3,542 |
$20K |
| 82962 |
|
3,380 |
2,508 |
$19K |
| 87070 |
|
1,502 |
1,402 |
$19K |
| 36415 |
|
1,576 |
1,419 |
$19K |
| J1100 |
Injection, dexamethasone sodium phosphate, 1 mg |
2,771 |
2,309 |
$18K |
| J0696 |
Injection, ceftriaxone sodium, per 250 mg |
2,371 |
1,928 |
$18K |
| G0423 |
Intensive cardiac rehabilitation; with or without continuous ecg monitoring; without exercise, per session |
363 |
58 |
$17K |
| 84702 |
|
775 |
600 |
$17K |
| J2785 |
Injection, regadenoson, 0.1 mg |
131 |
127 |
$17K |
| 86901 |
|
2,759 |
2,638 |
$17K |
| 74018 |
|
507 |
491 |
$16K |
| 99000 |
|
3,318 |
2,906 |
$16K |
| 90651 |
|
58 |
58 |
$16K |
| 96361 |
|
217 |
204 |
$16K |
| 72052 |
|
250 |
247 |
$15K |
| J2765 |
Injection, metoclopramide hcl, up to 10 mg |
2,127 |
1,872 |
$14K |
| 73080 |
|
377 |
364 |
$14K |
| 76811 |
|
126 |
125 |
$14K |
| 97750 |
|
202 |
202 |
$13K |
| 86900 |
|
2,760 |
2,639 |
$13K |
| 87493 |
|
197 |
185 |
$13K |
| 85730 |
|
1,499 |
1,430 |
$13K |
| 82670 |
|
285 |
280 |
$13K |
| 45385 |
|
100 |
92 |
$13K |
| J3010 |
Injection, fentanyl citrate, 0.1 mg |
1,834 |
1,620 |
$12K |
| T1999 |
Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in "remarks" |
528 |
320 |
$12K |
| 87481 |
|
176 |
174 |
$12K |
| 82248 |
|
1,594 |
1,506 |
$11K |
| J7040 |
Infusion, normal saline solution, sterile (500 ml = 1 unit) |
729 |
630 |
$11K |
| J2060 |
Injection, lorazepam, 2 mg |
1,800 |
1,545 |
$11K |
| A9552 |
Fluorodeoxyglucose f-18 fdg, diagnostic, per study dose, up to 45 millicuries |
39 |
39 |
$11K |
| 87147 |
|
1,697 |
1,097 |
$11K |
| J7120 |
Ringers lactate infusion, up to 1000 cc |
1,473 |
1,230 |
$11K |
| J1200 |
Injection, diphenhydramine hcl, up to 50 mg |
1,814 |
1,383 |
$11K |
| 96360 |
|
140 |
133 |
$11K |
| 86709 |
|
622 |
618 |
$10K |
| 86431 |
|
1,179 |
1,169 |
$10K |
| J1050 |
Injection, medroxyprogesterone acetate, 1 mg |
438 |
430 |
$10K |
| 84550 |
|
1,503 |
1,443 |
$10K |
| 96367 |
|
241 |
161 |
$10K |
| 83516 |
|
868 |
634 |
$9K |
| 72040 |
|
251 |
251 |
$8K |
| 77080 |
|
305 |
305 |
$8K |
| 94729 |
|
172 |
171 |
$8K |
| 87522 |
Neg quan hep c or qual rna |
176 |
175 |
$8K |
| 87661 |
|
177 |
175 |
$8K |
| 86376 |
|
498 |
459 |
$8K |
| 87205 |
|
1,293 |
1,207 |
$8K |
| 86705 |
|
436 |
434 |
$8K |
| 97010 |
|
175 |
103 |
$8K |
| 83001 |
|
242 |
237 |
$7K |
| 82950 |
|
927 |
912 |
$7K |
| 82803 |
|
257 |
246 |
$7K |
| J1170 |
Injection, hydromorphone, up to 4 mg |
833 |
647 |
$7K |
| 84402 |
|
410 |
400 |
$7K |
| J2550 |
Injection, promethazine hcl, up to 50 mg |
785 |
624 |
$7K |
| 0510 |
|
153 |
149 |
$6K |
| Z7610 |
|
1,248 |
856 |
$6K |
| 93226 |
|
85 |
85 |
$6K |
| 0636 |
|
836 |
412 |
$6K |
| 94726 |
|
133 |
132 |
$6K |
| 92507 |
|
131 |
74 |
$6K |
| 93970 |
|
27 |
27 |
$5K |
| 76817 |
|
65 |
63 |
$5K |
| 87015 |
|
427 |
238 |
$5K |
| 74021 |
|
151 |
138 |
$5K |
| 96523 |
|
319 |
188 |
$5K |
| J1030 |
Injection, methylprednisolone acetate, 40 mg |
480 |
465 |
$5K |
| 84100 |
|
726 |
560 |
$5K |
| 87045 |
|
331 |
320 |
$4K |
| 93225 |
|
85 |
85 |
$4K |
| 76870 |
|
60 |
58 |
$4K |
| 90662 |
|
133 |
130 |
$4K |
| 20610 |
|
206 |
191 |
$4K |
| 92587 |
|
56 |
56 |
$4K |
| 73590 |
|
156 |
152 |
$4K |
| 86625 |
|
136 |
132 |
$4K |
| 73140 |
|
129 |
126 |
$4K |
| 81002 |
|
1,088 |
1,045 |
$4K |
| 84270 |
|
203 |
201 |
$4K |
| 12001 |
|
78 |
78 |
$4K |
| 90688 |
|
140 |
136 |
$4K |
| 87899 |
|
206 |
134 |
$4K |
| 86481 |
|
38 |
38 |
$3K |
| 87280 |
|
183 |
166 |
$3K |
| 73090 |
|
76 |
70 |
$3K |
| 83615 |
|
400 |
366 |
$3K |
| 71101 |
|
45 |
45 |
$3K |
| J7611 |
Albuterol, inhalation solution, fda-approved final product, non-compounded, administered through dme, concentrated form, 1 mg |
1,104 |
958 |
$3K |
| 82274 |
|
146 |
144 |
$3K |
| 86141 |
|
237 |
237 |
$3K |
| 93922 |
|
63 |
63 |
$3K |
| 80076 |
|
239 |
233 |
$3K |
| 86356 |
|
36 |
34 |
$3K |
| 97112 |
|
106 |
76 |
$3K |
| 82533 |
|
104 |
98 |
$3K |
| 93246 |
|
144 |
144 |
$2K |
| 87798 |
|
25 |
25 |
$2K |
| J3475 |
Injection, magnesium sulfate, per 500 mg |
480 |
405 |
$2K |
| J0131 |
Injection, acetaminophen, not otherwise specified,10 mg |
368 |
363 |
$2K |
| 29125 |
|
54 |
52 |
$2K |
| 99291 |
|
13 |
13 |
$2K |
| 71271 |
|
28 |
28 |
$2K |
| 82553 |
|
154 |
140 |
$2K |
| 86328 |
|
39 |
39 |
$2K |
| 99201 |
|
64 |
55 |
$2K |
| 90677 |
|
12 |
12 |
$2K |
| 92551 |
|
103 |
103 |
$2K |
| 94060 |
|
51 |
51 |
$2K |
| 83520 |
|
123 |
70 |
$2K |
| 76816 |
|
29 |
26 |
$2K |
| 93321 |
|
43 |
43 |
$2K |
| 0258 |
|
153 |
144 |
$2K |
| 86706 |
|
82 |
82 |
$2K |
| 86147 |
|
33 |
33 |
$2K |
| 77061 |
|
42 |
42 |
$2K |
| 97802 |
|
14 |
14 |
$2K |
| 82784 |
|
107 |
102 |
$1K |
| A6223 |
Gauze, impregnated with other than water, normal saline, or hydrogel, sterile, pad size more than 16 sq. in., but less than or equal to 48 sq. in., without adhesive border, each dressing |
350 |
250 |
$1K |
| 93356 |
|
26 |
26 |
$1K |
| 83002 |
|
37 |
37 |
$1K |
| 86003 |
|
13 |
12 |
$1K |
| 86308 |
|
90 |
90 |
$1K |
| 86160 |
|
54 |
39 |
$1K |
| 97799 |
|
26 |
12 |
$1K |
| 83655 |
|
104 |
102 |
$977.92 |
| 72072 |
|
29 |
29 |
$924.42 |
| 82105 |
|
12 |
12 |
$919.40 |
| 83630 |
|
42 |
40 |
$892.72 |
| J3420 |
Injection, vitamin b-12 cyanocobalamin, up to 1000 mcg |
170 |
136 |
$872.22 |
| 72050 |
|
15 |
15 |
$842.25 |
| 96376 |
|
145 |
115 |
$819.17 |
| 82947 |
|
158 |
158 |
$812.40 |
| 80164 |
|
38 |
38 |
$809.24 |
| J3360 |
Injection, diazepam, up to 5 mg |
75 |
69 |
$795.45 |
| 82787 |
|
18 |
18 |
$769.86 |
| 90471 |
|
99 |
99 |
$765.92 |
| G0381 |
Level 2 hospital emergency department visit provided in a type b emergency department; (the ed must meet at least one of the following requirements: (1) it is licensed by the state in which it is located under applicable state law as an emergency room or emergency department; (2) it is held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or (3) during the calendar year immediately preceding the calendar year in which a determination under 42 cfr 489.24 is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment) |
39 |
39 |
$735.88 |
| G0279 |
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066) |
28 |
28 |
$727.95 |
| 97803 |
|
14 |
14 |
$705.00 |
| 82542 |
|
45 |
42 |
$703.50 |
| 86800 |
|
73 |
67 |
$700.69 |
| 45378 |
|
16 |
16 |
$685.86 |
| 82565 |
|
109 |
109 |
$653.41 |
| 86039 |
|
64 |
62 |
$634.65 |
| 99173 |
|
124 |
124 |
$628.99 |
| 84146 |
|
25 |
25 |
$609.87 |
| 93925 |
|
12 |
12 |
$609.84 |
| J2250 |
Injection, midazolam hydrochloride, per 1 mg |
74 |
68 |
$603.28 |
| J8499 |
Prescription drug, oral, non chemotherapeutic, nos |
453 |
354 |
$602.37 |
| Q0111 |
Wet mounts, including preparations of vaginal, cervical or skin specimens |
115 |
111 |
$601.81 |
| 84425 |
|
39 |
38 |
$599.46 |
| 93296 |
|
26 |
26 |
$574.18 |
| 11042 |
|
24 |
12 |
$554.10 |
| 83993 |
|
37 |
37 |
$548.72 |
| Q3014 |
Telehealth originating site facility fee |
90 |
78 |
$520.14 |
| 10060 |
|
24 |
24 |
$494.24 |
| 86225 |
|
54 |
54 |
$457.04 |
| 77062 |
|
12 |
12 |
$425.07 |
| J0690 |
Injection, cefazolin sodium, 500 mg |
28 |
24 |
$421.13 |
| 86200 |
|
53 |
52 |
$370.88 |
| 82785 |
|
39 |
35 |
$336.43 |
| Q9963 |
High osmolar contrast material, 350-399 mg/ml iodine concentration, per ml |
72 |
72 |
$323.22 |
| J2930 |
Injection, methylprednisolone sodium succinate, up to 125 mg |
63 |
50 |
$313.21 |
| 82977 |
|
25 |
25 |
$300.74 |
| 86703 |
|
24 |
24 |
$291.40 |
| 84145 |
|
15 |
15 |
$290.16 |
| 99070 |
|
73 |
56 |
$281.27 |
| 87209 |
|
12 |
12 |
$211.42 |
| 87075 |
|
15 |
14 |
$177.29 |
| 84630 |
|
14 |
12 |
$156.64 |
| 80178 |
|
13 |
13 |
$138.78 |
| 83550 |
|
54 |
54 |
$131.03 |
| J1630 |
Injection, haloperidol, up to 5 mg |
17 |
15 |
$123.76 |
| J7050 |
Infusion, normal saline solution, 250 cc |
18 |
12 |
$115.00 |
| 90716 |
|
12 |
12 |
$108.00 |
| 0255 |
|
12 |
12 |
$101.35 |
| 90707 |
|
12 |
12 |
$99.00 |
| 82150 |
|
12 |
12 |
$95.06 |
| 86258 |
|
26 |
14 |
$66.18 |
| 87177 |
|
12 |
12 |
$59.29 |
| 88305 |
|
46 |
45 |
$36.93 |
| J7512 |
Prednisone, immediate release or delayed release, oral, 1 mg |
130 |
119 |
$30.22 |
| J1010 |
Injection, methylprednisolone acetate, 1 mg |
13 |
13 |
$21.60 |
| 0250R |
|
127 |
65 |
$0.00 |
| 0272R |
|
520 |
210 |
$0.00 |