Industry Review
Recommendation: Buy
Micro Industry: Cardiovascular Medical Devices
Analyst: Bobby Ma
Date: April 12, 2020
NBA 4120
Executive Summary
This report focuses on medical device companies focusing on treating Cardiovascular diseases. They
design and manufacture devices for sale to healthcare providers to treat patients. Their operations are
primarily in the United States, but they are also beginning to expand their footprint internationally. The
industry includes Angio Dynamics. Merit Medical Systems, and Cardiovascular Systems.
Ticker
Name
ANGO Angio Dynamics
Merit Medical
MMSI Systems
Cardiovascular
CSII
Systems
Mkt
cap
Revenue
394.7
270.6
EPS
P/S
Rank
NM 1.5x High
1907.7
994.9 122.3x 1.9x High
1409.9
264.4
NM 5.3x Moderate
Note: Data as of April 12, 2020
Historical Returns of Company Stock vs S&P 500
188.00%
88.00%
-12.00%
-112.00%
Merit Medical Systems, Inc. (NasdaqGS:MMSI) - Share Pricing
Cardiovascular Systems, Inc. (NasdaqGS:CSII) - Share Pricing
AngioDynamics, Inc. (NasdaqGS:ANGO) - Share Pricing
S&P 500 (^SPX) - Index Value
Source: Capital IQ
1
Investment Thesis (Buy)
•
•
•
•
•
•
•
The small cap Cardiovascular Medical Devices Industry is trading at a discount relative to the
Russell 2000, and it will outperform the market because positive factors outweigh the negatives
in its future outlook
The industry has grown significantly as a result of receiving approval for innovative products that
advance the way various Cardiovascular Diseases are treated
Cardiovascular diseases are one of the most common types in the United States and globally,
and companies in the industry are well-poised to continue offer new treatments
The US FDA has expanded programs to develop “breakthrough technologies” in which the
industry certainly fits the criteria of and has seen success in
However, the shift to value-based care and industry consolidation will put some downward
pressure on pricing and margins
Internationally, brighter prospects in Asia will be counter-balanced by stringent EU Medical
Device Regulations
The industry is well-equipped to recover to pre-COVID-19 growth and operating levels after the
pandemic subsides due to the nature Cardiovascular Diseases being mandatory (not elective) for
long-term health and normalizing of supply chains
Industry Overview
Industry Definition
The Cardiovascular Medical Devices industry designs and manufactures medical devices for the purpose
of treating various heart and vascular diseases. Companies spend on R&D and go through an approval
process before being authorized to sell their products. Primary customers are health care providers that
use their products for their operations to treat patients.
Sector Breakdown
The small cap US Cardiovascular Medical Devices revenue (ANGO, CSII, MMSI) has experienced rapid
growth, culminating in 1.53 billion in 2019.
Industry Revenue
2,000.0
20.0%
1,500.0
15.0%
1,000.0
10.0%
500.0
5.0%
0.0
0.0%
2010
2011
2012
2013
2014
Total Revenue
2015
2016
2017
2018
2019
% Revenue Growth
2
The Cardiovascular Medical Devices industry fits within the broader Medical Devices Sector. As of April
9, 2020 the companies in the sector have a Market Cap of 1.14T. Industry revenue was 425.5 billion in
2018, with North America making up 169.3 billion. The Cardiovascular segment had revenue of 40.7
billion in 2018.
US Medical Devices Segmentation
Other
20.7%
Cardiovascular
25.9%
Diabetes
4.6%
Neurumodulation
and Spinal
12.4% Patient
Irradiation
20.9%
Recovery and
Non-invasive
15.5%
Source: IBISWorld
There are several major categories of Cardiovascular Disease:
1) Coronary Heart Disease: Disease of the blood vessels supplying the heart muscle
2) Peripheral Artery Disease: Disease of the arteries supplying the arms and legs
3) Stroke: Disruption of blood supply to the brain resulting in either blockage or rupture of blood
vessels
4) Aortic Aneurysm and Dissection: Dilation and rupture of the aorta, the main artery of the body
5) Deep Venous Thrombosis (DVT) and Pulmonary Embolism: Blood clots in the leg veins, which
can be dislodged and relocate to heart and lungs
6) Rheumatic Heart Disease: Damage to heart muscle and valves caused by fever from
streptococcal bacteria
7) Congenital Heart Disease: Malformations of heart structures existing at birth caused by genetic
factors or adverse exposure during carriage
US Medical Devices Distribution
International
Exports
28.6%
Hospitals
36.6%
Specialists
and
Third-Party Alternative
Distributors HC Providers
25.8%
9.0%
Source: IBISWorld
•
Products across the medical devices industry are sold to a number of distribution channels
3
•
•
•
Hospitals and Specialists & Alternative Healthcare Providers represent a more direct channel
where a salesforce from the company markets the products
Third-party distributors help with domestic distribution as well as the bulk of the products
exported internationally as they are familiar with the market
The small-cap cardiovascular devices industry largely follows the same structure, but exports are
far lower as companies first focus on the domestic market
Key Players
Top 10 Medical Device Companies (2014)
30
25%
20%
15%
10%
5%
0%
-5%
-10%
25
20
15
10
5
0
Johnson & Medtronic Siemens
Johnson
Roche
Covidien Abbot Labs General
Electric
Revenue (bn)
Stryker
Philips
Boston
Scientific
Growth Rate
Source: iHealthcare
•
•
Small and large companies each bring unique advantages towards product innovation
o Small companies are more focused on innovative products in key area / niche
o Large companies have resources / a platform
o Leads to dynamic where companies like Boston Scientific / Abbot Laboratories as well as
small cap players thrive
o ANGO, CSII, and MMSI have targeted focus, but compete against the broad platform,
brand name, and resource base of large camp medical device companies
Industry suppliers also have power in cost of inputs. Typically have a lot of options of firms and
industries to sell to, so the industry does not have negotiating leverage and thus are dependent
on commodity prices of various inputs, i.e. metals / alloys
US Regulations
Inpatient Prospect System rule
•
•
•
The Center for Medicare and Medicaid Services (CMS) finalized the Inpatient Prospect System
(IPPS) rule expanding on the Expedited Access Pathway (EAP) program begun in 2015
EAP provided provisions for specially designated “breakthrough technologies” that treated
serious, life-threatening, or irreversibly damaging conditions
o One approved technology in program is in Cardiovascular space so represents
opportunity for industry to take advantage to accelerate development timeline
Before, access to new technology add-on payments required demonstration of “substantial
clinical approvement”
4
•
Now, device manufacturers can demonstrate meeting cost criteria (i.e. existing payments are
not enough to cover cost of care) thus expediting access to reimbursements for new
technologies
Expansion of Value-Based Care
•
•
•
•
To curb healthcare costs and improve patient outcomes, federal and state governments, as well
as industry members, are phasing out fee-for-service models in favor of value-based care
o Fee-for-service charge payers per unit service performed, i.e. each procedure or visit
and all costs / products used during the medical engagement
o Value-based care bases payments off health outcomes and improvements from each
treatment
Fee-for-service encouraged volume of procedures, which created incentives that benefited
cardiovascular medical device companies as it led to a larger volume of purchases
Value-based care will force the industry to control costs and integrate themselves further into
the health care system to assess the patient outcomes from using their products
Over the past two decades, Cardiovascular care costs have doubled to US 556 billion, while
outcome improvement has stagnated making industry particularly vulnerable
Value-Based Arrangement Among HCTTF Members
41%
47%
52%
30%
2015
2016
2017
2018
Source: Healthcare Transformation Task Force
•
Adoption for value-based care has been growing, as public pressure forces shifts among the
payment scheme. In addition to task force members, Aetna estimates that 50% of all healthcare
payments were value-based in 2016 and growing
European Union Medical Device Regulations (EU MDR)
•
•
Coming May 26, 2020, the EU MDR will replace the current Medical Device Directive
o Regulation are binding and carry legal force, so consequences much steeper for noncompliant firms
Emphasis shift to product life cycle as opposed to strictly pre-market approval
o Assigns each device a unique device identification (UDI) code
o Clear obligations to monitor quality, safety, and performance of devices
o Necessitates investments into technology to ensure fast and accurate reporting of data
on each device with an UDI
o Non-compliance results in products being withdrawn from sale
5
•
MDR applies to all products sold within EU, so United States Cardiovascular Industry are
required to comply with new regulations
o Effect 1: May prevent firms in the industry from further European expansion due to
extra steps necessary to be incompliance with regulation, hurting revenue growth
prospects
o Effect 2: Firms that do enter the market must incur extra SG&A costs in order to register
each device to an UDI as well as maintain monitoring performance and provider
relationships regarding users of their products
Asian Regulations
•
•
The main countries companies in the US Cardiovascular Medical Devices industry have presence
in (albeit at a fledgling stage) are China, India, and Japan
Historically, environments have been a minefield of uncertainty and bureaucracy leading to an
unstable situation towards breaking into a new market
Recently, new initiatives will streamline the process for better access by US companies
•
China
• In 2014, the National Medical Products Administration (NMPA), the regulatory body responsible
for medical devices, introduced a class system based on risk to human body, in line with EU and
United States regulation structure
• In 2018, NMPA, approved an amendment to allow manufacturers to submit foreign clinical
study data in place of China study data
• New initiative allows R&D efficiency because same studies done in the United States can be
used in another country, making the costs to international expansion less of a burden for firms
in the US Cardiovascular Medical Devices industry
India
• No regulations existed prior to 2005, meaning the India government has been characterized by
uncertainty and local bureaucracy
• In 2017, the Central Drugs Standard Control Organization (CDSCO), published new Medical
Device Rules that came into effect in 2018
• Introduced risk-based class system, inspection rules, and unique identifiers
• Core feature for US industry is the government does not require clinical investigation for devices
approved in the United States
• Expedites international growth and improves R&D efficiency. Once the upfront costs of US
approval realize its benefits, the same device can be marketed in India as well
Japan
• Most developed and stable of the Asian countries
• Has risk-classification, registration system, and approval requirements
• US industry manufacturers must obtain Foreign Manufacturer Registration
• Cardiovascular Systems has a head start, with a core product already approved and several in
the process allowing early access to the Japanese market (approx. 12bn)
6
Healthcare Industry Consolidation
•
•
•
Increased consolidation among Healthcare Corporations squeeze and crowd out the US Small
Cap Cardiovascular Medical Devices Industry
Consolidation among other Medical Device Companies
o Acquisition of products by bigger firms incorporate innovative products in larger
portfolio and platform, allows for synergies in terms of marketing to providers
o Core success factor is leveraging product benefits and using litigation to protect from
copycats to outcompete other firms in terms of quality
o Top-notch innovation will still win out in the end, but the decrease in market share from
failure of technological advancement will prove more catastrophic
Consolidation among Healthcare Providers
o Industry revenue primarily comes from selling medical devices to Healthcare Providers
for use of treatments
o Increased M&A activity means heighted monopsony power from larger and fewer
buyers, limiting out revenue growth and putting downward pressure on prices
Global Healthcare M&A
500
4000
450
3500
400
3000
350
300
2500
250
2000
200
1500
150
1000
100
500
50
0
0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Deal Value
Deal Count
Source: Bain Capital 2019 Healthcare Report
COVID-19 Effects
•
•
Medical devices industry as a whole will be negatively affected in terms of both sales and costs
o Decreased demand from patients as lockdowns and prevention measures force people
to stay home
o Decreased demand from healthcare providers due to hospital shifting priorities to the
pandemic (i.e. caring for patients with Coronavirus)
o Increased costs of goods sold and less inventory manufactured due to factory and
supply chain disruptions
Cardiovascular Medical devices will not experience lowered demand from patients staying home
because diseases in the industry are not elective, but life-threatening / altering
7
•
•
Industry, however, will see decreased sales (~10%) YoY in 2020 due to hospital prioritization of
pandemic response, but will resume pre-COVID-19 trajectory in 2021
Gross Profit Margin of industry to also decrease ~15% due to factory shutdowns and increased
costs to acquire raw materials
Valuation
Key Profitability and Valuation Measures
Industry Revenue
2,000.0
20.0%
1,500.0
15.0%
1,000.0
10.0%
500.0
5.0%
0.0
0.0%
2010
2011
2012
2013
2014
Total Revenue
2015
2016
2017
2018
2019
% Revenue Growth
Industry Gross Profit
1,000.0
20.0%
800.0
15.0%
600.0
10.0%
400.0
5.0%
200.0
0.0
0.0%
2010
2011
2012
2013
2014
Total Gross Profit
2015
2016
2017
2018
2019
% GP Growth
Companies in the Cardiovascular Medical Devices have either not reached profitability or have barely
reached profitability. This is because of high R&D and marketing costs associated with getting new,
innovative products out to market. As a result, Revenue Growth and Gross Profit Margin were most
descriptive of the industry. Revenue Growth is important because the purpose of investing in products
through incurring high R&D and marketing is to scale and mass produce the product. The Gross Profit
Margin is a measure of how profitable each unit of the medical device is as that represents the greatest
share of variable costs after upfront R&D and marketing are assumed.
Price / Sales is the valuation metric of choice, because Cardiovascular Medical Device companies do not
have a lot of dept on their balance sheet, so the market capitalization makes up almost all of the
8
Enterprise Value. Because these companies are burning cash, they have negative operating income and
net income for most years of operation. Sales was chosen over book value because companies in this
industry have begun selling their products to generate revenue, so P / S is a more accurate measure over
P / B as to how effective the Industry’s products are on the market.
As more products pass clinical trials and can be marketed to hospitals and their patients, revenue and
gross profit will continue to increase, but operating income will start to become more positive as the
industry matures. Thus, in the future, EV / EBIT may be a more effective metric to value companies in
the industry.
Sales Growth and Gross Profit Margin were both chosen as valuation drivers of the industry. As the
valuation of metric of choice was P / S, sales growth is important to determine how much investors are
willing to pay for each dollar of sales as its ability to grow increases the attractiveness of the industry.
Meanwhile, gross profit margin is important because if companies in the industry can profit more on
each dollar of sales, then that also makes investors willing to pay more for sales.
Time Series Valuation (P / S over time)
5.00x
4.50x
4.00x
3.50x
3.00x
2.50x
2.00x
1.50x
1.00x
0.50x
0.00x
4.16x
2.66x
1.28x
Russell 2000 Index (^RUT) - Market Cap/Total Revenues
Index: CSII, ANGO, MMSI - Market Cap/Total Revenues
Source: Capital IQ
9
P / S vs Sales Growth (Dec 31 of CY)
4.0x
20.0%
3.0x
15.0%
2.0x
10.0%
1.0x
5.0%
.0x
0.0%
2010
2011
2012
2013
2014
Industry P/S
2015
2016
2017
2018
2019
% Revenue Growth
P / S vs Gross Margin (Dec 31 of CY)
4.0x
55.0%
54.0%
53.0%
52.0%
51.0%
50.0%
49.0%
48.0%
3.0x
2.0x
1.0x
.0x
2010
2011
2012
2013
2014
2015
Industry P/S
2016
2017
2018
2019
% Gross Margin
Revenue growth explains the Industry P / S multiple better as on the aggregate, Industry Gross Margin is
stable. But different regulatory and macroeconomic conditions affect sales growth over time which
causes the market to value the industry’s revenues differently.
Cross-Sectional Comparison
P / S vs % Revenue Growth
6.0x
5.0x
y = 17.99x + 1.4964
R² = 0.3453
4.0x
ANGO
2.1x
3.0x
P / S vs % Gross Margin
6.0x
CSII
5.6x
CSII
5.6x
y = 10.083x - 2.8459
R² = 0.869
5.0x
4.0x
3.0x
MMSI
2.0x
2.0x
MMSI
2.0x
2.0x
1.0x
ANGO
2.1x
1.0x
.0x
.0x
0.0%
5.0%
10.0%
15.0%
20.0%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Note: P/S multiples as of Dec 31, 2019
10
In the cross-sectional analysis, Gross Margin explains variation in P/S multiple the best. Each company’s
product mix has different economics, so if a product costs less to make but can be sold at a higher price,
then if its products pass clinical trials, then they will be more profitable.
Final Recommendation and Ranking
Due to the economic impact of the COVID-19 pandemic, the price target was calculated by projecting
out 2021 Revenue and Gross Profit (Appendix C). An industry average discount rate of 8.39% was used
to discount price targets to 2020 (Appendix D). I expect the discount rate to return to what it is
historically due to the resumption of normal hospital operations and people resuming treatment for
serious Cardiovascular diseases. Unlike other industries that rely heavily on disposable income, these
devices represent an inelastic, non-option purchase. The implied discounted share price is an average of
using Sales Growth and Operating Margin as the driver for the Price / Sales multiple.
Ticker
ANGO
MMSI
CSII
Current
Price
10.47
34.55
40.00
52-Wk Low–
High
7.48–23.21
19.50–63.64
26.00–55.22
CY19
Sales
$270.6
$994.9
$264.4
P/S
1.5x
1.9x
5.3x
Target
Price
Rank
17.88 High
44.18 High
43.02 Moderate
Note: Data as of April 12, 2020
Rationale for Rankings:
• Angio Dynamics ranks highest because by selling off their Fluid Management business mid-2019,
they can focus on higher-margin business. Combined with devices in the pipeline driving sales,
they are poised to see P/S expansion
• Merit Medical Systems is also poised to perform well. Being the most mature company out of
the three while generating operating income, they are poised to recover from the pandemic and
continue to develop their product line. Their current multiples suggest they are fairly valued for
their growth and margin profile, but strong fundamentals will drive growth in the stock price
• Cardiovascular Systems is the most moderate of the three. They have several products in clinical
trials and experiencing the highest revenue growth. However, their current P/S multiples
suggest investors are already paying a fair value based on future expectations of sales growth
11
Appendices
Appendix A: Historical Operating Income
Operating Income
CSII Revenue
% Revenue Growth
ANGO Revenue(1)
% Revenue Growth
MMSI Revenue
% Revenue Growth
Total Revenue
% Revenue Growth
CSII Gross Profit
% GP Growth
% Gross Margin
ANGO Gross Profit(1)
% GP Growth
% Gross Margin
MMSI Gross Profit
% GP Growth
% Gross Margin
Total Gross Profit
% GP Growth
% Gross Margin
CSII Operating Income
ANGO Operating Income(1)
MMSI Operating Income
Total Operating Income
CSII Mkt Cap
ANGO Mkt Cap
MMSI Mkt Cap
Total Mkt Cap
CSII P/S
ANGO P/S
MMSI P/S
Industry P/S
2010
71.5
2011
80.2
12.3%
223.4
2.8%
359.4
21.1%
663.2
13.3%
2012
92.7
15.6%
279.7
25.2%
394.3
9.7%
767.1
15.7%
2013
2014
2015
2016
2017
2018
2019
116.4 158.3 178.0 191.5 207.4 231.2 264.4
25.5% 36.0% 12.4%
7.6%
8.3% 11.5% 14.3%
340.2 357.8 346.4 357.6 344.6 349.0 270.6
21.6%
5.2% -3.2%
3.3% -3.6%
1.3%
2.2%
449.0 509.7 542.1 603.8 727.9 882.8 994.9
13.9% 13.5%
6.4% 11.4% 20.5% 21.3% 12.7%
906.1 1,026.2 1,066.6 1,153.1 1,279.9 1,463.1 1,530.0
18.1% 13.3%
3.9%
8.1% 11.0% 14.3%
4.6%
53.6%
63.2
14.1%
78.7%
129.5
2.2%
58.0%
166.2
27.6%
46.2%
360.4
14.9%
54.3%
71.2
12.7%
76.8%
147.6
13.9%
52.8%
182.8
10.0%
46.4%
403.1
11.9%
52.6%
90.1
26.5%
77.4%
169.7
15.0%
49.9%
194.4
6.3%
43.3%
455.8
13.1%
50.3%
125.5
39.4%
79.3%
182.2
7.4%
50.9%
225.2
15.9%
44.2%
534.6
17.3%
52.1%
142.6
13.6%
80.1%
173.2
-4.9%
50.0%
235.8
4.7%
43.5%
552.9
3.4%
51.8%
155.6
9.1%
81.2%
174.9
1.0%
48.9%
265.0
12.4%
43.9%
596.9
8.0%
51.8%
169.4
8.9%
81.7%
171.9
-1.7%
49.9%
326.3
23.1%
44.8%
669.0
12.1%
52.3%
188.4
11.2%
81.5%
186.5
8.5%
53.4%
394.8
21.0%
44.7%
771.2
15.3%
52.7%
212.4
12.7%
80.3%
156.0
0.5%
57.6%
432.4
9.5%
43.5%
802.2
4.0%
52.4%
(16.4)
21.6
32.5
37.8
(9.2)
18.4
39.8
49.0
(18.0)
17.4
35.6
35.0
(26.4)
21.4
33.6
28.6
(32.5)
26.9
40.7
35.1
(47.6)
9.8
38.6
0.8
(16.6)
19.9
37.0
40.3
0.1
22.3
64.9
87.3
1.7
28.1
73.3
103.1
(7.5)
(9.4)
54.5
37.5
217.4
296.8
585.6
55.3
77.5%
126.8
58.3%
130.2
43.9%
313.7
175.0 160.2 335.3 973.0 1,117.7 297.9 854.4 744.1 1,107.0 1,473.5
408.8 367.5 395.7 632.3 676.5 392.5 611.5 592.0 770.2 577.2
512.9 527.5 508.2 642.9 850.8 832.7 1,379.7 2,307.3 3,193.1 2,038.3
1,096.7 1,055.2 1,239.3 2,248.2 2,645.0 1,523.0 2,845.5 3,643.3 5,070.4 4,089.0
2.4x
1.9x
1.7x
1.9x
2.0x
1.6x
1.5x
1.6x
3.6x
1.4x
1.3x
1.6x
8.4x
1.9x
1.4x
2.5x
7.1x
1.9x
1.7x
2.6x
1.7x
1.1x
1.5x
1.4x
4.5x
1.7x
2.3x
2.5x
3.6x
1.7x
3.2x
2.8x
4.8x
2.2x
3.6x
3.5x
5.6x
2.1x
2.0x
2.7x
Note: Calendar Year Financial Data
(1) Note: ANGO sold its Fluid Management in Q2 2019. Revenue, Gross Profit, and Operating Income in
2019 are 10-K reported numbers for core, un-sold business. Growth rate in 2019 is the growth YoY (from
2018) in the portion of ANGO not sold.
12
Appendix B: Cross-Sectional Analysis
Cross-Sectional Analysis
CSII
ANGO
MMSI
Projections
% Revenue
% Gross Profit
P/S Growth
Margin
5.6x
14.3%
80.3%
2.1x
2.2%
57.6%
2.0x
12.7%
43.5%
Intercept Slope
Rev Growth
1.50 17.99
Gross
Margin
(2.85) 10.08
Appendix C: 2021 Projections
Operating Income
CSII Revenue
% Revenue Growth
ANGO Revenue
% Revenue Growth
MMSI Revenue
% Revenue Growth
Total Revenue
% Revenue Growth
CSII Gross Profit
% GP Growth
% Gross Margin
ANGO Gross Profit
% GP Growth
% Gross Margin
MMSI Gross Profit
% GP Growth
% Gross Margin
Total Gross Profit
% GP Growth
% Gross Margin
2019
264.4
14.3%
270.6
2.2%
994.9
12.7%
1,530.0
4.6%
2020
237.9
-10.0%
243.6
-10.0%
895.4
-10.0%
2021
317.2
20.0%
278.8
3.0%
1,094.3
10.0%
212.4
12.7%
80.3%
156.0
0.5%
57.6%
432.4
9.5%
43.5%
802.2
4.0%
52.4%
162.4
254.8
68.3%
119.3
80.3%
167.3
49.0%
330.8
60.0%
475.6
36.9%
43.5%
13
Appendix D: Price Target
Implied Share
Price
CSII
ANGO
MMSI
# of
2021
2021 Rev
Implied
Implied Share
Shares
Rev
Growth
P/S
Price
35.2
317.2
20.0%
5.1x
45.91
37.69
278.8
3.0%
2.0x
15.06
55.21 1,094.3
10.0%
3.3x
65.32
CSII
ANGO
MMSI
Implied
Implied Share
P/S
Price
5.3x
47.34
3.2x
23.70
1.5x
30.45
2021 GP Margin
80.3%
60.0%
43.5%
CSII
ANGO
MMSI
Discounted Avg Share Price
Avg Share Price
Discounted Average Share Price
CSII
46.63
43.02
ANGO
19.38
17.88
MMSI
47.88
44.18
Avg Share Price
46.63
19.38
47.88
Discounted Avg Share Price
Avg Share Price
Discounted Average Share Price
CSII
46.63
43.02
ANGO
19.38
17.88
MMSI
47.88
44.18
14
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15
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16