Rehabilitative Hospital Fee Schedule · Maximum Allowed Amount 459 $12.00 Procedure Code Mod 1 Mod...

Revenue

Code Mod 1 Mod 2 Mod 3 Mod 4

Medicaid

Maximum

Allowed

Amount

459 $12.00

Procedure

Code Mod 1 Mod 2 Mod 3 Mod 4

Medicaid

Maximum

Allowed

Amount

70030 $15.00

70100 $16.00

70110 $26.00

70120 $23.00

70130 $35.00

70134 $26.00

70140 $20.00

70150 $18.00

70160 $23.00

70190 $13.00

Provider Type: 26

Arkansas Medicaid Rehabilitative Hospital Fee Schedule

This fee schedule does not address the various coverage limitations routinely applied by Arkansas

Medicaid before final payment is determined (e.g., beneficiary and provider eligibility, benefit limits,

billing instructions, frequency of services, third party liability, age restrictions, prior authorization,

co-payments/coinsurance where applicable). Procedure codes and/or fee schedule amounts listed do

not guarantee payment, coverage or amount allowed.

Please note that Arkansas Medicaid will reimburse the lesser of the amount billed or the Medicaid

maximum. For a full explanation of the procedure codes and modifiers listed here, refer to your

Arkansas Medicaid provider manual and provider notices.

Run Date 8/5/19

Although every effort is made to ensure the accuracy of this information, discrepancies may occur.

This fee schedule may be changed or updated at any time to correct such discrepancies. The

reimbursement rates reflected in this fee schedule are in effect as of the date of this report. The

reimbursement rate applied to a claim depends on the claim’s date of service because Arkansas

Medicaid’s reimbursement rates are date-of-service effective. This fee schedule reflects only

procedure codes that are currently payable. Any procedure code reflecting a Medicaid maximum of

$0.00 is manually priced.

70200 $14.00

70210 $14.00

70220 $30.00

70240 $17.00

70250 $22.00

70260 $30.00

70300 $13.00

70310 $15.00

70320 $19.00

70328 $14.00

70330 $22.00

70336 $343.00

70350 $22.00

70355 $22.00

70360 $10.00

70370 $36.00

70371 $79.89

70380 $15.00

70450 $165.00

70460 $208.00

70470 $251.00

70480 $182.00

70481 $221.00

70482 $257.00

70486 $178.00

70487 $191.00

70488 $278.00

70490 $188.00

70491 $228.00

70492 $142.00

70540 $403.00

70542 $514.92

70551 $403.00

70552 $495.00

71045 $11.86

71047 $27.87

71048 $28.67

71100 $17.00

71101 $17.00

71110 $25.00

71111 $32.00

71120 $14.00

71130 $18.00

71250 $215.00

71260 $264.00

71270 $330.00

71550 $406.00

71555 $447.41

72020 $28.00

72040 $28.00

72050 $32.00

72052 $55.00

72070 $24.00

72072 $28.00

72074 $32.00

72080 $26.00

72081 $23.51

72082 $42.84

72083 $46.48

72084 $55.80

72100 $28.00

72110 $40.00

72114 $45.00

72120 $33.00

72125 $215.00

72126 $261.00

72127 $323.00

72128 $215.00

72129 $261.00

72130 $323.00

72131 $215.00

72132 $261.00

72133 $323.00

72141 $406.00

72142 $512.00

72146 $446.00

72147 $512.00

72148 $432.00

72149 $495.00

72159 $162.57

72170 $21.00

72190 $30.00

72192 $228.00

72193 $254.00

72194 $310.00

72196 $370.00

72198 $447.41

72200 $14.00

72202 $21.00

72220 $17.00

73000 $15.00

73010 $18.00

73020 $13.00

73030 $20.00

73050 $26.00

73060 $22.00

73070 $18.00

73080 $19.00

73090 $19.00

73092 $32.00

73100 $19.00

73110 $23.00

73120 $17.00

73130 $25.00

73140 $16.00

73200 $185.00

73201 $136.00

73202 $162.00

73220 $403.00

73221 $380.00

73225 $302.73

73501 $18.85

73502 $27.84

73503 $38.63

73521 $26.17

73522 $31.17

73523 $37.49

73551 $17.85

73552 $21.18

73560 $25.00

73562 $35.00

73564 $37.00

73565 $22.00

73590 $25.00

73592 $27.00

73600 $30.00

73610 $18.00

73615 $88.00

73620 $23.00

73630 $28.00

73650 $13.00

73660 $13.00

73700 $182.00

73701 $136.00

73702 $162.00

73720 $403.00

73721 $380.00

73725 $447.41

74018 $20.26

74019 $24.26

74021 $28.27

74022 $32.00

74150 $218.00

74160 $261.00

74170 $317.00

74181 $409.00

74185 $447.41

74210 $35.00

74220 $36.00

74230 $29.00

74240 $30.00

74241 $44.00

74245 $40.00

74246 $41.00

74247 $36.00

74249 $44.00

74250 $35.00

74251 $35.00

74260 $46.00

74270 $49.00

74280 $45.00

74283 $31.00

74290 $34.00

74300 $24.00

74301 $30.24

74340 $72.00

74400 $55.00

74410 $45.00

74415 $64.00

74420 $74.00

74710 $17.00

74775 $55.50

75635 $328.15

75885 $541.00

75887 $541.00

75889 $535.00

75898 $185.00

75984 $81.00

75989 $135.00

76010 $7.20

76098 $14.00

76100 $48.00

76101 $70.00

76102 $57.00

76120 $38.00

76125 $9.00

76496 $0.00

76497 $0.00

76498 $0.00

76499 $0.00

76506 $18.80

76511 $48.00

76512 $44.00

76513 $27.00

76516 $61.00

76519 $65.00

76529 $46.00

76536 $54.00

76604 $23.00

76700 $56.00

76705 $20.00

76706 $72.03

76770 $44.00

76775 $15.00

76776 $76.26

76800 $32.00

76801 $42.75

76802 $30.37

76805 $56.00

76810 $64.00

76811 $145.14

76812 $51.75

76815 $26.00

76816 $26.00

76817 $58.50

76818 $34.68

76825 $60.72

76827 $58.00

76828 $49.00

76830 $68.00

76856 $40.00

76857 $24.00

76870 $31.00

76872 $46.00

76873 $84.01

76936 $16.99

76965 $190.48

76977 $41.90

76999 $0.00

77001 $66.86

77002 $65.45

77003 $65.45

77011 $275.67

77013 $324.99

77014 $99.02

77022 $421.33

77046 $186.92

77047 $185.79

77072 $25.61

77073 $39.36

77074 $50.27

77075 $72.09

77076 $36.99

77077 $55.49

77078 $99.02

77080 $155.08

77081 $37.94

77084 $374.86

77280 $168.00

77285 $248.00

77290 $300.00

77295 $511.58

77299 $0.00

77300 $67.00

77301 $732.77

77321 $239.00

77331 $22.00

77332 $61.00

77333 $89.00

77334 $162.00

77336 $92.00

77370 $109.00

77371 $974.17

77372 $739.93

77373 $1,378.11

77399 $0.00

77401 $36.00

77402 $59.00

77407 $66.00

77412 $76.00

77417 $26.00

77435 $796.45

77470 $178.40

77499 $0.00

77520 $0.00

77523 $0.00

77600 $165.00

77605 $224.00

77610 $165.00

77615 $224.00

77620 $165.00

77761 $376.00

77762 $566.00

77763 $847.00

77778 $135.00

77789 $14.00

77790 $17.00

77799 $0.00

78015 $44.00

78016 $91.00

78018 $46.00

78020 $12.75

78070 $24.00

78075 $37.00

78099 $0.00

78102 $66.00

78103 $65.00

78104 $74.00

78110 $18.00

78111 $69.00

78120 $49.00

78121 $42.00

78122 $183.76

78130 $82.00

78135 $70.00

78140 $108.00

78185 $38.00

78191 $55.00

78195 $33.00

78199 $0.00

78201 $102.00

78202 $40.00

78205 $49.00

78206 $18.88

78215 $30.00

78216 $57.00

78230 $18.00

78231 $23.00

78232 $46.00

78258 $109.51

78261 $37.00

78262 $64.00

78264 $23.00

78267 $16.29

78278 $55.00

78282 $28.00

78290 $79.00

78291 $122.26

78299 $0.00

78300 $23.00

78305 $46.00

78306 $59.00

78315 $125.00

78320 $122.00

78350 $30.38

78351 $25.88

78399 $0.00

78414 $0.00

78428 $46.00

78445 $29.00

78456 $159.39

78457 $49.00

78458 $74.00

78459 $50.27

78466 $38.00

78468 $38.00

78469 $44.00

78472 $152.00

78481 $46.00

78494 $19.81

78496 $7.81

78499 $0.00

78580 $63.00

78599 $0.00

78600 $42.00

78601 $46.00

78605 $43.00

78606 $56.00

78607 $39.00

78610 $20.00

78630 $92.00

78635 $92.00

78645 $69.00

78647 $39.00

78650 $75.00

78660 $46.00

78699 $0.00

78700 $35.00

78701 $46.00

78707 $69.00

78710 $60.00

78715 $60.00

78725 $28.00

78730 $42.00

78740 $16.00

78760 $37.00

78761 $43.00

78799 $0.00

78800 $30.00

78801 $42.00

78802 $46.00

78803 $36.00

78805 $46.00

78806 $44.00

78807 $198.00

78810 $1,287.00

79030 $98.00

79900 $99.00

80047 $30.88

80048 $12.09

80050 $48.67

80051 $10.01

80053 $15.10

80055 $36.52

80061 $18.16

80069 $12.40

80072 $36.86

80074 $68.01

80076 $11.67

80081 $101.97

80197 $19.60

80201 $17.03

80400 $46.56

80402 $124.14

80406 $111.74

80408 $179.22

80410 $114.73

80412 $281.67

80414 $73.74

80415 $79.81

80416 $188.48

80417 $62.83

80418 $701.63

80420 $102.86

80422 $65.81

80424 $72.13

80426 $212.00

80428 $95.23

80430 $112.03

80432 $192.88

80434 $144.41

80435 $147.04

80436 $130.18

80438 $71.95

80439 $95.93

81000 $4.52

81001 $4.52

81002 $3.66

81005 $3.10

81007 $3.67

81015 $4.34

81099 $3.26

82009 $6.46

82010 $10.01

82013 $15.95

82016 $19.08

82017 $24.09

82024 $23.66

82030 $36.84

82040 $7.08

82042 $7.39

82045 $49.01

82075 $10.77

82085 $13.87

82088 $58.20

82108 $12.47

82120 $5.36

82127 $19.08

82128 $19.08

82135 $23.51

82136 $24.09

82139 $24.09

82140 $12.49

82143 $9.53

82150 $9.26

82154 $41.18

82157 $41.81

82160 $35.72

82163 $29.32

82164 $20.84

82172 $22.12

82175 $27.09

82180 $14.12

82232 $23.11

82240 $37.95

82247 $7.17

82248 $7.17

82252 $3.86

82261 $24.09

82270 $4.64

82274 $22.22

82286 $9.84

82300 $33.05

82306 $42.27

82308 $38.24

82310 $7.36

82330 $18.87

82331 $7.39

82340 $8.62

82355 $16.52

82360 $18.39

82365 $18.41

82370 $17.90

82374 $6.99

82375 $17.60

82376 $8.56

82379 $24.09

82380 $13.18

82382 $24.55

82383 $35.78

82384 $36.06

82390 $15.33

82415 $18.09

82435 $6.56

82436 $7.18

82438 $6.99

82441 $7.71

82465 $6.22

82480 $11.25

82482 $10.97

82485 $7.17

82495 $9.98

82507 $39.71

82523 $26.69

82525 $17.72

82528 $32.15

82533 $22.53

82540 $6.61

82542 $25.79

82550 $9.31

82552 $19.13

82565 $7.31

82570 $7.39

82575 $13.50

82585 $12.25

82595 $9.25

82600 $27.70

82607 $21.52

82608 $20.46

82610 $19.63

82615 $11.67

82626 $36.09

82633 $44.24

82634 $41.81

82638 $17.48

82652 $54.96

82656 $16.56

82657 $25.79

82658 $25.79

82664 $49.06

82668 $26.84

82670 $39.91

82671 $34.28

82672 $30.97

82677 $34.54

82679 $35.65

82696 $33.69

82705 $7.27

82710 $16.62

82715 $24.58

82725 $19.01

82726 $25.79

82728 $19.46

82731 $91.98

82735 $26.48

82746 $21.00

82757 $24.77

82759 $30.68

82760 $11.56

82775 $30.08

82776 $9.17

82784 $8.24

82785 $23.13

82800 $12.10

82803 $27.63

82805 $40.52

82810 $12.46

82812 $73.00

82938 $25.28

82941 $25.19

82943 $20.41

82946 $21.52

82947 $5.60

82948 $4.52

82950 $6.78

82951 $18.39

82952 $5.60

82955 $13.85

82960 $8.66

82963 $30.68

82965 $9.98

82977 $10.28

82978 $20.36

82979 $8.24

82985 $21.52

83001 $26.55

83002 $26.45

83003 $23.81

83009 $41.79

83010 $17.96

83012 $24.55

83013 $41.33

83014 $11.22

83015 $26.90

83018 $31.28

83020 $18.39

83021 $25.79

83030 $11.81

83033 $8.11

83036 $13.87

83045 $7.08

83050 $8.26

83051 $10.44

83060 $11.81

83065 $9.84

83068 $12.10

83069 $5.63

83070 $4.77

83080 $24.09

83088 $39.86

83150 $12.89

83491 $25.02

83497 $18.41

83498 $38.79

83500 $32.34

83505 $34.71

83516 $16.48

83525 $16.34

83527 $18.50

83528 $22.71

83540 $9.25

83550 $12.48

83570 $12.63

83582 $20.24

83586 $18.28

83593 $37.56

83605 $15.25

83615 $8.63

83625 $18.28

83630 $16.66

83632 $28.86

83633 $7.86

83655 $17.28

83661 $31.39

83670 $13.08

83690 $9.84

83718 $11.69

83719 $16.62

83727 $24.55

83735 $9.57

83775 $10.53

83785 $35.11

83789 $25.79

83825 $23.22

83835 $21.51

83857 $15.33

83864 $28.43

83872 $7.44

83873 $24.57

83874 $18.43

83880 $47.43

83885 $34.99

83915 $15.92

83916 $28.72

83918 $23.51

83919 $23.51

83930 $9.43

83935 $9.73

83937 $42.64

83945 $18.39

83950 $89.01

83970 $58.94

83986 $5.12

83992 $19.92

83993 $28.33

84030 $7.83

84035 $3.44

84060 $10.54

84066 $13.80

84075 $7.39

84078 $6.78

84080 $21.12

84081 $23.60

84085 $9.17

84087 $14.75

84100 $6.78

84105 $7.39

84106 $6.12

84110 $9.17

84119 $12.30

84120 $19.11

84126 $36.37

84132 $6.56

84133 $6.14

84135 $27.32

84138 $27.03

84140 $29.53

84143 $32.59

84144 $29.79

84146 $27.67

84150 $35.65

84154 $26.27

84155 $5.23

84156 $5.25

84157 $5.25

84160 $7.39

84163 $11.67

84165 $15.33

84166 $27.75

84202 $20.49

84203 $9.17

84206 $25.44

84207 $40.11

84210 $15.51

84220 $6.13

84228 $16.62

84233 $91.98

84234 $92.63

84235 $74.72

84238 $52.21

84244 $31.41

84252 $28.89

84255 $36.46

84260 $44.24

84275 $19.18

84285 $33.64

84295 $6.87

84300 $6.94

84302 $6.79

84315 $1.86

84375 $27.09

84376 $7.86

84377 $7.86

84378 $16.45

84379 $16.45

84403 $36.87

84410 $72.55

84425 $30.33

84430 $16.62

84436 $8.90

84437 $9.25

84439 $12.88

84442 $21.12

84443 $23.98

84445 $72.62

84446 $20.25

84449 $25.70

84450 $7.38

84460 $7.56

84478 $8.22

84479 $9.25

84480 $20.25

84481 $24.19

84484 $14.05

84485 $7.56

84488 $7.84

84490 $9.43

84510 $9.17

84512 $10.99

84520 $5.63

84525 $5.36

84540 $6.78

84545 $8.77

84550 $6.46

84560 $6.78

84577 $17.81

84578 $4.11

84580 $10.14

84583 $7.18

84585 $22.13

84586 $50.46

84588 $48.47

84590 $15.26

84597 $19.57

84600 $22.06

84620 $16.92

84630 $16.26

84681 $29.71

84702 $11.54

84703 $10.73

84704 $11.67

84999 $0.00

85002 $6.43

85004 $9.04

85007 $4.92

85009 $5.31

85014 $3.38

85018 $3.38

85025 $11.10

85027 $9.25

85032 $6.01

85041 $4.30

85044 $6.14

85045 $5.72

85046 $7.98

85048 $3.64

85049 $6.25

85055 $26.00

85060 $6.00

85170 $5.17

85175 $6.49

85210 $9.17

85220 $25.20

85230 $25.58

85240 $25.58

85244 $29.16

85250 $27.19

85260 $25.58

85270 $25.58

85280 $27.63

85290 $23.33

85291 $12.69

85292 $27.04

85293 $27.04

85300 $16.93

85301 $15.45

85302 $17.16

85345 $6.14

85347 $5.71

85348 $5.31

85360 $12.00

85362 $9.84

85380 $14.22

85390 $7.37

85396 $0.00

85400 $12.63

85420 $9.17

85421 $14.54

85441 $6.00

85445 $9.73

85460 $11.05

85461 $8.72

85520 $11.15

85530 $20.25

85540 $12.28

85547 $9.57

85549 $26.78

85555 $9.55

85557 $19.08

85576 $30.68

85610 $5.61

85612 $8.24

85635 $14.06

85651 $5.07

85652 $3.85

85670 $8.25

85675 $9.79

85730 $8.58

85732 $9.25

85810 $16.68

85999 $0.00

86000 $2.26

86003 $7.46

86005 $11.39

86008 $22.14

86021 $21.49

86022 $26.23

86023 $17.78

86038 $17.26

86060 $10.43

86063 $8.25

86140 $7.39

86141 $17.89

86148 $16.60

86155 $22.82

86162 $29.02

86171 $14.31

86215 $17.40

86235 $25.61

86255 $17.22

86256 $17.22

86277 $22.48

86280 $11.69

86310 $10.53

86316 $29.72

86317 $21.41

86318 $18.49

86320 $32.01

86325 $31.93

86327 $32.40

86329 $20.05

86331 $16.21

86332 $34.80

86334 $31.90

86335 $42.38

86336 $21.77

86337 $30.58

86340 $21.52

86341 $28.25

86343 $17.79

86344 $11.41

86353 $65.11

86356 $29.07

86359 $53.87

86360 $57.49

86361 $28.75

86376 $20.78

86382 $24.14

86384 $14.08

86403 $14.55

86406 $15.19

86430 $8.11

86486 $4.91

86490 $9.00

86510 $10.00

86580 $8.00

86590 $14.08

86592 $5.90

86593 $6.29

86617 $22.11

86687 $11.99

86689 $27.64

86704 $17.22

86705 $16.81

86706 $15.33

86707 $16.51

86708 $17.69

86709 $16.07

86800 $22.71

86803 $20.39

86804 $22.11

86805 $74.67

86806 $67.95

86807 $33.22

86808 $33.22

86812 $36.85

86813 $82.80

86816 $39.77

86817 $91.95

86821 $80.63

86850 $5.00

86860 $16.00

86870 $11.00

86885 $8.16

86890 $49.00

86891 $60.00

86911 $7.23

86920 $34.00

86921 $22.26

86922 $47.50

86923 $6.80

86927 $5.00

86930 $32.00

86931 $32.00

86932 $45.00

86945 $17.00

86950 $0.00

86960 $0.00

86965 $5.00

86970 $24.00

86971 $24.00

86972 $24.00

86975 $0.00

86976 $8.00

86977 $8.00

86978 $19.00

86985 $5.00

86999 $0.00

87015 $9.54

87040 $14.75

87045 $13.47

87070 $12.30

87075 $12.49

87076 $11.53

87081 $9.47

87084 $12.30

87086 $11.53

87088 $11.55

87101 $8.24

87102 $12.00

87103 $12.88

87106 $11.70

87109 $21.97

87110 $27.98

87116 $15.43

87118 $15.63

87140 $7.97

87143 $17.90

87147 $7.39

87158 $7.47

87164 $15.33

87166 $16.13

87176 $7.84

87177 $12.71

87181 $6.78

87184 $9.85

87186 $8.24

87187 $8.24

87188 $6.64

87190 $8.07

87197 $15.80

87198 $12.45

87199 $12.45

87205 $6.10

87206 $7.67

87207 $8.56

87220 $4.94

87230 $28.19

87250 $27.92

87252 $37.22

87253 $28.84

87255 $47.31

87260 $12.87

87265 $12.87

87267 $12.59

87269 $12.92

87270 $12.87

87271 $12.59

87272 $12.87

87274 $12.87

87276 $12.87

87278 $12.87

87280 $12.87

87285 $12.87

87290 $12.87

87299 $12.87

87301 $12.87

87320 $12.87

87324 $12.87

87328 $12.87

87329 $12.92

87332 $12.87

87335 $12.87

87338 $6.12

87340 $14.75

87350 $16.45

87380 $23.45

87385 $12.87

87390 $25.19

87391 $25.19

87420 $12.87

87425 $12.87

87430 $12.87

87449 $12.87

87450 $6.55

87471 $50.12

87475 $28.63

87476 $50.12

87480 $28.63

87481 $50.12

87482 $23.52

87485 $28.63

87486 $50.12

87487 $61.17

87490 $28.63

87491 $50.12

87492 $23.52

87495 $28.63

87496 $50.12

87497 $61.17

87500 $50.67

87510 $28.63

87511 $50.12

87512 $23.52

87516 $50.12

87517 $61.17

87520 $28.63

87521 $50.12

87522 $61.17

87525 $28.63

87526 $50.12

87527 $23.52

87528 $28.63

87529 $50.12

87530 $61.17

87531 $28.63

87532 $50.12

87533 $23.52

87534 $28.63

87535 $50.12

87536 $121.51

87537 $28.63

87538 $50.12

87539 $23.52

87540 $28.63

87541 $50.12

87542 $23.52

87550 $28.63

87552 $61.17

87555 $28.63

87556 $50.12

87557 $61.17

87560 $28.63

87561 $50.12

87562 $61.17

87580 $28.63

87581 $50.12

87582 $23.52

87590 $28.63

87591 $50.12

87592 $23.52

87650 $28.63

87651 $50.12

87652 $23.52

87660 $28.74

87797 $28.63

87798 $50.12

87799 $61.17

87802 $12.45

87803 $12.45

87804 $12.45

87807 $13.01

87809 $13.01

87810 $12.87

87850 $12.87

87880 $12.87

87899 $12.87

87999 $0.00

88104 $11.00

88106 $17.00

88108 $22.00

88112 $55.88

88125 $30.00

88130 $21.48

88140 $11.42

88142 $19.00

88143 $19.00

88147 $7.15

88148 $7.15

88150 $7.39

88152 $7.39

88153 $7.39

88155 $8.56

88160 $9.00

88162 $21.75

88164 $7.39

88165 $7.39

88166 $7.39

88172 $52.89

88174 $20.39

88175 $20.75

88182 $34.00

88184 $43.18

88185 $21.42

88199 $0.00

88230 $91.26

88233 $91.26

88235 $91.26

88237 $91.26

88239 $91.26

88240 $14.43

88241 $14.43

88245 $91.26

88248 $247.30

88249 $247.30

88261 $252.38

88262 $177.99

88263 $91.26

88264 $177.99

88267 $256.72

88269 $237.51

88271 $30.59

88272 $38.23

88273 $45.88

88274 $49.70

88275 $57.35

88280 $35.84

88283 $39.86

88285 $27.14

88289 $49.17

88299 $0.00

88300 $9.00

88302 $18.00

88304 $22.00

88305 $28.00

88307 $53.00

88309 $46.00

88311 $13.00

88312 $13.00

88313 $7.00

88314 $40.00

88319 $9.38

88333 $19.50

88334 $11.83

88342 $39.60

88346 $11.58

88348 $168.00

88350 $40.62

88355 $51.76

88356 $72.38

88358 $52.88

88360 $59.68

88361 $84.38

88362 $75.76

88365 $53.26

88367 $169.25

88368 $138.01

88381 $133.20

88399 $0.00

89049 $0.00

89050 $6.75

89051 $7.86

89055 $5.96

89060 $10.21

89125 $6.16

89160 $5.26

89190 $6.78

89220 $9.66

89230 $14.21

89240 $0.00

89300 $12.73

89310 $12.29

89320 $17.22

89322 $22.37

89325 $15.24

89329 $29.95

89330 $14.14

89331 $28.28

92507 UB $17.40

92507 $21.76

92508 UB $4.75

92508 $5.94

92521 UA $49.44

92522 UA $49.44

92523 UA $49.44

92524 UA $49.44

92611 $46.87

92612 $176.27

92614 $136.14

92616 $186.39

92700 $0.00

93980 $43.00

93981 $39.00

94010 $24.00

94060 $39.00

94070 $51.00

94150 $7.00

94200 $16.00

94250 $7.00

94375 $13.00

94400 $4.48

94450 $9.20

94618 $12.66

94640 $6.00

94642 $4.61

94644 $46.65

94664 $6.00

94680 $30.00

94681 $61.00

94690 $10.00

94750 $10.00

94760 $28.00

94761 $28.00

94770 $19.00

97001 $49.44

97003 $49.44

97110 UB $17.40

97110 $21.76

97150 U1 UB $4.75

97150 U2 $5.94

97150 UB $4.75

97150 $5.94

97161 $49.44

97162 $74.16

97163 $98.88

97164 $49.44

97165 $49.44

97166 $74.16

97167 $98.88

97168 $49.44

97530 UB $17.40

97530 $21.76

97750 $27.35

97799 $0.00

A9500 $70.66

A9502 $160.00

A9503 $64.00

A9504 $400.00

A9505 $16.88

A9507 $1,647.18

A9508 $14.30

A9510 $48.00

A9600 $811.30

C9407 $344.28

C9408 $344.28

Q4141 $0.00

S3620 $132.00

S3840 $0.00

S3842 $0.00

S3844 $0.00

S3846 $0.00

S3849 $0.00

S3850 $0.00

S3853 $0.00

T1015 U1 $12.00