rehabilitative hospital fee schedule · maximum allowed amount 459 $12.00 procedure code mod 1 mod...
TRANSCRIPT
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